Rupture of Abdominal Aortic and Iliac Aneurysms in Patients With and Without Antecedent Endovascular Repair

Abstract

Objectives: This study evaluated variables associated with increased rates of perioperative stroke in patients undergoing primary carotid endarterectomy (CEA) for asymptomatic disease in Michigan hospitals.Methods: Thirty-day outcomes for patients undergoing primary CEA for asymptomatic disease at 29 hospitals in Michigan between April 3, 2012 and December 31, 2014 were evaluated using a statewide registry and quality improvement platform (Blue Cross Blue Shield of Michigan-Vascular Interventions Collaborative). Primary outcomes of interest were the occurrence of any death or non-fatal stroke. Variables included patient demographics, comorbidities, and preoperative medical therapies as well as procedural, provider, and institutional variables. Analysis of variance was used to identify variables associated with perioperative stroke outcomes. Hospitals were classified as high stroke rate (>3%) and low stroke rate (<3%). A multilevel logistic regression model was constructed to assess the association between stroke and patient-level and hospital-level variables.Results: Of the 4556 primary CEA procedures identified, 2418 (53%) were performed for asymptomatic disease. The overall 30-day rate of any perioperative stroke or death for the group was 2.1%; however, nine hospitals (31%) had stroke rates exceeding 3%. Interestingly, the overall rate of stroke outcomes decreased from 3.4% in 2012 to 1.3% in 2014. Analysis of variance was used to identify variables having a significant effect on hospital stroke rate variability. Statistically significant variables included urban location, academic mission, nonelective procedure, median procedure volume per surgeon, non-white race, current smoking, eversion technique, shunt use, and protamine use.Conclusions: In Michigan, contemporary stroke rates for CEA in asymptomatic patients were within accepted benchmarks; however, considerable institutional variation was observed. Hospital-level variability in adverse stroke outcomes following CEA has important implications for providers and patients underscoring the need for regional collaborative quality improvement platforms to identify and share best practices.