Regional Variation in Patient Outcomes in Carotid Endarterectomy and Stenting in the Vascular Quality Initiative (VQI)
Katie E.M. Shean1, Sarah E. Deery, MD1, Sara L. Zettervall, MD1, Peter A. Soden, MD1, Thomas F.X. O'Donnell, MD1, Jeremy D. Darling, BA1, Joseph R. Schneider, MD/PhD2, Brian W. Nolan, MD3, Caron B. Rockman, MD4, Marc L. Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 3Dartmouth Hitchcock Medical Center, Hanover, NH, USA, 4NYU Langone Medical Center, New York, NY, USA.
Objective:
Quality metrics have been developed to improve outcomes following carotid artery revascularization; however few studies have evaluated regional differences in perioperative outcomes. This study aims to evaluate regional variation in mortality and perioperative outcomes following CEA and CAS.
Methods:
All patients who underwent CEA or CAS from 2009 to 2015 were identified in the Vascular Quality Initiative. Each of the 17 regions was evaluated. Patients were analyzed based on their symptom status. Variations in perioperative outcomes were compared using Chi square analysis and Fisher’s exact test.
Results:
A total of 57,555 carotid interventions were identified; 85% were CEA, with 56% of those asymptomatic. Within CAS, 39% were asymptomatic. Variation in 30-day mortality was significant in symptomatic patients (Symptomatic: CEA:0-2%, P=0.02, CAS:0-6%, P=0.01; Asymptomatic: CEA:0-1%, P=0.6, CAS:0-3%, P=0.06). Post-operative stroke/death revealed variation within both CAS groups ranging above the AHA guidelines (Symptomatic: 3-9%, P=0.1; Asymptomatic: 0-5%, P=0.2). Within CEA, the variation ranges were within the AHA guidelines, but a statistically significant difference was found in the symptomatic group (Symptomatic: 1-4%, P=0.009; Asymptomatic: 1-2%, P=0.4). Post-operative stroke varied, but did not meet statistical significance for any of the groups. There was significant variation in myocardial infarction, length of stay >2 days, the use of IV blood pressure medications, as well as discharge on dual antiplatelet therapy. Following CEA, there was significant variation in cranial nerve injuries (Symptomatic: 2-6%, P<0.001; Asymptomatic: 1-5%, P<0.001) and return to the operating room (Symptomatic: 1-4%, P=0.001; Asymptomatic: 0-3%, P<0.001). Following CAS, significant variation was found in access site complications (Symptomatic: 1-10%, P<0.001; Asymptomatic: 1-8%, P=0.006) and technical failures in the symptomatic patients (Symptomatic: 0-3%, P=0.001; Asymptomatic: 0-2%, P=0.7).
Conclusion:
Despite current guidelines, set forth by the AHA, unwarranted regional variation exists in perioperative stroke and mortality following carotid artery stenting. Additional quality metrics exist for other perioperative outcomes where significant variation was found, such as length of stay and discharge medications. These results highlight the need for further investigation and quality improvement efforts to improve adherence to current guidelines and to develop best practices.
Table 1: Outcomes, by symptom status and procedure performed
| Outcome Range, % (P-value) | Asymptomatic | Symptomatic | ||||||
| CEA | CAS | CEA | CAS | |||||
| 30-day Mortality | 0 – 1.0 | (0.6) | 0 – 2.9 | (0.06) | 0 – 1.7 | (0.02) | 0 – 6.1 | (0.01) |
| Stroke/Death | 0.5 – 2.1 | (0.4) | 0 – 4.7 | (0.2) | 1.2 – 3.9 | (0.009) | 2.6 – 8.8 | (0.1) |
| Stroke | 0.4 – 1.5 | (0.2) | 0 – 3.5 | (0.5) | 1.1 – 2.7 | (0.3) | 1.4 – 5.9 | (0.2) |
| MI | 0.2 – 1.4 | (0.008) | 0 – 4.3 | (0.02) | 0 – 2.1 | (<0.001) | 0 – 2.3 | (0.1) |
| LOS >2 days | 8.3 – 17.5 | (<0.001) | 5.8 – 22.4 | (<0.001) | 14.2 – 29.6 | (<0.001) | 10.4 – 35.3 | (<0.001) |
| Cranial Nerve Injury | 0.8 – 5.3 | (<0.001) | - | 1.5 – 6.3 | (<0.001) | - | ||
| Return to OR | 0.2 – 2.9 | (<0.001) | - | 0.6 – 3.7 | (0.001) | - | ||
| Access Site Complication | - | 1.2 – 8.0 | (0.006) | - | 0.9 – 10.2 | (<0.001) | ||
| Technical failure | - | 0 – 1.7 | (0.7) | - | 0 – 3.4 | (0.001) | ||
| IV BP medication | 17.6 – 36.5 | (<0.001) | 9.4 – 31.9 | (0.003) | 20.7 – 37.7 | (<0.001) | 13.0 – 32.5 | (<0.001) |
| D/C on dual antiplatelet | 16.1 – 39.5 | (<0.001) | 71.0 – 93.6 | (<0.001) | 20.0 – 44.3 | (<0.001) | 77.5 – 92.2 | (<0.001) |
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