Joseph R Schneider1, Irene B Helenowski2, Cheryl R Jackson3, Michael J Verta4, Kimberly C Zamor2, Nilesh H Patel3, Stanley Kim3, Andrew W Hoel2. 1. Vascular Surgery and Interventional Radiology Partners of Cadence Physician Group, a part of Northwestern Medicine, Winfield and Geneva, Ill; Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill. Electronic address: joe.schneider@cadencehealth.org. 2. Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill. 3. Vascular Surgery and Interventional Radiology Partners of Cadence Physician Group, a part of Northwestern Medicine, Winfield and Geneva, Ill. 4. Vascular Surgery and Interventional Radiology Partners of Cadence Physician Group, a part of Northwestern Medicine, Winfield and Geneva, Ill; Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill.
Abstract
OBJECTIVE: Carotid endarterectomy (CEA) is usually performed with eversion (ECEA) or conventional (CCEA) technique. Previous studies report conflicting results with respect to outcomes for ECEA and CCEA. We compared patient characteristics and outcomes for ECEA and CCEA. METHODS: Deidentified data for CEA patients were obtained from the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) database for years 2003 to 2013. Second (contralateral) CEA, reoperative CEA, CEA after previous carotid stenting, or CEA concurrent with cardiac surgery were excluded, leaving 2365 ECEA and 17,155 CCEA for comparison. Univariate analysis compared patients, procedures, and outcomes. Survival analysis was also performed for mortality. Multivariate analysis was used selectively to examine the possible independent predictive value of variables on outcomes. RESULTS: Groups were similar with respect to sex, demographics, comorbidities, and preoperative neurologic symptoms, except that ECEA patients tended to be older (71.3 vs 69.8 years; P < .001). CCEA was more often performed with general anesthesia (92% vs 80%; P < .001) and with a shunt (59% vs 24%; P < .001). Immediate perioperative ipsilateral neurologic events (ECEA, 1.3% vs CCEA, 1.2%; P = .86) and any ipsilateral stroke (ECEA, 0.8% vs CCEA, 0.9%; P = .84) were uncommon in both groups. ECEA tended to take less time (median 99 vs 114 minutes; P < .001). However, ECEA more often required a return to the operating room for bleeding (1.4% vs 0.8%; P = .002), a difference that logistic regression analysis showed was only partly explained by differential use of protamine. Life-table estimated 1-year freedom from any cortical neurologic event was similar (96.7% vs 96.7%). Estimated survival was similar comparing ECEA with CCEA at 1 year (96.7% vs 95.9%); however, estimated survival tended to decline more rapidly in ECEA patients after ∼2 years. Cox proportional hazards modeling confirmed that independent predictors of mortality included age, coronary artery disease, chronic obstructive pulmonary disease, and smoking, but also demonstrated that CEA type was not an independent predictor of mortality. The 1-year freedom from recurrent stenosis >50% was lower for ECEA (88.8% vs 94.3%, P < .001). However, ECEA and CCEA both had a very high rate of freedom from reoperation at 1 year (99.5% vs 99.6%; P = .67). CONCLUSIONS: ECEA and CCEA appear to provide similar freedom from neurologic morbidity, death, and reintervention. ECEA was associated with significantly shorter procedure times. Furthermore, ECEA obviates the expenses, including increased operative time, associated with use of a patch in CCEA, and a shunt, more often used in CCEA in this database. These potential benefits may be reduced by a slightly greater requirement for early return to the operating room for bleeding.
OBJECTIVE: Carotid endarterectomy (CEA) is usually performed with eversion (ECEA) or conventional (CCEA) technique. Previous studies report conflicting results with respect to outcomes for ECEA and CCEA. We compared patient characteristics and outcomes for ECEA and CCEA. METHODS: Deidentified data for CEA patients were obtained from the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) database for years 2003 to 2013. Second (contralateral) CEA, reoperative CEA, CEA after previous carotid stenting, or CEA concurrent with cardiac surgery were excluded, leaving 2365 ECEA and 17,155 CCEA for comparison. Univariate analysis compared patients, procedures, and outcomes. Survival analysis was also performed for mortality. Multivariate analysis was used selectively to examine the possible independent predictive value of variables on outcomes. RESULTS: Groups were similar with respect to sex, demographics, comorbidities, and preoperative neurologic symptoms, except that ECEApatients tended to be older (71.3 vs 69.8 years; P < .001). CCEA was more often performed with general anesthesia (92% vs 80%; P < .001) and with a shunt (59% vs 24%; P < .001). Immediate perioperative ipsilateral neurologic events (ECEA, 1.3% vs CCEA, 1.2%; P = .86) and any ipsilateral stroke (ECEA, 0.8% vs CCEA, 0.9%; P = .84) were uncommon in both groups. ECEA tended to take less time (median 99 vs 114 minutes; P < .001). However, ECEA more often required a return to the operating room for bleeding (1.4% vs 0.8%; P = .002), a difference that logistic regression analysis showed was only partly explained by differential use of protamine. Life-table estimated 1-year freedom from any cortical neurologic event was similar (96.7% vs 96.7%). Estimated survival was similar comparing ECEA with CCEA at 1 year (96.7% vs 95.9%); however, estimated survival tended to decline more rapidly in ECEApatients after ∼2 years. Cox proportional hazards modeling confirmed that independent predictors of mortality included age, coronary artery disease, chronic obstructive pulmonary disease, and smoking, but also demonstrated that CEA type was not an independent predictor of mortality. The 1-year freedom from recurrent stenosis >50% was lower for ECEA (88.8% vs 94.3%, P < .001). However, ECEA and CCEA both had a very high rate of freedom from reoperation at 1 year (99.5% vs 99.6%; P = .67). CONCLUSIONS:ECEA and CCEA appear to provide similar freedom from neurologic morbidity, death, and reintervention. ECEA was associated with significantly shorter procedure times. Furthermore, ECEA obviates the expenses, including increased operative time, associated with use of a patch in CCEA, and a shunt, more often used in CCEA in this database. These potential benefits may be reduced by a slightly greater requirement for early return to the operating room for bleeding.
Authors: Philip P Goodney; Brian W Nolan; Jens Eldrup-Jorgensen; Donald S Likosky; Jack L Cronenwett Journal: J Vasc Surg Date: 2010-10 Impact factor: 4.268
Authors: G Menyhei; M Björck; B Beiles; E Halbakken; L P Jensen; T Lees; D Palombo; I A Thomson; M Venermo; P Wigger Journal: Eur J Vasc Endovasc Surg Date: 2011-03-29 Impact factor: 7.069
Authors: David H Stone; Brian W Nolan; Andres Schanzer; Philip P Goodney; Robert A Cambria; Donald S Likosky; Daniel B Walsh; Jack L Cronenwett Journal: J Vasc Surg Date: 2010-01-04 Impact factor: 4.268
Authors: R Clement Darling; Manish Mehta; Sean P Roddy; Philip S K Paty; Paul B Kreienberg; Kathleen J Ozsvath; Benjamin B Chang; Dhiraj M Shah Journal: Cardiovasc Surg Date: 2003-10
Authors: Ramon Luengo-Fernandez; Alastair M Gray; Linda Bull; Sarah Welch; Fiona Cuthbertson; Peter M Rothwell Journal: Neurology Date: 2013-10-09 Impact factor: 9.910
Authors: Kimberly C Zamor; Andrew W Hoel; Irene B Helenowski; Adam W Beck; Joseph R Schneider; Karen J Ho Journal: Ann Vasc Surg Date: 2017-07-21 Impact factor: 1.466
Authors: Ahmed Abdel Rahim; Kareemaldin Elsamani; Ali Mahmoud Galal; Mohamed Ibrahim Hammoda; Devender Mittapalli Journal: Ann Med Surg (Lond) Date: 2022-08-28