Outcomes Of Eversion Versus Conventional Carotid Endarterectomy In The SVS Vascular Quality Initiative
Luke M. Stewart, MD, Emily L. Spangler, MD, Danielle C. Sutzko, MD, Benjamin J. Pearce, MD, Graeme E. McFarland, MD, Zdenek Novak, MD, PhD, Adam W. Beck, MD, FACS.
University of Alabama at Birmingham, Birmingham, AL, USA.
Objectives: Carotid Endarterectomy (CEA) is performed using two accepted techniques: Eversion (eCEA) and Conventional (cCEA). However, most studies comparing the two techniques are small single-institution series showing conflicting outcomes. We aim to compare intraoperative factors, the rate of postoperative neurologic events, and the rate of postoperative complications between the two techniques in a large national cohort.
Methods: The Society for Vascular Surgery Vascular Quality Initiative registry was used to identify patients undergoing CEA for asymptomatic or symptomatic carotid stenosis from 2013-19. Exclusions included concomitant coronary bypass, or proximal/distal endovascular interventions, urgent or emergent procedures, and those with prior ipsilateral CEA or carotid stent. T-test and X2 testing were used to compare demographic and perioperative variables. Those with p<.10 were placed in multivariable analysis to separately compare rate of neurologic event, return to operating room for bleeding, and rate of cranial nerve injury. Postoperative complications were compared by technique both overall and by symptomatic status (defined as ipsilateral neurologic event within 6 months).
Results: In this cohort of 84,635 CEAs, there were 73,701 cCEA (22% symptomatic) and 10,934 eCEA (19% symptomatic). No difference in ipsilateral neurologic event (1.0% cCEA vs 0.9% eCEA, p=.326) or ipsilateral stroke rates (0.7% cCEA vs 0.7% eCEA, p=.302) were seen by technique when compared overall or by symptomatic status (Table 1).
| Conventional CEA | Eversion CEA | p | Conventional CEA | Eversion CEA | p | |||
| Asymptomatic Patients | (n=57657) | (n=8849) | Symptomatic Patients | (n=16044) | (n=8849) | |||
| Overall Neurologic Event | 740 (1.3) | 116 (1.3) | .831 | Overall Neurologic Event | 344 (2.1) | 42 (2.0) | .698 | |
| Ipsilateral Neurologic Event | 500 (0.9) | 70 (0.8) | .469 | Ipsilateral Neurologic Event | 255 (1.6) | 31 (1.5) | .723 | |
| Ipsilateral Stroke | 364 (0.6) | 50 (0.6) | .460 | Ipsilateral Stroke | 188 (1.2) | 22 (1.1) | .639 | |
| Contralateral Neurologic Event | 149 (0.3) | 29 (0.3) | .240 | Contralateral Neurologic Event | 64 (0.4) | 7 (0.3) | .663 | |
| Contralateral Stroke | 108 (0.2) | 25 (0.3) | .062 | Contralateral Stroke | 50 (0.3) | 5 (0.2) | .574 | |
| Return to OR for Bleeding | 489 (0.8) | 112 (1.3) | <.001 | Return to OR for Bleeding | 166 (1.0) | 26 (1.2) | .373 | |
| Cranial Nerve Injury | 1508 (2.6) | 152 (1.7) | <.001 | Cranial Nerve Injury | 526 (3.3) | 45 (2.2) | .006 |
A higher rate of return to operating room for bleeding was found in eCEA (0.9% cCEA vs 1.3% eCEA, p<.001), and eCEA remained an independent risk factor for this on multivariable regression (OR for bleeding: 1.42, 95%CI: 1.17-1.71; p<.001). A lower rate of cranial nerve injury was seen in eCEA (2.8% cCEA vs 1.8% eCEA, p<.001). After multivariable adjustment, eCEA remained protective from cranial nerve injury in comparison to cCEA (OR for cranial nerve injury: 0.66 95%CI: 0.56-0.76; p<.001).
Conclusions: While no difference was seen between cCEA and eCEA in regards to neurologic event rates, eCEA technique is associated with lower cranial nerve injury rates but a slightly higher rate of return to OR for bleeding.
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