Article

Association between minor and major surgical complications after carotid endarterectomy: results of the New York Carotid Artery Surgery study.

Department of Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
Journal of Vascular Surgery (Impact Factor: 2.98). 01/2008; 46(6):1138-44; discussion 1145-6. DOI: 10.1016/j.jvs.2007.08.026
Source: PubMed

ABSTRACT Most studies on outcomes of carotid endarterectomy (CEA) have focused on the major complications of death and stroke. Less is known about minor but more common surgical complications such as hematoma, cranial nerve palsy, and wound infection. This study used data from a large, population-based cohort study to describe the incidence of minor surgical complications after CEA and examine associations between minor and major complications.
The New York Carotid Artery Surgery (NYCAS) study examined all Medicare beneficiaries who underwent CEA from January 1998 to June 1999 in NY State. Detailed clinical information on preoperative characteristics and complications < or =30 days of surgery was abstracted from hospital charts. Associations between minor (cranial nerve palsies, hematoma, and wound infection) and major complications (death/stroke) were examined with chi(2) tests and multivariate logistic regression.
The NYCAS study had data on 9308 CEAs performed by 482 surgeons in 167 hospitals. Overall, 10% of patients had a minor surgical complication (cranial nerve (CN) palsy, 5.5%; hematoma, 5.0%; and wound infection, 0.2%). Cardiac complications occurred in 3.9% (myocardial 1.1%, unstable angina 0.9%, pulmonary edema 2.1%, and ventricular tachycardia 0.8%). In both unadjusted and adjusted analyses, the occurrence of any minor surgical complication, CN palsy alone, or hematoma alone was associated with 3 to 4-fold greater odds of perioperative stroke or combined risk of death and nonfatal stroke (P < 0.0001). Patients with cardiac complications had 4 to 5-fold increased odds of stroke or combined risk of death and stroke.
Minor surgical complications are common after CEA and are associated with much higher risk of death and stroke. Patient factors, process factors, and direct causality are involved in this relationship, but future work will be needed to better understand their relative contributions.

0 Bookmarks
 · 
73 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective Cranial nerve palsy (CNP) and neck haematoma are complications of carotid endarterectomy (CEA). The effects of patient factors and surgical technique were analysed on the risk, and impact on disability, of CNP or haematoma in the surgical arm of the International Carotid Stenting Study (ICSS), a randomized controlled clinical trial of stenting versus CEA in patients with symptomatic carotid stenosis. Materials and methods A per-protocol analysis of early outcome in patients receiving CEA in ICSS is reported. Haematoma was defined by the surgeon. CNP was confirmed by an independent neurologist. Factors associated with the risk of CNP and haematoma were investigated in a binomial regression analysis. Results Of the patients undergoing CEA, 45/821 (5.5%) developed CNP, one of which was disabling (modified Rankin score = 3 at 1 month). Twenty-eight (3.4%) developed severe haematoma. Twelve patients with haematoma also had CNP, a significant association (p < .01). Independent risk factors modifying the risk of CNP were cardiac failure (risk ratio [RR] 2.66, 95% CI 1.11 to 6.40), female sex (RR 1.80, 95% CI 1.02 to 3.20), the degree of contralateral carotid stenosis, and time from randomization to treatment >14 days (RR 3.33, 95% CI 1.05 to 10.57). The risk of haematoma was increased in women, by the prescription of anticoagulant drugs pre-procedure and in patients with atrial fibrillation, and was decreased in patients in whom a shunt was used and in those with a higher baseline cholesterol level. Conclusions CNP remains relatively common after CEA, but is rarely disabling. Women should be warned about an increased risk. Attention to haemostasis might reduce the incidence of CNP. ICSS is a registered clinical trial: ISRCTN 25337470.
    Journal of Vascular Surgery 10/2014; · 2.98 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Carotid duplex ultrasound (CDUS) is commonly used to screen for carotid artery stenosis. Specificities of CDUS criteria however are lower than sensitivities, potentially resulting in false positive exams with subsequent unnecessary imaging or surgery. Our objective was to establish a multivariate, logistic regression to increase the specificity of CDUS for high-grade (≥70%) stenosis. A retrospective review collected CDUS velocities and radiographic measurements from patients who underwent both CDUS and CT angiography. After stratification with standard CDUS criteria, a logistic regression was created using peak systolic velocity (PSV), end diastolic velocity (EDV), and PSV ratio (PSV ICA/CCA ratio) as predictor variables. A receiver operating characteristic curve was generated to test the model's predictive ability. A cutoff probability for unequivocal high-grade stenosis was chosen based on optimal specificity. The regression model was applied to patients with equivocal high-grade stenosis. Probabilities for detection of high-grade stenosis were calculated. Descriptive statistics were generated to quantify the accuracy of the model. A total of 244 vessels were included. Standardized velocity criteria for ≥70% stenosis yielded a sensitivity of 90.6% (95% CI: 82.3% to 95.6%), specificity of 63.5% (95% CI: 55.4% to 70.5%), PPV of 57.0% (95% CI: 48.8% to 65.5%), and NPV of 92.7% (95% CI: 85.8% to 96.5%). Regression analysis produced a model for predicting the probability of high-grade stenosis defined as probability = logit(-1) [-4.97 + (0.00938*PSV) + (0.0135*EDV)+(0.103*PSV ICA/CCA ratio)]. A cutoff probability of 0.65 for high-grade stenosis yielded a sensitivity of 54.7% (95% CI: 43.9% to 65.0%), specificity of 94.3% (95% CI: 89.3% to 97.2%), PPV of 83.9% (95% CI: 71.6% to 91.9%), and NPV of 79.3% (95% CI: 72.8% to 84.5%). A cutoff PSV of 400 cm/sec was chosen for unequivocal stenosis of ≥70%. A total of 94 patients were found to meet criteria for high-grade stenosis (PSV ≥ 230 cm/sec) but fall short of criteria for unequivocal high-grade stenosis (PSV < 400 cm/sec). Application of the regression model resulted in identification of 15 patients with probability ≥0.65 for high-grade stenosis and 79 patients with probability <0.65. This resulted in a 16% potential reduction in CTA scans. Our regression model provides increased specificity of CDUS for high-grade stenosis in patients who have met initial highly sensitive screening criteria. Application of this model may limit the need for additional imaging and increase the threshold for operative intervention in asymptomatic patients with equivocal high-grade carotid stenosis.
    Annals of Vascular Surgery 02/2014; · 1.03 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Cerebral white matter lesions (WMLs) predict long-term survival of conservatively treated acute stroke patients with etiology other than carotid stenosis. In carotid endarterectomy patients, WMLs are associated with severe carotid stenosis and unstable plaques, with the risk of perioperative complications and with increased 30-day perioperative risk of death. However, no data exist on their effect on postoperative long-term survival, a factor important when considering the net benefit from carotid endarterectomy. Whether this effect is independent of classical risk factors and indications for surgery is not known either. We hypothesized that WMLs could be evaluated from preoperative routine computed tomography (CT) scans and are predictors of postoperative survival, independent of classical cardiovascular risk factors, indication category and degree of carotid stenosis.
    Cerebrovascular diseases extra. 01/2014; 4(2):122-31.

Full-text

Download
7 Downloads
Available from
Oct 15, 2014