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Impact of High-Risk Anatomic and Physiologic Characteristics for Symptomatic and Asymptomatic Patients undergoing Carotid Endarterectomy
Patric Liang, MD, Vaishnavi Rao, BS, Nicholas J. Swerdlow, MD, Chun Li, MD, Yoel Solomon, BS, Marc L. Schermerhorn, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.

Objective:
The ideal 30-day post-operative stroke/death rate after carotid endarterectomy (CEA) is <3% for asymptomatic patients and <6% for symptomatic patients. We evaluated the impact of CMS physiologic and anatomic high-risk criteria on major adverse event rates following CEA in asymptomatic and symptomatic patients.
Methods:
We retrospectively reviewed all patients undergoing CEA from 2011-2016 in the ACS-NSQIP procedure targeted database. Patients with high-risk anatomic or physiologic characteristics were identified by a predefined variable and were compared to normal risk patients. The primary outcome was 30-day stroke/death, stratified by symptom status.
Results:
We identified 21,673 patients undergoing CEA, of which 57% were treated for asymptomatic carotid disease. Of all patients studied, having high-risk physiology or anatomy yielded higher overall rates of 30-day stroke/death (physiology: 4.6 vs 2.3%, P < .001; anatomy: 3.4 vs 2.3%, P < .01) and cardiac events (physiology: 3.1 vs 1.6%, P < .01; anatomy: 2.3 vs 1.6%, P = .01), compared to normal risk patients. Patients who met criteria for high-risk physiology had higher rates of death (2.3 vs 0.5%, P < .001), but similar rates of stroke (2.6 vs 2.0%, P = .23) and CNI (2.3 vs 2.5%, P = .77). Whereas, patients with high-risk anatomy had higher rates of stroke (3.0 vs 2.0%, P < .01) and cranial nerve injury (4.6 vs 2.5%, P < .001), but similar rates of death (0.8 vs 0.5%, P = .09). Asymptomatic patients with high-risk anatomy or physiology had higher rates of 30-day stroke/death (anatomy: 2.7 vs 1.5%, P < .01; physiology: 4.8 vs 1.5%, P <.001), especially in the physiologic high-risk group, compared to normal risk patients (Table). However, these statistical differences were only seen following treatment of symptomatic patients with high-risk anatomy but not high risk-physiology (anatomy: 4.8 vs 3.5%, P = .03; physiology: 4.8 vs 3.5%, P = 0.12).
Conclusions:
Contemporary real-world outcomes following CEA in asymptomatic carotid disease patients meeting high-risk physiologic criteria show an unacceptably high 30-day stroke/death rate, well above the 3% threshold. These results suggest the need for better patient selection and preoperative optimization prior to elective CEA.

Table. Adjusted outcomes for symptomatic and asymptomatic patients with and without high-risk anatomy and physiology
Normal Risk
Symptomatic
N = 7,628
(%)
Asymptomatic
N = 10,448
(%)
Stroke3.11.2
Death0.80.4
Cardiac events1.61.6
Stroke/death3.51.5
CNI2.62.4
High Risk PhysiologyHigh Risk Anatomy
Symptomatic
N = 543
Asymptomatic
N = 525
Symptomatic
N = 1,127
Asymptomatic
N = 1,316
%P value%P value%P value%P value
Stroke3.30.762.5<.014.10.082.2<.01
Death1.70.032.5<.0011.30.0490.60.23
Cardiac events2.80.0453.6<.0012.40.062.50.01
Stroke/death4.80.124.8<.0014.80.032.7<.01
CNI3.00.581.90.444.4<.014.3<.001
CI, confidence interval; CNI, cranial nerve injury; OR, odds ratio. P-value corresponds to comparisons with normal risk patients. Shaded boxes indicate statistical significance of P < .05.


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