Improved quality of life among patients with symptomatic carotid artery disease undergoing carotid endarterectomy

A Delphi Consensus Study on Undergoing Carotid Endarterectomy: Patient Reported Outcome Measures

OBJECTIVE

Currently, evidence is lacking for disease specific patient reported outcome measures (PROMs) for use in atherosclerotic carotid artery stenosis (either symptomatic or asymptomatic) submitted to carotid endarterectomy (CEA). This study aimed to obtain expert consensus on the most important items to include in a PROM designed to capture the impact of atherosclerotic carotid artery stenosis and its treatment on health related quality of life.

METHODS

A three round modified Delphi consensus study was performed. A mixed expert Delphi panel of doctors (international panel of dedicated vascular surgeons and neurologists) and patients (either symptomatic or asymptomatic patients meeting criteria for carotid artery revascularisation) was implemented. The aim was to obtain pre-defined consensus on items in four pre-defined domains: generic, quality of life, symptom related, and treatment related. Consensus was reached in rounds two and three with > 70% overall expert agreement.

RESULTS

The experts agreed on 23 items (out of 49) which were distributed as follows: five in the generic, six in the quality of life, six in the symptom, and six in the treatment related domain. Interestingly, comparing the items that reached consensus in this study, with the generic and disease specific PROMs previously used in carotid artery disease investigation, the only constant items were "difficulty with walking" and "ability to perform daily activities" included in the symptom domain. Considering the items that reached expert consensus in the additional domains, emphasis was given to the impact of the diagnosis, treatment and follow up, and to fear or concern "about the future" and "about severe stroke". In the treatment domain emphasis was also attained on the side effects, long term patient satisfaction, and on the information provided regarding treatment options.

DISCUSSION

As hard clinical outcomes become increasingly rare, assessment of the impact of CEA becomes increasingly difficult. The consensus reached provides a newly defined disease specific PROM that warrants independent validation in specific populations in the future.

Health-related quality of life in ischaemic stroke survivors after carotid endarterectomy (CEA) and carotid artery stenting (CAS): confounder-controlled analysis

Introduction

Atherosclerotic carotid artery stenosis (CS)-related strokes are a significant overall stroke burden contributor.

Aim

To evaluate the effect of surgical (carotid endarterectomy – CEA) vs. percutaneous (neuroprotected carotid artery stenting – CAS) carotid revascularization on health-related quality of life (HRQoL) in stroke survivors: analysis controlled for major HRQoL determinants beyond strokes.

Material and methods

Our database of 856 carotid revascularization procedures (48.7% symptomatic CS) performed over 3 years showed 42 pairs (CEA-CAS) of right hemispheric stroke patients matched for age, sex, marital and educational status, hyper-tension, heart failure and diabetes, who underwent uneventful carotid revascularization, experienced no major adverse clinical events, and completed the Short Form Outcome Study (SF-36) questionnaire within 7 days before, 14 days after, 6 months after, and 12 months after carotid revascularization.

Results

Baseline HRQoL was low and similar in both groups (30.8 ±4.6% vs. 29.1 ±3.9%, p = 0.68; data given for CEA vs. CAS). National Institute of Health Stroke Scale chronic severity was 5.4 ±2.8 vs. 5.9 ±3.1 (p = 0.44). Revascularization was associated with a major HRQoL improvement, that was significantly greater in CAS (60.4 ±9.2% vs. 71.5 ±6.2%, p < 0.001). At 6 months the CEA-CAS difference was narrower (70.7 ±9.7% vs. 74.6 ±5.9%, p = 0.026), becoming statistically insignificant at 12 months (72.6 ±6.7% vs. 75.1 ±5.1%, p = 0.062). The early CEA-CAS difference was driven by less bodily pain and better physical functioning/role-physical plus better role-emotional and higher general well-being scores in CAS (p < 0.05).

Conclusions

Carotid revascularization has a major positive impact on stroke survivor patient-reported HRQoL. The improvement is initially greater in CAS, with the remaining difference small at 12 months and statistically insignificant.

Predictors of Health-Related Quality of Life for Mental Health Status in Patients After Carotid Endarterectomy

OBJECTIVE

To evaluate the health-related quality of life (HRQoL) in patients with carotid stenosis and identify the predictive factors that affect the mental health status in patients after carotid endarterectomy (CEA).

METHODS

A retrospective study was conducted of all patients presenting with carotid stenosis treated with CEA. Clinical data and demographics were collected for logistic regression analysis. The Short-Form General Health Survey Questionnaire (SF-36) and minimum clinically important difference were used to evaluate the mental health status of patients after CEA.

RESULTS

Between January 2015 and September 2017, a total of 224 patients were enrolled in this study. At baseline, mean SF-36 scores for physical component summary (PCS) (60.1 ± 26.3) and mental component summary (MCS) (59.9 ± 23.1) were significantly lower in patients with carotid disease than the urban population (P < 0.001). After CEA, the SF-36 scores for PCS (62.5 ± 21.7) and MCS (68.4 ± 18.7) were increased. However, only the improvement of MCS achieved minimum clinically important difference. After multiple logistic regression analysis, contralateral stenosis ≥50% (odds ratio [OR] 0.266, 95% confidence interval [CI] 0.141-0.517) and hoarseness (OR 0.160, 95% CI 0.040-0.644) had negative effects on MCS. Dizziness improvement had positive effects on MCS (OR 2.882, 95% CI 1.569-5.298).

CONCLUSIONS

Contralateral stenosis, dizziness improvement, and hoarseness may be the predictive factors that affect the mental health status in patients after CEA.

Quality of life after carotid endarterectomy: a review of the literature

Strokes are one of the leading causes of death, morbidity, and disability worldwide, mainly among elderly people. It is also the third most common cause of years of life being lost, indicating a high risk of premature mortality. Revascularisation with endarterectomy (CEA) is effective in reducing the risk of death and strokes in patients with carotid artery stenosis, but the effect of invasive treatment on quality of life (QoL) still needs attention. To shed more light on the patients’ perspective on this health condition, we carried out a review of the literature which aimed to analyze the level of health-related QoL among stroke survivors, with special attention to patients who had been treated with CEA. Strokes significantly reduce the level of QoL, which may subsequently be improved in the course of treatment with CEA. Patients experience a reduced level of QoL in the early postoperative period, but at 1 year following CEA, the level of QoL remains stable and is similar to that of chronically ill patients. The domains of QoL which are most affected are physical and emotional functioning, which also serve as markers for decreased QoL in the long term. Older age and comorbidities are predictors of worse QoL. Stroke survivors require proper care both immediately after a stroke happens and during the long-term rehabilitation. Measurement of QoL and of the determining factors that contribute to a reduced level of QoL, as well as focusing on determinants of QoL in stroke survivors may help to reduce patients’ disability and improve their daily functioning in society as well as reducing the cost of health care.

Patient-reported outcome measures in vascular surgery

Patient-reported outcomes (PROs) after vascular surgery are becoming increasingly important in the current era of health care reform. Although a number of general quality of life instruments exist, vascular disease-specific instruments may provide more targeted data on how patients feel after specific interventions. Here we provide a review of both generic and disease-specific instruments focused on arterial conditions, including peripheral arterial disease, carotid arterial disease, and aortic disease, which have been described in the literature. While many different tools currently exist, there is a paucity of well-validated, specific instruments that accurately reflect functional and objective measures of patients' arterial disease burden. A full understanding of the existing tools available to assess patients' perceived lifestyle impact of their disease and its treatments is essential for both research and clinical purposes, and to highlight the need for additional work on this topic.

Incidence, outcomes, and effect on quality of life of cranial nerve injury in the Carotid Revascularization Endarterectomy versus Stenting Trial

OBJECTIVE

Cranial nerve injury (CNI) is the most common neurologic complication of carotid endarterectomy (CEA) and can cause significant chronic disability. Data from prior randomized trials are limited and provide no health-related quality of life (HRQOL) outcomes specific to CNI. Incidence of CNIs and their outcomes for patients in the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) were examined to identify factors predictive of CNI and their impact on HRQOL.

METHODS

Incidence of CNIs, baseline and procedural characteristics, outcomes, and HRQOL scores were evaluated in the 1151 patients randomized to CEA and undergoing surgery ≤30 days. Patients with CNI were identified and classified using case report forms, adverse event data, and clinical notes. Baseline and procedural characteristics were compared using descriptive statistics. Clinical outcomes at 1 and 12 months were analyzed. All data were adjudicated by two neurologists and a vascular surgeon. HRQOL was evaluated using the Medical Outcomes Short-Form 36 (SF-36) Health Survey to assess general health and Likert scales for disease-specific outcomes at 2 weeks, 4 weeks, and 12 months after CEA. The effect of CNI on SF-36 subscales was evaluated using random effects growth curve models, and Likert scale data were compared by ordinal logistic regression.

RESULTS

CNI was identified in 53 patients (4.6%). Cranial nerves injured were VII (30.2%), XII (24.5%), and IX/X (41.5%), and 3.8% had Horner syndrome. CNI occurred in 52 of 1040 patients (5.0%) receiving general anesthesia and in one of 111 patients (0.9%) operated on under local anesthesia (P = .05). No other predictive baseline or procedural factors were identified. Deficits resolved in 18 patients (34%) at 1 month and in 42 of 52 patients (80.8%) by 1 year. One patient died before the 1-year follow-up visit. The HRQOL evaluation showed no statistical difference between groups with and without CNI at any interval. By Likert scale analysis, the group with CNI showed a significant difference in the difficulty eating/swallowing parameter at 2 and 4 weeks (P < .001) but not at 1 year.

CONCLUSIONS

In CREST, CNI occurred in 4.6% of patients undergoing CEA, with 34% resolution at 30 days and 80.8% at 1 year. The incidence of CNI was significantly higher in patients undergoing general anesthesia. CNI had a small and transient effect on HRQOL, negatively affecting only difficulty eating/swallowing at 2 and 4 weeks but not at 1 year. On the basis of these findings, we conclude that CNI is not a trivial consequence of CEA but rarely results in significant long-term disability.

Influence of internal carotid endarterectomy on patients' life quality

Appropriate treatment of symptomatic carotid artery stenosis can reduce ischemic cerebral strokes' risk and in some cases eliminate neurological symptoms. Endarterectomy is the most common surgical treatment. The aim of the study was to examine the influence of carotid endarterectomy on neurological symptoms and patients' life quality.

MATERIAL AND METHODS

The material comprised of 102 patients who underwent endarterectomy. All of the patients were given a questionnaire with a list of neurological symptoms (vertigos, headaches, left hemiparesis, right hemiparesis, numbness, acroparaesthesia, single syncope, recurrent syncopies, diplopia, tinnitus, concentration disturbances and aphasia) and with a numerical life quality scale to fill in before and a year after the surgery.

RESULTS

Vertigo, headache, single and recurrent syncopies and aphasia as well as cerebral stroke and amaurosis fugax were significantly more rarely observed after endarterectomy. The mean value of patients' life quality evaluated on a 10-point Likert scale after the surgery increased (3.9 vs 6.3).

CONCLUSIONS

A year after carotid endarterectomy patients' life quality improves which is connected with neurological symptoms' regression and no further symptoms' occurrence due to a preventive role of the surgery.

Quality of life after carotid endarterectomy

Background

Most studies documenting beneficial outcomes after carotid endarterectomy (CE) are limited to mortality and morbidity rates, costs, and length of hospital stay (LOS). Few have examined the dependency of patients and how they perceive their own health changes after surgery. The aim of the present study was to evaluate quality of life and independence in activities of daily living (ADL) and to study its determinants.

Methods

Sixty-three patients admitted in the Post Anaesthesia Care Unit (PACU) after CE were eligible for this 14-month follow-up study. Patients were contacted 6 months after discharge to complete a Short Form-36 questionnaire (SF-36) and to have their dependency in ADL evaluated.

Results

Among 59 hospital survivors at 6 months follow-up, 43 completed the questionnaires. Sixty-three percent reported that their general level of health was better on the day they answered the questionnaire than 12 months earlier. Patients had worse SF-36 scores for all domains except bodily pain than a general urban population, and comparison with a group of patients 6 months after surgical ICU discharge showed no differences. Six months after PACU discharge, the Lawton Instrumental Activities of ADL Scale and the Katz Index of ADL demonstrated higher dependency scores (5.9 ± 2.2 versus 4.3 ± 2.4 and 0.3 ± 0.8 versus 0.6 ± 0.9, p < 0.001 and p = 0.047). Sixty-five percent and 33% were dependent in at least one activity in instrumental and personal ADL, respectively. Patients dependent in at least one ADL task had higher Revised Cardiac Risk Index (RCRI) scores (1.0 versus 1.5, p = 0.017). After controlling for multiple comparisons, no significant differences were found.

Conclusion

Patients undergoing CE have improved self-perception of quality of life despite being more dependent. Almost all their scores are worse than those in an urban population. We could identify no predictors of greater dependency in ADL tasks six months after PACU discharge.

Effect of carotid artery stenting on cognitive function in patients with carotid artery stenosis: preliminary results

BACKGROUND AND PURPOSE

Stenosis of the carotid artery may be a cause of reduced cognitive performance that can be ameliorated with placement of a stent. The goal of this study was to measure cognitive performance and speed of psychomotor performance prospectively before and after carotid stent placement.

MATERIALS AND METHODS

Patients referred for stent placement for a unilateral carotid artery stenosis were enrolled in the study. Neuropsychologic testing was performed with a Mini-Mental State Examination, an extended mental status examination, a subjective cognitive status measure, and a psychomotor performance test for speed. The severity of the stenosis was measured on angiograms performed before stent placement. Three months after stent placement, CT angiograms were performed and the neuropsychologic testing was repeated. Differences in neuropsychologic test scores before and after stent placement were calculated and tested for significance with a Student t test.

RESULTS

Seventeen patients with a single unilateral carotid stenosis of more than 50% completed the study. Stenosis of the carotid artery averaged 80% before treatment and 18% after treatment. After stenting, the scores from the extended mental status examination improved significantly. The scores from the subjective cognitive status measure also improved. No significant change was noted in the scores from the Mini-Mental State Examination or in the speed of psychomotor performance.

CONCLUSION

Carotid stent placement in patients with a unilateral stenosis of the carotid artery resulted in significant improvement in cognitive test scores in this highly selected patient group. Further studies are needed to confirm these preliminary observations.

Outcomes studies in cerebrovascular neurosurgery

✓Successfully measuring cerebrovascular neurosurgery outcomes requires an appreciation of the current state-of-the-art epidemiological instruments, their specific relevance to surgical treatments and the underlying pathological entity, and ultimately the right set of questions for the next generation of studies. In this paper the authors address these questions with specific attention to measurement targets, individual modeling scales, and types of studies, all within a conceptual framework for specific disease models in their current state of outcomes modeling in cerebrovascular neurosurgery.

Effect of Carotid Endarterectomy on Patient Evaluations of Cognitive Functioning and Mental and Physical Health

The prophylactic effect of carotid endarterectomy (CEA) against stroke has been well established. As a consequence of the restoration of cerebral blood supply and reduced risk of stroke, cognitive functioning and perceived health may improve. Fifty-one patients with severe atherosclerotic disease of the carotid artery but without history of major stroke completed the Cognitive Failures Questionnaire and the Short Form 36 Health Survey before CEA and 3 and 12 months thereafter. Before CEA, patients reported significant but small deviations from the norm in physical function, general health, and vitality. Small improvements after CEA were observed in the perception of physical role function, general health, vitality, and mental health. Patients also retrospectively noted a slight worsening of health in the year before surgery and some improvement after surgery. Evaluation of cognitive failures in daily life did not change. Demographic or medical characteristics, such as a history of temporary ischemic symptoms, occlusion of the contralateral artery, and shunt use during surgery, did not affect outcome. In conclusion, no negative outcomes and even some limited positive effects in the perception of mental and physical health are to be expected after CEA.