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Kremer C, Lorenzano S, Bejot Y, Lal A, Epple C, Gdovinova Z, Mono ML, Karapanayiotides T, Jovanovic D, Dawson J, Caso V. Sex differences in outcome after carotid revascularization in symptomatic and asymptomatic carotid artery stenosis. J Vasc Surg 2023; 78:817-827.e10. [PMID: 37055001 DOI: 10.1016/j.jvs.2023.03.502] [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: 11/22/2022] [Revised: 03/11/2023] [Accepted: 03/19/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting results. Moreover, women are underrepresented in clinical trials, leading to limited conclusions regarding the safety and efficacy of acute stroke treatments. METHODS A systematic review and meta-analysis was performed by literature search including four databases from January 1985 to December 2021. Sex differences in the efficacy and safety of revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), for symptomatic and asymptomatic carotid artery stenoses were analyzed. RESULTS Regarding CEA in symptomatic carotid artery stenosis, the stroke risk in men (3.6%) and women (3.9%) based on 99,495 patients (30 studies) did not differ (P = .16). There was also no difference in the stroke risk by different time frames up to 10 years. Compared with men, women treated with CEA had a significantly higher stroke or death rate at 4 months (2 studies, 2565 patients; 7.2% vs 5.0%; odds ratio [OR], 1.49; 95% confidence interval [CI], 1.04-2.12; I2 = 0%; P = .03), and a significantly higher rate of restenosis (1 study, 615; 17.2% vs 6.7%; OR, 2.81; 95% CI, 1.66-4.75; P = .0001). For CAS in symptomatic artery stenosis, data showed a non-significant tendency toward higher peri-procedural stroke in women, whereas for asymptomatic carotid artery stenosis, data based on 332,344 patients showed that women (compared with men) after CEA had similar rates of stroke, stroke or death, and the composite outcome stroke/death/myocardial infarction. The rate of restenosis at 1 year was significantly higher in women compared with men (1 study, 372 patients; 10.8% vs 3.2%; OR, 3.71; 95% CI, 1.49-9.2; P = .005). Furthermore, CAS in asymptomatic patients was associated with low risk of a postprocedural stroke in both sexes, but a significantly higher risk of in-hospital myocardial infarction in women than men (8445 patients, 1.2% vs 0.6%; OR, 2.01; 95% CI, 1.23-3.28; I2 = 0%; P = .005). CONCLUSIONS A few sex-differences in short-term outcomes after carotid revascularization for symptomatic and asymptomatic carotid artery stenosis were found, although there were no significant differences in the overall stroke. This indicates a need for larger multicenter prospective studies to evaluate these sex-specific differences. More women, including those aged over 80 years, need to be enrolled in randomized controlled trials, to better understand if sex differences exist and to tailor carotid revascularization accordingly.
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Affiliation(s)
- Christine Kremer
- Neurology Department, Skåne University Hospital, Department Clinical Sciences Lund University, Malmö, Sweden.
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Yannick Bejot
- Dijon Stroke Registry, EA7460, Pathophysiology and Epidemiology of Cerebro-Cardiovascular diseases (PEC2), University Hospital of Dijon, University of Burgundy, UBFC, Dijon, France
| | - Avtar Lal
- European Stroke Organisation (ESO), Basel, Switzerland
| | - Corina Epple
- Neurology Department, Klinikum Hanau, Hanau, Germany
| | - Zuzana Gdovinova
- Neurology Department, Faculty of Medicine P.J. Safarik University Košice, Košice, Slovakia
| | - Marie-Luise Mono
- Department of Neurology, Municipal Hospital Waid und Triemli, Zürich, Switzerland; University Hospital and University of Bern, Bern, Switzerland
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dejana Jovanovic
- Department of Emergency Neurology, Neurology Clinic, Clinical Center of Serbia, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, Scotland
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 224] [Impact Index Per Article: 224.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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Deery SE, Holscher CM, Nejim B, Zettervall SL, Aranson NJ, Zarkowsky DS, Abularrage CJ, Hicks CW. In-hospital and one-year outcomes are similar for women and men following transcarotid artery revascularization in symptomatic and asymptomatic patients. J Vasc Surg 2022; 75:572-580.e3. [PMID: 34560217 PMCID: PMC8792188 DOI: 10.1016/j.jvs.2021.08.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/21/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In randomized controlled trials and retrospective series, women have higher rates of periprocedural stroke and death following carotid endarterectomy and transfemoral carotid artery stenting compared with men. We sought to compare outcomes by sex following transcarotid artery revascularization (TCAR) among patients in the Vascular Quality Initiative (VQI). METHODS We reviewed all patients in the VQI who underwent TCAR from 2017 to 2020. We stratified the analysis by symptom status. The primary outcome was in-hospital stroke/death, and secondary outcomes were in-hospital stroke and death and 1-year stroke/death, stroke, and death. We used multivariable logistic and Cox regression models to assess the association of sex with in-hospital and 1-year outcomes after adjusting for preoperative and intraoperative characteristics. RESULTS We identified 15,851 patients who underwent TCAR, of whom 7391 (47%) were symptomatic (2708 or 37% female) and 8460 (53%) were asymptomatic (3097 or 37% female). Women were less frequently considered anatomic high risk than men in both groups (symptomatic: 43% vs 46%; P = .004; asymptomatic: 44% vs 48%; P = .004). Among symptomatic patients, women more often had severe ≥70% stenosis (89% vs 87%; P = .02). There were no differences in in-hospital death, stroke, or stroke/death for women vs men following TCAR among symptomatic or asymptomatic patients (all P > .05). After adjusting for baseline differences between groups, female sex was not associated with in-hospital stroke/death in either symptomatic (odds ratio, 1.05; 95% confidence interval, 0.72-1.56) or asymptomatic (odds ratio, 0.93; 95% confidence interval, 0.53-1.63) patients undergoing TCAR. There were also no differences in 1-year stroke, death, or stroke/death risk for women compared with men with and without symptoms on unadjusted or adjusted analyses (P > .05). CONCLUSIONS We found no sex differences in in-hospital or 1-year stroke/death following TCAR, regardless of symptom status. TCAR appears to be as safe of a surgical procedure for women as for men in patients with both symptomatic and asymptomatic carotid artery disease.
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Affiliation(s)
- Sarah E Deery
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md; Division of Vascular and Endovascular Therapy, Maine Medical Center, Portland, Me
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Besma Nejim
- Division of Vascular Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pa
| | - Sara L Zettervall
- Division of Vascular Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Nathan J Aranson
- Division of Vascular and Endovascular Therapy, Maine Medical Center, Portland, Me
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado School of Medicine, Aurora, Colo
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md.
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Abstract
The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients. Stroke and cerebrovascular disease are prevalent in women. There are inherent biological and other differences in men and women, which affect the manifestations and outcome of stroke, with women experiencing worse disability and higher mortality following ischemic stroke than men. Due to the underrepresentation of female patients in most clinical trials, the ability to make firm but alternative recommendations for women specifically on the management of carotid stenosis is challenging. Although some data suggest that women might have worse periprocedural outcomes as compared to men following all carotid revascularization procedures, there is also an abundance of data to support a similar risk for carotid procedures in men and women, especially with carotid endarterectomy and transcarotid artery revascularization. Therefore, the indications for carotid revascularization are the same in women as they are in men. The choice of a carotid revascularization procedure in women is based upon the same factors as in men and requires careful evaluation of a particular patient's risk profile, anatomic criteria, plaque morphology, and medical comorbidities that might favor one technique over the other. When performing carotid revascularization procedures in women, tailored techniques and procedures to address the small diameter of the female artery are warranted.
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Affiliation(s)
- Caron Rockman
- Division of Vascular Surgery, NYU Grossman School of Medicine, New York, NY (C.R.)
| | - Valeria Caso
- Department of Cardiovascular Medicine, Santa Maria Della Misericordia Hospital, University of Perugia, Italy (V.C.)
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco (P.A.S.)
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Goicoechea S, Walsh M, Soult M, Halandras PM, Bechara C, Aulivola B, Crisostomo P. Female Gender Increases Risk of Stroke and Readmission after CEA and CAS. J Vasc Surg 2021; 75:1935-1944. [PMID: 34740804 DOI: 10.1016/j.jvs.2021.10.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/21/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Carotid endarterectomy (CEA) has historically demonstrated a higher rate of perioperative adverse events for female patients. However, recent evidence suggests similar outcomes for CEA between genders. In contrast, fewer studies have examined gender in carotid artery stenting (CAS). Using contemporary data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we aim to determine if gender impacts differences in postoperative complications in patients who undergo CEA or CAS. METHODS The ACS NSQIP database was queried from 2005-2017 using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes for retrospective review. Patients with carotid intervention (CEA or CAS) were stratified into asymptomatic vs symptomatic cohorts to determine the effect of gender on 30-day postoperative outcomes. Symptomatic patients were defined as those with perioperative transient cerebral ischemic attack or stenosis of carotid artery with cerebral infarction. Descriptive statistics were calculated. Risk-adjusted odds of 30-day postoperative outcomes were calculated using multivariate regression analysis with fixed effects for age, race, and comorbidities. RESULTS There were 106,568 patients with CEA or CAS (104,412 CEA and 2,156 CAS). Average age was 70.9 years old and female patients accounted for 39.9% of the population. For asymptomatic patients that underwent CEA or CAS, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.005), readmission (10%, p=0.004), bleeding complication (32%, p=0.001), and UTI (54%, p=0.001) as well as less infection (26%, p=0.001). In the symptomatic cohort, female gender was associated with significantly higher rates of CVA/stroke (32%, p=0.034), bleeding complication (203%, p=0.001), and UTI (70%, p=0.011), while female gender was associated with a lower rate of pneumonia (39%, p=0.039). Subset analysis found that, compared to male patients, female patients <75yo have an increased rate of CVA/stroke (21%, p=0.001) and readmission (15%, p<0.001), while female patients ≥75yo did not. In asymptomatic and symptomatic patients that underwent CEA, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.006 and 31%, p=0.044, respectively), but this finding was present not in patients undergoing CAS. CONCLUSION In patients undergoing carotid intervention, female gender was associated with significantly increased rates of postoperative CVA/stroke in the asymptomatic and symptomatic cohorts as well as readmission in the asymptomatic cohort. Female gender was associated with higher rates of CVA/stroke following CEA, but not CAS. We recommend that randomized control trials ensure adequate representation of female patients to better understand gender-based disparities in carotid intervention.
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Affiliation(s)
- Steven Goicoechea
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Martin Walsh
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Michael Soult
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Pegge M Halandras
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Carlos Bechara
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Bernadette Aulivola
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL
| | - Paul Crisostomo
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL.
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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Fornelli F, Sirignano P, Mansour W, Capoccia L, Cuozzo S, Speziale F, Sbarigia E. Could Gender Impact on Immediate and Long-term Carotid Artery Stenting Outcome? Insight from an Italian Single Center Experience. Ann Vasc Surg 2021; 76:342-350. [PMID: 33951519 DOI: 10.1016/j.avsg.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/27/2021] [Accepted: 04/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) has become a valid alternative to carotid endarterectomy in stroke prevention. However, female gender is still considered as an independent risk factor for CAS procedures, potentially limiting immediate and long-term benefits. Aim of present study was to evaluate gender differences in CAS submitted patients from an Italian high-volume center. MATERIAL AND METHODS a retrospective monocentric study has been conducted on 568 patients (366 males and 202 females), submitted to CAS, between January 2000 and December 2019. Besides gender sex, clinical anatomical, and procedural data were collected as possible factors determining the outcome, when associated to sex gender itself. Primary endpoint of this study consisted in evaluating the technical and procedural success ratio, and the incidence of major and minor stroke, transient ischemic attack, acute myocardial infarction (AMI) peri-procedurally and at medium and long term, between the male and the female population. Secondary endpoint of this study consisted in evaluating the percentage ratio of minor complications happening peri-procedurally in both genders. RESULTS Male patients were more likely to be octogenarians, clinical history of coronary artery disease, and smokers, while diabetes was more frequent in female patients. Anatomical and plaque morphology features were not different between the two groups. Technical success was obtained in all but two patients (99,6%), while procedural success was 95% (538/566 patients). During the peri-procedural time, no major stroke, 16 minor strokes (2,81%, 2,45% males vs. 3,45% females, P= 0,48), and 11 transient ischemic attack (2,18% males vs. 1,48% females, P= 0,56) were recorded. At a medium follow-up 57 months, 32 stroke (8 major strokes, 24 minor strokes) episodes (5,6%, males 5,7% vs. females 5,4%, P= 0,88), 24 AMIs (4,2%, males 4,6% vs. females 3,46%, P= 0,5;), 13 restenosis (2,8%, males 2,4% vs. females 1,9%, P= 0,71) and 223 deaths (39,2%, males 34,9% vs. females 47%, P= 0,0048) were noted. CONCLUSIONS Our results showed no differences in immediate, and long-term CAS outcomes between gender. Larger, prospective studies are required to assess the real importance and significance of gender in determining CAS procedures' benefit and outcome.
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Affiliation(s)
- Federica Fornelli
- Vascular and Endovascular Surgery Unit, Department of Surgery, "Sapienza" University of Rome, Rome, Italy
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of Surgery, "Sapienza" University of Rome, Rome, Italy.
| | - Wassim Mansour
- Vascular and Endovascular Surgery Unit, Department of Surgery, "Sapienza" University of Rome, Rome, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Unit, Department of Surgery, "Sapienza" University of Rome, Rome, Italy
| | - Simone Cuozzo
- Vascular and Endovascular Surgery Unit, Department of Surgery, "Sapienza" University of Rome, Rome, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery, "Sapienza" University of Rome, Rome, Italy
| | - Enrico Sbarigia
- Vascular and Endovascular Surgery Unit, Department of Surgery, "Sapienza" University of Rome, Rome, Italy
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Paraskevas KI, Cambria RP. Carotid Revascularization Procedural Volume and Perioperative Outcomes. Angiology 2021; 72:703-705. [PMID: 33827274 DOI: 10.1177/00033197211005605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, 1951St. Elizabeth's Medical Center, Brighton, MA, USA
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Giurgius M, Horn M, Thomas SD, Shishehbor MH, Barry Beiles C, Mwipatayi BP, Varcoe RL. The Relationship Between Carotid Revascularization Procedural Volume and Perioperative Outcomes in Australia and New Zealand. Angiology 2021; 72:715-723. [PMID: 33535812 DOI: 10.1177/0003319721991717] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke in selected patients. However, each intervention carries a risk of perioperative complications including stroke or death (S/D). We aimed to determine the relationship between operator volume, hospital volume, and the perioperative risk of S/D in carotid revascularization in Australia and New Zealand. Retrospective analysis was performed on prospectively collected data extracted from the Australasian Vascular Audit between 2010 and 2017. Annual caseload volume was analyzed in quintiles (Q) using multivariate regression to assess its impact on perioperative S/D. Carotid endarterectomy procedures (n = 16 765) demonstrated higher S/D rates for lower-volume operators (2.21% for Q1-Q3 [1-17 annual cases] vs 1.76% for Q4-Q5 [18-61 annual cases]; odds ratio [OR]: 1.28; 95% CI: 1.001-1.64; P = .049). Carotid artery stenting procedures (n = 1350) also demonstrated higher S/D rates for lower-volume operators (2.63% for Q1-Q3 [1-11 annual cases] vs 0.37% for Q4-Q5 [12-31 annual cases]; OR: 6.11; 95% CI: 1.27-29.33; P = .024). No significant hospital volume-outcome effect was observed for either procedure. An inverse relationship was demonstrated between operator volume and perioperative S/D rates following CEA and CAS. Consideration of minimum operator thresholds, restructuring of services and networked referral pathways of care in Australia and New Zealand, would likely result in improved patient outcomes.
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Affiliation(s)
- Mary Giurgius
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Marco Horn
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Shannon D Thomas
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
| | - Mehdi H Shishehbor
- Harrington Heart & Vascular Institute and Case Western Reserve University School of Medicine, University Hospitals, Cleveland, OH, USA
| | - C Barry Beiles
- Australasian Vascular Audit, Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - B Patrice Mwipatayi
- Department of Vascular Surgery, University of Western Australia, School of Surgery and Royal Perth Hospital, Perth, Australia
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
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Mallick D, Holscher CM, Canner JK, Zarkowsky DS, Abularrage CJ, Hicks CW. Sex does not have an impact on perioperative transfemoral carotid artery stenting outcomes among octogenarians. J Vasc Surg 2020; 72:1405-1412. [PMID: 32107096 DOI: 10.1016/j.jvs.2019.12.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/09/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Transfemoral carotid artery stenting (CAS) has been validated as an acceptable alternative to carotid endarterectomy in patients at high risk for open surgery. There are variable sex- and age-based differences in transfemoral CAS outcomes of published randomized controlled trials. The aim of our study was to evaluate sex-based differences in perioperative outcomes after transfemoral CAS performed in octogenarians. METHODS The National Surgical Quality Improvement Program targeted vascular module was queried for all patients ≥80 years of age who underwent transfemoral CAS between 2011 and 2017. Symptomatic status was defined as a history of prior ipsilateral stroke, transient ischemic attack, or amaurosis fugax. The primary outcome was a composite outcome of perioperative (30-day) stroke or death. Outcomes were compared for male vs female patients and stratified by symptomatic status using univariate and multivariable logistic regression analyses adjusting for emergent status, symptomatic status, comorbidities, and use of an embolic protection device. RESULTS Overall, there were 143 patients ≥80 years of age who underwent transfemoral CAS during the study period, including 95 men (66.4%) and 48 women (33.6%). Race (white, 88.0% vs 85.4%), symptomatic status (30.9% vs 29.2%), and degree of stenosis (severe, 71.6% vs 62.5%) were not significantly different for men vs women (P ≥ .27). Periprocedural stroke/death occurred in six men (6.4%) vs two women (4.2%; P = .59) and did not significantly differ when stratified according to symptomatic (6.9% vs 7.1%; P = .98) and asymptomatic (6.2% vs 2.9%; P = .49) status. Based on multivariable analysis, independent factors associated with the composite end point included emergent vs elective status (adjusted odds ratio OR [aOR], 20.3; 95% confidence interval [CI], 2.25-183) and failure to use an embolic protection device (aOR, 2.86; 95% CI, 1.59-50.0). Sex was not significantly associated with the primary outcome after risk adjustment (aOR, 0.81; 95% CI, 0.28-3.28). CONCLUSIONS We found no sex-based differences in risk of perioperative stroke/death among patients ≥80 years of age undergoing transfemoral CAS. Our study validates previous studies showing a high rate of perioperative complications after transfemoral CAS in octogenarians and suggests that the decision to use this technology in older patients should be determined by patients' anatomic and medical risk factors irrespective of sex.
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Affiliation(s)
- Dania Mallick
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Devin S Zarkowsky
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado School of Medicine, Aurora, Colo
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md.
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Lopez Ramos C, Brandel MG, Rennert RC, Hirshman BR, Wali AR, Steinberg JA, Santiago-Dieppa DR, Flagg M, Olson SE, Pannell JS, Khalessi AA. The Potential Impact of "Take the Volume Pledge" on Outcomes After Carotid Artery Stenting. Neurosurgery 2020; 86:241-249. [PMID: 30873551 PMCID: PMC7308658 DOI: 10.1093/neuros/nyz053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/31/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The "Volume Pledge" aims to centralize carotid artery stenting (CAS) to hospitals and surgeons performing ≥10 and ≥5 procedures annually, respectively. OBJECTIVE To compare outcomes after CAS between hospitals and surgeons meeting or not meeting the Volume Pledge thresholds. METHODS We queried the Nationwide Inpatient Sample for CAS admissions. Hospitals and surgeons were categorized as low volume and high volume (HV) based on the Volume Pledge. Multivariable hierarchical regression models were used to examine the impact of hospital volume (2005-2011) and surgeon volume (2005-2009) on perioperative outcomes. RESULTS Between 2005 and 2011, 22 215 patients were identified. Most patients underwent CAS by HV hospitals (86.4%). No differences in poor outcome (composite endpoint of in-hospital mortality, postoperative neurological or cardiac complications) were observed by hospital volume but HV hospitals did decrease the likelihood of other complications, nonroutine discharge, and prolonged hospitalization. From 2005 to 2009, 9454 CAS admissions were associated with physician identifiers. Most patients received CAS by HV surgeons (79.2%). On multivariable analysis, hospital volume was not associated with improved outcomes but HV surgeons decreased odds of poor outcome (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.97; P = .028), complications (OR 0.56, 95% CI 0.46-0.71, P < .001), nonroutine discharge (OR 0.70, 95% CI 0.57-0.87; P = .001), and prolonged hospitalization (OR 0.52, 95% 0.44-0.61, P < .001). CONCLUSION Most patients receive CAS by hospitals and providers meeting the Volume Pledge threshold for CAS. Surgeons but not hospitals who met the policy's volume standards were associated with superior outcomes across all measured outcomes.
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Affiliation(s)
- Christian Lopez Ramos
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Michael G Brandel
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Robert C Rennert
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Brian R Hirshman
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Arvin R Wali
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Jeffrey A Steinberg
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | | | - Mitchell Flagg
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Scott E Olson
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - J Scott Pannell
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
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Mayor JM, Salemi JL, Dongarwar D, Salihu HM, Montero-Baker M, Mills JL, Chung J. Sex-Based Differences in Ten-Year Nationwide Outcomes of Carotid Revascularization. J Am Coll Surg 2019; 229:38-46.e4. [PMID: 30922980 DOI: 10.1016/j.jamcollsurg.2019.02.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND We compared the rates of stroke, death, and/or MI between men and women, stratified by symptomatic status and procedure type (carotid endarterectomy [CEA] or carotid artery stent [CAS]). STUDY DESIGN Using the Nationwide Inpatient Sample, crude and propensity-matched rates of the composite end point of stroke/death/MI were estimated. Multivariable logistic regression was used to calculate the odds of stroke/death/MI associated with sex. RESULTS Between 2005 and 2015, there were 1,242,688 carotid interventions performed (1,083,912 CEA; 158,776 CAS; 515,789 [41.5%] were female patients). Symptomatic admissions comprised 11.3% of the cohort. In-hospital stroke/death/MI rates were more prevalent in men compared with women (4.2% vs 3.9%; p < 0.01). Subgroup analysis revealed symptomatic women vs men had higher rates of stroke after CEA (7.7% vs 6.2%; p < 0.01) and CAS (9.9% vs 7.6%; p < 0.01). Asymptomatic women experienced the same rates of stroke after either CEA (0.3% vs 0.3%; p = 0.051) or CAS (0.4% vs 0.5%; p = 0.09). Propensity-matched logistic regression revealed that symptomatic males vs females had lower odds of stroke after CEA (odds ratio [OR] 0.81; 95% CI 0.72 to 0.91) and CAS (OR 0.72; 95% CI 0.57 to 0.90). Asymptomatic men and women had similar odds of stroke after both CEA (OR 0.95; 95% CI 0.79 to 1.14) and CAS (OR 0.70; 95% CI 0.43 to 1.13). CONCLUSIONS This is the largest cohort study to date that demonstrates asymptomatic women undergoing CEA or CAS do not have a higher risk of perioperative stroke, death, or MI. Symptomatic men experience lower rates of stroke after CEA or CAS.
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Affiliation(s)
- Jessica M Mayor
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, TX
| | - Jason L Salemi
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, TX; Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, TX
| | - Hamisu M Salihu
- Center of Excellence in Health Equity, Training and Research, Baylor College of Medicine, Houston, TX; Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Miguel Montero-Baker
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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Newman WC, Kubilis PS, Hoh BL. Validation of a neurovascular comorbidities index for retrospective database analysis. J Neurosurg 2019; 130:273-277. [PMID: 29372882 DOI: 10.3171/2017.8.jns171413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/01/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE: Comorbidities have a significant effect on patient outcomes. Accounting for this effect is especially important in retrospective reviews of large databases; overpowered studies are at risk for finding significant results because of inaccurate patient risk stratification. The authors previously created a neurovascular comorbidities index (NCI) for patients with an unruptured intracranial aneurysm and found that the model's ability to predict patient outcomes was statistically significantly improved over that of the routinely used Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI). In this study, the authors aimed to validate use of the NCI over that of the CCI and ECI for risk stratification of patients with other neurovascular diseases. METHODS: The authors queried the National (Nationwide) Inpatient Sample database for the years 2002-2012 to compare the accuracy of the previously validated NCI with that of the CCI and ECI with respect to predicting outcomes for patients who had an arteriovenous malformation, a ruptured intracranial aneurysm, carotid artery stenosis, or dural arteriovenous fistula and who underwent surgical intervention. RESULTS: For patients with an arteriovenous malformation, the NCI outperformed the CCI and ECI in predicting poor outcome, hospital length of stay (LOS), and total cost but was equivalent to the CCI in predicting death. For patients with a ruptured intracranial aneurysm, the NCI outperformed the ECI and CCI in predicting death, poor outcome, LOS, and total cost. For patients with carotid artery stenosis, the NCI outperformed the ECI and CCI in predicting LOS, but it was equivalent to the ECI in predicting death and total cost and inferior to the CCI in predicting poor outcome (p < 0.002 for all). An insufficient number of patients with dural arteriovenous fistula who underwent surgical intervention were available for analysis (n < 10), and they therefore were excluded from study. For 11 of 12 metrics, the NCI was the significantly more efficient model. CONCLUSIONS: The NCI outperforms the CCI and ECI by providing more appropriate and efficient risk stratification of patients regarding death, outcome, LOS, and cost. Given this finding, the NCI should be used for retrospective reviews of patient outcomes instead of the CCI or ECI.
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Affiliation(s)
- William C Newman
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Paul S Kubilis
- 2Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Brian L Hoh
- 2Department of Neurosurgery, University of Florida, Gainesville, Florida
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 803] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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16
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Bennett KM, Hoch JR, Scarborough JE. Predictors of 30-day postoperative major adverse clinical events after carotid artery stenting: An analysis of the procedure-targeted American College of Surgeons National Surgical Quality Improvement Program. J Vasc Surg 2017; 66:1093-1099. [DOI: 10.1016/j.jvs.2017.04.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
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17
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Carotid artery stenting is associated with a higher incidence of major adverse clinical events than carotid endarterectomy in female patients. J Vasc Surg 2017; 66:794-801. [DOI: 10.1016/j.jvs.2017.03.413] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/01/2017] [Indexed: 11/23/2022]
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18
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Hung CS, Yeh CF, Lin MS, Chen YH, Huang CC, Li HY, Kao HL. Impact of hospital volume on long-term neurological outcome in patients undergoing carotid artery stenting. Catheter Cardiovasc Interv 2017; 89:1242-1249. [PMID: 28296028 DOI: 10.1002/ccd.26989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 01/28/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The impact of hospital volume on long-term outcome after carotid artery stenting (CAS) remains unknown. OBJECTIVES We designed a nationwide cohort study to elucidate the impact of hospital volume on the incidence of stroke after CAS. METHODS The Taiwan National Health Insurance Research database was used to identify all patients admitted for CAS from 2008 to 2012. We defined high-volume hospitals as those performing more than 20 CAS per year. The primary outcome was new ischemic stroke after discharging from the index CAS. Propensity score-matching was performed to create two matched groups for comparison. RESULTS A total of 3,248 patients underwent 3,576 CAS procedures were enrolled. There were 56 hospitals performing CAS during the study period. Among these 3,248 patients, 2,226 (68.5%) were performed in high-volume hospitals. A propensity score-matching created two groups with 1,000 patients in each group. During a median of 2.06 years follow-up, 35 (3.5%) and 52 (5.2%) patients in high-volume hospitals and low-volume hospitals developed new ischemic stroke 30 days after discharging from the index CAS, respectively (for low-volume hospitals, HR 1.50, 95%CI 1.06-2.12, P = 0.023). The use of embolic protection device did not result in different periprocedural or postdischarge strokes. The periprocedural (within 30 days after CAS) ischemic stroke or all-cause mortality rates during follow-up period were similar between two groups. CONCLUSIONS CAS performed in high-volume hospitals was associated with less new ischemic stroke after discharging from the index CAS, compared to those in low-volume hospitals. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Chi-Sheng Hung
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Fan Yeh
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Hsien Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Chang Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Yuan Li
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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AbuRahma AF, Campbell JE, Hariri N, AbuRahma J, Dean LS, Bates MC, Nanjundappa A, Stone PA, O'vil A. Clinical Outcome of Carotid Artery Stenting According to Provider Specialty and Volume. Ann Vasc Surg 2017; 44:361-367. [PMID: 28495538 DOI: 10.1016/j.avsg.2017.04.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/28/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several studies have demonstrated better outcomes for carotid endarterectomy with high-volume hospitals and providers. However, only a few studies have reported on the impact of operator specialty/volume on the perioperative outcome of carotid artery stenting (CAS). This study will analyze the correlation of CAS outcomes and provider specialty and volume. METHODS Prospectively collected data of CAS procedures done at our institution during a 10-year period were analyzed. Major adverse events (MAEs; 30-day stroke, myocardial infarction, and death) were compared according to provider specialty (vascular surgeons [VSs], interventional cardiologists [ICs], interventional radiologists [IRs], interventional vascular medicine [IVM]), and volume (≥5 CAS/year vs. <5 CAS/year). RESULTS Four hundred fourteen CAS procedures (44% for symptomatic indications) were analyzed. Demographics/clinical characteristics were somewhat similar between specialties. MAE rates were not significantly different between various specialties: 3.1% for IC, 6.3% for VS, 7.1% for IR, 6.7% for IVM (P = 0.3121; 6.3% for VS and 3.8% for others combined, P = 0.2469). When physicians with <5 CAS/year were excluded: the MAE rates were 3.1% for IC, 4.7% for VS, and 6.7% for IVM (P = 0.5633). When VS alone were compared with others, and physicians with <5 CAS/year were excluded, the MAE rates were 4.7% for VS vs. 3.6% for non-VS (P = 0.5958). The MAE rates for low-volume providers, regardless of their specialty, were 9.5% vs. 4% for high-volume providers (P = 0.1002). Logistic regression analysis showed that the odds ratio of MAE was 0.4 (0.15-1.1, P = 0.0674) for high-volume providers, while the odds ratio for VS was 1.3 (0.45-3.954, P = 0.5969). CONCLUSIONS Perioperative MAE rates for CAS were similar between various providers, regardless of specialties, particularly for vascular surgeons with similar volume to nonvascular surgeons. Low-volume providers had higher MAE rates.
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Affiliation(s)
- Ali F AbuRahma
- Charleston Area Medical Center Vascular Center of Excellence, Charleston, WV; Department of Surgery, West Virginia University, Charleston, WV.
| | - John E Campbell
- Department of Surgery, West Virginia University, Charleston, WV
| | - Nizar Hariri
- Department of Surgery, West Virginia University, Charleston, WV
| | - Joseph AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV
| | - L Scott Dean
- CAMC Health Education and Research Institute, Charleston, WV
| | - Mark C Bates
- Charleston Area Medical Center Vascular Center of Excellence, Charleston, WV; Department of Surgery, West Virginia University, Charleston, WV
| | | | - Patrick A Stone
- Department of Surgery, West Virginia University, Charleston, WV
| | - Ace O'vil
- Department of Surgery, West Virginia University, Charleston, WV
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20
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Kouvelos G, Koutsoumpelis A, Arnaoutoglou E, Nassis C, Bouris V, Peroulis M, Papadopoulos G, Matsagkas M. The effect of increasing operator experience on procedure-related characteristics in patients undergoing carotid artery stenting. Vascular 2017; 25:488-496. [PMID: 28142887 DOI: 10.1177/1708538117691431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To evaluate the efficacy and safety of carotid artery stenting for the treatment of severe carotid artery disease in our department and to investigate the effect of increasing operator experience on perioperative and procedure-related characteristics. Methods From January 2007 to February 2015 200 patients underwent 207 endovascular procedures for carotid artery stenosis. Of all, 113 arteries (56.5%) were symptomatic. Significant changes across time were calculated with the use of Change Point analysis using bootstrap and mean squared error estimates. Results The technical success was 98.6% (204/207 cases). Thirty-day neurological events included stroke in four patients (2%) and transient ischemic attack in two (1%). None of the patients died during the first 30 days. The most significant change of radiation duration occurred after the 33rd patient with a decrease from 25.31 min to 12.31 min, while for the total operative time that change occurred between the 31st and 33rd patient where mean operation time decreased from 88.89 min to 49.22 min. The most significant change of contrast media used occurred at the 40th patient with a decrease from 91.58 ml to 62 ml. During a mean follow-up period of 42 ± 20.02 months none of the patients experienced any cerebrovascular event. There was one case of significant recurrent stenosis, which was successfully treated by endovascular means. Conclusions Endovascular treatment of carotid artery stenosis performed in a single center with the use of a cerebral protection device seems to consist a safe therapeutic choice with acceptable results, within the referenced benchmarks proposed in the latest guidelines. Certain perioperative parameters such as the amount of contrast media used, the fluoroscopy and operation time, seem to decline overtime indicating increasing operator's experience. A number of performed cases above 40 was related to the significant decrease of those parameters and may represent the learning curve of the procedure.
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Affiliation(s)
- George Kouvelos
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
| | - Andreas Koutsoumpelis
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
| | - Eleni Arnaoutoglou
- 2 Department of Anesthesiology, University of Ioannina, Medical School, Ioannina, Greece
| | - Christos Nassis
- 3 Department of Neurology, Ioannina University Hospital, Ioannina, Greece
| | - Vasilios Bouris
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
| | - Michalis Peroulis
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
| | - George Papadopoulos
- 2 Department of Anesthesiology, University of Ioannina, Medical School, Ioannina, Greece
| | - Miltiadis Matsagkas
- 1 Department of Surgery, Vascular Surgery Unit, University of Ioannina, Medical School, Ioannina, Greece
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21
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Predictors of poor outcome after carotid intervention. J Vasc Surg 2016; 64:663-70. [DOI: 10.1016/j.jvs.2016.03.428] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/14/2016] [Indexed: 01/10/2023]
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22
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Panaich SS, Patel N, Agnihotri K, Arora S, Savani C, Sonani R, Patel NJ, Patel SV, Solanki S, Schreiber T, Grines C, Badheka AO. Volume-outcome relationship for peripheral endovascular interventions: a review of existing literature. Expert Rev Pharmacoecon Outcomes Res 2016; 16:103-9. [PMID: 26732517 DOI: 10.1586/14737167.2016.1138859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The incidence and prevalence of peripheral vascular disease has been increasing. When coexistent with coronary artery disease (CAD), it has shown to predict higher mortality along with poorer quality-of-life consequently leading to a marked increase in healthcare costs. Broadly, there has been an increase in utilization of endovascular techniques in the management of peripheral vascular diseases. An inverse relation between volume and outcomes has been noted in these procedures. Additionally, improved resource utilization has also been noted with higher hospital and operator volumes. This has led to proposals to regionalize these procedures to high volume hospitals. There have also been calls to introduce the idea of having a set threshold of procedures for providers. This review presents an overview of published literature on the volume-outcome relationship affecting the outcomes of peripheral endovascular procedures.
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Affiliation(s)
| | - Nilay Patel
- b Internal Medicine Department , Saint Peter's University Hospital , New Brunswick , NJ , USA
| | - Kanishk Agnihotri
- b Internal Medicine Department , Saint Peter's University Hospital , New Brunswick , NJ , USA
| | - Shilpkumar Arora
- c Internal Medicine Department , Mount Sinai St. Luke's Roosevelt Hospital , New York , NY , USA
| | - Chirag Savani
- d Epidemiology Department , New York Medical College , Valhalla , NY , USA
| | - Raj Sonani
- e Public Health Department , Emory University School of Medicine , Atlanta , GA , USA
| | - Nileshkumar J Patel
- f Cardiology Department , University of Miami Miller school of Medicine , Miami , FL , USA
| | - Samir V Patel
- g Internal Medicine Department , Western Reserve Health System , Youngstown , OH , USA
| | - Shantanu Solanki
- h Internal Medicine Department , Westchester Medical center at New York Medical College , Valhalla , NY , USA
| | | | - Cindy Grines
- i Cardiology Department , Detroit Medical Centre , Detroit , MI , USA
| | - Apurva O Badheka
- j Cardiology Department , The Everett Clinic , Everett , WA , USA
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23
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Bhatt P, Patel NJ, Patel A, Sonani R, Patel A, Panaich SS, Thakkar B, Savani C, Jhamnani S, Patel N, Patel N, Pant S, Patel S, Arora S, Dave A, Singh V, Chothani A, Patel J, Ansari M, Deshmukh A, Bhimani R, Grines C, Cleman M, Mangi A, Forrest JK, Badheka AO. Impact of Hospital Volume on Outcomes of Endovascular Stenting for Adult Aortic Coarctation. Am J Cardiol 2015; 116:1418-24. [PMID: 26471501 DOI: 10.1016/j.amjcard.2015.07.066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 07/29/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
Abstract
Use of transcatheter endovascular stenting has been increasing in the treatment of coarctation of aorta (CoA). The present study was undertaken on adults with CoA who underwent stent placement from 2000 to 2011 to analyze the relation of hospital volumes to the outcomes of stenting in adults with CoA. It was a retrospective study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2000 to 2011 and identified subjects using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code of 747.10 (CoA). Annual hospital volume was calculated using unique hospital identifiers. Weights provided by the Nationwide Inpatient Sample were used to generate national estimates. A total of 105 (weighted 521) subjects were identified with International Classification of Diseases, Ninth Revision, code of 39.90 (Endovascular stent). Hospital volumes were divided into tertiles. We compared the highest tertile (≥3 procedures annually) with other tertiles (<3 procedure annually). The composite outcomes of the analysis were procedure-related complications, length of stay (LOS), and cost in relation to the hospital volume. No inhospital death was reported in either group. Hospitals with ≥3 procedures annually had significantly lower incidence of complications (9.5% vs 23.0%) compared to the hospitals with <3 procedures annually (p-value 0.002). Similar results were obtained after multivariate regression analysis in relation to hospital volume. Shorter LOS and lower cost were observed with annual hospital volume of ≥3 procedures. In conclusion, stenting adults for CoA is remarkably safe, and the outcomes of the procedure have improved in centers with annual hospital volume of ≥3 procedures. There is also decreasing trend of procedure-related complications, shorter LOS, and lower costs compared to centers with annual volume <3 procedures.
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Agarwal S, Tuzcu EM, Kapadia SR. Choice and Selection of Treatment Modalities for Cardiac Patients: An Interventional Cardiology Perspective. J Am Heart Assoc 2015; 4:e002353. [PMID: 26486167 PMCID: PMC4845140 DOI: 10.1161/jaha.115.002353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Shikhar Agarwal
- Section of Interventional CardiologyHeart and Vascular Institute, Cleveland ClinicClevelandOH
| | - E. Murat Tuzcu
- Section of Interventional CardiologyHeart and Vascular Institute, Cleveland ClinicClevelandOH
| | - Samir R. Kapadia
- Section of Interventional CardiologyHeart and Vascular Institute, Cleveland ClinicClevelandOH
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25
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Agarwal S. Factors affecting outcome of carotid artery stenting. Am J Cardiol 2014; 114:1464. [PMID: 25201212 DOI: 10.1016/j.amjcard.2014.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/08/2014] [Indexed: 11/26/2022]
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