The Impact Of Adding Supra-aortic Trunk Surgical Reconstruction To Carotid Endarterectomy
Bernadette J. Goudreau, MD, MSc1, Linda J. Wang, MD,MBA2, Adam Tanious, MD, MMSc2, David C. Chang, PhD, MBA, MPH2, Alexander H. Shannon, MD1, Margaret C. Tracci, MD, JD1, Jahan Mohebali, MD, MPH2, W. Darrin Clouse, MD1.
1University of Virginia, Charlottesville, VA, USA, 2Massachusetts General Hospital, Boston, MA, USA.
OBJECTIVES: Additive risks of combining supra-aortic trunk surgical reconstruction (SAT) and carotid endarterectomy (CEA) for carotid bifurcation and proximal great vessel disease management are poorly described. This study sought to define the risk of adding open SAT to CEA. METHODS: Using the National Surgical Quality Improvement Program (2005-2015), patients who underwent CEA were evaluated. Isolated CEA (ICEA) and CEA+SAT were identified. Patients with nonocclusive indications were excluded. CEA+SAT were compared with ICEA as well as a propensity-matched ICEA cohort. Primary outcomes included 30-day stroke, death, and these as composite (S/D). Outcomes were further weighted within the context of symptomatic status.Univariate and logistic regression analyses were performed.
RESULTS: After exclusion, 79,747 patients were identified: 79,477 ICEA and 270 CEA+SAT. Most were male (60%) and 24% were symptomatic. Average age was 71±9 years. SAT reconstructions included 19 (7%) aorto-carotid bypasses, 21 (8%) carotid-subclavian transpositions, 85 (31%) carotid-carotid bypasses, and 145 (54%) carotid-subclavian bypasses. CEA+SAT were more likely to be female (47% vs 40%, p=.03), smokers (40% vs 28%, p<.001), and have chronic obstructive pulmonary disease (20% vs 11%, p<.001). There was no difference in 30-day mortality between cohorts (ICEA 0.7% vs CEA+SAT 1.5%, p=.12). However, CEA+SAT had higher rates of stroke (3.7% vs 1.6%, p=.01) and stroke and death (S/D) (4.8% vs 2.1%, p=.001). On logistic regression, predictors of S/D included CEA+SAT (OR 5.2, 95%CI 1.1-26, p=.046) and symptomatic status (OR 1.9, 95%CI 1.1-3.2, p=.02). After propensity matching, CEA+SAT continued to have higher rates of perioperative stroke (3.4% vs 0.4%, p=.01) and S/D (4.5% vs 1.5%, p=.04), with similar rates of mortality (1.5% vs 1.1%, p=.70). When the entire cohort was stratified by symptomatic status, there were no differences in primary endpoints between procedures in asymptomatic patients. In symptomatic patients, CEA+SAT carried significantly higher stroke (5.6% vs 2.1%, p=.04) and S/D risk (7.0% vs 2.8%, p=.03).
CONCLUSIONS: Addition of SAT to CEA confers increased risk of stroke and S/D over isolated CEA. Symptomatic status and SAT addition contribute to this risk. However, in patients with tandem disease, fully open reconstruction with CEA+SAT may be a reasonable approach. Yet, management strategies should be considered within context of lesion characteristics, patient longevity and individual risk profile, particularly in symptomatic patients.
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