Epidemiological Analysis of 37,424 Carotid Artery Stenosis Intervention Procedures During 11 Years in the Public Health System in Brazil: Stenting has Been More Common Than Endarterectomy.

BACKGROUND: Stroke is a leading cause of death worldwide, with carotid atherosclerosis accounting for 10-20% of cases. In Brazil, the Public Health System provides care for roughly two-thirds of the population. No studies, however, have analysed large-scale results of carotid bifurcation surgery in Brazil. METHODS: This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2019 in the country through web scraping of publicly available databases. RESULTS: Between 2008 and 2019, 37,424 carotid bifurcation revascularization procedures were performed, of which 22,578 were CAS (60.34%) and 14,846 (39.66%) were CEA. There were 620 in-hospital deaths (1.66%), 336 after CAS (1.48%) and 284 after CEA (1.92%) (P = 0.032). Governmental reimbursement was US$ 77,216,298.85 (79.31% of all reimbursement) for CAS procedures and US$ 20,143,009.63 (20.69%) for CEA procedures. The average cost per procedure for CAS (US$ 3,062.98) was higher than that for CEA (US$ 1,430.33) (P = 0.008). CONCLUSIONS: In Brazil, the frequency of CAS largely surpassed that of CEA. In-hospital mortality rates of CAS were significantly lower than those of CEA, although both had mortality rates within the acceptable rates as dictated by literature. The cost of CAS, however, was significantly higher. This is a pioneering analysis of carotid artery disease management in Brazil that provides, for the first time, preliminary insight into the fact that the low adoption of CEA in the country is in opposition to countries where utilization rates are higher for CEA than for CAS.

Evaluation of Factors Associated with, and Outcomes for Patients with Nonhome Discharge Destinations Following Carotid Endarterectomy.

INTRODUCTION: Following a carotid endarterectomy (CEA) procedure, patients are discharged to their homes or other locations than home such as an acute care facility or skilled nursing facility based on their functional status and level of medical attention needed. Decision-making for discharge destination following a CEA to home or nonhome locations is important due to the differences in survival and postoperative complications. While primary outcomes such as mortality and occurrence of stroke following CEA have been extensively studied, there is a paucity of information characterizing outcomes of discharge destination and the factors associated. The purpose of this study was to explore the factors associated with discharge to nonhome destinations after CEA, and outcomes after discharge. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent CEA from 2011 to 2018. Patients were divided into two groups based on their discharge destination (home versus nonhome). Univariate and multivariate analysis were performed for preoperative and intraoperative factors associated with different discharge destinations. Postoperative complications associated with discharge to nonhome destinations were analyzed and mortality after discharge from hospital was compared between the 2 groups. RESULTS: A total of 25,094 patients met the criteria for inclusion in the study, of which 39% were females and 61% were males; median age was 71 years. Twenty four thousand one hundred twenty-five patients (93.13%) were discharged to home (Group I) and 1,779 (6.87%) were discharged to nonhome destinations (Group II). Following preoperative and intraoperative factors were associated with discharge to nonhome locations: older age, diabetes mellitus, functional independent status, transfer from other hospitals, symptomatic status, need for preoperative blood transfusions, severe ipsilateral carotid stenosis, elective CEA, need for intraoperative shunt and general anesthesia (all P< 0.05). Following postoperative complications had statistically significant association with discharge to nonhome destinations: postoperative blood transfusion, pneumonia, unplanned intubation, longer than 48 hours on ventilator, development of stroke, myocardial infarction, deep vein thrombosis, and sepsis (all P< 0.05). Mortality after discharge from hospital was 0.39% (n = 100). Mortality among those who were discharged to home was 0.29% vs. 1.63% for those who were discharged to nonhome locations (P< 0.05). CONCLUSIONS: Majority of the patients after CEA are discharged back to their homes. This study identifies the factors which predispose patients discharged to locations, other than home. Patients who are not discharged home have higher mortality as compared to those who are discharged to their homes.

Endarterectomía carotídea, resultados a mediano y largo plazo / Carotid endarterectomy, medium to long-term results

Resumen Introducción: Entre el 50% al 80% de los pacientes con un ictus, presentan lesión de la arteria carótida común o interna, de estos un 15% a 30% quedan con discapacidad severa, y el 20% requiere de institucionalización. Objetivo: Analizar las variables epidemiológicas involucradas en la estenosis carotídea y los resultados a mediano-largo plazo de la endarterectomía carotídea. Materiales y Método: Estudio observacional, descriptivo y retrospectivo, donde se analizan 103 endarterectomías carotídeas sucesivas, realizadas en 97 pacientes, en un período de 12 años (2007 a 2018), en el Servicio de Cirugía del Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Sexo masculino 64,9%, edad promedio 70,2 años, sintomáticos 65,9%, presentación clínica más frecuente el ataque isquémico transitorio (48,4%), morbilidad global inmediata del procedimiento 20,3%, AVE perioperarorio 3,9% (ninguno discapacitante), disfunción de nervios periféricos 5,8%, mortalidad operatoria 70% y cuando se efectúa en un plazo menor a 2 semanas del evento isquémico. Conclusión: La endarterectomía carotídea sigue siendo el procedimiento quirúrgico de elección para tratar la estenosis carotídea severa; realizada en centros con experiencia, es un procedimiento seguro y eficaz en la prevención del infarto cerebral.

Introduction: Between 50 and 80% of patients with a stroke, have lesions of the common or internal carotid artery, of these 15 to 30% are severely disabled, and 20% require institutionalization. Aim: To analyze the epidemiological variables involved in carotid stenosis, and the medium to long-term results of carotid endarterectomy. Materials and Method: Observational, descriptive and retrospective study, analyzed 103 successive carotid endarterectomies procedures in 97 patients, in a period of 12 years (2007 to 2018), in the Surgery Department of the Dr. Eduardo Pereira Hospital, Valparaíso, Chile. Results: Male sex 64.9%, average age 70.2 years, symptomatic 65.9%, most frequent clinical presentation, transient ischemic attack (48.4%), immediate global morbidity of the procedure 20.3%, peri-operative AVE 3.9% (none disabling), peripheral nerve dysfunction 5.8%, operative mortality 70%, and when performed within a period less than 2 weeks of the ischemic event. Conclusion: Carotid endarterectomy remains the surgical procedure of choice, to treat severe carotid stenosis, performed in experienced centers, it is a safe and effective procedure in the prevention of cerebral ischemia.

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.

The association of Carotid Revascularization Endarterectomy versus Stent Trial (CREST) and Centers for Medicare and Medicaid Services Carotid Guideline Publication on utilization and outcomes of carotid stenting among "high-risk" patients.

OBJECTIVE: Since the 2004 approval by the United States Food and Drug Administration of carotid artery stenting (CAS), there have been two seminal publications about CAS reimbursement (Centers for Medicare and Medicaid Services guidelines; 2008) and clinical outcomes (Carotid Revascularization Endarterectomy versus Stent Trial [CREST]; 2010). We explored the association between these publications and national trends in CAS use among high-risk symptomatic patients. METHODS: The most recent congruent data sets of the Nationwide Inpatient Sample (NIS) were queried for patients undergoing carotid revascularization. The sample was limited to include only patients who were defined as "high-risk" if they had a Charlson Comorbidity Score of ≥3.0. Subgroup analyses were performed of high-risk patients with symptomatic carotid stenosis. Utilization proportions of CAS were calculated quarterly from 2005 to 2011 for NIS. Three time intervals related to Centers for Medicare and Medicaid Services guidelines and CREST publication were selected: 2005 to 2008, 2008 to 2010, and after 2010. Logistic regression with piecewise linear trend for time was used to estimate different trends in CAS use for the overall high-risk sample and for neurologically asymptomatic and symptomatic cases. Multivariate logistic regression was used to compare odds of postoperative mortality and stroke between these two procedures at different time intervals independent of confounding variables. RESULTS: During the study period, 20,079 carotid endarterectomies (CEAs) and 3447 CAS procedures were performed in high-risk patients in the NIS database. CAS utilization constituted 20.5% of carotid revascularization procedures among high-risk symptomatic patients, with a significant increase from 18.6% to 24.4% during the study period (P < .001). There was an initial increase during 2005 to 2008 in the rate of CAS compared with CEA, CAS utilization significantly decreased during 2008 to 2010 by a 3.3% decline in the odds ratio (OR) of CAS per quarter (OR, 0.967; 95% confidence interval [CI], 0.943-0.993; P = .002), and after CREST (after 2010), CAS utilization continued to increase significantly from the prepublication to the postpublication time interval. The odds of in-hospital mortality (OR, 2.56; 95% CI, 1.17-5.62; P = .019) and postoperative in-hospital stroke (OR, 1.53; 95% CI, 1.09-3.68; P = .024) were independently and significantly higher for CAS patients in the overall sample. CONCLUSIONS: The use of CAS for carotid revascularization in a high-risk cohort of patients has significantly increased from 2005 to 2011. Compared with CEA, CAS independently increased the odds of perioperative in-hospital stroke in all high-risk patients and of in-hospital mortality in symptomatic high-risk patients.

Impacto del tratamiento quirurgico de la enfermedad coronaria en pacientes sometidos a endarterectomia carotidea / Surgical treatment of coronary disease for patien undergoing carotid endarterectomy

Propósito: La asociación de enfermedad coronaria y carotídea plantea un reto cuyo manejo quirúrgico es objeto de debate. El objetivo de este estudio es determinar la prevalencia de enfermedad coronaria y el impacto de la revascularización miocárdica en la mortalidad operatoria y desarrollo de accidentes cerebro-vasculares en pacientes sometidos a endarterectomía carotídea. Métodos y resultados: Se revisan retrospectivamente 123 casos de procedimientos de endarterectomía carotídea que corresponden a 112 pacientes operados consecutivamente en el período entre febrero de 1987 y mayo de 1998. El grupo lo hacen 68 hombres y 44 mujeres con una edad promedio de 67 años. La asociación entre enfermedad carotídea con indicación de endarterectomía y grados variables de enfermedad coronaria, comprobadas ambas angiográfícamente se demostró en 67 pacientes (67/112 =60 por ciento); 56 de ellos (56/67 = 83 por ciento) tuvieron indicación de algún tipo de revascularización miocárdica. 65 pacientes (58 por ciento) se presentaron con síntomas, signos o antecedentes de enfermedad cerebro-vascular; en 14 de ellos, (21 por ciento) se diagnosticó enfermedad coronaria coexistente que requirió algún tipo revascularización miocárdica (RVM) adicional. 47 pacientes (42 por ciento) consultaron por razones diferentes a enfermedad cerebro-vascular: angina, claudicación de miembros inferiores, etc., y sus antecedentes o hallazgos del examen físico indicaron estudio de carótidas que se inició con dúplex carotídeo en 44 de ellos (93 por ciento). La mortalidad operatoria del grupo total fue de 6 por ciento (7 pacientes). La mortalidad operatoria de la endarterectomía como procedimiento aislado fue 1.3 por ciento...