A Majority of Patients who Suffer Postoperative Stroke after Carotid Endarterectomy Experience Significant Disability
Scott R. Levin, M.D.1, Alik Farber, M.D.1, Douglas W. Jones, M.D.1, Denis Rybin, Ph.D.1, Jeffrey A. Kalish, M.D.1, Kyla M. Bennett, M.D.2, Nkiruka Arinze, M.D.1, Jeffrey J. Siracuse, M.D.1.
1Boston University, Boston, MA, USA, 2University of Wisconsin, Madison, WI, USA.
OBJECTIVES: While modern rates of stroke after carotid endarterectomy (CEA) are low, the functional outcomes of post-CEA stroke are unclear. Our goal was to assess the degree of disability in CEA patients without baseline impairment who suffer a postoperative stroke.
METHODS: The National Surgical Quality Improvement Program database (2011-2014) was queried for CEA cases. Modified Rankin scale was used to assess the degree of disability from stroke: 0 - no symptoms, 1 - no significant disability, 2 - slight disability, 3 - moderate disability, 4 - moderately severe disability, 5 - severe disability, and 6 - dead. Patients were included if they had a preoperative Rankin score of 1 or less. 30-day outcomes among cohorts of postoperative Rankin scores 0-1, 2-3, and 4-5 were compared. Multivariable analysis was used to determine predictors of a higher postoperative Rankin score.
RESULTS: 8797 CEA patients with a preoperative Rankin score of 0 or 1 were identified. Mean age was 71.0 +/- 8.8 years and 61% were male. The majority were asymptomatic (88%) and on antiplatelets (90%) and statins (82%) preoperatively. Mean operative time was 2 hours. Postoperative stroke rate was 1.1% and mortality was 0.6% at 30 days. For patients suffering postoperative stroke, 35.4% still had a Rankin score of 0-1, while the majority had increased postoperative disability with Rankin scores of 2-3 (32.3%) and 4-5 (32.3%). Higher postoperative Rankin score cohorts exhibited longer total length of stay ([days] 2.2 ± 3.3 vs. 5.8 ± 3.9 vs. 11.9 ± 18.8, P<.001), myocardial infarction/dysrhythmia (1.9% vs. 6.3% vs. 15.6%, P<.001), and new stroke (.4% vs. 100% vs. 100%, P<.001). Multivariable analysis showed that postoperative disability, based on higher Rankin score, was independently associated with preoperative bleeding disorder (OR 1.79, 95% CI 1.04-3.11, P=.037) and operative time per hour (OR 1.38, 95% CI 1.11-1.70, P=.003).
CONCLUSIONS: Although the rate of stroke after CEA is low, more than half of patients who suffer a postoperative stroke will have some degree of disability, while a third will have moderately severe to severe disability. Risk factors for worse functional outcomes were identified. These findings provide an evidence base for improved informed consent and risk-benefit discussions with patients.
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