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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-valueAOR (95% CI)p-value
Primary Outcomes
30 Days Mortality4.28(2.69-6.81)<0.0013.06 (1.90-4.92)<0.001
30 Days Stroke1.28(0.78-2.10)0.3351.14(0.69-1.88)0.609
Secondary Outcomes
Length of IO time1.32(1.14-1.53)<0.0011.36(1.17-1.58)<0.001
Unplanned Reoperation1.85(1.32-2.60)<0.0011.68(1.19-2.37)0.003
Length of Stay in Hospital3.49(3.01-4.06)<0.0013.05(2.62-3.56)<0.001
Still in Hospital >30 Days3.17(1.06-9.48)0.0392.08(0.68-6.36)0.197
Carotid Artery Stenting (FS-D vs. FS-I)
Primary Outcomes
30 Days Mortality3.60(0.92-14.09)0.0653.42(0.86-13.67)0.082
30 Days Stroke2.67 (0.85-8.38)0.0932.53(0.80-8.01)0.113
Secondary Outcomes
Length of IO Time1.51(0.74-3.05)0.2561.46 (0.72-2.97)0.291
Unplanned Reoperation1.21(0.23-6.42)0.8221.33(0.25-7.08)0.741
Length of Stay in Hospital2.30(1.28-4.14)0.0052.18(1.21-3.93)0.01
Still in Hospital >30 Days4.57 (0.22-96.58)0.3295.81(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-valueAOR (95% Ci)p-value
Primary Outcomes
30 Days Mortality1.91(0.50-7.37)0.3452.35(0.59-9.38)0.227
30 Days Stroke3.43(1.04-11.30)0.0433.46(0.32-1.97)0.046
Secondary Outcomes
Length of IO Time0.30(0.14-0.58)0.0010.25(0.12-0.52)<0.001
Unplanned Reoperation0.62(0.12-3.24)0.5680.69(0.13-3.68)0.664
Length of Stay in Hospital0.74(0.41-1.34)0.3240.78(0.43-1.41)0.407
Still in Hospital >30 Days2.09(0.11-41.00)0.6291.32(0.06-26.98)0.856

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