R. S. Turley1, K. McGinigle1, C. K. Shortell1, L. Mureebe1 1Duke University Medical Center,Vascular Surgery,Durham, NC, USA
Introduction: Although evidence supports carotid endarterectomy (CEA) to reduce stroke risk in symptomatic and asymptomatic patients, evolution of medical therapy and carotid stenting have sparked controversy over the validity of these 20 year old trials. Furthermore, subset analyses from these trials suggested that women might not see the same stroke risk reduction after CEA as compared to men. The objective of this study is to estimate contemporary outcomes of CEA and compare these to older values and investigate potential gender bias in patient selection and outcomes of CEA.
Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to evaluate post-operative complication rates after CEA form 2010 – 2011 (Cohort2). Data from 2006-2007 (Cohort1) was used for comparison. Primary study endpoints were postoperative stroke and a composite of stroke, peripheral nerve injury, myocardial infarction and surgical complications. Univariate comparisons were conducted using Pearson's chi-square test for categorical variables and Wilcoxon rank-sum tests for continuous variables.
Results: A total of 27,014 procedures were available for analysis. 5.15% of study population were in Cohort1. The postoperative stroke rate for Cohort1 was 1.57 %, and 1.43% for Cohort2 (p = 0.36). The composite outcome rate was 7.94% for Cohort1 and 6.39% for Cohort2 (p < 0.001). Within each cohort, there was no difference in composite outcome based on gender (Table1). However, in the more recent procedures (Cohort2), there is a small but significant increase in the postoperative stroke risk for women (1.67%) as compared to men (1.27%, p = 0.03). This coincides with a differential in the indication for procedure. Multivariate analysis revealed significant contributors to the composite outcome: history of chronic obstructive pulmonary disease, congestive heart failure, recent weight loss, and ASA class. Neither gender nor symptomatic status proved to be a contributor to either postoperative stroke or to the composite outcome.
Conclusion: Complications following CEA have improved from prior large multicenter randomized trials, as well as over the last few years. Although best medical therapy has also improved, our analysis suggests outcomes after CEA have similarly evolved such that we should continue to aggressively pursue CEA for patients who meet established criteria. Gender should not be a factor in recommendation for CEA, and more weight should be placed on other identified pre-operative factors.
