Modern Perioperative Outcomes after Reoperative Carotid Endarterectomy are Worse than Expected
Brianna M. Krafcik, M.S., Alik Farber, M.D., Thomas W. Cheng, M.S., Jeffrey A. Kalish, M.D., Denis Rybin, Ph.D., Gheorghe Doros, Ph.D., Lauren Roberts, Jeffrey J. Siracuse, M.D..
Boston University, Boston, MA, USA.
OBJECTIVES: Reoperative carotid endarterectomy (CEA) can be technically challenging due to scarring and there is little data describing its outcomes. Our goal was to determine the effect of CEA reoperation on perioperative outcomes.
METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2005-2014) was queried for patients undergoing CEA. Patients undergoing first-time CEA (iCEA) were compared with those undergoing reoperative CEA > 1 month after iCEA (rCEA). Multivariable analysis was used to assess for the effect of CEA reoperation.
RESULTS: Our query identified 140 rCEA and 75,943 iCEA procedures . There were no differences in baseline demographics or comorbidities except that the rCEA cohort had a higher proportion of patients with end staged renal disease (3.6% vs. 1.1%, P=.004). Rates of prior stroke with deficit (11.5% vs. 9.1%, P=.43) and without deficit (20.8% vs. 15.4%, P=0.137) were similar. There were no differences between rCEA and iCEA groups in surgical site infection (0.7% vs. 0.3%, P=.462), return to the operating room (3.6% vs. 4%, P=.81), readmission within 30 days (6% vs. 6.9%, P=.81), myocardial infarction (MI) (2.1% vs. 1.9%, P=.13), and perioperative death (0.7% vs. 0.9%). A higher rate of perioperative stroke (5% vs. 1.6%, P=.002) and longer operative time (136+/-54 vs. 116+/-49 minutes) was noted after rCEA. Multivariate analysis revealed rCEA to be independently associated with postoperative stroke (OR 3.71, 95% CI 1.6-8.6, P=.002), major adverse cardiac events (composite stroke/MI/death) (OR 2.76, 95% CI 1.32-5.8, P=.007), and operative time (OR 1.21, 95% CI 1.12-1.3, P<.001).
CONCLUSION: Reoperative carotid surgery has a higher risk of perioperative stroke compared to index carotid endarterectomy. Alternatives such as medical management or carotid stenting should be further investigated in this population.
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