Frequency of Coronary Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting at a Single Tertiary Texas Hospital 2010 to 2016 With Morphologic Studies of the Operatively Excised Specimens

This study examines the frequency of coronary endarterectomy (CE) procedures during coronary artery bypass grafting (CABG), and determines the quantity of plaque in the specimens. Of the 2,268 CABG operations performed from January 2010 to June 2016, 35 patients had CE during CABG. The specimens were incised into 5-mm cross sections, stained by the Movat method, and examined. The number of CEs performed ranged from 0.21% to 4.01%. A total of 140 cm of specimens were examined, and all 140 cm contained considerable quantities of atherosclerotic plaque and narrowed lumens. The quantity of plaque present was similar to or greater than that observed in previously studied patients with fatal coronary artery disease. The frequency of CE during CABG varies greatly in surgeons. The quantity of plaque is enormous, and the lumens are severely narrowed.

The role of surgery when endovascular treatment is considered the first choice therapy for ruptured intracranial aneurysms

AIM

Nowadays endovascular therapy is more and more considered as first choice treatment for ruptured intracranial aneurysms. The aim of this study was to understand the impact that endovascular treatment (EVT), chosen as first therapeutic strategy, has had in the selection of ruptured intracranial aneurysms submitted to surgery at our Institution and what role neurosurgeons still play in this setting.

METHODS

From 1998 to 2002, 272 consecutive patients were treated at the Hospital of Toulouse for ruptured intracranial aneurysms: 222 by embolization and 50 by surgery. The two groups were homogeneous for sex, age and aneurysms multiplicity.

RESULTS

The patients of the surgical group had a worst clinical-radiological status at the treatment time than those treated by EVT. Clipping was performed for different reasons: 16% for failure of attempted EVT; 32% for intracranial hematoma requiring surgical evacuation; 30% for aneurysm morphology unsuitable for EVT and 22% for absence of the endovascular operator. Aneurysms of the middle cerebral artery (MCA) represented the main surgical group. The aneurysms judged unsuitable for EVT and addressed to surgery had often a complex morphology representing a challenge also for surgery. Mid-term outcome is significantly better for patients treated by EVT.

CONCLUSION

The results show that microsurgery continues to have a role in the treatment of ruptured intracranial aneurysms even when EVT is the first choice. The precarious clinical conditions of the patients submitted to surgery and the frequent complexity of their aneurysms explain their worst outcome. This would advise training dedicated vascular Neurosurgeons to guaranty a high level treatment when EVT is not possible.

Results of coronary artery endarterectomy and coronary artery bypass grafting for diffuse coronary artery disease

BACKGROUND

Coronary artery endarterectomy with coronary artery bypass grafting for diffuse coronary artery disease has been associated with increased morbidity and mortality. We evaluated our institutional experience to redefine the role of coronary endarterectomy for diffuse coronary artery disease.

METHODS

From 1985 to 2002 isolated coronary artery endarterectomy with coronary artery bypass grafting was performed in 1,478 consecutive patients. The short-term outcomes were compared with concurrent series of conventional coronary artery bypass graft surgery, and risk factors for adverse outcomes after coronary endarterectomy were identified.

RESULTS

Patients in the coronary endarterectomy group were of higher risk with increased incidence of comorbidities and three-vessel coronary disease. The operative mortality (3.2% versus control 2.2%; p = 0.03) and the incidence of major postoperative morbidity (not significant) were comparable between the groups. Prolonged cardiopulmonary bypass time, recent acute myocardial infarction, redo surgery, and poor ventricular function were important predictors of in-hospital mortality. Vessel endarterectomized, technique of endarterectomy, and cardiopulmonary bypass versus off-pump technique did not alter results. At long-term follow-up, 5-year and 10-year survivals were 83% +/- 5%, and 74% +/- 3%, respectively, and freedom from angina at 5 and 10 years was 75% +/- 5%, and 69% +/- 4%, respectively, with 96% of survivors in New York Heart Association class II.

CONCLUSIONS

In selected patients with diffuse coronary artery disease, coronary endarterectomy can be used as a tool for myocardial revascularization. The operative mortality and major morbidity were comparable or similar to coronary artery bypass grafting, and short-term and long-term results were favorable.

Pro-CAS

BACKGROUND AND PURPOSE

The German Societies of Angiology and Radiology have instituted a prospective registry of carotid angioplasty and stenting (CAS) to limit uncontrolled use of CAS and to collect data about technique and results of CAS outside clinical trials.

METHODS

A total of 38 centers register their patients prospectively before CAS is performed. At discharge, technical details, periprocedural medication, and the clinical course are reported on a standardized form.

RESULTS

During the first 48 months, 3853 planned interventions were recorded, and CAS was actually attempted on 3267 patients of whom 1827 (56%) were symptomatic and 1433 (44%) were asymptomatic. In 3127 (98%) cases, stents were used, of which 2784 (89%) were of the self-expanding type. Other technical aspects such as the use of guiding catheters and protection devices varied widely among the centers. Periprocedural medication rather uniformly included aspirin and clopidogrel before and after CAS and high-dose heparin and atropin during CAS. CAS was successful in 3207 (98%) cases. There was a 0.6% (n=18) mortality rate, a 1.2% (n=38) major stroke rate, and a 1.3% (n=41) minor stroke rate. The combined stroke and death rate was 2.8% (n=90).

CONCLUSIONS

These prospective multicenter data are likely to give a realistic picture of the possibilities and limitations of CAS in the general community. They suggest that CAS may be performed with similar results in the general community as they have been reported by highly specialized centers and in clinical studies.

Pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension: hemodynamic characteristics and changes

OBJECTIVE

To see whether degree of pulmonary hypertension or severity of cardiac failure affect the success of pulmonary thromboendarterectomy (PTE) in chronic thromboembolic pulmonary hypertension.

METHODS

From May 1996 to June 1999, 33 patients, all in New York Heart Association (NYHA) class 3 or 4 were treated with PTE. Preoperative hemodynamic values were: central venous pressure (CVP) 8+/-6 (1-23), mean pulmonary artery pressure (mPAP) 50+/-10 (30-69), cardiac output (CO) 3.3+/-0.9 (1.8-5.2), pulmonary vascular resistance (PVR) 1056+/-344 (523-1659), and right ventricle ejection fraction (RVEF) 12+/-5 (5-21). To establish whether some hemodynamic or cardiac variables correlate with surgical failure (early death or functional non-success), these patients were divided into a low risk or a high risk group for each variable: CVP (<9 or > or =9), mPAP (<50 or > or =50), CO (> or =3.5 or <3.5), PVR (> or =1100 or <1100), and RVEF (> or = 10 or <10). The duration of 3-4 NYHA class period (<24 or > or = 24 months) was also included in the study.

RESULTS

Three patients (9. 1%) died in hospital, one (3.0%) underwent lung transplant shortly after PTE, and in five cases (15.2%) mPAP and PVR at the 3-month follow-up examination corresponded with our definition of functional nonsuccess (mPAP and PVR decreased by less than 40% of preoperative values). One of the five functional nonsuccess patients underwent lung transplant 3 months after the operation and another died 17 months after the operation from a non-related cause. Thus PTE was successful in 24 patients and unsuccessful in nine. None of the hemodynamic variables considered was found to be associated with the disparate outcomes. At the 3-month examination, all surviving patients were in NYHA class 1 or 2 except for three in NYHA class 3. At 2 years, hemodynamic values were: CVP 2+/-2 (0-4), mPAP 16+/-3 (12-21), CO 5.0+/-1.0 (3.4-6.5), PVR 182+/-51 (112-282), and RVEF 35+/-5 (26-40). All differences were significant with respect to baseline values (P<0.001). Preoperative mPAP and RVEF values had a strict linear correlation (R=0.45; P=0.014).

CONCLUSIONS

None of the variables considered was correlated with early death or functional nonsuccess. Neither preoperative severity of pulmonary hypertension nor degree of cardiac failure influenced the outcome of the operation. PTE leads to hemodynamic recovery even in very compromised patients.

[Significant regional differences in the frequency of vascular surgery]

The six health care regions of Sweden were compared with regard to the frequency of vascular surgery for three diagnoses: chronic lower extremity ischaemia, abdominal aorta aneurysm, and carotid stenosis. In 1995, the frequency of intervention for chronic lower extremity ischaemia varied from 26/100,000 of the population in northern Sweden to 68/100,000 in the southern region, the variation being greater for critical limb ischaemia than for intermittent claudication. In the country as a whole, the frequency of abdominal aorta aneurysm surgery increased five-fold from 1987-89 to 1993-95. During 1995, regional figures varied from 4.7 to 8.4 per 100,000 for elective procedures, and from 3.8 to 5.5 per 100,000 for emergency procedures. Overall surgical mortality varied regionally, and emergency surgery mortality differed between regional and county hospitals. Carotid surgery manifested the greatest regional difference in frequency, which was 7-fold greater in the southern than in the northern region, while its overall mean frequency was 6/100,000.

Factors affecting the results of surgery for chronic critical leg ischemia--a nationwide survey. Finnvasc Study Group

PURPOSE

To assess the factors affecting immediate outcome of surgery for chronic critical leg ischemia, especially the influence of surgeon's caseload and hospital volume.

METHODS

The data of Finnvasc registry were retrospectively analyzed. A total of 11,747 surgical vascular reconstructions included 1,761 operations for chronic critical leg ischemia during 1991 to 1994.

RESULTS

The 30-day postoperative leg amputation rate was 7.5% and the mortality rate 4.7%. Diabetes, previous vascular surgery or amputation, preoperative ulcer or gangrene, a surgeon's annual caseload fewer than 10 operations, and hospital volume fewer than 20 operations for chronic critical leg ischemia adversely affected amputation rates. The presence of coronary artery disease and renal dysfunction increased postoperative mortality rates. Both amputation rates and postoperative mortality rates were affected by the type of procedure.

CONCLUSIONS

A surgeon's caseload and hospital volume affect amputation rate, but not mortality rate, in patients operated for chronic critical leg ischemia.

Influence of surgical experience on the results of carotid surgery. The Finnvasc Study Group

OBJECTIVE

To assess the 30-day mortality and morbidity rates related to carotid endarterectomy on a nation-wide basis.

DESIGN

Retrospective cross-sectional study based on vascular registry Finnvasc.

MATERIALS AND METHODS

A total of 17,465 recorded vascular and endovascular procedures included exactly 1600 carotid endarterectomies performed by 104 surgeons in 23 hospitals. Fourteen per cent of the patients were operated on for asymptomatic carotid stenosis.

RESULTS

The combined mortality and permanent stroke rate was 3.3%, without any difference between operations done on symptomatic or asymptomatic patients. There was a clear inverse association between surgeon's carotid case load and poor outcomes in carotid surgery (p < 0.005), the critical patient mass per surgeon and year being 10 operations. There was no association between outcome after carotid surgery and hospital volume of carotid operations.

CONCLUSIONS

Surgeon's experience in carotid surgery clearly improves the results of carotid surgery.

Incorporation of endovascular training into a vascular fellowship program

BACKGROUND

Despite expanding indications for endovascular therapy of peripheral vascular disease, vascular surgeons have largely remained bystanders in the use of this form of treatment for the disease, which is the focus of their profession. Lack of access to training in endovascular techniques is a major obstacle to increasing involvement by vascular surgeons. This paper reports our experience in the endovascular training of vascular surgical fellows without the involvement of radiologists.

METHODS

The results of vascular surgery fellows receiving instruction in endovascular diagnostic and therapeutic procedures from vascular surgery faculty were reviewed.

RESULTS

Endovascular training of vascular surgery fellows exceeded the case levels recommended by all involved societies. A diverse case mix of 355 endovascular diagnostic procedures were performed with a major complication rate of 0.3% and no procedure-related deaths. Two hundred six endovascular interventions were performed, with an initial technical success rate of 96.6%, a 30-day success rate of 93%, no major complications, and an overall intervention-related mortality rate of less than 1%.

CONCLUSIONS

Vascular surgery fellows can receive endovascular training by vascular surgery faculty without the involvement of radiologists and can do so with acceptable success and complication rates. This experience is sufficient to qualify them to perform and teach endovascular therapy in their future practices.

An institutional experience with arterial atheroembolism

Seemingly minor blue-toe lesions resulting from atheroemboli are associated with unstable atherosclerotic plaques, which are at risk for causing recurrent emboli, tissue loss, and potentially death. At Washington University Medical Center, 62 patients (31 males and 31 females), ranging in age from 38 to 89 years (mean 62.8 +/- 11.7 years), were treated for cutaneous manifestations of atheroembolic disease. Most patients (62%) had spontaneous bouts of atheroembolism, but 13 (21%) had recently undergone an inciting invasive radiologic study, 10 (16%) were on anticoagulation therapy, and one (2%) experienced abdominal trauma. In addition to the cutaneous manifestations, 18 patients (29%) also developed coincidental deterioration in renal function and four (6%) had intestinal infarction from atheroemboli. Arteriography in nearly all patients (97%) implicated the aorta and iliac arteries most commonly (80%), with the femoral (13%), popliteal (3%), and subclavian (3%) arteries less frequently incriminated. Forty-two patients underwent bypass grafting procedures (36 anatomic and six extra-anatomic) after exclusion of the native diseased artery, 20 patients had endarterectomies (six with additional bypass grafts), and five patients had no corrective vascular procedures. The 30-day operative mortality rate was 5% in this series. Nineteen patients (31%) required minor amputations, whereas two required major leg amputations. Thus limb salvage was possible in 86 of 88 (98%) limbs. No further episodes of atheroembolism occurred in the involved limbs during follow-up (1 to 53 months, mean 20.2 months). We advocate urgent arteriography and surgical correction or bypass with exclusion of the offending lesion.(ABSTRACT TRUNCATED AT 250 WORDS)

Resolution of vascular steal after pulmonary thromboendarterectomy

Patients who undergo thromboendarterectomy for relief of chronic, major-vessel thromboembolic pulmonary hypertension (CT-E PH) offer a unique opportunity to evaluate potential resolution of hypertensive lesions in the small, nonelastic pulmonary arteries. Prior studies have demonstrated that, postoperatively, these patients commonly develop new perfusion scan defects. This "vascular steal" phenomenon occurs almost exclusively in lung segments which, preoperatively, were normally perfused by lung scan, were served by segmental arteries normal by pulmonary angiography, and, at surgery, were uninvolved with thrombi by direct inspection. In this study, we explored whether this intriguing "steal" phenomenon resolves over time. Twenty-nine patients who returned at 11 or more months following thromboendarterectomy were reevaluated by perfusion lung scan, repeated right heart catheterization (26 patients), and pulmonary angiography (25 patients). "Steal" of one or more lung segments occurred in 79 percent of patients in postoperative, predischarge perfusion scans. All demonstrated postoperative improvement in pulmonary hemodynamics, which persisted at follow-up. Postoperative "steal" improved in 96 percent of patients and 86 percent of the "stolen" segments. The results suggest that, in CT-E PH, hypertensive lesions in the small, nonelastic pulmonary arteries are responsible for "steal," and that, with relief of pulmonary hypertension, these lesions can resolve. The study also indicates that postoperative "steal" does not connote either new thromboembolic events or a poor hemodynamic result.

[Carotid thromboendarterectomy. The authors' personal experience]

Carotid endarterectomy is the most frequently employed surgical intervention in the treatment of strokes due to atherosclerosis obstruction of the blood flow in extracranial carotid district. The presence of cerebrovascular clinical symptoms is accepted indication for surgical treatment. For the patients without symptoms there is, however, not yet a complete agreement on the treatment modalities. The authors believe that, due to the low morbidity and mortality of carotid endarterectomy, a surgical approach can be used in patients in which is present a degree of stenosis > 75% and, moreover, in patients where the degree of stenosis is > 50%, but in which the atherosclerotic plaque is non homogeneous due to the presence of ulceration or hemorrhage. Non invasive ultrasonic techniques constitute the mainstay of the diagnostic procedures for carotid artery disease and in recent years they have led to improved sensitivity and ability in differentiating between the operable carotid stenoses and the inoperable obstructions. With these techniques it is possible to arrive to a 90% diagnostic accuracy. Also the recently introduced angio-RM has comparable results, but the high costs do not make it possible to use it in screening procedures. Many doubts are present regarding the possibility of evaluating the occurrence of neurologic deficits during the surgical procedures. Local anaesthetic techniques are somewhat popular among vascular surgeons in that they allow an immediate evaluation of the neurologic activity of the patients during surgical treatment. However reports have been published in the literature of neurologic deficits arising after the period of test occlusion.

Is the iliac artery a suitable inflow conduit for iliofemoral occlusive disease: an analysis of 514 aortoiliac reconstructions

PURPOSE

The aorta is the conventional inflow source for reconstructions in patients with aortoiliofemoral occlusive disease. In patients with unilateral iliac or femoral disease, femoral-to-femoral bypasses have been used but with less favorable patency rates. The purpose of this study is to evaluate the performance of the unobstructed iliac artery as an inflow source for ipsilateral, contralateral, or bilateral reconstructions in iliofemoral occlusive disease.

METHODS

Over the past 6 years 322 reconstructions have been performed with the iliac artery as the donor vessel. Patients were evaluated for proximal hemodynamically significant lesions by augmented pullout pressures during aortography. Patients who had balloon angioplasty were excluded.

RESULTS

Results were compared with 192 patients who underwent conventional aortodistal bypass operation for occlusive disease during the same period. Both groups were similar in risk factors, age, sex, and indications for operation. For the iliac group the operative mortality rate was 1.6%, and the 30-day patency rate was 97%, similar to those in the aortic group (3.6% and 95%, respectively). Cumulative patency rates at 5 years by life-table analysis were 82% for iliac artery inflow and 77% for aortic inflow reconstructions.

CONCLUSIONS

Our experience suggests that an unobstructed iliac artery is a reasonable inflow source for reconstructions in iliofemoral occlusive disease. The long-term patency rate is comparable to aortodistal bypasses and superior to other extraanatomic bypasses.

Concomitant subclavian and carotid artery disease: the need for a combined surgical correction

To determine the importance of carotid artery disease in patients undergoing revascularization of the proximal subclavian artery for a subclavian steal syndrome, an 18-year experience of 55 patients was reviewed. Concomitant carotid artery disease (> 50% stenosis) was present in 35 patients (Group I: 63.6%). Twenty patients (Group II: 36.4%) had no evidence of hemodynamically significant carotid disease. Twenty-five patients in Group I (Group IA: 71.4%) were treated by endarterectomy (CEA) for all their carotid lesions while one or both carotid lesions were left untreated in 10 patients (Group IB: 28.6%). The actuarial 5-year freedom rate from neurological events was 87.2% in Group IA, 34.9% in Group IB (p < 0.001) and 100% in Group II (Group IB vs. II, p < 0.001; Group IA vs. Group II, p = ns). All untreated carotid lesions had a deleterious effect on the early and late functional results after surgical reconstruction of the subclavian artery. We conclude that the combined correction of subclavian and carotid lesions should be recommended in every case.

Carotid endarterectomy in elderly patients

Between 1971 and 1989, 749 carotid endarterectomies were performed at our institution for symptomatic carotid occlusive disease in patients older than 70 years of age. Of these procedures, 693 were done in patients 71 through 80 years of age, and 56 were done in patients between the ages of 81 and 90 years. The neurologic morbidity and perioperative mortality in the former group were 2.9% and 1.4%, respectively, whereas in the latter group the corresponding values were 5.4% and 0%, respectively. For the entire group, the neurologic morbidity was 3.1% and the mortality was 1.3%. Of the 23 new postoperative neurologic deficits, 19 (83%) occurred in high-risk patients with severe preoperative neurologic or medical risks, and 14 (61%) of these deficits were minor. In selected elderly patients with symptomatic hemodynamically significant carotid occlusive disease, endarterectomy seems to be a safe procedure that is associated with acceptably low perioperative morbidity and mortality.

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

A total of 243 consecutive carotid endarterectomies (CEA) performed at Providence Medical Center in Portland, Oregon, were retrospectively reviewed over a 22-month period. Of these, 137 patients (56%) underwent CEA for asymptomatic disease, 52 (37%) of whom had stenotic lesions of 79% or less. There were 6 deaths (3%) and 12 strokes (5%). Four strokes were in asymptomatic patients. These data prompted development of criteria for CEA: (1) hemisphere-specific transient ischemic attacks, reversible ischemic neurologic deficits, or amaurosis fugax with an appropriate carotid lesion; (2) completed stroke with major recovery and significant carotid stenosis; (3) asymptomatic lesion with greater than 80% stenosis (D+) either by carotid arteriogram or non-invasive lab evaluation; and (4) other indications only with a supporting second opinion from a disinterested vascular surgeon, neurosurgeon or neurologist. A prospective review followed institution of the guidelines. In 21 months, 148 operations were performed, a 36% reduction over the initial study period. Of these, 46 (31%) were for asymptomatic lesions. Two patients (4%) did not fulfill the guideline criteria. There were six strokes (4%) and no deaths. The reduction of CEAs appears to be related to a significant decrease in "inappropriate" operations being performed. Surgeons' familiarity with the data rather than external pressures seems to be the major factor in changing practice patterns. The decrease in stroke/death rate is not statistically significant.

Carotid endarterectomy in Great Britain and Ireland: trends and current practice

Of 309 questionnaires on carotid endarterectomy sent to all surgeons in Great Britain and Ireland who might use this technique, 298 (96 per cent) were returned. In all, 110 (37 per cent) of 298 surgeons performed at least one carotid endarterectomy in 1989; 67 performed less than 10 and 43 greater than 10. In total, these 110 surgeons performed 1417 operations in 1989, a situation that has changed little over 5 years since the previous survey. Transient ischaemic attack and minor stroke remain the main indications for carotid endarterectomy; the operation was hardly ever performed for asymptomatic stenosis. By 1989 almost all surgeons initially assessed prospective patients using a technique less invasive than conventional angiography; duplex scanning was used 'always' or 'sometimes' by 70 per cent of surgeons. While 72 per cent of surgeons in 1984 'always' required conventional angiograms before operation, by 1989 only 21 per cent did so, most now relying on less invasive techniques. During operation there was an increasing use of shunts, carotid sinus nerve blockade and patch closure of the arteriotomy. The overall number of carotid endarterectomies performed annually in Great Britain and Ireland has remained steady over the past 5 years and is relatively low for a population of 60 millions. An increase in the number of surgeons performing the operation is almost entirely accounted for by an increase in those performing less than 10 carotid endarterectomies per year.

Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography

BACKGROUND AND METHODS

In a nationally representative population 65 years of age or older, we have demonstrated that about one quarter of coronary angiographies and upper gastrointestinal endoscopies and two thirds of carotid endarterectomies were performed for reasons that were less than medically appropriate. In this paper we examine whether specific characteristics of patients (age, sex, and race), physicians (age, board-certification status, and experience with the procedure), or hospitals (teaching status, profit-making status, and size) predict whether a procedure will be performed appropriately.

RESULTS

In general, we found that little of the variability in the appropriateness of care (4 percent or less) could be explained on the basis of standard, easily obtainable data about the patient, the physician, or the hospital. For all three procedures, however, performance in a teaching hospital increased the likelihood that the reasons would be medically appropriate (P = 0.09 for angiography, P = 0.30 for endoscopy, and P less than 0.01 for endarterectomy). In addition, angiographies were more often performed for appropriate reasons in older or more affluent patients (P less than 0.01 for both). Being treated by a surgeon who performed a high rather than a low number of procedures decreased the likelihood of an appropriate endarterectomy by one third, from 40 to 28 percent (P less than 0.01).

CONCLUSIONS

Appropriateness of care cannot be closely predicted from many easily determined characteristics of patients, physicians, or hospitals. Thus, for the present, if appropriateness is to be improved it will have to be assessed directly at the level of each patient, hospital, and physician.

Coronary artery reoperations

From June 1976 to June 1989, 138 previously revascularized coronary patients were reoperated upon. This represents 3.28% of all aortocoronary bypass procedures performed during the same period in our institution. Characteristics of this group, risk factors, coronarographic data, perioperative morbidity and mortality are analyzed and compared to the data of the general population undergoing bypass surgery. The mean age of individuals requiring reoperation was 59 years. The mean interval between the two operations reached 73 months (5 to 180 months). Angiographic lesions were more extensive with three-vessel disease in 65% of the reoperated patients. The mean ejection fraction was 55%. A mean of 2.1 bypass grafts per patient were inserted with 60% of cases having an internal mammary artery graft. Perioperative infarction occurred in 8.0% of the reoperations and an intraaortic balloon counterpulsation was necessary in 4.3% at the end of the procedure. Operative mortality was 5%. Symptomatic improvement was obtained in 85% of the cases. In recent years, cardiac transplantation has been performed for 11 previously bypassed patients with severely impaired ventricular function. There were no postoperative deaths. Cardiac transplantation can be considered as a more valuable alternative to repeat coronary artery bypass grafting in such cases.

Does inappropriate use explain small-area variations in the use of health care services?

We studied the relationship of the appropriateness of the use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy to their rates of use in 23 adjacent counties in one state. We measured appropriateness by means of a detailed review of the medical records of Medicare beneficiaries who had the procedures performed in 1981, using present criteria derived by an expert panel. Use rates per 10,000 Medicare enrollees in a county varied from 13 to 158 for coronary angiography, 5 to 41 for carotid endarterectomy, and 42 to 164 for upper gastrointestinal tract endoscopy. Inappropriate use varied by county from 8% to 75% for coronary angiography, from 0% to 67% for carotid endarterectomy, and from 0% to 25% for endoscopy. For coronary angiography, inappropriate use accounted for 28% of the variance in the county rate. For the other two procedures, no significant correlations were found between inappropriateness of use and rate of use. We conclude that little of the variation in the rates of use of these procedures can be explained by inappropriate use.

Relation between surgeons' practice volumes and geographic variation in the rate of carotid endarterectomy

We examined the relation between the number of operative procedures carried out by individual surgeons and the variation in the rate of carotid endarterectomy among Medicare beneficiaries in areas of high, average, and low use of the procedure in 1981. Rates ranged from 48 per 100,000 in the low-use area to 178 per 100,000 in the high-use area. Two variables accounted for most of the differences in the rates: the number of surgeons performing the procedure and the number of endarterectomies performed by surgeons with high practice volumes. Twice as many surgeons in the high-use area and 25 percent more in the average-use area performed carotid endarterectomy as compared with those in the low-use area. If the average number of cases per surgeon had been the same, the differences in the number of surgeons would have accounted for 36 percent and 15 percent, respectively, of the differences in use. Surgeons who performed 15 or more carotid endarterectomies during the year accounted for most of the variation in the rates. These high-volume surgeons represented 15 percent and 17 percent of the surgeons in the areas of high and average use, respectively, as compared with 4 percent of those in the low-use area. They accounted for 60 and 77 percent, respectively, of the additional endarterectomies. Three fourths of the surgeons performing carotid endarterectomies carried out fewer than 10, and 24 percent did only 1. We conclude that most of the geographic variation in the rate of carotid endarterectomy is caused by a few surgeons in high-use areas who perform large numbers of operations.

Risk factors in a community experience with carotid endarterectomy

Experience with 1035 carotid endarterectomies in a single community over a 2-year period was analyzed. Twenty-two surgeons working in six hospitals were involved. All surgeons had full-time or part-time appointments at the University of Rochester, 18 had special interest in vascular surgery, and eight had obtained a certificate of qualification in vascular surgery. Mortality rate was 1.4% (14 deaths), with additional permanent, nonfatal, neurologic morbidity of 3.4%. Mortality and morbidity were independent of surgeon, caseload, or hospital. Age and prior history of myocardial infarction influenced the incidence of postoperative myocardial infarction but not the incidence of death or neurologic morbidity. Factors that increased the risk of postoperative death or neurologic complication included hypertension; contralateral carotid disease as manifested by stroke, endarterectomy, or occlusion; whether the patient was a woman; and symptoms of crescendo ischemia. Lack of preoperative neurologic symptoms was correlated with decreased risk of myocardial infarction and neurologic complications. Overall mortality and neurologic morbidity associated with operation for "asymptomatic stenosis" was 3.1% (seven of 222 cases). However, the incidence of contralateral carotid disease was high in the patients in the asymptomatic group (60%), and all complications in this group occurred in patients with prior contralateral carotid endarterectomy or occlusion (p less than 0.05).

Physician ratings of appropriate indications for three procedures: theoretical indications vs indications used in practice

We previously reported substantial disagreement among expert physician panelists about the appropriateness of performing six medical and surgical procedures for a large number of theoretical indications. A recently completed community-based medical records study of about 4,500 patients who had one of three procedures--coronary angiography, upper gastrointestinal endoscopy, and carotid endarterectomy--shows that many of the theoretical indications are seldom or never used in practice. However, we find that there is also substantial disagreement (5, 25, or 32 per cent for angiography, endoscopy, or endarterectomy, respectively) about the appropriateness of indications used in actual cases if disagreement is defined by first discarding the two extreme of nine ratings, then looking for at least one rating near the bottom (1 to 3) and one near the top (7 to 9) of the 9-point scale. Patients should know that a substantial percentage of procedures are performed for indications about which expert physicians disagree.

The appropriateness of carotid endarterectomy

Carotid endarterectomy is a commonly performed but controversial procedure. We developed from the literature a list of 864 possible reasons for performing carotid endarterectomy, and asked a panel of nationally known experts to rate the appropriateness of each indication using a modified Delphi technique. On the basis of the panel's ratings, we determined the appropriateness of carotid endarterectomy in a random sample of 1302 Medicare patients in three geographic areas who had had the procedure in 1981. Thirty-five percent of the patients in our sample had carotid endarterectomy for appropriate reasons, 32 percent for equivocal reasons, and 32 percent for inappropriate reasons. Of the patients having inappropriate surgery, 48 percent had less than 50 percent stenosis of the carotid artery that was operated on. Fifty-four percent of all the procedures were performed in patients without transient ischemic attacks in the carotid distribution. Of these procedures, 18 percent were judged appropriate, as compared with 55 percent judged appropriate in patients with transient ischemic attacks in the carotid distribution. After carotid endarterectomy, 9.8 percent of patients had a major complication (stroke with residual deficit at the time of hospital discharge or death within 30 days of surgery). We conclude that carotid endarterectomy was substantially overused in the three geographic areas we studied. Furthermore, in situations in which the complication rate is equal to or above the study's aggregate rate, carotid endarterectomy would not be warranted, even in cases with an appropriate indication, because the risks would almost certainly outweigh the benefits.

Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures

We studied the appropriateness of use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy and its relationship to geographic variations in the rates of use of these procedures. We selected geographic areas of high, average, and low use of these procedures and randomly sampled Medicare beneficiaries who had received one of the procedures in 1981. We determined the indications for the procedures using a detailed review of medical records and used previously developed ratings of appropriateness to assign an appropriateness score to each case. Differences among sites in levels of appropriateness were small. For example, in the high-use site for coronary angiography, 72% of the procedures were appropriate, compared with 81% in the low-use site. Coronary angiography was performed 2.3 times as frequently in the high-use site compared with the low-use site. Under the conditions of this study, we did find significantly levels of inappropriate use: 17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy. We conclude that differences in appropriateness cannot explain geographic variations in the use of these procedures.

Use of carotid endarterectomy in five California Veterans Administration medical centers

Although carotid endarterectomy is a controversial and frequently performed surgical procedure, little is known about the clinical appropriateness of its use in actual practice. Are the majority of procedures performed for highly accepted clinical reasons? We studied the clinical appropriateness of 107 procedures performed on 95 patients in 1981 in five Veterans Administration teaching medical centers. Standards for judging appropriate use were based on the recommendations of a multidisciplinary panel of nine physicians. Fifty-five percent of the procedures studied were judged clearly appropriate, 32% equivocal, and 13% clearly inappropriate. The rate of serious operative complications was 5.6%. These results suggest that carotid endarterectomy is overutilized within at least some segments of the Veterans Administration population.

Changing patterns in the practice of carotid endarterectomy in a large metropolitan area

Changes in the practice of carotid endarterectomy were studied by review of all endarterectomies performed in the greater Cincinnati area during 1980 and from July 1983 through June 1984. The number of operations rose from 431 to 750 (74% increase). The perioperative stroke rate fell from 8.6% in 1980 to 5.1% in 1983-1984; operative mortality declined from 2.8% to 2.3%; and the combined stroke or death rate declined from 9.5% to 6.5%. Asymptomatic carotid artery disease was the indication for 50% of the endarterectomies during both time periods. The combined stroke or death rate for asymptomatic patients declined from 6.9% to 5.3%, but both rates were higher than the 3% suggested as acceptable for prophylactic carotid endarterectomy. We conclude that carotid endarterectomy is becoming an increasingly common procedure, that morbidity continues to decline, and that mortality continues to be significant. Citywide surgical morbidity and mortality remain excessive for patients with asymptomatic carotid disease.