Survival and Long-Term Cardiovascular Outcomes after Carotid Endarterectomy in Patients with Chronic Renal Insufficiency

Avgerinos, Efthimios D.; Go, Catherine; Ling, Jennifer; Makaroun, Michel S.; Chaer, Rabih A.

doi:10.1016/j.avsg.2014.07.029

Cited by 30 publications

(20 citation statements)

References 24 publications

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“…Ballotta et al found diabetes and coronary disease to be independent predictors of late death following carotid revascularization surgery [24]. Renal insufficiency has been shown to predict mortality, and it has been suggested that for patients on dialysis, the risks of CEA outweigh the benefits in patients with asymptomatic disease [4,25]. Female gender and statin use have been demonstrated to be protective [8].…”

Section: Discussionmentioning

confidence: 99%

“…Renal insufficiency has been repeatedly identified as an independent risk factor for stroke [4,18,19]. Statins, conversely, have repeatedly been associated with decreased long-term stroke risk [20].…”

Section: Discussionmentioning

confidence: 99%

“…While the perioperative morbidity and mortality of modern carotid endarterectomy is quite low [1][2][3], the long-term risks for patients with this disease process remain elevated compared to healthy counterparts. Patients remain at above average risk of future strokes and death even after carotid revascularization [4]. Data from the major symptomatic trials showed a 5-year risk of any stroke after CEA was 17-20%.…”

Section: Introductionmentioning

confidence: 99%

“…The 5-year stroke rate was 12.4% in the Asymptomatic Carotid Atherosclerosis Study (ACAS) and 6.9% at 5 years in the Asymptomatic Carotid Surgery Trial (ACST). [5][6][7] Several recent reviews of both symptomatic and asymptomatic patients have reported long term stroke rates after CEA of 13-16% up to 10 years after surgery [4,8]. Carotid revascularization helps prevent stroke attributed to large artery territory, however many patients have other risk factors for stroke making it difficult to predict patients' overall benefit from surgery.…”

Section: Introductionmentioning

confidence: 99%

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Somatosensory Evoked Potentials and Electroencephalography During Carotid Endarterectomy Predict Late Stroke But Not Death

Domenick

Chaer

Thirumala

et al. 2016

Annals of Vascular Surgery

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Objective-Late stroke and death rates are anticipated to be higher in patients undergoing carotid endarterectomy (CEA) compared to healthy counterparts. However, little is known regarding predictors, other than the baseline comorbidities. We have recently shown that dual intraoperative Somatosensory Evoked Potentials (SSEP) and electroencephalogram (EEG) monitoring improves the ability to predict perioperative strokes. We seek to determine if dual intraoperative monitoring (IOM) can further predict long-term strokes and death.Methods-Consecutive patients who underwent CEA under dual SSEP and EEG intraoperative monitoring between 1/1/2000 and 12/31/2010 were analyzed. Patients were divided in two groups, those with and those without IOM changes. IOM changes were classified as either occurring during carotid cross clamp placement or at any time during the operation. Endpoints were time to stroke and death. Log rank tests and Cox regression analysis were used to identify predictors of postoperative stroke and death.Results-A total of 853 CEAs (mean age 70.6±9.5 years, 58.7% male, 38.9% symptomatic) were performed during the study period with a mean clinical follow up of 48±38 months. 107 patients (13.6%) had significant SSEP or EEG changes at the time of clamping, while considerably more patients (217, 25.4%) had SSEP and/or EEG changes recorded at any point during the procedure, including during clamping. Baseline characteristics including rates of bilateral disease, statin use, and antiplatelet use, were similar between groups. Female gender, symptomatic disease, and significant contralateral carotid stenosis were more frequent in the group with IOM changes. The overall stroke-free survival rate at 5 years was significantly higher in patients without IOM changes (94.7% vs. 88.2%, p<0.05) and at 10 years (86.1% vs. 78.0%, p<0.05). Despite differences in stroke-free survival, overall survival at 10 years was not different Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusion-Intraoperative SSEP and/or EEG changes are predictive of late stroke but not death following CEA indicating a need for further elucidation and management of the underlying risk factors driving the elevated stroke risk in this subset of CEA patients. Presented at Vascular and Endovascular 2016 Meeting at Park City Utah HHS Public Access

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Somatosensory Evoked Potentials and Electroencephalography During Carotid Endarterectomy Predict Late Stroke But Not Death

Domenick

Chaer

Thirumala

et al. 2016

Annals of Vascular Surgery

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“…For CEA patients, especially asymptomatic patients in whom the objective is long-term stroke risk reduction, information about life expectancy and long-term outcomes beyond 30 days is critically important in decision-making. 19,20 We hypothesized that an AD model would predict both perioperative adverse events and long-term survival after CEA. To test this, we applied an AD model to a retrospective database of patients at our institution with long-term follow-up data available.…”

Section: Introductionmentioning

confidence: 99%

An Accumulated Deficits Model Predicts Perioperative and Long-Term Adverse Events After Carotid Endarterectomy

Sridharan

Chaer

et al. 2017

Annals of Vascular Surgery

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Evaluation of Mortality Data From the Social Security Administration Death Master File for Clinical Research

et al. 2019

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IMPORTANCE Despite its documented undercapture of mortality data, the US Social Security Administration Death Master File (SSDMF) is still often used to provide mortality end points in retrospective clinical studies. Changes in death data reporting to SSDMF in 2011 may have further affected the reliability of mortality end points, with varying consequences over time and by state. OBJECTIVE To evaluate the reliability of mortality rates in the SSDMF in a cohort of patients with atherosclerotic cardiovascular disease (ASCVD). DESIGN, SETTING, AND PARTICIPANTS This observational analysis used the IBM MarketScan Medicare and commercial insurance databases linked to mortality information from the SSDMF. Adults with ASCVD who had a clinical encounter between January 1, 2012, and December 31, 2013, at least 2 years of follow-up, and from states with 1000 or more eligible adults with ASCVD were included in the study. Data analysis was conducted between April 18 and May 21, 2018. MAIN OUTCOMES AND MEASURES Kaplan-Meier analyses were conducted to estimate state-level mortality rates for adults with ASCVD, stratified by database (commercial or Medicare). Constant hazards of mortality by state were tested, and individual state Kaplan-Meier curves for temporal changes were evaluated. For states in which the hazard of death was constant over time, mortality rates for adults with ASCVD were compared with state-level, age group-specific overall mortality rates in 2012, as reported by the National Center for Health Statistics (NCHS). RESULTS This study of mortality data of 667 516 adults with ASCVD included 274 005 adults in the commercial insurance database cohort (171 959 male [62.8%] and median [interquartile range (IQR)] age of 58 [52-62] years) and 393 511 in the Medicare database cohort (245 366 male [62.4%] and median [IQR] age of 76 [70-83] years). Of the 41 states included, 11 states (26.8%) in the commercial cohort and 18 states (43.9%) in the Medicare cohort had a change in the hazard of death after 2012. Among states with constant hazard, state-level mortality rates using the SSDMF ranged widely, from 0.06 to 1.30 per 100 person-years (commercial cohort) and from 0.83 to 6.07 per 100 person-years (Medicare cohort). Variability between states in mortality estimates for adults with ASCVD using SSDMF data greatly exceeded variability in overall mortality from the NCHS. No correlation was found between NCHS mortality estimates and those from the SSDMF (ρ = 0.29 [P = .06] for age 55-64 years; ρ = 0.18 [P = .27] for age 65-74 years). CONCLUSIONS AND RELEVANCE The SSDMF appeared to markedly underestimate mortality rates, with variable undercapture among states and over time; this finding suggests that SSDMF data are not reliable and should not be used alone by researchers to estimate mortality rates.

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Survival and Long-Term Cardiovascular Outcomes after Carotid Endarterectomy in Patients with Chronic Renal Insufficiency

Cited by 30 publications

References 24 publications

Somatosensory Evoked Potentials and Electroencephalography During Carotid Endarterectomy Predict Late Stroke But Not Death

Somatosensory Evoked Potentials and Electroencephalography During Carotid Endarterectomy Predict Late Stroke But Not Death

An Accumulated Deficits Model Predicts Perioperative and Long-Term Adverse Events After Carotid Endarterectomy

Evaluation of Mortality Data From the Social Security Administration Death Master File for Clinical Research

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