Differences in Perioperative Outcomes after Carotid Revascularization between White and Non-white Patients.

BACKGROUND: Racial disparities in carotid endarterectomy (CEA) and carotid artery stenting (CAS) continue to persist. We aimed to provide a large-scale analysis of racial disparities in perioperative outcomes of carotid revascularization in a nationally representative cohort of patients, with sub-analyses stratifying by procedure type and symptomatic status. METHODS: We studied all patients undergoing carotid revascularization between 2011 and 2018 in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Database. Univariate methods were used to compare patients' demographic and medical characteristics. Multivariable logistic regression analysis was used to compare adjusted perioperative outcomes between white patients (WP) and non-white patients (NWP). Sub-analysis was performed stratifying by method of revascularization and symptomatic status. RESULTS: A total of 31,356 carotid revascularizations were performed in 26,550 (84.7%) white patients and 4,806 (15.3%) non-white patients. On adjusted analysis, NWP had increased odds of stroke (OR:1.2, 95%CI:1.1-1.5, P = 0.0496), unplanned return to the OR (OR:1.4, 95%CI:1.1-1.6, P < 0.001) and restenosis (OR:2.6, 95%CI:1.7-3.9, P < 0.001). On sub-analysis, NWP undergoing CAS had increased odds of stroke/death (OR:2.2, 95%CI:1.1-4.3, P = 0.025), stroke (OR:2.9, 95%CI:1.3-6.0, P = 0.007), and stroke/TIA (OR:2.1, 95%CI:1.0-4.2, P = 0.025). NWP undergoing CEA had increased odds of unplanned return to the OR (OR:1.4, 95%CI:1.2-1.6, P < 0.001) and restenosis (OR:2.7, 95%CI:1.7-4.0, P < 0.001). CONCLUSION: NWP had higher rates of 30-day stroke, driven primarily by higher rates of perioperative stroke/death in NWP undergoing CAS. NWP undergoing CEA did not have higher rates of stroke/death after adjusted analysis, although they had higher rates of unplanned return to OR and restenosis. Upon stratification for symptomatic status, the stroke/death rate between NWP and WP was shown to be non-significant.

Cost-effectiveness of transcarotid artery revascularization versus carotid endarterectomy.

OBJECTIVE: Recent studies have demonstrated that transcarotid artery revascularization (TCAR) has comparable outcomes to the surgical gold standard, carotid endarterectomy (CEA). However, few studies have analyzed the cost of TCAR, and no study has evaluated its cost-effectiveness. The purpose of this study is to conduct a cost-effectiveness analysis comparing TCAR with CEA for carotid artery stenosis. METHODS: We built a Markov microsimulation using transition probabilities and utilities from existing literature for symptomatic patients undergoing TCAR or CEA. Costs were derived from literature then converted to 2019 dollars. The model included six health states with monthly cycle lengths: surgery, death, alive after surgery, alive after myocardial infarction, alive after stroke, and alive after stroke and death. Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a 5-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness. RESULTS: For symptomatic patients, CEA cost $7821 for 2.85 QALYs, whereas TCAR cost $19154 for 2.92 QALYs, leading to an ICER of $152,229 per QALY gained in the TCAR arm. Sensitivity analysis demonstrated that our model was most sensitive to probability of restenosis, costs of TCAR, and costs of CEA. Probabilistic sensitivity analysis demonstrated TCAR would be considered cost-effective in 49% of iterations. CONCLUSIONS: This study found that, although 5-year costs for TCAR were greater than CEA, TCAR afforded greater QALYs than CEA. TCAR became cost-effective at 6 years of follow-up.

Analysis of Medicare Payments and Patient Outcomes With Pre-Operative Imaging for Carotid Endarterectomy.

OBJECTIVE: The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in preoperative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease. METHODS: We used a 20% Medicare sample from 2006 to 2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated preoperative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use. RESULTS: A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8 ± 7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4 ± 1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5 ± 2.1 ultrasounds, 0.95 ± 0.86 neck CTs and 0.47 ± 0.7 MRIs per patient. The average payment for ultrasound was $140 ± 40, $282 ± 94 for CT and $410 ± 146 for MRI. The average inpatient reimbursements were $7,413 ± 4,215 for patients without CSI compared with $7,792 ± 3,921 for patients with CSI, P < 0.001. The average LOS during CEA admission was 2.5 ± 3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by postoperative day 2 compared with ultrasound alone (88.9% vs. 91.5%, respectively, P < 0.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups. CONCLUSIONS: Our analysis found preoperative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources.

Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications.

BACKGROUND: Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. METHODS: The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. The secondary outcomes included perioperative/in-hospital complications and mortality. RESULTS: There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5, 2.1 ± 2.5, and 2.2 ± 2.8 days (P = 0.0001), respectively, and after CAS were 1.7 ± 2.6, 1.8 ± 2.1, and 2 ± 2.6 days (P < 0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS > 1 day (P = 0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1 day (OR 1.42, 95% CI 1.06-1.91) (P = 0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P = 0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P = 0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P = 0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P = 0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts. CONCLUSIONS: Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.

Improving Quality of Carotid Interventions: Identifying Hospital-Level Structural Factors that can Improve Outcomes.

BACKGROUND: "Structural factors" relating to organization of hospitals may affect procedural outcomes. This study's aim was to clarify associations between structural factors and outcomes after carotid endarterectomy (CEA) and carotid endarterectomy stenting (CAS). METHODS: A systematic review of studies published in English since 2005 was conducted. Structural factors assessed were as follows: population size served by the vascular department; number of hospital beds; availability of dedicated vascular beds; established clinical pathways; surgical intensive care unit (SICU) size; and specialty of surgeon/interventionalist. Primary outcomes were as follows: mortality; stroke; cardiac complications; length of hospital stay (LOS); and cost. RESULTS: There were 11 studies (n = 95,100 patients) included in this systematic review. For CEA, reduced mortality (P < 0.0001) and stroke rates (P = 0.001) were associated with vascular departments serving >75,000 people. Larger hospitals were associated with lower mortality, stroke rate, and cardiac events, compared with smaller hospitals (less than 130 beds). Provision of vascular beds after CEA was associated with lower mortality (P = 0.0008) and fewer cardiac events (P = 0.03). Adherence to established clinical pathways was associated with reduced stroke and cardiac event rates while reducing CEA costs. Large SICUs (≥7 beds) and dedicated intensivists were associated with decreased mortality after CEA while a large SICU was associated with reduced stroke rate (P = 0.001). Vascular surgeons performing CEA were associated with lower stroke rates and shorter LOS (P = 0.0001) than other specialists. CAS outcomes were not influenced by specialty but costless when performed by vascular surgeons (P < 0.0001). CONCLUSIONS: Structural factors affect CEA outcomes, but data on CAS were limited. These findings may inform reconfiguration of vascular services, reducing risks and costs associated with carotid interventions.

Outcome differences between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in postoperative ventricular arrhythmia, neurological complications, and in-hospital mortality.

Objective: We study whether the carotid artery stenting (CAS) and carotid endarterectomy (CEA) differ from each other in postoperative ventricular arrhythmia, along with neurological complications (perioperative stroke and transient ischemic attack), in-hospital mortality, and estimated medical cost. Methods: This study used data of patients with carotid artery stenosis from the National Inpatient Sample (NIS) database (2011-2014) from the United States of America. Based on the procedure that patients received, individuals were categorized into groups of CAS and CEA. Multilevel analyses were conducted to examine the difference in the following outcomes: postoperative ventricular arrhythmia, neurological complications, in-hospital mortality, and medical costs between CAS and CEA. The patient age, gender, race, Charlson Comorbidity Index, primary payer, emergency department service record, bed size of hospital, region of the hospital, and location of the hospital were adjusted in each model. In addition, preexisting cardiovascular diseases (CVDs) were adjusted for when predicting postoperative ventricular arrhythmia; postoperative CVDs were adjusted for in the model of in-hospital mortality. Results: A total of 127,321 carotid artery stenosis hospitalizations were included in our analyses (n = 17,074 in CAS, n = 110,247 in CEA). Multivariate logistic regressions showed that compared with patients underwent CAS, those with CEA had a lower odds of postoperative ventricular arrhythmia (odds ratio [OR] = 0.81, 95% confidence interval [CI]: [0.66-0.98]), less neurological complications (OR = 0.55, 95% CI: [0.51-0.59] in general; OR = 0.63, 95% CI: [0.57-0.69] in ischemic stroke; OR = 0.26, 95% CI: [0.20-0.32] in hemorrhagic stroke; and OR = 0.58, 95% CI: [0.47-0.71] in transient ischemic attack), and in-hospital mortality (OR = 0.52, 95% CI: [0.42-0.64]). Generalized linear model indicated patients undergoing CEA had lower medical cost (ß = -4329.99, 95% CI: [-4552.61, -4107.38]) than patients undergoing CAS. Conclusions: In short-term outcomes, CEA was associated with a lower risk of postoperative ventricular arrhythmia, neurological complications, in-hospital mortality, and lower cost as compared with CAS.

Clinical impact of sex on carotid revascularization.

BACKGROUND: The impact of sex in the management of carotid disease is unclear in the current literature. Therefore, we evaluated the effect of sex on perioperative outcomes following carotid endarterectomy (CEA) and carotid artery stenting (CAS). METHODS: We included patients who underwent CEA or CAS between 2012 and 2017 in the Vascular Quality Initiative database. Our primary outcome was perioperative stroke/death. Secondary outcomes were in-hospital stroke, 30-day mortality, and in-hospital MI. We compared perioperative outcomes between female and male patients, stratified by treatment modality and symptom status, and used multivariable regression to account for differences in baseline characteristics. RESULTS: A total of 83,436 patients underwent either a CEA (71,383) or CAS (12,053). Asymptomatic and symptomatic CEA females were less likely to be on a preoperative antiplatelet agent, when compared to males. Females overall, were less likely to be on a preoperative statin and more likely to have chronic obstructive pulmonary disease. Within the CAS cohort, females were more likely to have a previous ipsilateral CEA. There were no differences between males and females in major adverse events following CEA for asymptomatic disease. Following CEA for symptomatic disease, there was no difference in stroke/death rate or in-hospital stroke. However, females experienced a higher 30-mortality after adjustment (univariate: 1.0% vs 0.7%, P = .04; adjusted: odds ratio [OR], 1.4:1.02-1.94). Following CAS for asymptomatic disease, females experienced a higher rate of perioperative stroke/death (2.9% vs 1.9% P = .02; OR, 1.5: 1.05-2.03) and in-hospital stroke (2.1% vs 1.2% P = .01; OR, 1.8: 1.20-2.60). There were no differences in outcomes for symptomatic females vs males undergoing CAS. CONCLUSIONS: Females with carotid disease less frequently receive optimal medical treatment with antiplatelet agents and statins. This is an important target area for quality improvement issue in both females and males. Furthermore, among symptomatic CEA patients the female sex is associated with higher mortality and among asymptomatic CAS patients, females experience higher rates of stroke/death. These findings suggest that careful patient selection is necessary in the treatment of female patients. Quality improvement projects should be created to further investigate and eliminate the disparities of optimal medical management between the sexes.

Epidemiological Analysis of Carotid Artery Stenosis Intervention during 10 years in the Public Health System in the Largest City in Brazil: Stenting Has Been More Common than Endarterectomy.

BACKGROUND: Stroke is the second leading cause of death worldwide with approximately 5.7 million cases/year, and carotid atherosclerosis accounts for 10 to 20% of cases. METHODS: In Brazil, the Unified Health System (Sistema Único de Saúde [SUS]) is a tax-funded public health care system that provides care for roughly half the population. São Paulo is the eighth largest city in the world with an estimated population of over 12 million people, of whom more than 5 million rely solely on SUS. This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2017 in the city of São Paulo through web scraping of publicly available databases. RESULTS: Three thousand seven hundred and four carotid revascularization procedures were performed between 2008 and 2017, of which 2,432 were CAS (65.7%). Rates of CAS ranged from 59.9% in 2016 to 86% in 2011. There were 57 in-hospital deaths (1.54%), 34 after CAS (1.4%; 34/2,432) and 23 after CEA (1.81%; 23/1,272) (P = 0.562). SUS reimbursements were US $7,862,017.09 (81.44% of all reimbursements) for 2,432 CAS procedures and US $1,792,324.06 (18.56%) for 1,272 CEA procedures. Average SUS reimbursement for CAS (US $3,232.73) was more than double than that for CEA (US $1,409.05). CONCLUSIONS: In a city whose population exceeds that of some European countries, costs of CAS and CEA to the public health care system totaled more than US$ 9 million over 10 years. Epidemiologically, CAS was performed more commonly than CEA with no difference in in-hospital mortality between CAS and CEA, but reimbursements were 2.29 times higher for CAS. The low adoption of CEA in São Paulo is in contrast to countries where utilization rates are higher for CEA than for CAS.

Assessment of long-term survival and stroke after carotid endarterectomy and carotid stenting in patients older than 80 years.

OBJECTIVE: The objective of this study was to analyze preoperative risk factors affecting long-term survival and the occurrence of stroke in patients older than 80 years undergoing either carotid endarterectomy (CEA) or carotid artery stenting (CAS) for carotid stenosis. METHODS: Data of all consecutive patients treated from January 1999 to December 2017 were retrospectively reviewed and outcomes analyzed. Kaplan-Meier analysis was used to estimate long-term survival and the risk of stroke for both groups. Cox proportional hazards analysis was used to assess the relative risk of all-cause mortality and long-term stroke for patients in the presence of selected comorbidities, including preoperative symptoms, coronary artery disease, chronic renal failure, atrial fibrillation (AF), hypertension, diabetes mellitus, and dyslipidemia. A P value <.05 was considered statistically significant. RESULTS: A total of 473 patients older than 80 years (298 men [63%]) underwent either CEA (n = 178) or CAS. At 30 days, one patient died in the CEA group of unrelated causes; no deaths were recorded after CAS (0.6% vs 0%; P = .18). At 5 years, survival was 67.6% ± 4.9% after CEA and 90.2% ± 2.3% after CAS (P < .0001). The main cause of death after CEA and CAS was a neoplasm. Estimated freedom from any stroke at 5 years was 97.3% ± 0.5% after CEA and 93.2% ± 1.2% after CAS (P = .07). The presence of preoperative AF significantly affected long-term mortality after CAS (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.34-1.98; P = .04) as well as being classified as American Society of Anesthesiologists class 3 at evaluation of the preoperative anesthesiology risk. The presence of preoperative AF was the only factor that significantly affected the occurrence of long-term stroke after both CAS (HR, 2.28; 95% CI, 1.86-5.63; P = .001) and CEA (HR, 3.45; 95% CI, 2.29-8.19; P = .005). CONCLUSIONS: Both CEA and CAS showed low 30-day mortality and any-stroke rates in patients older than 80 years. In the long term, survival was significantly better after CAS; however, deaths after CEA and CAS were mainly unrelated to the procedure. No significant differences were recorded in the occurrence of any stroke in the long term. The presence of preoperative AF significantly affected long-term survival after CAS as well as being classified as American Society of Anesthesiologists class 3 at evaluation of the preoperative anesthesiology risk. The presence of preoperative AF also significantly affected long-term risk of stroke after both CAS and CEA.

Regional variation in use and outcomes of combined carotid endarterectomy and coronary artery bypass.

OBJECTIVE: In treating concomitant carotid and coronary disease, some recommend staged carotid endarterectomy (CEA) and coronary artery bypass grafting, whereas others favor the combined approach (CCAB). Pressure to reduce surgical variation and to improve quality is real, yet little is known about how geographic practice differences affect outcomes. Using the Vascular Quality Initiative (VQI), this study evaluated regional variation in use and outcomes of CCAB. METHODS: All CCAB procedures in the VQI from 2003 to 2017 were reviewed and stratified into four regions, as defined by the United States Census Bureau. Primary outcomes included perioperative stroke, death, myocardial infarction (MI), and these as composite (SDM). A χ2 analysis was performed. RESULTS: There were 1495 CCAB procedures identified, representing 1.8% of the VQI CEAs. Regions included the following: Midwest (MW), 32%; Northeast (NE), 39%; South (S), 25%; and West (W), 4%. Most were male (70%) and white (92%). There was significant regional variation in proportional volume of CCABs to all CEAs (0.7% [W] to 2.5% [MW]; P < .001). Regional variation in patch use (78% [W] to 93% [MW]; P < .001), shunting (29% [W] to 71% [MW]; P < .001), and electroencephalography monitoring (13% [W] to 52% [NE]; P < .001) was also significant. Overall perioperative stroke was 3.6%; death, 3.0%; and SDM, 6.8%. No regional difference was seen in outcomes of mortality (1.5% [MW] to 4.2% [NE]; P = .05), stroke (2.8% [NE] to 4.4% [MW]; P = .52), and MI (0.6% [MW] to 1.8% [W]; P = .62). When the Bonferroni correction was used, there remained no difference in stroke, MI, or SDM across regions, but mortality became significant. Using the Society for Vascular Surgery guidelines for consideration of CCAB, the minority of patients fell within the symptomatic carotid stenosis (SYMP, 15%; n = 218) or severe (≥70%) asymptomatic bilateral carotid disease (BIL, 18%; n = 267) categories. The most common indication was asymptomatic unilateral severe carotid stenosis (UNI, 37%; n = 552). There were no differences in regional outcomes stratified by indication (SYMP, BIL, UNI). Overall, when SYMP and BIL were compared with UNI, UNI had lower rates of stroke (2.4% vs 4.9%; P = .03) but similar MI (0.7% vs 1.2%; P = .40) and mortality (2.2% vs 2.5%; P = .75). CONCLUSIONS: Significant variation exists across VQI centers in the use of CCAB. Despite differences in volume and practices, regional perioperative outcomes are similar. UNI is the most commonly used indication and has lower stroke rates relative to SYMP and BIL. CCAB is performed well across the United States, but most patients fall outside of Society for Vascular Surgery guidelines.

A comparative analysis of long-term mortality after carotid endarterectomy and carotid stenting.

BACKGROUND: The value of carotid intervention is predicated on long-term survival for patients to derive a stroke prevention benefit. Randomized trials report no significant difference in survival after carotid endarterectomy (CEA) vs carotid artery stenting (CAS), whereas observational studies of "real-world" outcomes note that CEA is associated with a survival advantage. Our objective was to examine long-term mortality after CEA vs CAS using a propensity-matched cohort. METHODS: We studied all patients who underwent CEA or CAS within the Vascular Quality Initiative from 2003 to 2013 (CEA, n = 29,235; CAS, n = 4415). Long-term mortality information was obtained by linking patients in the registry to their respective Medicare claims file. We assessed the long-term rate of mortality for CEA and CAS using Kaplan-Meier estimation. We assessed the crude, adjusted, and propensity-matched (total matched pairs, n = 4261) hazard ratio (HR) of mortality for CEA vs CAS using Cox regression. RESULTS: The unadjusted Kaplan-Meier estimated 5-year mortality was 14.0% for CEA and 18.3% for CAS. The crude HR of all-cause mortality for CEA vs CAS was 0.75 (95% confidence interval [CI], 0.70-0.81), indicating that patients who underwent CEA were 25% less likely to die before those who underwent CAS. This survival advantage persisted after adjustment for age, sex, and comorbidities (adjusted HR, 0.75; 95% CI, 0.69-0.82). This effect was confirmed on a propensity-matched analysis, with an HR of 0.76 (95% CI, 0.69-0.85). Finally, these findings were robust to subanalyses that stratified patients by presenting symptoms and were more pronounced in symptomatic patients (adjusted HR, 0.69; 95% CI, 0.61-0.79) than in asymptomatic patients (adjusted HR, 0.80; 95% CI, 0.71-0.90). CONCLUSIONS: During the last 15 years, patients who underwent CEA in the Vascular Quality Initiative have a long-term survival advantage over those who underwent CAS in real-world practice. Despite no difference in long-term survival in randomized trials, our observational study demonstrated a survival benefit for CEA that did not diminish with risk adjustment.

Comparison of outcomes in women and men following carotid interventions in the Washington state's Vascular Interventional Surgical Care and Outcomes Assessment Program.

BACKGROUND: The benefit for carotid endarterectomy (CEA) to prevent a potential stroke has been shown to be less beneficial for women compared with men and the risk of carotid stenting (CAS) is higher in women than men. We hypothesized that a community-based Washington state registry data would also reveal increased morbidity and mortality for women undergoing carotid interventions. METHODS: Deidentified data for CEA and CAS between 2010 and 2015 were obtained from 19 hospitals participating in the Washington State Vascular-Interventional Surgical Care and Outcomes Assessment Program. Data analysis compared in-hospital composite outcome of stroke and mortality from CEA and CAS between women and men. RESULTS: Over the study period, 3704 individuals underwent CEA (n = 2759; 49.5% symptomatic) and CAS (n = 945; 60.9% symptomatic). Women accounted for 39.5% of the cohort. Women were slightly younger than men (70.0 ± 10.2 vs 71.0 ± 9.6 years respectively; P < .01), less likely to be smokers (70.1% vs 75.6%; P < .01), and less likely to have a diagnosis of coronary artery disease (32.9% vs 46.5%; P < .01). Fewer women underwent CEA for symptomatic carotid disease (46.1% vs 51.8%; P < .01). There were no statistically significant differences in the postoperative in-hospital stroke and mortality among women and men undergoing CEA (asymptomatic, 0.8% vs 1.4% [P = .36]; symptomatic, 1.8% vs 2.2% [P = .58]) and CAS (asymptomatic, 1.4% vs 2.2% [P = .56]; symptomatic, 4.6% vs 2.5% [P = .18]). Hospital duration of stay and discharge disposition were similar for women and men. A subanalysis of the octogenarian cohort undergoing CAS demonstrated a substantial increase in-hospital stroke and mortality among women and men (11.6% [CAS] vs 2.2% [CEA]; P = .024). CONCLUSIONS: In the Washington state Vascular-Interventional Surgical Care and Outcomes Assessment Program registry, hospital composite outcome of stroke and mortality following carotid interventions from 2010 to 2015 were noted to be similar for women and men. The notable exception to this finding was observed in subcohort of women undergoing CAS for symptomatic carotid disease at age 80 years or older. These findings should be taken into account when risk stratifying patients for carotid interventions.

Racial and Socioeconomic Disparities After Carotid Procedures.

BACKGROUND: Race has been associated with inferior outcomes after multiple procedures, but the association of socioeconomic status with procedures for cerebrovascular disease is not well established. MATERIALS AND METHODS: Elective carotid artery stenting (CAS) and carotid endarterectomy (CEA) procedures were identified in the National Inpatient Sample, 2012 to 2014. Median household income was estimated from patient ZIP codes. Chi-square and multivariable logistic regression analysis evaluated outcomes, accounting for age, race, gender, comorbidities, procedure, income, insurance, and hospital characteristics. RESULTS: We identified 234 825 carotid procedures (205 835 CEA and 28 990 CAS). Blacks and Hispanics were more likely to be among the lowest quartile income patients (LQIPs) compared to whites (53.5% and 38.7% vs 27.0%, respectively; P < .0002). Compared to highest income quartile patients, LQIP had lower rates of private insurance (16.3% vs 22.0%) and higher Medicaid use (4.7% vs 2.0%; all P < .0002). Lowest quartile income patients were more likely to receive CAS (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.27-1.37), as were blacks and Hispanics (OR = 1.09, 95% CI: 1.02-1.26; OR = 1.31, 95% CI: 1.24-1.40, respectively). In multivariable regression, postoperative stroke was associated with LQIP, black race, and Hispanic ethnicity (OR = 1.16, 95% CI: 1.06-1.28; OR = 1.52, 95% CI: 1.33-1.73; OR = 1.43, 95% CI: 1.24-1.64, respectively). Subgroup analysis demonstrated that whites also had higher odds of stroke in the lower income quartile (OR = 1.2, 95% CI: 1.1-1.4). Mortality was associated with LQIP (OR = 1.6, 95% CI: 1.2-2.1), black race (OR = 1.8, 95% CI: 1.4-2.5), and CAS (OR = 1.3, 95% CI: 1.1-1.6). Length of stay in the lowest income quartile was longer than in patients with the highest income ( P < .0001). CONCLUSIONS: Race was associated with increased hospital mortality, postoperative stroke, and overall complications after carotid procedures. Lower income was significantly associated with increased stroke and mortality irrespective of race. Disparate utilization and outcomes for carotid procedures are multifactorial. Efforts to reduce disparities will need to focus on race and other socioeconomic factors.

The impact of race on outcomes after carotid endarterectomy in the United States.

OBJECTIVE: Black patients undergoing carotid endarterectomy (CEA) in the United States are more often symptomatic at presentation and have more comorbidities compared with white patients. However, the impact of race on outcomes after CEA is largely unknown. METHODS: We identified CEA patients in the Vascular Quality Initiative registry (2012-2017) and compared them by race (black vs white). All other nonwhite races (891 [1.4%]) and Hispanics (2222 [3.4%]) were excluded. We used multilevel logistic regression to account for differences in demographics and comorbidities. We assessed long-term survival using multivariable Cox regression. The primary outcome was perioperative stroke/death, with long-term survival as a secondary outcome. RESULTS: We included 57,622 CEA patients; 2909 (5.0%) were black, of whom 983 (34%) were symptomatic. Of the 54,713 white patients, 16,132 (30%) were symptomatic. Black patients, compared with white patients, had a higher vascular disease burden and were less likely to be operated on in a high-volume hospital or by a high-volume surgeon. In addition, black symptomatic patients, compared with white symptomatic patients, were more often operated on <2 weeks after the index neurologic symptom (47% vs 40%; P < .001). Perioperative stroke/death was comparable between black and white patients (symptomatic, 2.8% vs 2.2% [P = .2]; asymptomatic, 1.6% vs 1.3% [P = .2]), as was unadjusted survival at 3 years (93% vs 93%; P = .7). However, after adjustment, black patients did experience better long-term survival compared with white patients (hazard ratio, 0.8; 95% confidence interval, 0.7-0.9; P = .01). On multilevel logistic regression, race was not associated with perioperative stroke/death (odds ratio, 1.0; 95% confidence interval, 0.8-1.3; P = .98). CONCLUSIONS: Despite the greater prevalence of vascular risk factors in black patients and racial inequalities in surgical treatment, rates of perioperative stroke/death and unadjusted survival were similar between white and black patients. Moreover, black patients experienced better adjusted long-term survival after CEA.

Factors that Predict Failure to Meet Merit-Based Incentive Payment System Quality Measures for Asymptomatic Carotid Endarterectomy.

BACKGROUND: The Physician Quality Reporting System (PQRS) created by the Centers for Medicare and Medicaid Services financially penalizes providers who fail to meet expected quality of care measures. The purpose of this study is to evaluate the factors that predict failure to meet PQRS measures for carotid endarterectomy (CEA). METHODS: PQRS measure 260 (discharge by postoperative day 2 following CEA in asymptomatic patients) and 346 (rate of postoperative stroke or death following CEA in asymptomatic patients) were evaluated using hospital records from the state of Florida from 2008 to 2012. The impact of demographics, comorbidities, hospital factors, admission variables, and individual practitioner data upon timely discharge, and postoperative stroke and death. Odds ratios, 95% confidence intervals, and significance (P < 0.05) were determined through the development of a logistic regression model. Surgeons were identified by national provider identifier number, and practitioner data obtained from the American Medical Association Physician Masterfile. RESULTS: A total of 34,235 patient records and 701 providers were identified over the 5-year period. Significant negative predictors for PQRS measure 260 included weekend admission (odds ratio [OR], 2.9), Medicaid (OR, 2.4), surgeon historical postoperative stroke rate >2.0% (OR, 1.7), African-American race (OR, 2.0), and female gender (OR, 1.3). The presence of any of these factors was associated with a 13.5% rate of failure. The most significant negative predictor for PQRS measure 346 was surgeon postoperative stroke rate >2.0% (OR, 6.2 for stroke and OR, 29.0 for death). Surgeons in this underperforming group had worse outcomes compared to their peers despite having patients with fewer risk factors for poor outcomes. Surgeon specialty, board certification, and case volume do not impact either PQRS measures. CONCLUSIONS: Selected groups of patients and surgeons with a disproportionately high rate of postoperative stroke are at risk of failing to meet PQRS pay for performance quality measures. Awareness of these risk factors may help mitigate and minimize the risk of adversely impacting the value stream. Further evaluation of the causative factors that lead to surgeon underperformance could help to improve the quality of care.

The Asymptomatic Carotid Surgery Trial-2 (ACST-2): an ongoing randomised controlled trial comparing carotid endarterectomy with carotid artery stenting to prevent stroke.

BACKGROUND: A successful open surgical operation to remove atheromatous carotid artery narrowing that has not yet caused a stroke (asymptomatic carotid stenosis) carries some procedural risk but, if completed successfully, halves patients' future annual stroke risk for at least 10 years. A newer, less invasive alternative is carotid stenting, which also carries some procedural risk, especially if the carotid lesion has recently given rise to a stroke (symptomatic carotid stenosis). For both surgery and stenting, improvements in technique (and in medication) have reduced risk. Early studies showed that treating carotid narrowing by stenting, particularly for symptomatic lesions, caused more procedural minor strokes than surgery, but more recent trials in symptomatic and in asymptomatic patients found that both procedures might now be equally safe and effective. However, low patient numbers, short follow-up of the long-term effects on stroke rates and wide confidence intervals mean that worldwide uncertainty persists between carotid surgery and carotid stenting, and national and international guidelines remain unclear as to which is generally better. OBJECTIVES: The second Asymptomatic Carotid Surgery Trial (ACST-2) compares carotid endarterectomy (CEA) with carotid artery stenting (CAS) directly, randomising patients with asymptomatic carotid stenosis for whom a carotid procedure is considered definitely necessary; both procedures seem anatomically feasible, and there is substantial uncertainty as to which of the two would be better for such individuals. Although it will compare procedural risks, the trial's primary aim is to compare the long-term durability of protection against strokes occurring in the years post procedure due to any remaining or recurrent carotid disease. DESIGN: Randomised controlled trial comparing CEA with CAS. SETTING: Hospitals in the UK and worldwide, in which carotid procedures are common. PARTICIPANTS: Men and women with severely stenotic atherosclerotic carotid artery disease, with or without previous stroke but with no recent symptoms from the randomised artery. INTERVENTIONS: CEA and CAS. OUTCOMES: (1) Periprocedural risk defined as myocardial infarction, stroke or death within 30 days after the randomised procedure and (2) long-term rates of disabling or fatal stroke during follow-up of patients. MEASUREMENT OF COSTS AND OUTCOMES: Measurement of intervention costs and stroke costs (periprocedural and during follow-up) and of quality of life [EuroQol-5 Dimensions (EQ-5D®)] for patients in the top six recruiting countries (UK, Italy, Belgium, Germany, Serbia and Sweden), who currently constitute 85% of those randomised. PROGRESS SO FAR: By the end of March 2016, ACST-2 had included 2125 patients, nearly two-thirds of the planned recruitment of 3600; 1061 were randomly allocated to CEA and 1064 to CAS. CONCLUSIONS: Further funding has been secured and recruitment continues, with completion anticipated by the end of 2019. ACST-2 will report initial results in 2021. TRIAL REGISTRATION: Current Controlled Trials ISRCTN21144362. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 57. See the NIHR Journals Library website for further project information. Funding was also received from BUPA Foundation [BUPAF/33(a)/05].

Comparison of 30-day readmission rates and risk factors between carotid artery stenting and endarterectomy.

OBJECTIVE: The aim of this study was to analyze the rates, reasons, and risk factors of 30-day readmission, both planned and unplanned, after carotid revascularization as well as to evaluate major outcomes associated with those readmissions. METHODS: Using the Premier Healthcare database, we retrospectively identified patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) between 2009 and 2015. The primary outcome was 30-day all-cause readmission. Secondary outcomes included mortality and overall cost associated with readmissions. Univariate and multivariate analyses were used and further validated using coarsened exact matching on baseline differences between CEA and CAS patients. RESULTS: A total of 95,687 patients underwent carotid revascularization, 13.5% of whom underwent CAS. Crude 30-day readmission rates were 6.5% after CEA vs 6.1% after CAS (P = .10). Stroke, bleeding, pneumonia, and respiratory failure were the most common reasons for readmission after both CEA and CAS (6.7% vs 8.3%, 6.9% vs 5.3%, 3.4% vs 2.4%, and 4.4% vs 3.9%; all P > .05). Myocardial infarction and wound complications were more likely to be an indication for readmission after CEA (4.1% vs 2.5% and 4.1% vs 1.5%, respectively; P < .05). On the other hand, readmissions due to vascular or stent-related complications were more likely after CAS compared with CEA (5.8% vs 3.8%; P = .003). On multivariate analysis, CEA was found to be associated with 41% higher odds of readmission than CAS (adjusted odds ratio, 1.41; 95% confidence interval, 1.29-1.54; P < .001). Age, female gender, emergency/urgent procedures, concomitant cardiac procedures, rural hospitals, and Midwest region were significantly associated with 30-day readmission. Other risk factors included major preoperative comorbidities (diabetes, congestive heart failure, renal disease, chronic obstructive pulmonary disease, peripheral vascular disease, and history of cancer) as well as the occurrence of postoperative stroke and renal complications during the index admission and nonhome discharge. Coarsened exact matching between CEA and CAS patients also yielded higher adjusted rates of readmission after CEA (6.2% vs 4.9%; P < .001). On the other hand, patients readmitted after CAS had a longer length of hospital stay (5 days vs 4 days; P = .001), increased readmission mortality (6.2% vs 2.8%; P < .001), and higher rehospitalization costs ($8903 vs $7629; P = .01) compared with those readmitted after CEA. CONCLUSIONS: Our results show that CAS is associated with lower 30-day readmission rates compared with CEA. However, CAS readmissions are more complex and are associated with higher mortality and costs. We have also identified patients who are at high risk of readmissions, which can help focus attention on interventions that can improve the management of these patients and reduce readmission rates.

Pre-operative Carotid Plaque Echolucency Assessment has no Predictive Value for Long-Term Risk of Stroke or Cardiovascular Death in Patients Undergoing Carotid Endarterectomy.

INTRODUCTION: In patients with carotid stenosis receiving medical treatment, carotid plaque echolucency has been thought to predict risk of future stroke and of other cardiovascular events. This study evaluated the prognostic value of pre-operative plaque echolucency for future stroke and cardiovascular death in patients undergoing carotid endarterectomy in the first Asymptomatic Carotid Surgery Trial (ACST-1). METHODS: In ACST-1, 1832/3120 patients underwent carotid endarterectomy (CEA), of whom 894 had visual echolucency assessment according to the Gray-Weale classification. During follow-up patients were monitored both for peri-procedural (i.e. within 30 days) death, stroke, or MI, and for long-term risk of stroke or cardiovascular death. Unconditional maximum likelihood estimation was used to calculate odds ratios of peri-procedural risk and Kaplan-Meier statistics with log-rank test were used to compare cumulative long-term risks. RESULTS: Of 894 operated patients in whom echolucency was assessed, 458 plaques (51%) were rated as echolucent and peri-procedural risk of death/stroke/MI in these patients was non-significantly higher when compared with patients with non-echolucent plaques (OR 1.48 [95% CI 0.76-2.88], p = .241). No differences were found in the 10 year risk of any stroke (30/447 [11.6%] vs. 29/433 [11.0%], p = .900) or cardiovascular (non-stroke) death (85/447 [27.9%] vs. 93/433 [32.1%], p = .301). CONCLUSION: In ACST-1, carotid plaque echolucency assessment in patients undergoing CEA offered no predictive value with regard to peri-operative or long-term stroke risk or of cardiovascular (non-stroke) death.

Modified Eversion Carotid Endarterectomy (mECEA): Analysis of Clinical and Financial Outcomes.

BACKGROUND: Several carotid endarterectomy techniques have been described, including conventional carotid endarterectomy (CCEA) performed with patch repair and eversion carotid endarterectomy (ECEA) performed with transection of the internal carotid artery. We describe our simplified technique of modified eversion carotid endarterectomy (mECEA) with longitudinal arteriotomy limited to the carotid bulb, without transection of the internal carotid artery and present our analysis of its safety, efficacy, and cost effectiveness. METHODS: A retrospective review of all carotid endarterectomies performed by 3 vascular surgeons over a 3-year period was completed. About 197 mECEA were performed during the study period. Follow-up data were obtained on 77.7% of patients. A comparison was made with the contemporary literature with respect to outcomes for both CCEA and ECEA. RESULTS: Between January 2012 and December 2014, a total of 197 mECEA were performed. The perioperative stroke and death rates for those undergoing mECEA was 0.5% and 0.5%, respectively. Late stroke and death rates were 3.0% and 5.1%, respectively. Perioperative rate of myocardial infarction was 1.0%. Early restenosis rates of >70% occurred in 1.4%, whereas late restenosis of >70% occurred in 2.7%. Mean operating time for those undergoing mECEA was 57.9 min. Average costs savings for mECEA compared to CCEA were $5,835. CONCLUSIONS: This simplified technique has comparable outcomes to those described in the contemporary literature for both CCEA and ECEA with respect to postoperative neurologic events as well as restenosis rates. In our institution, the short mean operative times with mECEA has led to reduced resource utilization.