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Outcomes of Different Practice Patters in the Use of Completion Imaging after Carotid Endarterectomy
Hanaa Dakour-Aridi, MD, Mohamed Gamal Mohamed Gaber, MD, Satinderjit Locham, MD, Mahmoud Malas, MD, MHS.
University of California San Diego, La jolla, CA, USA.

Background:The use of completion duplex or angiography to confirm the technical adequacy of CEA remains a matter of controversy. This study aims to describe practice patterns and study the association between CI and postoperative outcomes after CEA.
Methods: CEA data from the VQI database (2003-2018) were utilized. Surgeons’ practice patterns were defined as rare (<5% of CEA cases),selective (5%-90%),or routine (≥90%).Multivariable logistic models, and Cox proportional hazards models were used.
Results:Out of 98,055 CEA cases,26,716(27.3%) were performed with CI.Difference in baseline characteristics are shown in Table 1. On univariable analysis, no difference in pre-discharge,30-day and 2-year stroke, and stroke/death rates were seen between patients who had CI and those who did not.However, patients who underwent CI had higher rates of intraoperative immediate re-exploration compared to those with no CI (3.5% vs.0.9%),were also more likely to return to the OR (RTOR) for bleeding or neurological causes (1.6% vs. 1.2%) and had longer operative times [mean (SD),125±46 vs. 112±43 minutes](all p<0.001).After multivariable adjustment, CI was associated with 3.8 higher odds of immediate re-exploration[OR(95%CI):3.8(2.7-5.4)] and 24% higher odds of RTOR [OR(95%CI):1.24(1.1-1.4)].There was a trend towards lower restenosis rates at 2 years in patients who received CI; however, the difference disappeared on multivariable adjustment [HR(95%CI):0.93(0.82-1.07)](Table 2). In our cohort, 45% out of 1,920 surgeons were shown to not perform CI, whereas 15.8% rarely performed CI, 22.8% selectively and 16.5% routinely. Performing CI rarely had higher rates of immediate re-exploration (7.5% vs.3.3%vs.3.4%,P<0.001) and RTOR (4.3% vs.1.6% vs.1.5%,p<0.001) compared to selective and routine performance, respectively. Rarely performing CI was also associated with almost 3 times higher adjusted odds of 30-day stroke/death and repeat revascularization compared to not performing [OR(95%CI):3.38 (2.37-4.84) & 3.02 (2.16-4.25), respectively].
Conclusion: Surgeon practice patterns with CI vary widely across the US.The performance of CI during CEA increases the odds of immediate re-exploration but does not seem to offer an advantage in reducing postoperative stroke and death or restenosis. Selective CI based on operative course might be warranted.

Table 1. Baseline Characteristics of Patients underwent Completion Imaging (Duplex or angiography)
No Completion Imaging PerformedCompletion ImagingP value
Number of Patients(N=71,339, 72.8%)(N=26,716, 27.3%)
Age, years71 (64-77)71 (64-77)0.26
Females28205 (39.5)10554 (39.5)0.93
White Race65409 (91.9)24414 (91.4)<0.001
ASA class
I/II4335 (6.4)1424 (5.7)<0.001
III50424 (74.2)19120 (76.7)
IV/V13,211 (19.4)4,383(17.5)
Symptomatic Carotid Stenosis15989 (22.4)5886 (22.0)0.2
Diabetes25377 (35.6)9259 (34.7)0.01
HTN63509 (89.1)23751 (88.9)0.63
CAD19569 (27.5)7186 (26.9)0.1
CHF7238 (10.2)2875 (10.8)0.01
COPD15703 (22.0)6208 (23.3)<0.001
CKD24481 (35.1)9013 (34.5)0.11
Pre-operative medications
Aspirin58869 (82.6)22718 (85.1)<0.001
Beta blocker41340 (58.0)15687 (58.8)0.02
Statin57,352 (80.4)21.953 (82.2)<0.001
P2Y12 Inhibitors20516 (28.8)9289 (34.8)<0.001
Transfer from
Hospital3502 (4.9)1135 (4.3)<0.001
Rehabilitation Unit397 (0.6)114 (0.3)
Patching42,073 (89.1)16,497 (88.8)0.27
Eversion CEA5,652 (12.0)2,959 (15.9)<0.001
None32316 (45.4)12387 (46.4)
Routine36180 (40.8)12870 (48.2)
Selective (Pre-/Intraoperative Indication)2765 (3.9)1433 (5.4)

Table 2. Association between Completion Imaging and Post-Operative Outcomes after CEA
Unadjusted AnalysisAdjusted Analysis
No Completion Imaging Performed Completion ImagingP valueCompletion vs No-CI
In-hospital Outcomes(N=71,339, 72.8%)(N=26,716, 27.3%)OR (95%CI)p-value
Death198 (0.28)84 (0.31)0.341.15 (0.90-1.48)0.24
Stroke704 (1.15)286 (1.29)0.101.16 (1.00-1.35)0.06
Stroke/Death840 (1.2)343 (1.3)0.171.12 (0.96-1.30)0.15
Immediate Re-exploration670 (0.9)935 (3.5)<0.0013.84(2.74-5.38)<0.001
Return to the OR for bleeding or neuro causes885 (1.2)421 (1.6)<0.0011.24 (1.08-1.42)<0.01
Operative time, mean (SD)112 (43.0)125 (46.1)<0.001-
Thirty-Day Outcomes
Stroke/Death1181 (1.7)479 (1.8)0.141.13 (1.0-1.27)0.04
Repeat Revascularization1350 (3.2)552 (3.3)0.521.02(.837-1.24)0.84
Two-Year Outcomes% Freedom from outcomes (95%CI)% Freedom from outcomes (95%CI)P-valueHR (95%CI)p-value
Stroke/Death84.9% (84.1-85.6)85.9 (84.8-87.0)0.100.96 (0.88-1.06)0.43
High-Grade Restenosis92.8 (92.3-93.2)93.7(93.1-94.3)0.040.93 (0.82-1.07)0.32

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