Outcomes after carotid endarterectomy: is there a high-risk population? A National Surgical Quality Improvement Program report.

OBJECTIVE: Carotid endarterectomy (CEA) is the standard treatment of carotid stenosis for symptomatic and asymptomatic patients. Carotid angioplasty and stenting (CAS), however, has been proposed as alternative therapy for patients deemed at high-risk for CEA. This study examined 30-day adjudicated outcomes in a contemporary series of CEAs and assessed the validity of criteria used to define a potential high-risk patient population for CEA. METHODS: Patients undergoing isolated CEA in private sector hospitals between Jan 1, 2005, and Dec 31, 2006, were identified using the prospectively gathered National Surgical Quality Improvement Program database. The primary study end points were 30-day stroke and death rates. Demographic, preoperative, and intraoperative variables were examined using multivariate models to identify variables associated with the study end points. Variables used to define systemic "high-risk" patients in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study (active cardiac disease, severe chronic obstructive pulmonary disease, and octogenarian status) were examined individually and in composite fashion for association with study endpoints. RESULTS: Of the 3949 CEAs performed, 59% were in men, 30% were "high-risk" (19% age >80), and 43% had a previous neurologic event. The 30-day stroke rate was 1.6%, the death rate was 0.7%, and combined stroke/death rate was 2.2%. Multivariate analysis showed that intraoperative transfusion (odds ratio [OR], 5.95; 95% confidence interval [CI], 1.71-20.66; P = .005), prior major stroke (OR, 5.34; 95% CI, 2.96-9.64; P < .0001), shorter height (surrogate for small artery size; OR, 1.09; 95% CI, 1.02-1.16; P = .010), and increased anesthesia time (OR, 1.02; 95% CI, 1.00-1.03; P = .008) were predictive of stroke. Critical limb ischemia (OR, 12.72; 95% CI, 3.49-46.40; P < .0001) and poor functional status (OR, 7.05; 95% CI, 2.95-16.82; P < .0001) were independent correlates of death. Systemic high-risk variables, either combined or individually, did not increase risk of stroke or death on multivariate analysis. CONCLUSION: CEA is associated with favorable 30-day outcomes across a spectrum of patient comorbidity features including octogenarian status. Anatomic and technical features are the important predictors of perioperative stroke, whereas critical limb ischemia and poor functional status are important predictors of death for patients undergoing CEA. These data refute the concept that CAS is preferred for patients deemed high-risk by virtue of systemic comorbidities.

Common femoral artery occlusive disease: contemporary results following surgical endarterectomy.

OBJECTIVE: Proliferation of endovascular techniques with perceived reduction in treatment morbidity repetitively question the precept that surgical endarterectomy is the preferred treatment for occlusive disease of the common femoral artery (CFA). This study details a contemporary experience with common femoral endarterectomy (CFE) with and without concomitantly performed endovascular therapies. METHODS: Technical, hemodynamic, and clinical success of CFE performed between 2002 and 2005 were determined according to the Society of Vascular Surgery reporting standards. Primary and assisted patencies of the CFA segment, freedom from reintervention in the ipsilateral limb, and survival were assessed using Kaplan-Meier life-table analysis. Multivariate analysis was performed to evaluate factors associated with patency and survival. RESULTS: CFE was performed on 65 limbs in 58 patients (mean age 71 +/- 10; male 77%; diabetes 28%; creatinine >/= 1.5 mg/dL 19%). Forty-four cases (68%) were performed for claudication, and 21 cases (32%) for critical limb ischemia. Thirty-seven cases (57%) were performed as a hybrid procedure wherein concomitant endovascular interventions were performed. Twenty iliac (TASC II A-30%; B-35%; C-20%; D-15%) and 25 femoropopliteal (TASC II A-24%; B-60%; C-12%; D-4%) lesions were treated. Technical success was achieved in 100% of the cases. Hemodynamic success was achieved in 95% of the cases with mean postoperative increase in ankle-brachial index (ABI) of 0.24 +/- 0.24. All but one patient (98.5%) had improvement in symptoms and/or ABI. Average hospital stay was 3.2 days (range 1-12 days). There were 3 (5%) major complications requiring reintervention (early failure secondary to untreated inflow lesion, hematoma, and wound infection), six (9%) minor complications which were treated conservatively (five wound infections, one lymph leak), and no perioperative mortality. With a mean follow-up period of 27 months (range 1-58 months), 1- and 5-year primary patencies were 93% and 91%, respectively. Assisted patency was 100% at both time points. There was no difference in patencies between CFE performed alone or as a hybrid procedure. Multivariate analysis showed congestive heart failure (CHF) as the only predictor of primary failure (odds ratio [OR] 18.5 [2.6-142.9]; P = .004). Freedom from reintervention in the ipsilateral limb was 82% at 1 year and 78% at 5 years, with CHF again as the only predictor of reintervention (OR 5.3 [1.4-19.6]; P =.012). Survival was 89% at 1 year and 70% at 5 years. There were no amputations. CONCLUSIONS: These data suggest CFE should remain the standard of care for occlusive disease of the CFA. Its safety and efficacy establish a standard for comparison with emerging endovascular therapies.