Influence of age and hospital volume on the results of carotid endarterectomy: a statewide analysis of 9918 cases

PURPOSE: This study evaluated the impact of patient age and hospital volume on the results of carotid endarterectomy (CEA) in contemporary practice. METHODS: The Maryland Health Services Cost Review Commission (MHSCRC) database was reviewed to identify all patients who underwent elective CEA as the primary procedure in all acute care hospitals in the state over the past 6 years. RESULTS: From January 1990 through December 1995, 9918 elective CEAs were performed in 48 hospitals at a total charge of $68.9 million. Postoperative death and neurologic complications occurred in 90 (0.9%) and 166 (1.7%) cases, including 0.8% and 1.7%, 0.9% and 1.6%, 0.9% and 1.8%, and 1.4% and 1.3% of patients < 65 years, 65 to 69 years, 70 to 79 years, and > or = 80 years old, respectively. The mean length of stay and hospital charges increased linearly with increasing age: 4.2 days/$6550, 4.4 days/$6834, 4.8 days/$7059, and 5.6 days (p < 0.0001 vs others)/$7756 (p < 0.005 vs 70 to 79 years and p < 0.0003 vs < 70 years old), respectively, for patients < 65, 65 to 69, 70 to 79, and > or = 80 years old. The mortality rate was 1.9% in low-volume hospitals, 1.1% in moderate-volume hospitals, and 0.8% in high-volume hospitals. The neurologic complication rate was significantly higher (6.1%; p < 0.0001) in low-volume when compared with moderate-volume (1.3%) and high-volume (1.8%) hospitals. CONCLUSIONS: CEA is a safe procedure in the majority of hospitals in contemporary practice, even among the very elderly, who may experience a longer length of stay and higher charges correlating with their documented greater medical complexity.     

Use of outpatient preoperative evaluation to decrease length of stay for vascular surgery

Interventions that decrease perioperative length of stay can result in considerable cost-savings. This study assesses the impact of same-day admission using outpatient preoperative evaluation on the lengths of stay and hospital costs for patients who underwent carotid end-arterectomy (CEA) or lower extremity revascularization (LER). Patient characteristics and length of stay were compared for two 1-yr periods before and after outpatient preoperative evaluation had been implemented. There were no significant differences before and after the initiation of outpatient preoperative evaluation in the CEA and LER groups in mean age and ASA physical status distributions. The average preoperative length of stay decreased significantly from 7.0 to 1.9 days in the CEA group and from 9.0 to 2.8 days in the LER group. This reduction in the length of stay was associated with a cost-savings of $900 per patient and did not have an adverse effect on patient outcome. We conclude that outpatient preoperative evaluation clinics reduce the cost and length of stay in vascular surgery patients. Implications: We found that outpatient preoperative evaluation and same-day admission were associated with a decrease of 4.5 days in the preoperative length of stay for carotid endarterectomy and lower-extremity revascularization. This was not accompanied by increased mortality and led to hospital cost-savings of approximately $900 per patient.     

Reduction of hospital resources utilization in vascular surgery: a four-year experience

PURPOSE: Managed care whether through risk or through capitated contracts results in reduction in resources, reduced length of hospital stay, and reduced utilization of hospital resources (collectively referred to as resource reductions). These resource reductions will become even more noticeable as a greater proportion of Medicare patients who need vascular operations select a managed-care senior product. We examined the results of a 4-year experience with resource management in an academic vascular surgery practice during which best practice plans were developed and implemented. METHODS: We analyzed hospital cost data, which included both total hospital and intensive care unit length of stay, average units per operation for laboratory, pharmacy, and radiology services and operating room and direct hospital costs for 257 carotid endarterectomies performed over fiscal years (FY) 1994, 1995, 1996, and 1997 (6 month data) and 175 infrainguinal bypass procedures performed during the same period. RESULTS: For carotid endarterectomy, length of stay decreased 66% over the 4-year period to an average of 2.07 days in FY97. Both radiology and pharmacy utilization were reduced after the first year of institution of best practice plans (56% and 32% respectively) with 4-year total reductions of 86% and 55% by FY97. The most notable changes included elimination of routine postoperative laboratory testing, use of aspirin rather than low-molecular-weight dextran, emphasis on oral rather than intravenous vasoactive drugs, and routine use of duplex scanning alone rather than angiography for diagnosis after FY94-95. The length of operating room time for carotid endarterectomy remained relatively constant from FY94 to FY97. As a result of these multiple factors, our study showed a 30% decrease in total average direct hospital costs for carotid endarterectomy from $9974 to $7002 in this 4-year period. Infrainguinal bypass graft procedures showed a progressive decrease in total cost of 28% for patients without complications to $15,186 but remained unchanged for those with complications. Laboratory use, pharmacy use, and radiology use were not significantly different. CONCLUSIONS: Case management for patients undergoing carotid endarterectomy and infrainguinal bypass grafting involving an integrated team of vascular surgeons, surgical house staff, a dedicated vascular nurse, and a social work case manager resulted in dramatic reductions both in length of stay and hospital resource utilization. As these costs decreased, operating room expenses assumed increasing importance. Operating room costs account for 60% of the direct costs of carotid endarterectomy and a comparable percentage for uncomplicated infrainguinal bypass grafting. Further substantial reductions in direct hospital costs will depend primarily on reductions in operating room costs, particularly those related to length of time in the operating room.     

A cost comparison of balloon angioplasty and stenting versus endarterectomy for the treatment of carotid artery stenosis

PURPOSE: Percutaneous transluminal angioplasty with stenting (PTAS) of the carotid artery has been advocated as an alternative treatment for high-grade stenosis. Rationale for this approach includes less morbidity, shorter recovery, and lower cost when compared with carotid endarterectomy (CEA). METHODS: The clinical results and hospital charges of patients who underwent elective treatment for carotid stenosis were reviewed. During a concurrent 14-month period, 218 patients were admitted 229 times for 234 procedures for the treatment of 239 carotid bifurcation stenoses, 109 by PTAS and 130 by CEA. Hospital charges were reviewed for each hospitalization and were categorized according to radiology, operating room, cardiac catheterization laboratory, and all other hospital charges. RESULTS: The combined incidence of postprocedure strokes and deaths were: PTAS, eight strokes (7.7%) and one death (0.9%); CEA, two strokes (1.5%) and two deaths (1.5%). Total hospital charges per admission for the two groups were $30,140 for PTAS and $21,670 for CEA. The average postprocedure length of stay for PTAS was 2.9 days (median, 2 days) and for CEA was 3.1 days (median, 3 days). Cardiac catheterization laboratory charges for the PTAS group were $12,968, whereas the operating room charges for the CEA group were $4263. When hospitalizations that were extended by complications were excluded, the average total charges for the PTAS group (n = 84) dropped to $24,848 (mean length of stay, 1.9 days) and for the CEA group (n = 111) to $19,247 (mean length of stay, 2.6 days). CONCLUSIONS: After evaluating hospital charges, PTAS for the treatment of carotid stenosis cannot currently be justified on the basis of reduced costs alone. With future cost-containing measures, total hospital charges can be reduced in both groups.     

Predicting soft tissue changes in mandibular advancement surgery: a comparison of two video imaging systems

BACKGROUND: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented. OBJECTIVE: To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention. DESIGN: Cost-effectiveness analysis using published data from clinical trials. SETTING: General population of asymptomatic 65-year-old men. INTERVENTION: Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (> or = 60%), disease was confirmed by angiography before carotid endarterectomy was done. MEASUREMENTS: Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios. RESULTS: When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120,000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50,000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found). CONCLUSIONS: Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable.     

Uptake and intracellular activity of moxifloxacin in human neutrophils and tissue-cultured epithelial cells

BACKGROUND AND PURPOSE: In light of previously reported concerns regarding carotid endarterectomy (CEA) use in our city, our goal was to determine the influence of a prospective audit and educational campaign on the performance of CEA with respect to surgical appropriateness and complication frequency. METHODS: Results of our previous audit of 291 CEAs, along with CEA practice guidelines and notification of prospective surveillance, were supplied to surgeons performing CEA in our city. After this, 184 consecutive patients undergoing CEA from September 1996 to August 1997 were followed prospectively. On the basis of blinded standardized remeasurements of angiographic carotid stenoses, CEA was classified as appropriate for patients with symptomatic carotid stenoses >/=70%, uncertain for those with symptomatic stenoses <70% or asymptomatic stenoses >/=60%, and inappropriate for patients with asymptomatic carotid stenoses <60% or preoperative neurological or medical instability. RESULTS: Forty percent of patients were asymptomatic. Compared with our prior audit, the rate of appropriate CEAs improved from 33% previously to 49% of cases in the present study (P=0.0005), uncertain indications did not change significantly (49% versus 47%; P=0.61), and inappropriate indications dropped from 18% to 4% (P=0. 00002). Perioperative stroke or death occurred in 6.4% of symptomatic patients but developed in only 2.7% of asymptomatic patients, which was improved from the 5.1% rate previously found. CONCLUSIONS: In our city, the use of a surgical audit identified areas of concern regarding CEA, and subsequent education and ongoing surveillance significantly improved the use and performance of this procedure.     

Effect of the Asymptomatic Carotid Atherosclerosis Study on carotid endarterectomy in Florida

BACKGROUND AND PURPOSE: The value of carotid endarterectomy (CEA) has been defined by several recent multicenter trials. The clinical effect of these trials remains undetermined since the Asymptomatic Carotid Atherosclerosis Study (ACAS) Clinical Advisory (dated September 28, 1994). METHODS: Patients undergoing CEA (ICD-9-CM 38.12) in nonfederal Florida hospitals were identified from the discharge database. Data were analyzed by federal fiscal year (FY, October 1 through September 30), comparing the years following the Advisory (FY95-FY96) to the preceding 3 years (FY92-FY94). RESULTS: There was a 68.3% increase in the number of CEAs during FY95-FY96 (mean FY92-FY94, 7,343; mean FY95-FY96, 12,356). This exceeded increases in total hospital discharges (4.5%), surgical discharges (2.2%), and the state's population (4.7%). The increase in CEAs spanned all patient demographic groups (gender, race, and age), although the magnitude was not consistent (range, 57.8% increase for 55 to 64 age group; 92.9% increase for > 84 age group). Concomitantly, there was a significant decrease in mortality (1.2% versus 0.8%), cardiac complication rate (ICD-9-CM 997.1, 4.1% versus 3.0%) and percentage of patients discharged > 7 days postoperatively (8.9% versus 4.9%). Mean length of stay declined 28% (5.8 versus 4.1 days), and mean adjusted charges declined 7% ($19,456 versus $18,055). Although the average case was less costly, the increased volume resulted in an estimated $56 million increase in annual hospital payments. CONCLUSIONS: The dramatic increase in the number of CEAs performed in the state of Florida after release of the ACAS Clinical Advisory suggests a causal relationship and mandates further cost-effectiveness analyses.     

Indications, outcomes, and provider volumes for carotid endarterectomy

CONTEXT: While trials have demonstrated that carotid endarterectomy is superior to best medical therapy, most recently among asymptomatic patients, uses and outcomes of the procedure in more representative settings have not been established. OBJECTIVES: To profile the use and outcomes of carotid endarterectomy in a representative sample of Ohio's Medicare beneficiaries and to examine the relationships between provider-specific procedural volumes and patient outcomes. DESIGN: Retrospective cohort using Medicare Provider Analysis and Review files supplemented by detailed reviews of medical records on a random sample of patients. SETTING: Ohio hospitals performing carotid endarterectomy. PATIENTS: A random sample of 678 charts of the 4120 non-health maintenance organization Medicare beneficiaries who underwent carotid endarterectomy between July 1, 1993, and June 30, 1994. MAIN OUTCOME MEASURES: Nonfatal stroke or death within 30 days of surgery. RESULTS: The reviewed patients were similar to all eligible patients in sociodemographic characteristics and 30-day mortality rates. Among the 678 patients, indications for surgery were asymptomatic carotid stenosis in 167 (24.6%), transient ischemic attack in 294 (43.4%), completed stroke in 62 (9.1%), and nonspecific symptoms in 155 (22.9%). Thirty-two patients (4.7%) died or suffered nonfatal strokes by 30 days postoperatively. In univariate analyses, rates varied by hospital volume (P=.004) but not surgeons' volume (P=.47), although power to detect this difference was limited. Patients at higher- and lower-volume hospitals had similar indications and distributions of comorbidities. In analyses controlling for indications, comorbid conditions, and surgeon's volume, being operated on in a higher-volume hospital conferred a 71% reduction in risk for 30-day stroke or death (odds ratio, 0.29; 95% confidence interval, 0.12-0.69; P=.006). CONCLUSIONS: Almost half (47.5%) of the carotid endarterectomies among Ohio's Medicare population are performed on persons who are asymptomatic or who have nonspecific symptoms. These results highlight the importance of identifying patients and providers having the most favorable outcome profiles. The higher rate of adverse outcomes observed in lower-volume hospitals deserves further investigation, as it does not appear to be due to differences in patient selection.     

US national survey of physician practices for the secondary and tertiary prevention of ischemic stroke. Design, service availability, and common practices

BACKGROUND AND PURPOSE: Stroke is largely a preventable disease. However, there are little data available concerning the use of stroke prevention diagnostic and treatment modalities by practicing physicians. These data are critical for the rational allocation of resources and targeting of educational efforts. The purposes of this national survey were to gather information about physicians' stroke prevention practice patterns and their attitudes and beliefs regarding secondary and tertiary stroke prevention strategies. METHODS: We conducted a national survey of stroke prevention practices among a stratified random sample of 2000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and the use of diagnostic and preventive strategies for patients at elevated risk of stroke. RESULTS: Sixty-seven percent (n = 1006) of eligible physicians completed the survey. Diagnostic studies considered readily available by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography was perceived as being readily available by 68% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logistic regression analyses showed that the availability of services varied with physician specialty (noninternist primary care, internal medicine, neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or large metropolitan areas), and for carotid endarterectomy, region of the country (South, Central, Northeast, and West). The odds of carotid endarterectomy being reported as readily available were approximately 2.5 to 3.5 times greater for physicians practicing in the central, northeastern, and western regions compared with those practicing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulation with international normalized ratios, and 78% reported monitoring anticoagulated patients at least once a month. Fewer than 20% of physicians reported knowing the perioperative carotid endarterectomy complication rates at the hospital where they perform the operation themselves or refer patients to have the procedure done. CONCLUSIONS: Although all routine and most specialized services for secondary and tertiary stroke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for monitoring warfarin therapy has not yet become universal. Physician knowledge of carotid endarterectomy complication rates is generally lacking. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the way in which services are provided.     

Time-dependent changes in CT-based dosimetry of I-125 prostate brachytherapy

OBJECTIVE: To determine if overnight hospital stay after carotid endarterectomy (CEA) is feasible and safe in the Australian setting. DESIGN: Case series with follow-up of 4-11 months (mean, 7 months). PATIENTS AND SETTING: All patients undergoing primary CEA performed by a vascular surgeon (BMB) between 30 May and 11 November 1996. Surgery was performed in one of four hospitals (a district general public hospital with about 400 beds and three private hospitals) in the Gosford area of New South Wales. INTERVENTIONS: CEA using regional anaesthesia and sedation, after diagnosis by duplex ultrasound scan, avoiding cerebral angiography and intensive care; planned discharge after overnight hospital stay; review at one month and duplex ultrasound scan at four months. OUTCOME MEASURES: Length of hospital stay and complications. RESULTS: 65 patients were admitted for CEA during the study period and 59 were scheduled for overnight stay (one had "re-do" surgery, two remained longer for reasons unrelated to carotid artery disease, and three had been scheduled before the change to overnight stay). 54 (92%) were discharged on the first postoperative day, and only three required readmission within 30 days (for urinary retention, angina and reperfusion syndrome). There were no deaths, no myocardial infarctions and no recognised instances of cerebral ischaemia during follow-up. CONCLUSION: CEA can be performed safely without cerebral angiography or intensive care, with over 90% expectation of a single night's stay in hospital.     

Glucose and lactate kinetics during a short exercise bout in pregnancy

Recent studies have shown that carotid endarterectomy for significant lesions lowers the risk of stroke and also reduces medical costs by averting the high costs of strokes. However, there has been no information on the cost effect of duplex ultrasound examination which has evolved as the prime means of discovering these carotid lesions. This study reviewed the findings and management of 100 consecutive new patients referred for duplex ultrasound management of the carotid arteries and the cost effects resulting. Seventy-three patients with < 70% stenosis were managed non-operatively; the remaining 27 with 33 lesions producing > 70% stenosis were treated by carotid endarterectomy. It was estimated that 6.5 patients would have had a stroke within 18 months if not operated on. While the medical costs of these strokes would have been $958,838, the cost of avoiding them was $300,494; the result was a significant medical costs saving of $658,344.     

Assessment of the efficacy of noninvasive screening for patients with asymptomatic neck bruits

BACKGROUND AND PURPOSE: Several recent clinical trials have shown that endarterectomy is efficacious in patients with asymptomatic carotid artery stenosis. The purpose of this study was to evaluate the effectiveness of various test strategies for screening and diagnosing carotid artery disease. METHODS: We constructed a model of the natural history of carotid artery disease using literature-based estimates of the prevalence and incidence of carotid artery stenosis and associated morbidity and mortality. Markov cohort simulation was used to estimate the mean quality-adjusted life years and monetary costs associated with various management strategies. RESULTS: Screening is cost-effective in the baseline model. Key parameters affecting the efficacy of screening are prevalence of operable lesions, benefit of surgery, surgical complication rates, quality of life with stroke, rate of stenosis progression, and excess morbidity and mortality. CONCLUSIONS: Asymptomatic patients with carotid bruits may benefit from screening if the prevalence rate is > or = 20%, the benefits and risks associated with surgery are similar to those observed in the Asymptomatic Carotid Atherosclerosis Study, and the quality of life with stroke is considerably lower than the quality of life without stroke. Ultrasound followed by three-dimensional time-of-flight MR angiography, if indicated, is a promising test strategy.     

The effect of Medicare's payment system for rehabilitation hospitals on length of stay, charges, and total payments

BACKGROUND: Medicare's system for the payment of rehabilitation hospitals is based on limits derived from a hospital's average allowable charges per patient discharged during a base year. Thereafter, payments are capped but hospitals receive incentive payments if charges per patient are reduced in succeeding years. We hypothesized that per-patient charges would increase during the base year and then decrease in subsequent years. Hospitals would thus have higher reimbursement limits and receive incentive payments for reducing their charges. METHODS: We analyzed Medicare claims data for 190,921 discharges from 69 rehabilitation hospitals from 1987 through 1994. We compared total charges, length of stay, and interim payments before, during, and after each hospital's base year. RESULTS: After we controlled for inflation and temporal and seasonal trends, mean charges per patient discharged increased from $25,131 for patients discharged before the base year to $32,167 for patients discharged in the base year (a 28 percent increase, P<0.001) and the mean length of stay increased from 22.1 to 26.7 days (a 21 percent increase, P<0.001). After the base year, mean charges decreased to $29,307 (a 9 percent decrease) and the mean length of stay decreased to 24.0 days (a 10 percent decrease) (P<0.001 for both comparisons). Analysis of data on patients according to diagnosis -- for example, spinal cord injury, brain injury, stroke, amputations and deformities, hip fracture, and arthritis and joint disorders -- showed similar findings for each, with increases in charges and length of stay in the base year, followed by smaller reductions thereafter. For-profit hospitals had greater increases than nonprofit hospitals in their per-patient charges (mean increase, $7,434 vs. $2,929; P<0.001) and length of stay (mean increase, 4.6 vs. 2.3 days, P<0.001) during the base year. CONCLUSIONS: Although Medicare's reimbursement system for rehabilitation hospitals put an upper limit on total payments, its design was associated with substantial extra costs, including significantly increased payments to hospitals and doctors and increased numbers of hospital days for the average patient.     

Combined carotid endarterectomy and coronary artery bypass grafting in asymptomatic carotid artery stenosis

The role of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in patients with severe asymptomatic carotid artery disease and concurrent symptomatic coronary artery disease is controversial. The objective of this report is to investigate the safety of combined CEA/CABG. The medical records of 30 patients who underwent combined CEA/CABG for coexistent asymptomatic carotid and symptomatic coronary artery occlusive disease were reviewed. All patients were scheduled for either elective or urgent myocardial revascularization due to their symptomatic coronary artery disease. Color-flow duplex scanning identified internal carotid artery stenosis of 80 to 99 per cent in 28 patients (93%) and 50 to 79 per cent in 2 patients (7%). Seventeen patients (57%) were male. The mean age was 64 +/- 10 years (range, 42-84 years). Contralateral internal carotid artery occlusion was present in four patients. Severe left main coronary artery disease was present in 12 patients (40%) and 7 patients (23%) had an ejection fraction of less than 50 per cent. There were no perioperative deaths or strokes. One patient suffered a myocardial infarction on postoperative day 1. This study demonstrates the safety of combined CEA/CABG for coexistent coronary and asymptomatic carotid disease. Using this surgical approach for critical coexistent disease may minimize the incidence of perioperative cerebrovascular complications in patients undergoing CABG.     

Determinants of outcome after carotid endarterectomy

BACKGROUND: The efficacy of carotid endarterectomy for selected patients has been evaluated with randomized controlled clinical trials. The generalizability of these studies to average surgical practice remains an important public health concern. OBJECTIVE: The objective of the study was to determine the predictors of outcome after carotid endarterectomy on a regional basis. Patients and Methods: The study was designed as a retrospective cohort study and included all consecutive patients presented for carotid endarterectomy at the 8 University of Toronto-affiliated hospitals in the period from January 1, 1994, to December 31, 1996. The main outcome measure was 30-day postoperative stroke or death rate. RESULTS: During the study interval, 1280 primary carotid endarterectomies were performed. The overall combined stroke and death rate was 6.3% for all patients who underwent endarterectomy (4.0% for patients who were asymptomatic). The significant predictors of poor outcome were the following: presenting symptoms (odds ratio, 1.74; 95% confidence interval [CI], 0.96, 3.12), low surgeon volume (<6 cases per year; odds ratio, 3.98; 95% CI, 1.65, 9.58), and left-sided surgery (odds ratio, 1.72; 95% CI, 1.07, 2.76). CONCLUSION: These data suggest that adoption of the recommendations of the symptomatic carotid endarterectomy trials is appropriate. However, endarterectomy for asymptomatic lesions remains of uncertain benefit on a regional basis and must be individualized to the experience of the specific surgeon. The surgeon volume/outcome relationship that is identified in this study suggests a need for a minimum volume threshold for this procedure.     

Comparison of North American Symptomatic Carotid Endarterectomy Trial and population-based outcomes for carotid endarterectomy

PURPOSE: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) advocated the use of carotid endarterectomy (CEA) for transient ischemic attacks (TIAs), nondisabling strokes, and ipsilateral high-grade stenosis in highly selected patients. Whether similar results are achieved when CEA is applied to an entire geographically defined population is unknown but important if the NASCET recommendations are to be applied broadly to all community patients. METHODS: To determine the survival rate to ipsilateral stroke after CEA for all symptomatic patients in a defined population, we reviewed the medical records of all patients residing in Olmsted County, Minn. (approximately 100,000), who underwent a CEA for TIA or nondisabling stroke between 1970 and 1995. Their outcomes were compared with the NASCET results. RESULTS: In the community of Olmsted County, 297 patients (108 women and 189 men) underwent 322 CEAs during the study period. TIAs or nondisabling stroke was the indication in 254 patients (86%), whereas the remaining 14% had asymptomatic stenosis. After CEA for symptomatic lesions, survival rate free of ipsilateral stroke was 97% at 2 years, 93% at 5 years, and 92% at 10 years. These results are similar to the NASCET survival rates free of ipsilateral stroke at 2 years (91%). However, the 30-day postoperative stroke rate for patients older than 80 years was significantly higher than that for patients younger than 80 years. CONCLUSIONS: When the NASCET results are compared with a population-based experience in which all symptomatic patients undergoing CEA were analyzed, the early outcomes were similar. Our population-based data also document the remarkably durable long-term results of CEA in preventing stroke and present another benchmark for carotid stent angioplasty.     

Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis

OBJECTIVE: To assess the value of carotid endarterectomy for prevention of stroke in patients with asymptomatic carotid stenosis. DESIGN: Systematic review and meta-analysis of randomised controlled trials in patients with asymptomatic carotid stenosis in which subjects were allocated to carotid endarterectomy or to medical treatment alone. SUBJECTS: Five trials enrolled 2440 patients with stenosis >/ 50%. MAIN OUTCOME MEASURES: Stroke ipsilateral to the stenosis, all strokes, and perioperative complications (stroke or death). RESULTS: In patients who underwent carotid endarterectomy (n=1215) there was a significant reduction in the odds of ipsilateral stroke plus perioperative stroke or death (odds ratio 0.62; 95% confidence interval 0.44 to 0.86), corresponding to a 2% absolute risk reduction over about 3.1 years. The prevalence of stroke in any location was also reduced (0.68; 0.51 to 0.9) in patients undergoing carotid endarterectomy. During the immediate postoperative period there was an increased prevalence of stroke or death among such patients (4.51; 2.36 to 8.64). CONCLUSION: Carotid endarterectomy in patients with asymptomatic carotid stenosis unequivocally reduces the incidence of ipsilateral stroke, though the absolute benefit is relatively small. Given the modest benefit of surgery for unselected patients with asymptomatic carotid artery stenosis carotid endarterectomy cannot be routinely recommended for these patients pending reliable identification of high risk subgroups, and medical management is a sensible alternative for most patients.     

Comparison between the scintigraphic uptake and plasma clearance of 99mTc-diethylenetriaminepentacetic acid (DTPA) for the evaluation of the glomerular filtration rate in dogs

Over the last few years, there has been increased emphasis on early discharge of patients following carotid endarterectomy in the United States. Recent studies have shown that short-stay hospitalization for carotid endarterectomy may be safe and cost-effective. However, this is not always possible because of reasons that are not clearly delineated. In order to optimize the early discharge of patients following carotid endarterectomy, an analysis of the causes of delayed discharges was performed in the present series. Since hemodynamic instability has been shown to be the most frequent complication following carotid endarterectomy, the authors investigated whether it was an important factor preventing early postoperative discharge. This study reviewed the data of 100 consecutive patients admitted for elective carotid endarterectomy. The incidence of post-carotid endarterectomy hemodynamic instability was 37% (n = 37), with hypertension occurring in 25 patients (68%) and hypotension occurring in 12 patients (32%). Hemodynamic instability tended to occur with the use of general anesthesia as compared with regional anesthesia. Hemodynamic instability did not correlate with pre-existent history of hypertension, nor with the type of drug used when general anesthesia was applied. All the patients were successfully treated either in the recovery room or in a monitored area. The average total length of stay was 1.65 days with 79% of the patients being discharged on the first postoperative day and 21% having delayed discharge ranging from 2 to 15 days (mean 4 days). The main reasons for delayed discharges were cardiac and urinary tract complications. Blood pressure instability accounted for only 2% of cases. Thus, these data show that hemodynamic instability does not significantly affect early discharge.     

Asymptomatic severe carotid stenosis: immediate surgery or watchful waiting? A decision analysis

OBJECTIVE: To analyze, for patients with asymptomatic severe carotid stenosis, the risks and benefits of two strategies: (1) immediate prophylactic carotid endarterectomy (CEA), and (2) medical management followed by CEA only after a transient ischemic attack (TIA) or a minor stroke has occurred. DESIGN: A Markov-based decision analysis model that simulates and counts the possible clinical outcomes (deaths, TIAs, and major strokes) of the two strategies. Data were drawn from the current literature. SUBJECTS: A hypothetical cohort of asymptomatic patients with severe (> 75% diameter reduction) carotid stenosis identified by noninvasive diagnostic tests. MAIN RESULTS: Given the immediate surgery-related risks, patients with a stroke incidence without preceding TIA of 3% per year will benefit from prophylactic CEA only if they survive more than 4 years after the procedure, whereas those with a higher stroke incidence (5% per year) will benefit from prophylactic CEA after just 2 years. However, the gain yielded by prophylactic CEA remains small. As age- or cardiovascular-related mortality increases, the maximum tolerated combined surgical mortality and morbidity rate below which prophylactic CEA yields an improved 5-year stroke- and surgery-related-event-free survival decreases--from 5% for patients aged 55 years to 2% for patients aged 85 years with a stroke incidence of 3% per year, and from 8.5% for patients aged 55 years to 4% for patients aged 85 years with a stroke incidence of 5% per year. On the other hand, for risk-intolerant patients who value the 2-year stroke- and surgery-related-event-free survival more than life in the distant future, the combined surgical morbidity and mortality rate below which prophylactic CEA remains the preferred strategy is below 3% at any age. CONCLUSION: Risk-intolerant patients should not undergo prophylactic CEA. On the other hand, for risk-tolerant patients willing to accept an immediate and dangerous procedure to decrease the future risk of death or chronic disability due to stroke, assessment of both perioperative risk and the risk of premature death from coexistent coronary artery disease should guide individual therapeutic decision-making.     

Feasibility and safety of 1-day postoperative hospitalization for carotid endarterectomy

OBJECTIVE: To determine whether 1-day postoperative hospitalization after carotid endarterectomy is safe and the degree to which this can be achieved. DESIGN: Consecutive sample series of all carotid endarterectomies performed by a single surgical group. SETTING: A single tertiary-care hospital. PATIENTS: All who underwent carotid endarterectomy. Patients with procedures combined with coronary revascularization and patients undergoing the first part of a staged bilateral carotid endarterectomy performed in 1 hospitalization were excluded. INTERVENTION: In December 1993, a fast-track protocol was initiated, aiming for a 1-day stay after carotid endarterectomy without admission to an intensive care unit (ICU). Before this date, postoperative care included obligatory monitoring for at least 1 night in an ICU. MAIN OUTCOME MEASURES: Length of stay, admission to and stay in the ICU, complications, and hospital readmission rate. RESULTS: Over a 21-month period, 152 patients had 163 carotid endarterectomies. Of these, 124 were elective and 39 urgent (patients with a critical stenosis). Indications were stroke (n = 14 [8.6%]), transient ischemic attack (n = 50 [30.7%]), amaurosis fugax (n = 36 [22.1%]), and asymptomatic stenosis (n = 63 [38.7%]). General anesthesia was used for 159 procedures, cervical block for 4. Mean operation time was 2.6 hours. Postoperative stay was 1 day for 82 procedures (50%), 2 days for 49 procedures (30%), 3 days for 12 procedures (7%), and longer for 20 procedures (12%). In the last half of the study, 61% of patients (50/82) were discharged on postoperative day 1 and 87% (71/82) by postoperative day 2. One hundred three patients went to a surgical floor postoperatively. Overall, 60 patients went to the ICU, but only 18 (22%) of the last 82 procedures required ICU admission. The total stay averaged 3.8 days. Twenty-one patients (13%) experienced complications, including 3 deaths within 30 days and 5 neurological deficits. There were 14 early readmissions, but none was attributable to discharge on the first or second postoperative day. CONCLUSIONS: Early discharge home after carotid endarterectomy is safe and efficacious, and obligatory admission to an ICU is not necessary. At least 60% of patients who undergo carotid endarterectomy can have a postoperative stay of 1 day, and more than 80% can be discharged by postoperative day 2. A short postoperative stay is not associated with a significant risk of readmission for complications.