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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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Table 1. Baseline Characteristics of Patients underwent Completion Imaging (Duplex or angiography)
No Completion Imaging PerformedCompletion ImagingP value
Number of Patients(N=71,339, 72.8%)(N=26,716, 27.3%)
Age, years71 (64-77)71 (64-77)0.26
Females28205 (39.5)10554 (39.5)0.93
White Race65409 (91.9)24414 (91.4)<0.001
ASA class
I/II4335 (6.4)1424 (5.7)<0.001
III50424 (74.2)19120 (76.7)
IV/V13,211 (19.4)4,383(17.5)
Comorbidities
Symptomatic Carotid Stenosis15989 (22.4)5886 (22.0)0.2
Diabetes25377 (35.6)9259 (34.7)0.01
HTN63509 (89.1)23751 (88.9)0.63
CAD19569 (27.5)7186 (26.9)0.1
CHF7238 (10.2)2875 (10.8)0.01
COPD15703 (22.0)6208 (23.3)<0.001
CKD24481 (35.1)9013 (34.5)0.11
Pre-operative medications
Aspirin58869 (82.6)22718 (85.1)<0.001
Beta blocker41340 (58.0)15687 (58.8)0.02
Statin57,352 (80.4)21.953 (82.2)<0.001
P2Y12 Inhibitors20516 (28.8)9289 (34.8)<0.001
Transfer from
Hospital3502 (4.9)1135 (4.3)<0.001
Rehabilitation Unit397 (0.6)114 (0.3)
Patching42,073 (89.1)16,497 (88.8)0.27
Eversion CEA5,652 (12.0)2,959 (15.9)<0.001
Shunting<0.001
None32316 (45.4)12387 (46.4)
Routine36180 (40.8)12870 (48.2)
Selective (Pre-/Intraoperative Indication)2765 (3.9)1433 (5.4)

Table 2. Association between Completion Imaging and Post-Operative Outcomes after CEA
Unadjusted AnalysisAdjusted Analysis
No Completion Imaging Performed Completion ImagingP valueCompletion vs No-CI
In-hospital Outcomes(N=71,339, 72.8%)(N=26,716, 27.3%)OR (95%CI)p-value
Death198 (0.28)84 (0.31)0.341.15 (0.90-1.48)0.24
Stroke704 (1.15)286 (1.29)0.101.16 (1.00-1.35)0.06
Stroke/Death840 (1.2)343 (1.3)0.171.12 (0.96-1.30)0.15
Immediate Re-exploration670 (0.9)935 (3.5)<0.0013.84(2.74-5.38)<0.001
Return to the OR for bleeding or neuro causes885 (1.2)421 (1.6)<0.0011.24 (1.08-1.42)<0.01
Operative time, mean (SD)112 (43.0)125 (46.1)<0.001-
Thirty-Day Outcomes
Stroke/Death1181 (1.7)479 (1.8)0.141.13 (1.0-1.27)0.04
Repeat Revascularization1350 (3.2)552 (3.3)0.521.02(.837-1.24)0.84
Two-Year Outcomes% Freedom from outcomes (95%CI)% Freedom from outcomes (95%CI)P-valueHR (95%CI)p-value
Stroke/Death84.9% (84.1-85.6)85.9 (84.8-87.0)0.100.96 (0.88-1.06)0.43
High-Grade Restenosis92.8 (92.3-93.2)93.7(93.1-94.3)0.040.93 (0.82-1.07)0.32


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