Effect Of Postoperative Stroke Timing On Perioperative Mortality After Carotid Revascularization
Christina Cui, MAS, Kevin Yei, BS, Mahmoud Malas, MD, MHS, FACS, Omar Al-Nouri, DO.
University of California, San Diego, La Jolla, CA, USA.
Objective: In-hospital stroke (IHS) has historically been associated with worse outcomes than out-of-hospital stroke (OHS). This is largely due to delays in diagnosis and treatment. Studies comparing timing of postoperative stroke after carotid revascularization are lacking. We aimed to study the effect of in-hospital stroke (IHS) vs. out-of-hospital stroke (OHS) on perioperative mortality in a large nationally representative cohort of carotid revascularization patients.
Methods: We included all cases in the targeted carotid artery stenting (CAS) and carotid endarterectomy (CEA) files from ACS NSQIP 2011-2018. Statistical analysis included Fisher's test and logistic regression. Patients were divided into three cohorts: in-hospital stroke (IHS), out-of-hospital stroke (OHS), and no stroke. We adjusted for age, concomitant cancer, method of revascularization, urgency, high-risk physiology, degree of contralateral stenosis, history of comorbidities (diabetes, chronic obstructive pulmonary disease, congestive heart failure) and pre-operative medications (aspirin and statin). We then performed a sub-analysis stratifying by revascularization method.
Results: A total of 31,304 carotid revascularizations were performed with 420 (1.34%) in-hospital strokes and 207 (0.66%) out-of-hospital strokes. On adjusted analysis, there was significantly higher perioperative mortality with both IHS [OR:19.75, 95%CI:13.61-28.18, p<0.001] and OHS [OR:29.73, 95%CI:18.76-45.82, p<0.001]. There was no statistical difference in perioperative mortality between IHS vs. OHS.
Most patients (n=30100, 96.15%) underwent CEA, which also demonstrated increased perioperative mortality for both IHS [OR: 18.88, 95%CI: 4.766-68.33, p=0.005] and OHS [OR: 14.55, 95%CI:0.69-110.54, p<0.001] when compared to patients with no strokes. No differences were seen between IHS and OHS patients. A minority of patients (n=1256, 4.17%) underwent CAS, which similarly demonstrated increased perioperative mortality for both IHS [OR: 19.72, 95%CI: 13.32-19.35, p<0.001] and OHS [OR: 31.08, 95%CI: 19.35-48.38, p<0.001] compared to no stroke patients, but no differences between IHS and OHS patients.
Conclusion: Any postoperative stroke after carotid revascularization significantly increased odds of 30-day mortality. IHS and OHS had comparable mortality, in contrast to previous studies demonstrating worse outcomes after IHS compared to OHS. Improved follow-up and rescue phenomenon within the carotid revascularization patient population may contribute to these results. However, overall mortality remains high, emphasizing the importance of vigilant in-hospital monitoring and follow-up after discharging the patient.
|30-Day Mortalityn (%)||P-value||Adjusted OR (95% CI)||P-Value||Adjusted OR (95% CI)||P-Value|
|No Stroke (n=30677)||153 (0.50%)||< 0.001||Reference||-||0.03 (0.02-0.05)||< 0.001|
|IHS (n=420, 1.34%)||46 (10.95%)||-||19.75 (13.61-28.18)||< 0.001||0.66 (0.39-1.13)||0.128|
|OHS (n=207, 0.66%)||28 (13.53%)||-||29.73 (18.76-45.82)||< 0.001||Reference||-|
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