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Elizaga N, Ghosh R, Saldana-Ruiz N, Schermerhorn M, Soden P, Dansey K, Zettervall SL. Carotid endarterectomy and transcarotid artery revascularization can be performed with acceptable morbidity and mortality in patients with chronic kidney disease. J Vasc Surg 2024; 80:431-440. [PMID: 38649102 DOI: 10.1016/j.jvs.2024.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/07/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Patients with chronic kidney disease (CKD) are considered a high-risk population, and the optimal approach to the treatment of carotid disease remains unclear. Thus, we compared outcomes following carotid revascularization for patients with CKD by operative approach of carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid arterial revascularization (TCAR). METHODS The Vascular Quality Initiative was analyzed for patients undergoing carotid revascularizations (CEA, TFCAS, and TCAR) from 2016 to 2021. Patients with normal renal function (estimated glomular filtration rate >90 mL/min/1.72 m2) were excluded. Asymptomatic and symptomatic carotid stenosis were assessed separately. Preoperative demographics, operative details, and outcomes of 30-day mortality, stroke, myocardial infarction (MI), and composite variable of stroke/death were compared. Multivariable analysis adjusted for differences in groups, including CKD stage. RESULTS A total of 90,343 patients with CKD underwent revascularization (CEA, n = 66,870; TCAR, n = 13,459; and TFCAS, n = 10,014; asymptomatic, 63%; symptomatic, 37%). Composite 30-day mortality/stroke rates were: asymptomatic: CEA, 1.4%; TCAR, 1.2%; TFCAS, 1.8%; and symptomatic: CEA, 2.7%; TCAR, 2.3%; TFCAS, 3.7%. In adjusted analysis, TCAR had lower 30-day mortality compared with CEA (asymptomatic: adjusted odds ratio [aOR], 0.4; 95% confidence interval [CI], 0.3-0.7; symptomatic: aOR, 0.5; 95% CI, 0.3-0.7), and no difference in stroke, MI, or the composite outcome of stroke/death in both symptom cohorts. TCAR had lower risk of other cardiac complications compared with CEA in asymptomatic patients (aOR, 0.7; 95% CI, 0.6-0.9) and had similar risk in symptomatic patients. Compared with TFCAS, TCAR patients had lower 30-day mortality (asymptomatic: aOR, 0.5; 95% CI, 0.2-0.95; symptomatic: aOR, 0.3; 95% CI, 0.2-0.4), stroke (symptomatic: aOR, 0.7; 95% CI, 0.5-0.97), and stroke/death (asymptomatic: aOR, 0.7; 95% CI, 0.5-0.97; symptomatic: aOR, 0.6; 95% CI, 0.4-0.7), but no differences in MI or other cardiac complications. Patients treated with TFCAS had higher 30-day mortality (aOR, 1.8; 95% CI, 1.2-2.5) and stroke risk (aOR, 1.3; 95% CI, 1.02-1.7) in symptomatic patients compared with CEA. There were no differences in MI or other cardiac complications. CONCLUSIONS Among patients with CKD, TCAR and CEA showed rates of stroke/death less than 2% for asymptomatic patients and less than 3% for symptomatic patients. Given the increased risk of major morbidity and mortality, TFCAS should not be performed in patients with CKD who are otherwise anatomic candidates for TCAR or CEA.
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Affiliation(s)
- Norma Elizaga
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Rahul Ghosh
- Texas A&M University School of Medicine, College Station, TX
| | | | - Marc Schermerhorn
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Peter Soden
- Division of Vascular Surgery, Brown University, Providence, RI
| | - Kirsten Dansey
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Sara L Zettervall
- Division of Vascular Surgery, University of Washington, Seattle, WA.
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Klarin D, Lancaster RT, Ergul E, Bertges D, Goodney P, Schermerhorn ML, Cambria RP, Patel VI. Perioperative and long-term impact of chronic kidney disease on carotid artery interventions. J Vasc Surg 2017; 64:1295-1302. [PMID: 27776697 DOI: 10.1016/j.jvs.2016.04.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 04/06/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Chronic kidney disease (CKD) increases morbidity and mortality after vascular procedures and adversely affects late survival of patients. The presence of CKD also confers increased risk of stroke in patients with asymptomatic carotid stenosis. Patients undergoing carotid intervention in the Vascular Study Group of New England database were stratified by CKD status referable to periprocedural and late outcomes. METHODS All carotid artery stenting and carotid endarterectomies (CEAs) performed from 2003 to 2013 were stratified by CKD severity as mild (estimated glomerular filtration rate [eGFR] >60 mL/min/1.73 m2), moderate (eGFR 30-59), and severe (eGFR <30). The impact of CKD on outcomes of carotid procedures was evaluated using univariate and multivariate methods. RESULTS Of 12,568 patients identified, 11,746 (93%) underwent CEA and 822 (7%) underwent carotid artery stenting. Procedures were performed for symptomatic disease in 40%. CKD severity was mild in 58%, moderate in 35%, and severe in 7%. The 30-day stroke rate was very low across all CKD groups (1.76% mild vs 1.84% moderate and 1.34% severe; P = .009). The 30-day mortality increased with worsening renal function (0.4% mild vs 0.9% moderate and 0.9% severe; P = .01). Independent predictors of 30-day stroke or death included American Society of Anesthesiologists (ASA) class 4 or 5 (odds ratio, 2.3; 95% confidence interval [CI], 1.5-3.4; P = .0001). Multivariable Cox hazards regression showed that severe CKD (hazard ratio [HR], 1.8; 95% CI, 1.3-2.6), ASA class 4 or 5 (HR, 1.7; 95% CI, 1.3-2.2), preoperative cortical symptoms (HR, 1.5; 95% CI, 1.2-1.8), history of diabetes (HR, 1.4; 95% CI, 1.1-1.7), and age (HR, 1.03/y; 95% CI, 1.02-1.04) independently (all P < .01) predicted neurologic events or death at median follow-up of 12.7 months (interquartile range, 10.3-15.2 months). CKD did not increase the risk of neurologic events at 1-year follow-up. Predictors (P < .05) of late death included moderate CKD (HR, 1.3; 95% CI, 1.01-1.7), severe CKD (HR, 2.2; 95% CI, 1.6-2.9), ASA class 4 or 5 (HR, 1.6; 95% CI, 1.2-2.0), history of diabetes (HR, 1.4; 95% CI, 1.2-1.7), chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8), and cortical symptoms (HR, 1.3; 95% CI, 1.05-1.6). The 1-, 5-, and 10-year survival rates decreased with worsening renal function (log-rank test, P < .001), but patients with severe CKD maintained a 71% survival at 5 years. CONCLUSIONS CKD severity increases risk of perioperative mortality as well as late mortality. Patients with CKD benefit from stroke-free survival especially after CEA. Unlike patients with peripheral arterial occlusive disease, for whom severe CKD reduces median survival to ∼2.5 years, patients with CKD and carotid disease exhibit much longer survival. This suggests that carotid interventions have utility in carefully selected patients with moderate and severe CKD, particularly in symptomatic disease.
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Affiliation(s)
- Derek Klarin
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Robert T Lancaster
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Emel Ergul
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Daniel Bertges
- Division of Vascular Surgery, The University of Vermont Medical Center, Burlington, Vt
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Virendra I Patel
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
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Carotid Revascularization in Asymptomatic Patients after Renal Transplantation. Ann Vasc Surg 2017; 38:130-135. [DOI: 10.1016/j.avsg.2016.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/13/2016] [Accepted: 06/17/2016] [Indexed: 11/22/2022]
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Mehaffey JH, LaPar DJ, Tracci MC, Cherry KJ, Kern JA, Kron I, Upchurch GR. Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy. Ann Vasc Surg 2016; 39:195-203. [PMID: 27554691 DOI: 10.1016/j.avsg.2016.05.126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 04/11/2016] [Accepted: 05/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day. RESULTS Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05). CONCLUSIONS Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.
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Affiliation(s)
- James H Mehaffey
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
| | - Damien J LaPar
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Margret C Tracci
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Kenneth J Cherry
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Irving Kron
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Gilbert R Upchurch
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
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Avgerinos ED, Go C, Ling J, Makaroun MS, Chaer RA. Survival and Long-Term Cardiovascular Outcomes after Carotid Endarterectomy in Patients with Chronic Renal Insufficiency. Ann Vasc Surg 2015; 29:15-21. [DOI: 10.1016/j.avsg.2014.07.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/10/2014] [Accepted: 07/27/2014] [Indexed: 11/15/2022]
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Long-term Morbidity and Mortality of Carotid Endarterectomy in Patients with End-stage Renal Disease Receiving Hemodialysis. J Stroke Cerebrovasc Dis 2014; 23:545-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/07/2013] [Accepted: 05/10/2013] [Indexed: 11/21/2022] Open
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Impact of chronic renal insufficiency on the early and late clinical outcomes of carotid artery stenting using serum creatinine vs glomerular filtration rate. J Am Coll Surg 2014; 218:797-805. [PMID: 24655873 DOI: 10.1016/j.jamcollsurg.2013.12.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 12/12/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study analyzed the impact of chronic renal insufficiency (CRI) on early and late clinical outcomes of carotid artery stenting (CAS) using serum creatinine and glomerular filtration rate (GFR). STUDY DESIGN There were 313 CAS patients classified into 3 groups: normal (serum creatinine <1.5 mg/dL or GFR ≥ 60 mL/min/1.73 m(2)); moderate CRI, and severe CRI (serum creatinine ≥ 3 or GFR < 30 mL/min/1.73 m(2)). Major adverse events ([MAE] stroke, death, and myocardial infarction) were compared for all groups. RESULTS Using serum creatinine, perioperative stroke rates for normal, moderate, and severe CRI were: 5%, 0%, and 25%, respectively, (p = 0.05) vs 4.6%, 3.7%, and 11.1%, respectively, (p = 0.44) using GFR. The perioperative MAE rates for symptomatic patients were 9.3% and 0% (p = 0.355) and 2% and 5.9% (p = 0.223) for asymptomatic patients for normal and moderate/severe CRI, respectively, using serum creatinine vs 8.1% and 7.8%, respectively, for symptomatic patients and 2.5% and 3%, respectively, for asymptomatic patients using GFR. At a mean follow-up of 21 months, late MAE rates in normal vs moderate/severe CRI patients were 8.2% and 14%, respectively, (p = 0.247) using serum creatinine vs 6.6% and 13.3%, respectively, (p = 0.05) using GFR. Late MAE rates for symptomatic patients in normal vs moderate/severe CRI were: 8.7% vs 27%, respectively, (p = 0.061) using serum creatinine and 5.7% vs 18.8%, respectively, (p = 0.026) using GFR. Late death rate was 0.55% in normal vs 7.6% (p = 0.002) for moderate/severe CRI. Freedom from MAE at 3 years in symptomatic patients was 81% in normal and 46% in moderate/severe CRI (p = 0.0198). A multivariate Cox regression analysis showed that a GFR of < 60 mL/min/1.73 m(2) had an odds ratio of 1.6 (p = 0.222) of having a MAE after CAS. CONCLUSIONS The GFR was more sensitive in detecting late MAE after CAS. Carotid artery stenting in moderate CRI patients can be done with a satisfactory perioperative outcome; however, late death was significant.
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AbuRahma AF, Srivastava M, Chong B, Dean LS, Stone PA, Koszewski A. Impact of Chronic Renal Insufficiency Using Serum Creatinine vs Glomerular Filtration Rate on Perioperative Clinical Outcomes of Carotid Endarterectomy. J Am Coll Surg 2013; 216:525-32; discussion 532-3. [DOI: 10.1016/j.jamcollsurg.2012.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 12/07/2012] [Indexed: 11/28/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. J Am Coll Cardiol 2011; 57:e16-94. [PMID: 21288679 DOI: 10.1016/j.jacc.2010.11.006] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42:e464-540. [PMID: 21282493 DOI: 10.1161/str.0b013e3182112cc2] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011; 124:e54-130. [PMID: 21282504 DOI: 10.1161/cir.0b013e31820d8c98] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kretz B, Abello N, Brenot R, Steinmetz E. The impact of renal insufficiency on the outcome of carotid surgery is influenced by the definition used. J Vasc Surg 2010; 51:43-50. [DOI: 10.1016/j.jvs.2009.08.070] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 08/21/2009] [Accepted: 08/21/2009] [Indexed: 11/30/2022]
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Wang GJ, Fairman RM, Jackson BM, Szeto WY, Pochettino A, Woo EY. The outcome of thoracic endovascular aortic repair (TEVAR) in patients with renal insufficiency. J Vasc Surg 2009; 49:42-6. [DOI: 10.1016/j.jvs.2008.07.070] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 07/22/2008] [Accepted: 07/23/2008] [Indexed: 11/28/2022]
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Sidawy AN, Aidinian G, Johnson ON, White PW, DeZee KJ, Henderson WG. Effect of chronic renal insufficiency on outcomes of carotid endarterectomy. J Vasc Surg 2008; 48:1423-30. [DOI: 10.1016/j.jvs.2008.07.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 07/07/2008] [Accepted: 07/09/2008] [Indexed: 11/29/2022]
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Chronic kidney disease and postoperative mortality: A systematic review and meta-analysis. Kidney Int 2008; 73:1069-81. [DOI: 10.1038/ki.2008.29] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Debing E, Van den Brande P. Chronic Renal Insufficiency and Risk of Early Mortality in Patients Undergoing Carotid Endarterectomy. Ann Vasc Surg 2006; 20:609-13. [PMID: 16741650 DOI: 10.1007/s10016-006-9080-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 04/04/2006] [Accepted: 04/10/2006] [Indexed: 10/24/2022]
Abstract
We compared early outcome after carotid endarterectomy (CEA) in patients (n = 857 with 1,011 CEA interventions) with and without chronic renal insufficiency (CRI). Two groups were compared: a group with normal renal function (n = 909) and a group with CRI (creatinine >/=1.5 mg/dL and clearance of </=30 mL/min, as well as dialysis and transplant patients, n = 102). Mean age was significantly higher in CRI patients (71.22 vs. 68.33 years, p = 0.001). The incidence of smokers was 53.9% in the non-CRI group vs. 39.2% in CRI patients (p = 0.005). Hypertension (88.2% vs. 75.1, p = 0.003) and cardiac disease (58.8% vs. 47.4%, p = 0.029) were more common in the CRI group. The perioperative mortality rate was significantly higher in CRI patients (3.9% vs. 1.0%, p = 0.013). Multivariate logistic regression analysis showed a significant association between CRI and 30-day death rate (odds ratio = 3.76, p = 0.032). In this series, CRI patients presented an increased mortality. The mortality risk may be related to the increased rates of preoperative hypertension and coronary disease and perioperative myocardial infarction. A more reserved attitude seems indicated in planning CEA for patients with renal dysfunction in combination with a history of coronary artery disease.
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Affiliation(s)
- Erik Debing
- Department of Vascular Surgery, Academic Hospital, Free University of Brussels, Brussels, Belgium.
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Tarakji A, McConaughy A, Nicholas GG. The Risk of Carotid Endarterectomy in Patients with Chronic Renal Insufficiency. ACTA ACUST UNITED AC 2006; 63:326-9. [PMID: 16971203 DOI: 10.1016/j.cursur.2006.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Revised: 05/30/2006] [Accepted: 06/12/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) has been associated with less favorable outcome in patients with chronic renal insufficiency (CRI). The authors compared results of CEA in the presence and absence of CRI at their institution over a 5-year period. DESIGN/SETTING/PARTICIPANTS This article is a retrospective review of 1351 patients who underwent CEA between 1998 and 2004. Chronic renal insufficiency was present in 143 patients. Renal insufficiency was graded as mild (creatinine 1.6-2.9 mg/dL) or severe (creatinine > or = 3.0 mg/dL or on hemodialysis). The composite endpoint was stroke or death within 30 days postoperatively. The results were compared with 150 consecutive patients having CEA in the absence of renal insufficiency between 2002 and 2003. RESULTS For the 143 patients with CRI, the composite endpoint was 9.0%, whereas the composite endpoint for the 150 control patients without CRI was 2.6% (p = 0.032). For patients with severe CRI (creatinine > or = 3.0 or on hemodialysis), the composite endpoint was 19.0% (p = 0.08). For those with mild CRI (creatinine 1.6-2.9), the composite endpoint was 7.3% (p = 0.06). CONCLUSIONS Chronic renal insufficiency is associated with increased incidence of stroke, myocardial infarction, and death after CEA. For patients with advanced CRI, carotid artery stenting (CAS) or aggressive medical management may be alternative treatment options.
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Affiliation(s)
- Ahmad Tarakji
- Department of Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania 18105-1556, USA.
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Riera-Vázquez R, Lozano-Vilardell P, Manuel-Rimbau E, Juliá-Montoya J, Corominas-Roura C, Merino-Mairal O. Endarterectomía carotídea en pacientes de alto riesgo. ANGIOLOGIA 2006. [DOI: 10.1016/s0003-3170(06)74983-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Chiche L, Koskas F, Kieffer E. Regarding: carotid endarterectomy in patients with chronic renal insufficiency: a recent series of 184 cases. J Vasc Surg 2005; 42:597; author reply 597. [PMID: 16171624 DOI: 10.1016/j.jvs.2005.03.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 03/21/2005] [Indexed: 10/25/2022]
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Ascher E, Marks NA, Schutzer RW, Hingorani AP. Carotid endarterectomy in patients with chronic renal insufficiency: A recent series of 184 cases. J Vasc Surg 2005; 41:24-9. [PMID: 15696039 DOI: 10.1016/j.jvs.2004.10.047] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The published results of carotid endarterectomy (CEA) in chronic renal insufficiency (CRI) patients are contradictory, mostly because of the relatively small number of patients in these studies. To better assess the neurologic complications and mortality, we reviewed a recent and substantially larger series of CRI patients who underwent CEAs. METHODS From March 2000 to March 2003, 675 consecutive primary CEAs were performed in 609 patients (346 men, 57%) under general anesthesia. Asymptomatic carotid artery stenosis accounted for 71% of cases. CRI (serum creatinine level > or = 1.5 mg/dL) was detected in 166 patients (27%) who underwent 184 CEAs. The remaining 443 patients (73%) had 491 CEAs. RESULTS Patients with CRI were different in age (76 +/- 8 years vs 72 +/- 9 years, P < .001), male gender (73% vs 51%, P < .001), coronary artery disease (50% vs 28%, P < .001), and diabetes mellitus incidence (38% vs 27%, P < .02). No significant difference in stroke rates was observed between the CRI patients and the control group (1.2% vs 0.5%). The mortality rate for CRI patients was 3%, whereas it was 0% for the control group ( P < .002). The 143 CRI patients with serum creatinine levels from 1.5 to 2.9 mg/dL had a 0.7% mortality rate, whereas it was 17% for 23 patients with serum creatinine levels of 3 mg/dL or more ( P < .001). The stroke rate for the former group was 0.7% and 4.3% for the latter group (NS). Asymptomatic (16) and symptomatic (7) patients with serum creatinine levels of 3 mg/dL or more had mortality rates of 13% and 28%, respectively, with P = .6. CONCLUSION The high mortality rate observed in patients with serum creatinine levels of 3 mg/dL or more after CEA calls for a nonoperative approach in the management of asymptomatic patients.
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Hagiwara N, Toyoda K, Nakayama M, Inoue T, Yasumori K, Ibayashi S, Okada Y. Renal cholesterol embolism in patients with carotid stenosis: a severe and underdiagnosed complication following cerebrovascular procedures. J Neurol Sci 2004; 222:109-12. [PMID: 15240205 DOI: 10.1016/j.jns.2004.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2003] [Revised: 03/04/2004] [Accepted: 04/06/2004] [Indexed: 11/16/2022]
Abstract
Here, we report two cases with rapidly progressive renal failure, caused by cholesterol crystal embolism (CCE), after an angiography for carotid artery stenosis. The diagnosis was determined by histological examination and from clinical symptoms, including livedo reticularis and eosinophilia. Neurologists and neuroradiologists tend to underdiagnose CCE, which results from the same atherosclerotic risk factors as cerebrovascular disease. We need to understand more about CCE and identify its unique clinical symptoms to enable an early diagnosis and treatment.
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Affiliation(s)
- Noriko Hagiwara
- Department of Cerebrovascular Disease, Cerebrovascular Center and Clinical Research Institute, National Kyushu Medical Center, 1-8-1 Jigyohama, Chuou, Fukuoka 810-8563, Japan
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