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Exploring Outcomes Of Urgent And Emergent Carotid Revascularization In The VQI
Elisa Caron, MD
1, Camila Guetter, MD, MPH
1, Isa Van Galen, MD
1, Jemin Park, MD
1, Jeremy Darling, MD
1, Randall A. Bloch, MD
2, Kristina A. Giles, MD
3, Kirsten Dansey, MD, MPH
4, Marc L. Schermerhorn, MD
1.
1Beth Israel Deconess Medical Center, Boston, MA, USA,
2St Elizabeth's Medical Center, Brighton, MA, USA,
3Maine Medical Center, Portland, ME, USA,
4University of Washington, Seattle, WA, USA.
Objective: Despite the few clinical indications, there were many urgent or emergent carotid procedures recorded in the Vascular Quality Initiative (VQI) database. As such, we sought to assess outcomes of urgent and emergent carotid revascularization.
Methods: We identified all patients who underwent carotid revascularization in the VQI from 2011-2023. Patients were stratified by urgency status, preoperative symptom and procedure type. Elective was defined as a planned/scheduled procedure, while urgent was defined as surgery within 24 hours. Emergent was defined as surgery within 6 hours. We excluded patients whose primary procedure was a planned intracranial treatment. The primary outcome was perioperative stroke/death. Secondary outcomes included perioperative death, and stroke. Chi-square and logistic regression were used to evaluate perioperative outcomes.
Results: Of the 224,509 operations, 188,918 (84%) were elective, 32,264 (14%) were urgent, and 3,327 (1%) were emergent. Most urgent or emergent cases were symptomatic (68% & 73%), although there were 10,369 (32%) urgent and 901(27%) emergent, asymptomatic procedures. Stroke accounted for 88% of emergent procedures and 68% of urgent procedures. Of the 3,327 emergent procedures, 772 (23%) were CEA, 140 (4.2%) TCAR and 2415 (73%) tfCAS. 32,264 cases were classified as urgent, of which 19,302(59%) were CEA, 6,277 (20%) TCAR and 6,955 (22%) tfCAS. Compared to elective procedures, among all patients, urgent procedures were associated with increased odds of stroke/death (3.4% vs 1.2%; aOR 2.05 [95% CI 1.84-2.27]), as were emergent procedures (11% vs 1.2%; aOR: 3.59 [2.93-4.40]). These differences persisted
following analysis of asymptomatic (3.3% vs 1.1%, aOR: 2.5 [2.11-2.93]) and (10.9% vs 1.1%, aOR: 5.69 [4.05-7.87]) and symptomatic patients (3.5%vs 1.8%; aOR: 1.7 [1.49-1.94]) and (11.0% vs 1.8%; aOR: 2.84 [2.20-3.65]). Differences persisted in analysis by procedure for both asymptomatic and symptomatic patients as well. (Table 1)
Conclusion:Urgent or emergent carotid revascularization was associated with increased odds of all perioperative outcomes. Given the increased risk of urgent or emergent surgery, careful consideration should be given when assessing patients who may ostensibly benefit from expedited surgery, where possible.
Table 1: Adjusted Perioperative Outcomes Following Carotid Revascularization Stratified by Urgency. | Elective | Urgent | Emergent | p-value | Elective vs Urgent | Elective vs Emergent |
| Overall | (N=188918) | (N=32264) | (N=3327) | | aOR* | 95% CI | p-value | aOR* | 95% CI | p-value |
| Stroke/Death | 2318 (1.2%) | 1111 (3.4%) | 366 (11.0%) | <0.001 | 2.05 | 1.84, 2.27 | <0.001 | 3.59 | 2.93, 4.40 | <0.001 |
| Death | 514 (0.3%) | 391 (1.2%) | 258 (7.8%) | <0.001 | 3.33 | 2.75, 4.03 | <0.001 | 9.35 | 6.90, 12.6 | <0.001 |
| Stroke(any) | 1974 (1.0%) | 837 (2.6%) | 160 (4.8%) | <0.001 | 1.75 | 1.55, 1.97 | <0.001 | 1.97 | 1.50, 2.55 | <0.001 |
| Asymptomatic |
| All | (N=145659) | (N=10369) | (N=901) | |
| Stroke/Death | 1546 (1.1%) | 341 (3.3%) | 98 (10.9%) | <0.001 | 2.5 | 2.11, 2.93 | <0.001 | 5.69 | 4.05, 7.87 | <0.001 |
| Death | 345 (0.2%) | 146 (1.4%) | 77 (8.5%) | <0.001 | 4.5 | 3.42, 5.86 | <0.001 | 18.8 | 11.9, 29.0 | <0.001 |
| Stroke(any) | 1309 (0.9%) | 238 (2.3%) | 37 (4.1%) | <0.001 | 2.03 | 1.67, 2.45 | <0.001 | 2.4 | 1.45, 3.80 | <0.001 |
| CEA | (N=92442) | (N=5738) | (N=251) | |
| Stroke/Death | 879 (1.0%) | 155 (2.7%) | 16 (6.4%) | <0.001 | 2.54 | 1.95, 3.28 | <0.001 | 9.93 | 5.12, 17.8 | <0.001 |
| Death | 206 (0.2%) | 71 (1.2%) | 9 (3.6%) | <0.001 | 4.65 | 3.12, 6.82 | <0.001 | 16.6 | 6.43, 36.9 | <0.001 |
| Stroke(any) | 740 (0.8%) | 100 (1.7%) | 8 (3.2%) | <0.001 | 1.76 | 1.24, 2.44 | 0.001 | 5.75 | 2.19, 12.5 | <0.001 |
| TCAR** | (N=37703) | (N=2291) | (N=60) | |
| Stroke/Death | 411 (1.1%) | 89 (3.9%) | 3 (5.0%) | <0.001 | 2.97 | 2.28, 3.81 | <0.001 | 1.75 | 0.10, 8.15 | 0.6 |
| Death | 89 (0.2%) | 26 (1.1%) | 3 (5.0%) | <0.001 | 3.43 | 2.06, 5.51 | <0.001 | 8.24 | 0.44, 42.3 | 0.045 |
| Stroke(any) | 350 (0.9%) | 74 (3.2%) | 1 (1.7%) | <0.001 | 2.99 | 2.24, 3.92 | <0.001 | 2.1 | 0.12, 9.75 | 0.5 |
| tfCAS | (N=15514) | (N=2340) | (N=590) | |
| Stroke/Death | 256 (1.7%) | 97 (4.1%) | 79 (13.4%) | <0.001 | 2.02 | 1.48, 2.71 | <0.001 | 5.14 | 3.30, 7.87 | <0.001 |
| Death | 50 (0.3%) | 49 (2.1%) | 65 (11.0%) | <0.001 | 4.91 | 2.93, 8.26 | <0.001 | 16.1 | 8.43, 30.5 | <0.001 |
| Stroke(any) | 219 (1.4%) | 64 (2.7%) | 28 (4.7%) | <0.001 | 1.61 | 1.12, 2.29 | 0.009 | 2.39 | 1.25, 4.31 | 0.006 |
| Symptomatic |
| All | (N=43259) | (N=21895) | (N=2426) | |
| Stroke/Death | 772 (1.8%) | 770 (3.5%) | 268 (11.0%) | <0.001 | 1.7 | 1.49, 1.94 | <0.001 | 2.84 | 2.20, 3.65 | <0.001 |
| Death | 169 (0.4%) | 245 (1.1%) | 181 (7.5%) | <0.001 | 2.17 | 1.68, 2.80 | <0.001 | 5.24 | 3.55, 7.70 | <0.001 |
| Stroke(any) | 665 (1.5%) | 599 (2.7%) | 123 (5.1%) | <0.001 | 1.57 | 1.35, 1.82 | <0.001 | 1.89 | 1.37, 2.58 | <0.001 |
| CEA | (N=27654) | (N=13294) | (N=521) | |
| Stroke/Death | 438 (1.6%) | 429 (3.2%) | 28 (5.4%) | <0.001 | 1.93 | 1.60, 2.34 | <0.001 | 2.41 | 1.15, 4.53 | 0.011 |
| Death | 93 (0.3%) | 113 (0.9%) | 11 (2.1%) | <0.001 | 2.15 | 1.46, 3.16 | <0.001 | 3.63 | 1.11, 9.58 | 0.017 |
| Stroke(any) | 375 (1.4%) | 352 (2.6%) | 18 (3.5%) | <0.001 | 1.87 | 1.52, 2.31 | <0.001 | 1.59 | 0.55, 3.61 | 0.3 |
| TCAR** | (N=9265) | (N=3986) | (N=80) | | | | | | | |
| Stroke/Death | 188 (2.0%) | 135 (3.4%) | 4 (5.0%) | <0.001 | 1.65 | 1.30, 2.08 | <0.001 | 2.71 | 0.81, 6.75 | 0.059 |
| Death | 38 (0.4%) | 36 (0.9%) | 2 (2.5%) | 0.0025 | 1.83 | 1.12, 2.98 | 0.014 | 4.91 | 0.76, 17.5 | 0.036 |
| Stroke(any) | 169 (1.8%) | 114 (2.9%) | 2 (2.5%) | 0.0035 | 1.58 | 1.23, 2.03 | <0.001 | 1.6 | 0.26, 5.21 | 0.5 |
| tfCAS | (N=6340) | (N=4615) | (N=1825) | | | | | | | |
| Stroke/Death | 146 (2.3%) | 206 (4.5%) | 236 (12.9%) | <0.001 | 1.9 | 1.48, 2.46 | <0.001 | 3.73 | 2.68, 5.20 | <0.001 |
| Death | 38 (0.6%) | 96 (2.1%) | 168 (9.2%) | <0.001 | 3.44 | 2.20, 5.56 | <0.001 | 9.6 | 5.67, 16.6 | <0.001 |
| Stroke(any) | 121 (1.9%) | 133 (2.9%) | 103 (5.6%) | <0.001 | 1.56 | 1.17, 2.09 | 0.003 | 2.22 | 1.47, 3.32 | <0.001 |
| *adjusted for procedure, age, sex, race, BMI, symptom severity(asymptomatic, amaurosis, TIA, stroke), prior symptoms(>6months), degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF, anemia, prior MI, medication use, anesthesia type, physician volume, and insurance.** Due to low event rate, TCAR specific model adjusted for age, sex, symptom severity, degree of stenosis (ipsilateral and contralateral), prior ipsilateral procedures, diabetes, hypertension, CKD, COPD, CAD, CHF , and physician volume. Abbreviations: aOR= Adjusted odds ratio, CI=confidence interval, CEA=Carotid Endarterectomy, TCAR=Trans carotid Artery revascularization, tfCAS=Transfemoral carotid artery stenting, TIA= Transient Ischemic Attack, CKD= Chronic Kidney Disease, COPD=Chronic Obstructive Pulmonary Disease, CAD=Coronary Artery Disease, CHF= Congestive Heart Failure, MI= Myocardial Infarction. |
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