Arin L. Madenci1, James T. McPhee2, Matthew T. Menard3
1University of Michigan Medical School, Ann Arbor, MI; 2Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, MA; 3Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA.
OBJECTIVES: The safety of CAS as an alternative treatment to CEA for carotid occlusive disease remains controversial. Outcomes following these procedures have previously been defined by randomized trials with carefully selected patients, institutional studies and problematic administrative databases. We sought to utilize a well-validated national clinical database to compare perioperative outcomes for 2011, the first year CAS was captured in the NSQIP.
METHODS: All patients undergoing either CEA or CAS in 2011 captured by the American College of Surgeons NSQIP database were identified. Outcome measures of interest were 30-day death, stroke, myocardial infarction (MI), reintervention and readmission (URA). All statistical analyses were performed using SAS v9.3.
RESULTS: 4,615 patients undergoing CAS (n=267, 5.9%) or CEA (n=4248, 94.1%) were included in the analysis. Median age was 71 years; 6.1% of patients had symptomatic disease. The CAS cohort were younger (p<0.01), more frequently female (p<0.01), less hypertensive (p<0.01), and had better pre-operative ASA scores (p<0.01), but were more frequently coagulopathic (p<0.01). Thirty-day death was significantly higher in patients undergoing CAS cf. CEA (n=5, 1.9% vs. n=24, 0.6%. p=0.03). There was no association between surgical approach and perioperative stroke, MI, reintervention or URA. Non-vascular surgeon status was associated with increased mortality (p=0.02), as was pre-operative dyspnea (p=0.03), heart failure (p=0.03) and dialysis (p<0.01). Risk factors for stroke included pre-admission status (p=0.04) and need for emergency surgery (p=0.02). Patients undergoing CAS had a significantly shorter length of stay (median, 1; range, 0-24 days vs. 1, 0-91 days, p<0.01).
CONCLUSIONS: Based on a national cohort of patients from this large clinical database, CAS was associated with higher 30-day mortality than CEA. Vascular surgeons performed both procedures more safely than other specialists.
AUTHOR DISCLOSURES: A. L. Madenci: Nothing to disclose; J. T. McPhee: Nothing to disclose; M. T. Menard: Nothing to disclose.
Posted April 2013