Modifiable risk factors for occurrence of ipsilateral ischemic events after carotid endarterectomy beyond perioperative period

Blecha, Matthew; DeJong, Matthew; Nam, Janice; Penton, Ashley

doi:10.1016/j.jvs.2022.09.021

Cited by 2 publications

(5 citation statements)

References 28 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We recently identified lack of patch placement at CEA to be the lead predictor of long term ipsilateral ischemic event after index hospital admission amongst 171 816 CEA in the VQI. 20 This finding held true in this study for those with severe coronary disease. The European Society for Vascular Surgery Guidelines recommend routine patch use over primary as multiple systematic reviews have demonstrated significant reduction in restenosis and ipsilateral stroke.…”

Section: Discussionsupporting

confidence: 69%

Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative

Penton

Lin

Kolde

et al. 2023

Vasc Endovascular Surg

Self Cite

View full text Add to dashboard Cite

Objective The purpose of this study was to investigate outcomes of simultaneous CEA and CABG utilizing the Vascular Quality Initiative (VQI). Additionally, we seek to investigate risks for both perioperative and long-term mortality and adverse neurological outcomes. Methods All carotid endarterectomies in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEA in the database. We extracted 2 cohorts from these CEA. The first group was patients who underwent simultaneous carotid endarterectomy (CEA) and coronary artery bypass (CABG) (N = 3137). The second group encompassed patients who underwent CABG or percutaneous coronary artery angioplasty/stent within 5 years of ultimately undergoing CEA (N = 27,387). We investigated the following outcomes in a multivariable fashion: 1. Risks for mortality in long term follow-up for both cohorts combined; 2. Risks for ischemic event in the cerebral hemisphere ipsilateral to the CEA site after index hospital admission in follow up for both cohorts combined. Tertiary outcomes are also investigated in the manuscript. Results On multivariable analysis, patients undergoing simultaneous combined CEA and CABG had equivalent long-term survival to patients who underwent coronary revascularization within 5 years of ultimately undergoing CEA. Five-year survival is noted to be 84.5% vs 86% with a Cox regression non-significant P-value (.203). Significant multivariable risks for reduced long term survival (P < .03 for all) included: advancing age (HR 2.48/year); smoking history (HR 1.26); Diabetes (HR 1.33); history of CHF (HR 1.66); history of COPD (HR 1.54); baseline renal insufficiency at the time of surgery (HR 1.30); anemia (HR1.64); lack of preoperative aspirin (HR 1.12); and lack of preoperative statin (HR 1.32); lack of patch placement at CEA site (HR 1.16); perioperative MI (HR 2.04); perioperative CHF (1.66); perioperative dysrhythmia (HR 1.36); cerebral reperfusion injury (HR 2.23); perioperative ischemic neurological event (HR 2.48); and lack of statin at discharge (HR 2.04). Amongst patients with documented neurological status in follow up, combined CEA and CABG had over 99% freedom from ischemic cerebral event ipsilateral to the CEA site after discharge. Conclusions Combined CEA and CABG provides excellent long-term mortality prevention in patients with co-existing severe coronary and carotid atherosclerosis. Simultaneous CEA and CABG provides equivalent stroke prevention and long-term survival to both a cohort of patients undergoing coronary revascularization within 5 years of CEA and patients undergoing isolated CEA or CABG in the literature. The two most impactful modifiable risk factors towards long-term stroke and mortality prevention for patients undergoing simultaneous CEA-CABG are patch placement at CEA site and adherence to statin medication therapy.

show abstract

Section: Discussionsupporting

confidence: 69%

Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative

Penton

Lin

Kolde

et al. 2023

Vasc Endovascular Surg

Self Cite

View full text Add to dashboard Cite

show abstract

“…Patch angioplasty is clearly linked to reduced rates of ipsilateral stroke and restenosis at long term follow up. [2][3][4]9,12 In a retrospective study reviewing 1151 patients, Malas et al found patch angioplasty compared to primary repair significantly reduced the two-year risk of restenosis. 2 A recent VQI analysis assessing 126,290 patients found patch angioplasty was significantly protective against ipsilateral cerebral ischemia at 5-years.…”

Section: Discussionmentioning

confidence: 99%

“…2 A recent VQI analysis assessing 126,290 patients found patch angioplasty was significantly protective against ipsilateral cerebral ischemia at 5-years. 4 Most notably, AbuRahama et al conducted a systematic meta-analysis, with an emphasis on randomized controlled trials from the last three decades, which reviewed primary arterial closure, patching and eversion CEA techniques. This study demonstrated CEA with patching in comparison to primary closure lowers perioperative stroke rates, stroke and death rates, carotid thrombosis rates and late restenosis rates.…”

Section: Discussionmentioning

confidence: 99%

“…These variables (other than protamine) were selected because they were all noted to be associated with a significant reduction in the rate of ipsilateral cerebral ischemia in follow up after CEA. 4 Protamine was selected due to its association with reduced return to the operating room for bleeding without altering perioperative stroke rates. 5,6 Further, these variables are modifiable and are driven by a combination of physician initiative and patient compliance.…”

Section: Introductionmentioning

confidence: 99%

“…1 Patch placement has been associated with lower rates of carotid restenosis as well as new onset neurological deficits following CEA. [2][3][4] Protamine administration after unclamping in CEA has been definitively linked to reduced perioperative bleeding complications without increased risk of cerebral ischemia. 5,6 Smoking cessation is also recommended to minimize the risk of recurrent stenosis, stroke, myocardial infarction and malignancy.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy

Penton

Kelly

et al. 2023

Vasc Endovascular Surg

Self Cite

View full text Add to dashboard Cite

Introduction The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up. Methods There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing. Results There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics ( P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking. Conclusions Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.

show abstract

Modifiable risk factors for occurrence of ipsilateral ischemic events after carotid endarterectomy beyond perioperative period

Cited by 2 publications

References 28 publications

Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative

Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative

Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy

Contact Info

Product

Resources

About