Ultrasound-Based Nomogram Identifies Breast Cancer Patients Unlikely to Harbor Axillary Metastasis: Towards Selective Omission of Sentinel Lymph Node Biopsy.

BACKGROUND: As tumor biology takes precedence over anatomic staging to determine breast cancer (BC) prognosis, there is growing interest in limiting axillary surgery. There is a need for tools to identify patients at the lowest risk of harboring axillary lymph node (ALN) disease, to determine when omission of sentinel lymph node biopsy (SLNB) may be appropriate. We examined whether a nomogram using preoperative axillary ultrasound (axUS) findings, clinical tumor size, receptor status, and grade to calculate the probability of nodal metastasis (PNM) has value in surgical decision making. METHODS: This was a retrospective analysis of female patients (February 2011-October 2014) with invasive BC who underwent preoperative axUS and axillary surgery. Cases with locally advanced BC, neoadjuvant treatment, or bilateral BC were excluded. PNM was calculated for each case. Using various PNM thresholds, the proportion of cases with ALN metastasis on pathology was examined to determine an optimal PNM cut-point to predict ALN negativity. RESULTS: Of 357 included patients, 72% were node-negative on surgical staging, and 69 (19.6%) had a PNM < 9.3%. Of these 69 patients, 6 had ALN metastasis on surgical pathology, yielding a false negative rate (FNR) of 8.7% for predicting negative ALN when a PNM threshold of < 9.3% was used. CONCLUSION: A nomogram incorporating axUS findings and tumor characteristics identified a sizeable subgroup (19.6%) in whom ALN was predicted to be negative, with an 8.7% FNR. Surgeons can use this nomogram to quantify the probability of ALN metastasis and select patients who may benefit from omitting SLNB.

Pain Control in Breast Surgery: Survey of Current Practice and Recommendations for Optimizing Management-American Society of Breast Surgeons Opioid/Pain Control Workgroup.

INTRODUCTION: The opioid epidemic in the United States is a public health crisis. Breast surgeons are obligated to provide good pain control for their patients after surgery but also must minimize administration of narcotics to prevent a surgical episode of care from becoming a patient's gateway into opioid dependence. METHODS: A survey to ascertain pain management practice patterns after breast surgery was performed. A review of currently available literature that was specific to breast surgery was performed to create recommendations regarding pain management strategies. RESULTS: A total of 609 surgeons completed the survey and demonstrated significant variations in pain management practices, specifically within regards to utilization of regional anesthesia (e.g., nerve blocks), and quantity of prescribed narcotics. There is excellent data to guide the use of local and regional anesthesia. There are, however, fewer studies to guide narcotic recommendations; thus, these recommendations were guided by prevailing practice patterns. CONCLUSIONS: Pain management practices after breast surgery have significant variation and represent an opportunity to improve patient safety and quality of care. Multimodality approaches in conjunction with standardized quantities of narcotics are recommended.

Routine Axillary Ultrasound for Patients with T1-T2 Breast Cancer Does Not Increase the Rate of Axillary Lymph Node Dissection Based on Predictive Modeling.

BACKGROUND: Since publication of the American College of Surgeons Oncology Group Z0011 trial results, demonstrating that many patients with nonpalpable axillary lymph nodes and one or two positive sentinel nodes do not require axillary lymph node dissection (ALND), preoperative axillary ultrasound (AUS) has become controversial. Clinicians are concerned that AUS may lead to unnecessary ALND. The authors developed an algorithm (Algorithm 1) in which the number of AUS-suspicious nodes and tumor biology direct management. For estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) breast cancer with a single AUS-suspicious node and a positive lymph node needle biopsy (LNNB), sentinel lymph node biopsy (SLNB) is performed with a specimen X-ray documenting retrieval of the clipped node. Other patients with positive LNNB receive neoadjuvant chemotherapy. The authors hypothesized that routine AUS and this algorithm could decrease ALND compared with a strategy of no preoperative AUS. METHODS: Decision-tree analysis and Monte Carlo simulation were used to assess the expected number of ALNDs under two strategies (routine AUS vs no AUS). Probabilities were drawn from a literature review and an institutional database. The authors assumed nodal pathologic complete response rates as reported in the literature. Four additional algorithms were created to assess whether any other treatment model could decrease the rate of ALND. RESULTS: Using the routine AUS and the authors' algorithm, the predicted ALND rate was 9%, versus 10% for a strategy of no AUS, with overlapping uncertainty intervals. The remaining treatment algorithms showed similar results. DISCUSSION: Use of AUS may help to tailor patient care without leading to overutilization of ALND, as long as neoadjuvant chemotherapy is administered when appropriate.

Positive Ultrasound-guided Lymph Node Needle Biopsy in Breast Cancer may not Mandate Axillary Lymph Node Dissection.

BACKGROUND: The ACOSOG Z0011 (Z11) trial demonstrated that in patients with nonpalpable axillary lymph nodes (LN) and one to two positive sentinel LN (SLN), axillary LN dissection (ALND) is unnecessary.JAMA 305:569-575, [2011], Ann Surg 264:413-42, [2016] The Z11 trial did not require preoperative axillary ultrasound (axUS). In many centers, preoperative axUS is part of the standard workup of a newly diagnosed breast cancer patient, but in light of the Z11 results, its role is now questioned. METHODS: We retrospectively analyzed newly diagnosed breast cancer patients at two institutions. Inclusion criteria were patients with (1) no palpable lymphadenopathy, (2) abnormal axUS, (3) axillary LN metastasis confirmed preoperatively by axUS-lymph node needle biopsy, (4) no neoadjuvant therapy, and (5) ALND. LN disease burden was dichotomized as N1 versus N2-3. We examined relationships between clinicopathologic factors, including axUS characteristics, and LN disease burden. RESULTS: Of 129 included cases, 67 had N1 disease (51.9%) and 62 had N2-3 disease (48.1%). Factors significantly associated with N1 disease were tumor size ≤2 cm (p = 0.012), nonlobular histology (p = 0.013), and one suspicious LN on axUS (p = 0.008). For patients with both tumor size on imaging ≤2 cm and one abnormal LN on axUS, only 27% had N2-3 disease (p = 0.007). CONCLUSIONS: More than half of patients without palpable adenopathy but with preoperative US-guided biopsy proven axillary LN metastases had N1 disease. For patients with both tumor size ≤2 cm and only 1 abnormal LN on axUS, 73% had N1 disease. This suggests that such patients, if they are otherwise analogous to Z11 patients, may undergo attempt at SLNB.

Prospective Study Comparing Surgeons' Pain and Fatigue Associated with Nipple-Sparing versus Skin-Sparing Mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) is more technically challenging than skin-sparing mastectomy (SSM) but offers quality-of-life and cosmetic advantages. However, surgeon physical symptoms related to NSM workload have not been documented. METHODS: This was a prospective study using questionnaires to compare surgeon-reported physical symptoms before, during, and after NSM versus SSM. Surgeons also answered general questions about each mastectomy. Bilateral cases were performed simultaneously by two surgeons, who completed independent questionnaires. RESULTS: Questionnaires were completed after 82 SSMs and 44 NSMs. On a 0-10 scale, surgeons reported NSM was more physically demanding than SSM (7.0 vs. 4.5, p < 0.001). Mean visualization was more difficult (5.7 vs. 3.2, p < 0.001) and mean fatigue score was greater (5.6 vs. 3.1, p < 0.001) after NSM than SSM. The mean increase in neck pain (on a 0-4 scale) was greater for NSM than SSM, both from before-to-during surgery (0.8 vs. 0.2, p = 0.003) and before-to-after surgery (0.9 vs. 0.2, p = 0.002). The mean increase in lower back pain was greater for NSM than SSM, both from before-to-during surgery (0.7 vs. 0.2, p = 0.008) and before-to-after surgery (0.9 vs. 0.2, p = 0.003). Surgeons reported that NSM was more mentally demanding (p < 0.001), complex (p = 0.01), and difficult (p < 0.001) than SSM. CONCLUSION: Surgeons experienced greater physical symptoms, mental strain, and fatigue with NSM than SSM. This raises concern that mild but repetitive pain over the course of a breast surgeon's career may lead to repetitive stress injury.

Normal Axillary Ultrasound Excludes Heavy Nodal Disease Burden in Patients with Breast Cancer.

BACKGROUND: Axillary lymph node stage is important in guiding adjuvant treatment for breast cancer. The role of axillary ultrasound (AUS) in axillary staging is uncertain. METHODS: From an institutional database, all newly diagnosed invasive breast carcinomas from February 1, 2011 to October 31, 2014 were identified; exclusions were for stage IV disease, palpable adenopathy, or receipt of neoadjuvant chemotherapy. AUS findings, categorized as suspicious versus not suspicious, were correlated with the number of nodal metastasis from surgical pathology. The false-negative rate of nonsuspicious AUS for identifying ≥3 lymph nodes positive on final pathology was calculated. RESULTS: A total of 513 cancers were included. Overall, 400 AUSs were not suspicious (78%), and 113 were suspicious (22%). The sensitivity and specificity of AUS for predicting ≥3 nodal metastasis were 71 and 83%, respectively. The false-negative rate for detecting ≥3 nodal metastasis was 4%. False-negative rate was higher for lobular versus nonlobular carcinomas (12.0 vs. 2.3%, p = 0.004) and for pT2-pT4 tumors versus pT1 tumors (8.2 vs. 1.7 %, p = 0.005). CONCLUSIONS: Patients with normal axillary physical exam and ultrasound rarely harbor a large nodal disease burden. Randomized trials of sentinel lymph node biopsy versus no axillary surgery in patients with normal AUS must be powered for subgroup analysis of patients with invasive lobular carcinoma and pT2-pT4 tumors. Preoperative identification of nodal metastasis may decrease the need for second surgeries and identify candidates for neoadjuvant chemotherapy. AUS is a noninvasive means of predicting disease burden preoperatively and as such is a powerful tool to individualize treatment plans.

Is Sentinel Lymph Node Biopsy Reliable After Recent Oncoplastic Breast Reduction?

An oncoplastic breast reduction may disrupt normal lymphatic drainage and make subsequent identification of the sentinel lymph nodes (SLNs) unreliable. There are little data on the success rate of sentinel lymph node biopsy (SLNB) after recent oncoplastic breast reduction, and there is no agreement on whether SLNB should be done at the time of the partial mastectomy and reduction for ductal carcinoma in situ (DCIS). The primary goals of this study were to evaluate the identification rate of SLNB after recent oncoplastic or functional breast reduction and to examine recurrence rates in this setting. Results reveal SLNB is feasible in this setting. At least one SLN was found in all patients, and there were no recurrences with an average follow-up of 34 months.

Class I obesity is paradoxically associated with decreased risk of postoperative stroke after carotid endarterectomy.

INTRODUCTION: Although obesity is a risk factor for vascular disease, previous studies have shown an obesity paradox with decreased mortality in obese patients undergoing vascular surgery. This study examined the relationship between body mass index (BMI) and outcomes after carotid endarterectomy (CEA). METHODS: The 2005-2009 American College of Surgeons National Surgical Quality Improvement Program database was queried to evaluate 30-day outcomes after isolated CEA across National Institutes of Health-defined obesity classes. χ(2) analysis was used to assess the unadjusted relationship of BMI category to postoperative outcomes. The independent association of BMI with morbidity and mortality was assessed with multivariable logistic regression, adjusting for preoperative and operative characteristics. RESULTS: In the cohort of 23,652 CEA, 1.8% of patients were underweight (BMI <18.5), 26.6% were normal weight (BMI 18.5-24.9), 39.4% were overweight (BMI 25.0-29.9), 21.1% were class I obese (BMI 30.0-34.9), 7.5% were class II obese (BMI 35.0-39.9), and 3.5% were class III obese (BMI ≥ 40). The overall stroke and mortality rates were 1.4% and 0.6%, respectively. On univariable analysis, there were U-shaped relationships between death (P = .017) and stroke (P = .029), with the lowest incidence in overweight and class I obese patients. The incidence of surgical site infection (SSI) (P = .021) increased incrementally with increasing BMI. On multivariable analysis, class I obesity was the only variable associated with decreased risk of stroke (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.31-0.83; P = .007). Independent risk factors for stroke were previous transient ischemic attack (OR, 1.97; P = .006), American Society of Anesthesiologists class 4 to 5 (OR, 1.62; P = .010), surgery performed by a nonvascular surgeon (OR, 1.85; P = .015), and hemiplegia (OR, 1.97; P = .018). There was also a trend, although not statistically significant, toward decreased mortality risk associated with class I obesity (OR, 0.53; 95% CI, .26-1.08; P = .080). Class II obesity was associated with an increased risk of SSI compared with normal weight (OR, 2.21; 95% CI, 1.01-4.82; P = .047). BMI category was not associated with the risk of myocardial infarction. CONCLUSIONS: An obesity paradox exists for stroke and mortality after CEA; for stroke, but not mortality, this protective association was independent of patient demographics and comorbidities. Obesity is not a contraindication to CEA, and surgeons may safely undertake CEA in obese patients when indicated.

Comparison of long-term survival after open vs endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries.

CONTEXT: Endovascular repair of abdominal aortic aneurysm (AAA) compared with open repair increases perioperative survival, but it is not known if it increases long-term survival. OBJECTIVE: To compare long-term outcomes after open vs endovascular repair of AAA. DESIGN, SETTING, AND PATIENTS: Retrospective analysis of patients 65 years or older in the Medicare Standard Analytic File, 2003-2007, who underwent isolated repair of intact AAA. Cause of death was determined from the National Death Index. MAIN OUTCOME MEASURES: The primary outcome was all-cause mortality. Secondary outcomes were AAA-related mortality, hospital length of stay, 1-year readmission, repeat AAA repair, incisional hernia repair, and lower extremity amputation. RESULTS: Of 4529 included patients, 703 were classified as having undergone open repair and 3826 as having undergone endovascular repair. Mean and median follow-up times were 2.6 (SD, 1.5) and 2.5 (interquartile range, 2.4) years, respectively. In unadjusted analysis, both all-cause mortality (173 vs 752; 89 vs 76/1000 person-years, P = .04) and AAA-specific mortality (22 vs 28; 11.3 vs 2.8/1000 person-years, P < .001) were higher after open vs endovascular repair. After adjusting for emergency admission, age, calendar year, sex, race, and comorbidities, there was a higher risk of both all-cause mortality (hazard ratio [HR], 1.24 [95% CI, 1.05-1.47]; P = .01) and AAA-related mortality (HR, 4.37 [95% CI, 2.51-7.66]; P < .001) after open vs endovascular repair. The adjusted hospital length of stay was, on average, 6.5 days (95% CI, 6.0-7.0 days, P < .001) longer after open repair (mean, 10.4 days), compared with endovascular repair (mean, 3.6 days). Incidence of incisional hernia repair was higher after open AAA repair (19 vs 23; 12 vs 3 per 1000 person-years; adjusted HR, 4.45 [95% CI, 2.37-8.34, P < .001]), whereas the incidence of 1-year readmission (188 vs 1070; 274 vs 376/1000 person-years; adjusted HR, 0.96 [95% CI, 0.85-1.09, P = .52]), repeat AAA repair (15 vs 93; 9.7 vs 12.3/1000 person-years; adjusted HR, 0.80 [95% CI, 0.46-1.38, P = .42]), and lower extremity amputation (3 vs 25; 1.9 vs 3.3/1000 person-years; adjusted HR, 0.55 [95% CI, 0.16-1.86, P = .34]) did not differ by repair type. CONCLUSION: Among older patients with isolated intact AAA, use of open repair compared with endovascular repair was associated with increased risk of all-cause mortality and AAA-related mortality.

Outcomes of Margin Reexcision after Oncoplastic Breast Reduction.

Tissue rearrangement after an oncoplastic breast reduction may complicate identification of margins during reexcision. Little is known about outcomes of reoperation in this setting. Methods: This is a single-institution, retrospective analysis of outcomes of margin reexcisions after lumpectomy with concurrent oncoplastic Wise-pattern reduction from 2015 to 2020. Outcomes assessed were the rate of successful breast conservation, in-breast recurrence, wound issues or complications, effect on cosmesis, and delay to onset of adjuvant therapy. Results: From 2015 to 2020, 649 patients underwent lumpectomy with oncoplastic Wise-pattern reduction. Forty-seven patients (7.2%) had greater than or equal to one positive margin(s); of these, 28 went directly to mastectomy, and 19 underwent margin reexcision. Residual disease was found in seven of 19 patients (37%) at reexcision. The rate of successful breast-conserving therapy was 95% with a mean follow-up of 31 months. There was one (5%) in-breast recurrence (invasive ductal carcinoma [IDC] occurring 30 months after the original operation); this patient had a mastectomy for treatment of her recurrence. The overall complication rate was 37%. Radiation was administered to 18 patients (95%), and two patients (11%) had delay of radiation past 6 weeks due to wound complications. Of the 14 patients with photographs available, 12 of 14 patients (86%) were blindly assessed to have equivalent or better cosmesis after margin reexcision (versus initial lumpectomy). Conclusion: Margin reexcision after oncoplastic breast reduction with Wise-pattern is feasible and effective, and can be done without compromising the initial cosmetic results.

Angiotensin receptor blockers and antiplatelet agents are associated with improved primary patency after arteriovenous hemodialysis access placement.

OBJECTIVE: Dialysis access failure is a major cause of morbidity, mortality, and cost in end-stage renal disease. We undertook a study to determine the influence of medication use on dialysis access failure. METHODS: After institutional review board approval, we performed a retrospective analysis of all upper extremity hemodialysis accesses placed from 2005 to 2009 at the Washington DC Veterans Affairs Medical Center. For each access, the date of failure was recorded. For patients who died or were lost to follow-up, the date of the last documented functional patency (censoring) was recorded. The primary exposures were 12 medication classes. Patient demographics, behaviors, comorbidities, and access characteristics were used as covariates. Patency rates were calculated using Kaplan-Meier methods. Cox proportional hazard models controlling for patient characteristics and all medication classes, with procedures clustered within patients, were used to determine the influence of medication class on primary patency. RESULTS: Two hundred sixty autogenous and 126 prosthetic newly placed accesses were identified. Of these, three lower extremity accesses and six accesses with unknown thrombosis date were excluded. Forty-five (18%) of the remaining 257 autogenous accesses were excluded for primary nonfunctionality (patent, but with inadequate venous dilatation for initial hemodialysis), because the primary outcome was long-term functional patency. The remaining 212 autogenous and 120 prosthetic accesses were analyzed. Primary patency rates at 1 and 2 years were 55.2% and 49.1% for autogenous accesses, and 50.2% and 29.7% for prosthetic accesses, respectively. On multivariable analysis, angiotensin receptor blockers (ARBs) were associated with reduced hazard of both autogenous (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.16-0.76; P = .008) and prosthetic (HR, 0.41; 95% CI, 0.18-0.95;P = .039) access failure. On subgroup analysis, ARBs prolonged autogenous access primary patency among patients receiving antiplatelet medication (aspirin, clopidogrel; HR, 0.16; 95% CI, 0.05-0.52;P = .002) but had no demonstrable benefit among patients not receiving antiplatelets (HR, 1.35; 95% CI, 0.34-5.31;P = .670). There were no significant drug-drug interactions in the analysis of prosthetic accesses. Weighted regression models demonstrated low multicollinearity among the model variables. CONCLUSION: Our data suggest that therapy with an ARB plus antiplatelet agent is associated with prolonged autogenous access primary patency, and therapy with an ARB with or without antiplatelet agents is associated with prolonged prosthetic access primary patency. Randomized studies are needed to confirm the causal role of ARBs and to determine the optimal therapeutic regimen (dose, timing, and duration) to promote access patency.

The Impact of Genomic Profiling on Adjuvant Therapy Recommendation in Postmenopausal Women with ER-Positive, T1-2 Breast Cancer: Can Genomic Profiling Eliminate the Need for Sentinel Lymph Node Biopsy?

INTRODUCTION: With the advent of genomic assays, sentinel lymph node biopsy (SLNB) may be less impactful in determining adjuvant breast cancer therapy. We evaluated the influence of SLNB on adjuvant therapy recommendation when the Oncotype DX recurrence score (RS) is known. METHODS: We reviewed postmenopausal women with ER-positive/HER2-negative, pT1-2 breast cancers with non-suspicious axillary ultrasound treated with SLNB at the time of cancer resection, from 2011 to 2015. For each case, the recommended adjuvant therapy based on the actual SLNB was compared with recommendations if SLNB had been omitted (presumed negative). RESULTS: Surgical nodal status was N0 in 184 patients (84.8%), Nmi-N1 in 29 patients (13.4%), and N2-3 in 4 patients (1.8%). SLNB resulted in a recommendation for axillary lymph node dissection in 4.1% (n = 9). Axillary surgery resulted in a change in radiation recommendation (nodal radiation considered or recommended) in 15.2% (n = 33). Of the 147 patients with known RS, 95 patients had RS > 18, 29 had RS 18-25, and 23 had RS < 25. When chemotherapy was only recommended for RS > 25, or N2-3 disease, SLNB changed the recommendation to have chemotherapy in one patient (0.7%), and the recommendation of which chemotherapy regimen (second- vs. third-generation) in an additional 5 patients. CONCLUSION: SLNB changed the recommendation for/against chemotherapy, or the chemotherapy regiment recommended, in 4.8% of postmenopausal women with early-stage, ER-positive/HER2-negative breast cancer, and sonographically negative axilla when using RS > 25 or N2-3 disease as an indication for chemotherapy. Preoperative genomic profiling can guide de-escalation of axillary surgery.

Hyperglycemia is associated with increased risk of morbidity and mortality after colectomy for cancer.

BACKGROUND: The relationship of hyperglycemia to general surgery outcomes is not well-understood. We studied the association of operative day and postoperative day 1 (POD1) blood glucose (BG) with outcomes after open colectomy for cancer. STUDY DESIGN: We retrospectively analyzed the 2000-2005 Veterans Affairs Surgical Quality Improvement Program database, linked with Veterans Affairs Decision Support System BG values. Median BG was categorized as hypoglycemic (<80 mg/dL); normoglycemic (BG 80-120 mg/dL); or mildly (BG 121-160 mg/dL), moderately (BG 161-200 mg/dL), or severely (BG >200 mg/dL) hyperglycemic. The relationship of BG to postoperative outcomes was assessed with multivariable logistic regression. RESULTS: We identified 9,638 colectomies. We excluded 511 procedures for emergency status or preoperative coma, mechanical ventilation, or sepsis. After excluding patients without recorded BG, we analyzed operative day and POD1 BG in 7,576 and 5,773 procedures, respectively. On multivariable analysis, operative day moderate hyperglycemia was associated with surgical site infection (odds ratio = 1.44; 95% CI, 1.10-1.87). POD1 severe hyperglycemia was associated with cardiac arrest (odds ratio = 2.31; 95% CI, 1.08-4.98) and death (odds ratio = 1.97; 95% CI, 1.23-3.15). POD1 mild (odds ratio = 2.20; 95% CI, 1.05-4.60), moderate (odds ratio = 3.44; 95% CI, 1.51-7.84), and severe (odds ratio = 3.94; 95% CI, 1.64-9.58) hyperglycemia and hypoglycemia (odds ratio = 6.74; 95% CI, 1.75-25.97) were associated with myocardial infarction. Associations were similar in diabetic and nondiabetic patients. CONCLUSIONS: Even mild hyperglycemia was associated with adverse outcomes after colectomy, suggesting that a perioperative BG target of 80 to 120 mg/dL, although avoiding hypoglycemia, might be appropriate. Randomized clinical trials are needed to confirm these findings.

Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy.

BACKGROUND: The role of obesity as a risk factor after carotid endarterectomy is not well-described. We undertook a study of the association of obesity with 30-day outcomes after carotid endarterectomy. STUDY DESIGN: After obtaining Institutional Review Board approval, we retrospectively analyzed prospectively collected data from carotid endarterectomies in the 2005-2006 Veterans Affairs Surgical Quality Improvement Program database. The association of body mass index (BMI; calculated as kg/m(2)) on 30-day outcomes was assessed using multivariable logistic regression. RESULTS: From 3,706 carotid endarterectomies, we excluded 22 for missing BMI and 39 for emergency status; 3,645 carotid endarterectomies were analyzed. BMI was underweight (<18.5) in 1.6%, normal (18.5 to 24.9) in 31.0%, overweight (25.0 to 29.9) in 40.8%, class I obese (30.0 to 34.9) in 19.3%, class II obese (35.0 to 39.9) in 5.8%, and class III obese (≥40) in 1.6%. On multivariable analysis, class II to III (odds ratio = 6.95; 95% CI, 1.89-25.58; p = 0.004) obesity was associated with death, and class II to III obesity was associated with cardiac complications (odds ratio = 3.68; 95% CI, 1.27-10.66; p = 0.02) compared with normal weight. CONCLUSIONS: Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy. Surgeons should consider this when evaluating the risks and benefits of carotid endarterectomy in obese patients. Carotid artery stenting was not assessed, and future studies are needed to examine its role in management of obese patients.