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Nazari P, Golnari P, Ansari SA, Cantrell DR, Potts MB, Jahromi BS. Unplanned readmission after carotid stenting versus endarterectomy: analysis of the United States Nationwide Readmissions Database. J Neurointerv Surg 2023; 15:242-247. [PMID: 35169035 PMCID: PMC9985736 DOI: 10.1136/neurintsurg-2021-018523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospital readmissions are costly and reflect negatively on care delivered. OBJECTIVE To have a better understanding of unplanned readmissions after carotid revascularization, which might help to prevent them. METHODS The Nationwide Readmissions Database was used to determine rates and reasons for unplanned readmission following carotid endarterectomy (CEA) and carotid artery stenting (CAS). Trends were assessed by annual percent change, modified Poisson regression was used to estimate risk ratios (RR) for readmission, and propensity scores were used to match cohorts. RESULTS Analysis yielded 522 040 asymptomatic and 55 485 symptomatic admissions for carotid revascularization between 2010 and 2015. Higher 30-day readmission rates were noted after CAS versus CEA in both symptomatic (9.1% vs 7.7%, p<0.001) and asymptomatic (6.8% vs 5.7%, p<0.001) patients. Readmission rates trended lower over time, significantly so for 90-day readmissions in symptomatic patients undergoing CEA. The most common cause for 30-day readmission was stroke in both symptomatic (5.5%) and asymptomatic (3.9%) patients. Factors associated with a higher risk of readmission included age over 80; male gender; Medicaid health insurance; and increases in severity of illness, mortality risk, and comorbidity indices. Analysis of matched cohorts showed that CAS had higher readmission than CEA (RR=1.14 (95% CI 1.06 to 1.22); p<0.001) only in asymptomatic patients. Adverse events during initial admission which predicted 30-day readmission included acute renal failure and acute respiratory failure in asymptomatic patients; hematoma and cardiac events were additional predictive adverse events in symptomatic patients. CONCLUSIONS Readmission is not uncommon after carotid revascularization, occurs more often after CAS, and is predicted by baseline factors and by preventable adverse events at initial admission.
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Affiliation(s)
- Pouya Nazari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pedram Golnari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sameer A Ansari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Donald R Cantrell
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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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: 184] [Impact Index Per Article: 184.0] [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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Qumsiyeh Y, Siada S, Yan Y, Dirks R, Ali A, Daneshvar M, O'Banion LA. Carotid endarterectomy is safe for octogenarians. J Vasc Surg 2023; 77:176-181. [PMID: 35940506 DOI: 10.1016/j.jvs.2022.07.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/18/2022] [Accepted: 07/25/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Carotid endarterectomy (CEA) has demonstrated superior results in stroke risk reduction for patients with symptomatic and asymptomatic high-grade carotid stenosis. However, this benefit has long been questioned for the elderly and high-risk populations. In the present study, we aimed to provide high-volume, single-institution data with long-term follow-up examining the risk factors for postoperative stroke and stroke-free survival stratified by age for asymptomatic and symptomatic patients undergoing CEA. METHODS A single-institution retrospective review of 840 consecutive patients who had undergone CEA from 2011 to 2018 was performed, inclusive of both symptomatic and asymptomatic operative indications. The primary end point was perioperative stroke within 30 days of surgery. The secondary end points were late stroke, death, and myocardial infarction. Patients aged >80 years were compared with those aged <80 years to examine freedom from stroke and death. Statistically significant differences were defined as those with P < .05. RESULTS A total of 840 patients were evaluated with a median follow-up of 416 ± 1244 days. Of the 840 patients, 499 (59%) were men, and 604 (72%) were White. The mean age was 72 ± 9 years, with 202 (24%) aged ≥80 years. CEA was performed for symptomatic disease in 305 patients (36%), of whom 143 (47%) had had strokes and 162 (53%) had had transient ischemic attacks. The overall 30-day postoperative stroke rate was 1.0% (eight patients; 0.6% for asymptomatic and 1.6% for symptomatic; P = .147). Compared with younger patients, octogenarians had had a similar stroke rate after CEA (1.5% vs 0.8%; P = .407). Hispanic race was an independent risk factor for postoperative stroke. White race and preoperative statin use both appeared to be protective. Kaplan-Meier survival curves demonstrated decreased a 5-year stroke-free survival in patients aged ≥80 years (P = .031). However, overall, the estimated 5-year survival was similar to the U.S. general population across both age groups. CONCLUSIONS CEA for octogenarians is safe and effective for both symptomatic and asymptomatic populations with excellent 30-day outcomes and long-term survival mirroring that of the general population.
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Affiliation(s)
- Yazen Qumsiyeh
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA.
| | - Sammy Siada
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
| | - Yueqi Yan
- Biostatistics and Data Support Center, University of California, Merced, CA
| | - Rachel Dirks
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
| | - Amna Ali
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
| | - Meelod Daneshvar
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
| | - Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco-Fresno, Fresno, CA
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Mehta A, Patel PB, Bajakian D, Schutzer R, Morrissey N, Malas M, Schermerhorn M, Patel VI. Transcarotid Artery Revascularization Versus Carotid Endarterectomy and Transfemoral Stenting in Octogenarians. J Vasc Surg 2021; 74:1602-1608. [PMID: 34082003 DOI: 10.1016/j.jvs.2021.05.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/01/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Transfemoral carotid artery stenting (TFCAS) has higher combined stroke and death rates in elderly patients with carotid artery stenosis compared with carotid endarterectomy (CEA). However, transcarotid artery revascularization (TCAR) may have similar outcomes to CEA. This study compared outcomes after TCARs relative to those after CEAs and TFCAS, focusing on elderly patients. METHODS We included all patients with carotid artery stenosis, and no prior endarterectomy or stenting, who underwent either a CEA, TFCAS, or TCAR in the Vascular Quality Initiative from September 2016 (TCAR commercially available) to December 2019. We categorized patients into age decades: 60-69 years, 70-79 years, and 80-90 years. Outcomes included 30-day and one-year composite rates of stroke or death. Cox-proportional hazards models evaluated both outcomes after adjusting for patient demographics, clinical factors, symptomatology, hospital CEA volume, and clustering. RESULTS We identified 33,115 patients who underwent either a CEA, TFCAS, or TCAR for carotid artery stenosis (35% in their 60s, 44% in their 70s, and 21% in their 80s), where half (50%) were symptomatic. The majority of patients had CEAs (80%), followed by TFCAS (11%) and then TCARs (9.1%). The overall rate of 30-day stroke/death was 1.5% and of one-year stroke/death was 4.4%. Octogenarians had the highest 30-day and one-year stroke/death rates relative to their peers (2.3% and 6.3%, respectively). Among all patients, the adjusted hazards of TCARs relative to CEAs was similar for 30-day stroke/death (HR 1.10 [95%-CI 0.75-1.62]) and slightly higher for one-year stroke/death (HR 1.34 [1.02-1.76]). Among octogenarians, however, the adjusted hazards of TCARs relative to CEAs was similar for both 30-day stroke/death (HR 1.12 [0.59-2.13]) and one-year stroke/death (HR 1.28 [0.85-1.94]). TFCAS relative to CEAs had higher hazards of both 30-day stroke/death (HR 1.78 [1.10-2.89]) and one-year stroke/death (HR 1.85 [1.35-2.54]) in octogenarians. CONCLUSIONS TCARs had similar outcomes relative to CEAs among octogenarians with respect to 30-day and one-year rates of stroke/death. TCAR may serve as a promising less-invasive treatment for carotid disease in older patients who are deemed high anatomic, surgical, or clinical risk for CEAs.
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Affiliation(s)
- Ambar Mehta
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY
| | - Priya B Patel
- Division of General Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Danielle Bajakian
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY
| | - Richard Schutzer
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY
| | - Nicholas Morrissey
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Virendra I Patel
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY.
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