Carotid endarterectomy in a community hospital: a change in physicians' practice patterns

A systematic review and meta-analysis of complication rates after carotid procedures performed by different specialties

OBJECTIVE

Different competencies and skills are required and obtained during medical specialization. However, whether these have an impact on procedural outcomes of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. We assessed the reported association between operator specialization and procedural outcomes after CEA or CAS to determine whether CEA and CAS should be performed by specific specialties.

METHODS

We systematically searched PubMed and Embase up to August 21, 2017, for randomized clinical trials and observational studies that compared two or more specialties performing CEA or CAS for symptomatic and asymptomatic carotid artery stenosis. The composite primary outcome was procedural stroke or death (ie, occurring within 30 days of the procedure or before discharge). Risk estimates were pooled with a generic inverse variance random effects model.

RESULTS

A total of 35 studies (26 providing data on CEA, 8 providing data on CAS, and 1 providing data on both CEA and CAS) were included, describing 256,033 CEA and 38,605 CAS procedures. For CEA, decreased risk of procedural stroke or death for operations performed by vascular surgeons was found with pooled unadjusted relative risk (RR) of 0.63 (95% confidence interval [CI], 0.46-0.86; seven studies) compared with neurosurgeons and RR of 0.81 (95% CI, 0.66-0.99; six studies) compared with general surgeons. An increased risk of procedural stroke or death for operations performed by neurosurgeons compared with cardiothoracic surgeons was found with a pooled unadjusted RR of 1.22 (95% CI, 1.02-1.46). No studies adjusted for potential confounding, and no significant unadjusted associations were found in other comparisons of operator specialty for the primary outcome. For CAS, no differences in procedural stroke or death were found by operator specialty.

CONCLUSIONS

Studies were at high risk of bias mainly because of potential confounding by patient selection for CEA and CAS. Current evidence is insufficient to restrict CEA or CAS to specific specialties.

Who doesn't receive carotid endarterectomy when appropriate?

OBJECTIVE

The purpose of this study was to identify clinical and nonclinical factors associated with failure to perform carotid endarterectomy (CEA) in patients with clinically appropriate indications. We analyzed data from a prospective cohort study performed at five Veterans Affairs medical centers. Patients were referred for carotid artery evaluation if they had at least 50% stenosis in one carotid artery, had no history of CEA, and were independently classified preoperatively as appropriate candidates for CEA, according to clinical criteria. The primary outcome was receipt of CEA within 6 months of evaluation. Data were collected by medical record review and interview regarding clinical status, and patient and physician perception of the risks and benefits of CEA.

RESULTS

Among clinically appropriate candidates for CEA, 66.8% (n = 233) did not undergo the operation. Compared with patients who did undergo CEA, a greater proportion of these patients had no symptoms (68.7% vs 45.7%; P <.001). A twofold greater proportion of patients who did not undergo CEA were in the highest quartile of reported aversion to surgery. Moreover, a fourfold greater proportion were perceived by their physicians to be at less than 5% risk for future stroke without the operation, and more than a twofold greater proportion were believed to experience less than 5% efficacy from the operation by their providers (P <.01). In multivariable analyses, four characteristics were significantly associated with whether an appropriate candidate did not receive CEA: asymptomatic disease, less than 70% stenosis, high expressed aversion to surgery score, and low (<5%) provider-perceived efficacy of the operation.

CONCLUSION

Among patients in the Veterans Affairs health care system who are clinically appropriate candidates for CEA, those who did not receive the operation were less likely to have symptomatic disease or high-grade carotid artery stenosis, but were more likely to report high aversion to surgery and to have a provider who believed CEA would not be efficacious.

Revisiting the appropriateness of carotid endarterectomy

BACKGROUND AND PURPOSE

In the 1980s, carotid endarterectomy was controversial because proof of efficacy was lacking, complication rates were high, and one third of cases were reported to be inappropriate. Since publication of several randomized controlled trials (RCTs), rates of carotid endarterectomy have doubled nationwide. This study assesses the appropriateness and use of carotid endarterectomy since publication of the RCTs.

METHODS

Using the literature, we developed a list of 1557 mutually exclusive indications for carotid endarterectomy and asked a panel of national experts to rate the appropriateness of each indication using the RAND methodology. We used these ratings to assess appropriateness in a sample of 2124 patients who underwent the procedure in 1997 to 1998 in 6 hospitals. We also analyzed the reasons for the procedure and rates of death, stroke, and myocardial infarction within 30 days of surgery.

RESULTS

Overall, 84.9% of operations were done for appropriate reasons, 4.5% for uncertain reasons, and 10.6% for inappropriate reasons. Among procedures considered inappropriate, the most common reasons were high comorbidity (46.6%) and minimal stenosis (27.1%). Overall, 72.5% were asymptomatic, 17.4% had a carotid transient ischemic attack, and 10.1% had a stroke. The 30-day rate of death or stroke was 5.47% for symptomatic patients and 2.26% for asymptomatic patients. Among patients having combined carotid and coronary artery bypass graft surgery, the rate was 10.32%. The complication rate in asymptomatic patients with high comorbidity was 5.56%.

CONCLUSIONS

Since the RCTs, rates of overuse appear to have fallen considerably, although they are still significant. A major shift has occurred toward operating on asymptomatic patients. Although overall complication rates were low, rates among asymptomatic patients with high comorbidity exceeded recommended thresholds.

Depression and practice guidelines

Over the past two decades there have been great advances in the understanding of depression and in the development of pharmacological agents and psychosocial treatments that have demonstrated efficacy in the treatment of this common and disabling illness. Unfortunately, this knowledge and evidence is not consistently translated into actual treatment, and depression remains undiagnosed in a large percentage of patients, and when it is accurately diagnosed, it often is suboptimally treated.The frequent failure to properly diagnose depression may be due to the continuing stigma of mental illness, the persistence of the biomedical, rather than the biopsychosocial, paradigm of illness and treatment, educational issues and the time constraints in the typical medical practice. The suboptimal treatment may be due to all of these issues plus the difficulty in changing physician behaviours even when there exists much evidence that would seem to dictate such a change. The development of a criteria-based nomenclature and the subsequent development and dissemination of evidence-based practice guidelines addresses some of these issues. Copyright 2001 John Wiley & Sons, Ltd.

Regional performance of carotid endarterectomy. Appropriateness, outcomes, and risk factors for complications

BACKGROUND AND PURPOSE

Guided by the findings of randomized controlled trials evaluating carotid endarterectomy (CEA), we examined the appropriateness of CEAs performed in our city and determined the incidences and risk factors for postoperative stroke, death, and cardiac complications.

METHODS

Using health records, we retrospectively reviewed 291 consecutive CEAs performed in our region over 18 months. Based on randomized controlled trial results and standardized remeasurements of angiographic carotid stenoses, indications for CEA were considered appropriate for symptomatic carotid stenoses > or = 70%, uncertain for < 70% symptomatic or > or = 60% asymptomatic stenoses, or inappropriate for < 60% asymptomatic stenoses and for patients with preoperative neurological or medical instability.

RESULTS

We found that 41% of patients (118/291) were asymptomatic. Surgical indications were appropriate in 33% of cases (92/281), uncertain in 49% (138/281), and inappropriate in 18% (51/281). Stroke or death occurred within 30 days postoperatively in 5.2% (9/174) of symptomatic patients and 5.1% (6/117) of asymptomatic patients. At least one cardiac complication (angina, congestive heart failure, dysrhythmia, or myocardial infarction) developed in 8.9% (26/291). Independent preoperative risk factors for stroke or death were histories of angina or congestive heart failure and lack of antiplatelet medication; for cardiac complications, risk factors were age > 75 years and a history of congestive heart failure.

CONCLUSIONS

Almost 1 in 5 patients underwent CEA inappropriately, which was most commonly due to apparent over-estimation of stenosis severity, and half had uncertain indications. Our high complication rate possibly negated any overall surgical benefit in the large group of asymptomatic patients.