Postoperative Outcomes Of Carotid Endarterectomy And Stenting In Functionally Dependent And Independent Patients.
Ahsan Zil-E-Ali, MD, MPH1, Victoria Kusztos2, Faisal Aziz, MD1.
1Penn State College of Medicine, Hershey, PA, USA, 2Albert Einstein College of Medicine, New York, NY, USA.
Objectives: The purpose of this study was to stratify patients undergoing either carotid endarterectomy (CEA) or carotid artery stenting (CAS) based on pre-procedural functional status (FS) and quantify the predictive ability of FS as a potential predictor of adverse postoperative outcomes. Methods: We reviewed patients undergoing CEA and CAS between 2011 and 2018 using the National Surgical Quality Improvement Program (NSQIP). Primary outcomes were mortality and stroke within 30 days post-operation. Outcomes were adjusted with a multivariate logistic regression risk prediction model. Results: Among patients undergoing CEA, 25325 (97.24%) were FS-I and 718 were FS-D (2.76%). In the CAS population, 1074 (95.89%) were FS-I and 46 (4.11%) were FS-D. In an adjusted logistic model, we found that FS-D patients undergoing CEA had three times higher odds of mortality than the FS-I patients (AOR: 3.06, CI: 1.90, 4.92, p<0.001). Among patients undergoing CAS, a similar higher odds of mortality was seen in FS-D patients compared to FS-I patients (AOR: 3.42, CI: 0.86, 13.67, p=0.082). Odds of developing a stroke following either intervention were insignificant in both groups. Among FS-D patients, those undergoing CAS were three times more likely to develop a stroke, compared to those undergoing CEA (AOR: 2.35, CI: 0.32,1.97, p=0.046). Conclusions: Preoperative functional dependence is associated with increased risk of mortality in patients undergoing CEA. CEA should be used cautiously, and alternative treatment should be considered for FS-D patients.
Table 1. Univariate and Multivariate Analysis using Logistic Regression Modelling for Primary and Secondary Outcomes for Functionally Dependent (FS-D) patients compared to Functionally Independent (FS-I) Patients undergoing CEA and CAS. FS-I is Reference.(UOR=Unadjusted Odds Ratio, AOR, Adjusted Odds Ratio, IO=Intraoperative)
| Carotid Endarterectomy (FS-D vs. FS-I) | ||||
| UOR (95% CI) | p-value | AOR (95% CI) | p-value | |
| Primary Outcomes | ||||
| 30 Days Mortality | 4.28(2.69-6.81) | <0.001 | 3.06 (1.90-4.92) | <0.001 |
| 30 Days Stroke | 1.28(0.78-2.10) | 0.335 | 1.14(0.69-1.88) | 0.609 |
| Secondary Outcomes | ||||
| Length of IO time | 1.32(1.14-1.53) | <0.001 | 1.36(1.17-1.58) | <0.001 |
| Unplanned Reoperation | 1.85(1.32-2.60) | <0.001 | 1.68(1.19-2.37) | 0.003 |
| Pneumonia | 9.53(2.94-30.97) | <0.001 | 5.43(1.62-18.11) | 0.006 |
| Length of Stay in Hospital | 3.49(3.01-4.06) | <0.001 | 3.05(2.62-3.56) | <0.001 |
| Still in Hospital >30 Days | 3.17(1.06-9.48) | 0.039 | 2.08(0.68-6.36) | 0.197 |
| Carotid Artery Stenting (FS-D vs. FS-I) | ||||
| Primary Outcomes | ||||
| 30 Days Mortality | 3.60(0.92-14.09) | 0.065 | 3.42(0.86-13.67) | 0.082 |
| 30 Days Stroke | 2.67 (0.85-8.38) | 0.093 | 2.53(0.80-8.01) | 0.113 |
| Secondary Outcomes | ||||
| Length of IO Time | 1.51(0.74-3.05) | 0.256 | 1.46 (0.72-2.97) | 0.291 |
| Unplanned Reoperation | 1.21(0.23-6.42) | 0.822 | 1.33(0.25-7.08) | 0.741 |
| Pneumonia | 23.39(2.38-229.47) | 0.007 | 20.81(1.66-261.54) | 0.019 |
| Length of Stay in Hospital | 2.30(1.28-4.14) | 0.005 | 2.18(1.21-3.93) | 0.01 |
| Still in Hospital >30 Days | 4.57 (0.22-96.58) | 0.329 | 5.81(0.17-194.35) | 0.326 |
Table 3. Univariate and Multivariate Analysis using Logistic Regression Modeling for Primary and Secondary Outcomes for the Functionally Dependent (FS-D) patients undergoing CAS compared with CEA. FS-D CEA is Reference.(UOR=Unadjusted Odds Ratio, AOR, Adjusted Odds Ratio, IO=Intraoperative)
| FS-D Carotid Artery Stenting vs. FS-D Carotid Endarterectomy | ||||
| UOR (95% CI) | p-value | AOR (95% Ci) | p-value | |
| Primary Outcomes | ||||
| 30 Days Mortality | 1.91(0.50-7.37) | 0.345 | 2.35(0.59-9.38) | 0.227 |
| 30 Days Stroke | 3.43(1.04-11.30) | 0.043 | 3.46(0.32-1.97) | 0.046 |
| Secondary Outcomes | ||||
| Length of IO Time | 0.30(0.14-0.58) | 0.001 | 0.25(0.12-0.52) | <0.001 |
| Unplanned Reoperation | 0.62(0.12-3.24) | 0.568 | 0.69(0.13-3.68) | 0.664 |
| Pneumonia | 6.40(0.92-44.41) | 0.06 | 11.29(1.32-96.74) | 0.027 |
| Length of Stay in Hospital | 0.74(0.41-1.34) | 0.324 | 0.78(0.43-1.41) | 0.407 |
| Still in Hospital >30 Days | 2.09(0.11-41.00) | 0.629 | 1.32(0.06-26.98) | 0.856 |
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