Outcomes of Different Practice Patters in the Use of Completion Imaging after Carotid Endarterectomy
Hanaa Dakour-Aridi, MD, Mohamed Gamal Mohamed Gaber, MD, Satinderjit Locham, MD, Mahmoud Malas, MD, MHS.
University of California San Diego, La jolla, CA, USA.
Background:The use of completion duplex or angiography to confirm the technical adequacy of CEA remains a matter of controversy. This study aims to describe practice patterns and study the association between CI and postoperative outcomes after CEA.
Methods: CEA data from the VQI database (2003-2018) were utilized. Surgeons’ practice patterns were defined as rare (<5% of CEA cases),selective (5%-90%),or routine (≥90%).Multivariable logistic models, and Cox proportional hazards models were used.
Results:Out of 98,055 CEA cases,26,716(27.3%) were performed with CI.Difference in baseline characteristics are shown in Table 1. On univariable analysis, no difference in pre-discharge,30-day and 2-year stroke, and stroke/death rates were seen between patients who had CI and those who did not.However, patients who underwent CI had higher rates of intraoperative immediate re-exploration compared to those with no CI (3.5% vs.0.9%),were also more likely to return to the OR (RTOR) for bleeding or neurological causes (1.6% vs. 1.2%) and had longer operative times [mean (SD),125±46 vs. 112±43 minutes](all p<0.001).After multivariable adjustment, CI was associated with 3.8 higher odds of immediate re-exploration[OR(95%CI):3.8(2.7-5.4)] and 24% higher odds of RTOR [OR(95%CI):1.24(1.1-1.4)].There was a trend towards lower restenosis rates at 2 years in patients who received CI; however, the difference disappeared on multivariable adjustment [HR(95%CI):0.93(0.82-1.07)](Table 2). In our cohort, 45% out of 1,920 surgeons were shown to not perform CI, whereas 15.8% rarely performed CI, 22.8% selectively and 16.5% routinely. Performing CI rarely had higher rates of immediate re-exploration (7.5% vs.3.3%vs.3.4%,P<0.001) and RTOR (4.3% vs.1.6% vs.1.5%,p<0.001) compared to selective and routine performance, respectively. Rarely performing CI was also associated with almost 3 times higher adjusted odds of 30-day stroke/death and repeat revascularization compared to not performing [OR(95%CI):3.38 (2.37-4.84) & 3.02 (2.16-4.25), respectively].
Conclusion: Surgeon practice patterns with CI vary widely across the US.The performance of CI during CEA increases the odds of immediate re-exploration but does not seem to offer an advantage in reducing postoperative stroke and death or restenosis. Selective CI based on operative course might be warranted.
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| No Completion Imaging Performed | Completion Imaging | P value | |
| Number of Patients | (N=71,339, 72.8%) | (N=26,716, 27.3%) | |
| Age, years | 71 (64-77) | 71 (64-77) | 0.26 |
| Females | 28205 (39.5) | 10554 (39.5) | 0.93 |
| White Race | 65409 (91.9) | 24414 (91.4) | <0.001 |
| ASA class | |||
| I/II | 4335 (6.4) | 1424 (5.7) | <0.001 |
| III | 50424 (74.2) | 19120 (76.7) | |
| IV/V | 13,211 (19.4) | 4,383(17.5) | |
| Comorbidities | |||
| Symptomatic Carotid Stenosis | 15989 (22.4) | 5886 (22.0) | 0.2 |
| Diabetes | 25377 (35.6) | 9259 (34.7) | 0.01 |
| HTN | 63509 (89.1) | 23751 (88.9) | 0.63 |
| CAD | 19569 (27.5) | 7186 (26.9) | 0.1 |
| CHF | 7238 (10.2) | 2875 (10.8) | 0.01 |
| COPD | 15703 (22.0) | 6208 (23.3) | <0.001 |
| CKD | 24481 (35.1) | 9013 (34.5) | 0.11 |
| Pre-operative medications | |||
| Aspirin | 58869 (82.6) | 22718 (85.1) | <0.001 |
| Beta blocker | 41340 (58.0) | 15687 (58.8) | 0.02 |
| Statin | 57,352 (80.4) | 21.953 (82.2) | <0.001 |
| P2Y12 Inhibitors | 20516 (28.8) | 9289 (34.8) | <0.001 |
| Transfer from | |||
| Hospital | 3502 (4.9) | 1135 (4.3) | <0.001 |
| Rehabilitation Unit | 397 (0.6) | 114 (0.3) | |
| Patching | 42,073 (89.1) | 16,497 (88.8) | 0.27 |
| Eversion CEA | 5,652 (12.0) | 2,959 (15.9) | <0.001 |
| Shunting | <0.001 | ||
| None | 32316 (45.4) | 12387 (46.4) | |
| Routine | 36180 (40.8) | 12870 (48.2) | |
| Selective (Pre-/Intraoperative Indication) | 2765 (3.9) | 1433 (5.4) |
| Unadjusted Analysis | Adjusted Analysis | ||||||||
| No Completion Imaging Performed | Completion Imaging | P value | Completion vs No-CI | ||||||
| In-hospital Outcomes | (N=71,339, 72.8%) | (N=26,716, 27.3%) | OR (95%CI) | p-value | |||||
| Death | 198 (0.28) | 84 (0.31) | 0.34 | 1.15 (0.90-1.48) | 0.24 | ||||
| Stroke | 704 (1.15) | 286 (1.29) | 0.10 | 1.16 (1.00-1.35) | 0.06 | ||||
| Stroke/Death | 840 (1.2) | 343 (1.3) | 0.17 | 1.12 (0.96-1.30) | 0.15 | ||||
| Immediate Re-exploration | 670 (0.9) | 935 (3.5) | <0.001 | 3.84(2.74-5.38) | <0.001 | ||||
| Return to the OR for bleeding or neuro causes | 885 (1.2) | 421 (1.6) | <0.001 | 1.24 (1.08-1.42) | <0.01 | ||||
| Operative time, mean (SD) | 112 (43.0) | 125 (46.1) | <0.001 | - | |||||
| Thirty-Day Outcomes | |||||||||
| Stroke/Death | 1181 (1.7) | 479 (1.8) | 0.14 | 1.13 (1.0-1.27) | 0.04 | ||||
| Repeat Revascularization | 1350 (3.2) | 552 (3.3) | 0.52 | 1.02(.837-1.24) | 0.84 | ||||
| Two-Year Outcomes | % Freedom from outcomes (95%CI) | % Freedom from outcomes (95%CI) | P-value | HR (95%CI) | p-value | ||||
| Stroke/Death | 84.9% (84.1-85.6) | 85.9 (84.8-87.0) | 0.10 | 0.96 (0.88-1.06) | 0.43 | ||||
| High-Grade Restenosis | 92.8 (92.3-93.2) | 93.7(93.1-94.3) | 0.04 | 0.93 (0.82-1.07) | 0.32 | ||||
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