Adverse events are not increased with trainee participation in transcarotid revascularization

Outcomes of Transcarotid Artery Revascularization Stratified by Institutional Designation: Academic Versus Community Hospitals

BACKGROUND

The extent of practice setting's influence on transcarotid artery revascularization (TCAR) outcomes is not yet established. This study seeks to assess and compare TCAR outcomes in academic and community-based healthcare settings.

METHODS

Retrospective review of prospectively maintained, systemwide TCAR databases from 2 institutions was performed between 2015 and 2022. Patients were stratified based on the setting of surgical intervention (i.e., academic or community-based hospitals). Relevant demographics, medical conditions, anatomic characteristics, intraoperative and postoperative courses, and adverse events were captured for multivariate analysis.

RESULTS

We identified 973 patients who underwent TCAR, 570 (58.6%) were performed at academic and 403 (41.4%) at community-based hospitals. An academic facility was defined as a designated teaching hospital with 24/7 service-line coverage by a trainee-led surgical team. Baseline comorbidity between cohorts were similar but cases performed at academic institutions were associated with increased complexity, defined by high cervical stenosis (P < 0.001), prior dissection (P < 0.01), and prior neck radiation (P < 0.001). Intraoperatively, academic hospitals were associated with longer operative time (67 min vs. 58 min, P < 0.001), higher blood loss (55 mLs vs. 37 mLs, P < 0.001), and longer flow reversal time (9.5 min vs. 8.4 min, P < 0.05). Technical success rate was not statistically different. In the 30-day perioperative period, we observed no significant difference with respect to reintervention (1.5% vs. 1.5%, P ≥ 0.9) or ipsilateral stroke (2.7% vs. 2.0%, P = 0.51). Additionally, no difference in postoperative myocardial infarction (academic 0.7% vs. community 0.2%, P < 0.32), death (academic 1.9% vs. community 1.4%, P < 0.57), or length of stay (1 day vs. 1 day, P < 0.62) was seen between the cohorts.

CONCLUSIONS

Cases performed at academic centers were characterized by more challenging anatomy, more frequent cardiovascular risk factors, and less efficient intraoperative variables, potentially attributable to case complexity and trainee involvement. However, there were no differences in perioperative outcomes and adverse events between the cohorts, suggesting TCAR can be safely performed regardless of practice setting.

The impact of an anesthesia residency teaching service on anesthesia-controlled time and postsurgical patient outcomes: a retrospective observational study on 15,084 surgical cases

BACKGROUND

Limited data exists regarding the impact of anesthesia residents on operating room efficiency and patient safety outcomes. This investigation hypothesized that supervised anesthesiology residents do not increase anesthesia-controlled or prolonged extubation times compared to supervised certified registered nurse anesthetists (CRNA)/certified anesthesiologist assistants (CAA) or anesthesiologists working independently. Secondary objectives included differences in critical outcomes such as intraoperative hypotension, cardiac and pulmonary complications, acute kidney injury, and mortality.

METHODS

This retrospective single-center 24-month (January 1, 2020- December 31, 2021) cohort focused on primary outcomes of anesthesia-controlled times and prolonged extubation (>15 min) with additional assessment of secondary patient outcomes in adult patients having general anesthesia with an endotracheal tube or laryngeal mask airway for elective non-cardiac surgery. The study excluded sedation, obstetric, endoscopic, ophthalmology, and non-operating room procedures. Procedures were divided into three groups: anesthesiologists working solo, anesthesiologists supervising residents, or anesthesiologists supervising CRNA/CAAs. After univariate analysis, multivariable models were constructed to control for the univariate cofactor differences in the primary and secondary outcomes.

RESULTS

A total of 15,084 surgical cases met the inclusion criteria for this study for the three different care models: solo anesthesiologists (1,204 cases), anesthesiologist/resident pairing (3,146 cases), and anesthesiologist/CRNA/CAA (14,040 cases). Before multivariate analysis, the resident group exhibited longer anesthesia-controlled times (median, [interquartile range], 26.1 [21.7-32.0], p < 0.001), compared to CRNA/CAA (23.9 [19.7-29.5]), and attending-only surgical cases (21.0 [17.9-25.4]). After adjusting for covariates in a general linear regression model (age, BMI, ASA classification, comorbidities, arterial line insertion, surgical service, and surgical location), there were no significant differences in the anesthesia-controlled times between the provider groups. Prolonged extubation times (>15 min) were significantly less common in the anesthesiologist-only group compared to the other groups (p < 0.001). Despite these time differences, there were no clinically significant differences among the groups in postoperative pulmonary or cardiac complications, renal impairment, or the 30-day mortality rate of patients.

CONCLUSION

Anesthesia residents do not increase anesthesia-controlled operating room times or adversely affect clinically relevant patient outcomes compared to anesthesiologists working independently or supervising certified registered nurse anesthetists or certified anesthesiologist assistants.