Comparison of 30 Day Stroke and Death in Hybrid Intervention and Open Surgical Reconstruction for the Treatment of Tandem Carotid Bifurcation and Supra-aortic Trunk Disease.

OBJECTIVE: The optimal approach for the treatment of tandem carotid bifurcation and supra-aortic trunk (SAT) disease remains controversial. The hybrid technique of carotid endarterectomy (CEA) with ipsilateral proximal endovascular intervention (IPE) has provided an attractive alternative to CEA with open SAT reconstruction (SATr). However, no studies have compared cohorts treated by these two approaches. METHODS: Using the National Surgical Quality Improvement Program (2005-2017), patients who underwent CEA + IPE and CEA + SATr were identified. Non-occlusive indications were excluded. Primary outcomes included 30 day stroke, death, and their composite (stroke and/or death [SD]). Univariable and logistic regression analyses were performed. RESULTS: In total, 372 patients were identified: 319 CEA + SATr and 53 CEA + IPE. SATr included 19 (5.9%) aorta to carotid bypasses, 22 (6.9%) carotid subclavian transpositions, 96 (30.1%) carotid carotid bypasses, 179 (56.1%) carotid subclavian bypasses, and three (0.9%) SAT endarterectomies. The mean age was 69 ± 10 years. The majority were men (53%), white (85%), and had a history of hypertension (84%). There were no demographic differences between the operative cohorts except that those having CEA + SATr were more likely to have hypertension (86% vs. 74%; p = .031). CEA + SATr had longer operative times and longer hospital length of stay. There were no differences in outcomes between the cohorts: stroke (CEA + SATr 4.1% vs. CEA + IPE 3.8%; p = .92), death (1.6% vs. 0%; p = .36), or SD (5.3% vs. 3.8%; p = .63). After risk adjustment, predictors of SD included symptomatic status (odds ratio [OR] 3.9, 95% confidence interval [CI] 1.1-13.5; p = .034), congestive heart failure (OR 16.5, 95% CI 2.0-136; p = .011), and return to the operating room (OR 8.5, 95% CI 2.3-30.8; p = .001). Operative method was not predictive (p = .63). CONCLUSION: Outcomes following CEA + SATr and CEA + IPE are similar. Although proposed as a safer, less invasive alternative, the hybrid approach did not reduce the risk of operative stroke or death relative to open reconstruction for the treatment of occlusive, tandem carotid/SAT disease. Based upon lesion and patient factors, both may be considered management options in select patients.

Impact of Adding Carotid Endarterectomy to Supra-aortic Trunk Surgical Reconstruction.

BACKGROUND: Up to 20% of patients requiring open supra-aortic trunk (SAT) reconstruction have significant carotid artery stenosis. The addition of carotid endarterectomy (CEA) to SAT has been described. Yet, additive risks are not well defined and controversy remains as to whether concomitant CEA increases stroke risk. This study assessed the perioperative effects of adding CEA to SAT. METHODS: Using the National Surgical Quality Improvement Program (NSQIP), patients who underwent SAT from 2005 to 2015 were evaluated. SAT + CEA were identified. An isolated SAT (ISAT) cohort was created by removing patients who underwent concurrent secondary procedures. Nonocclusive indications were excluded. SAT + CEA were compared with ISAT as well as a propensity-matched ISAT cohort. Primary outcomes were 30-day stroke, death, and composite stroke/death/myocardial infarction (SDM). Univariate and logistic regression analyses were performed. RESULTS: After review, 1,515 patients were identified: 1,245 ISAT (82%) and 270 SAT + CEA (18%). Most were women (56%), 86% were Caucasian, and 24% were symptomatic. Average age was 65 ± 12 years and SAT + CEA were older (69 vs. 64 years, P < 0.001). CEA + SAT were more likely to be men (53% vs. 42%, P < 0.001), have hypertension (86% vs. 75%, P < 0.001) and diabetes (26% vs. 20%, P = 0.04). SAT procedures included the following: carotid-subclavian bypass (68%), carotid-carotid bypass (16%), aorta-great vessel bypass (9%), and carotid-subclavian transposition (7%). ISAT were more likely to undergo carotid-subclavian bypass than SAT + CEA (71% vs. 54%, P < 0.001). Overall stroke was 2.3%, death 1.4%, and SDM 4.6%. There were no differences in 30-day stroke (ISAT 2.0% vs. SAT + CEA 3.7%, P = 0.09) or mortality (1.4% vs. 1.5%, P = 0.88). SAT + CEA had higher rates of SDM (7% vs. 4%, P = 0.03). On logistic regression, urgency was a predictor of SDM (operating room [OR] 3.6, 95% confidence interval [CI] 1.5-8.4, P = 0.003); addition of CEA was not predictive of stroke (OR 1.4, 95% CI 0.5-4.2, P = 0.52) or SDM (OR 1.5, 95% CI 0.6-3.6, P = 0.40). After propensity matching, there were no longer differences in demographics or primary end points between the 2 cohorts. CONCLUSIONS: Addition of CEA does not confer increased perioperative stroke or SDM risk over ISAT. Perioperative outcomes appear to be more affected by disseminated disease risk factors than the addition of CEA. In patients undergoing SAT, it is reasonable to consider performing combined CEA in populations with tandem carotid bifurcation disease and appropriate operative risk profile.