Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis.

Knappich C; Kuehnl A; Haller B; Salvermoser M; Algra A; Becquemin JP; Bonati LH; Bulbulia R; Calvet D; Fraedrich G; Gregson J; Halliday A; Hendrikse J; Howard G; Jansen O; Malas MB; Ringleb PA; Brown MM; Mas JL; Brott TG; Morris DR; Lewis SC; Eckstein HH

doi:10.1161/STROKEAHA.119.026320

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Journal article

Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis.

Knappich C From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany.
Kuehnl A From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany.
Haller B Institute of Medical Informatics, Statistics and Epidemiology (B.H.), Klinikum rechts der Isar, Technical University of Munich, Germany.
Salvermoser M From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany.
Algra A Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Centre for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands.
Becquemin JP Vascular Institute Paris East, Private Hospital Paul D'Egine, Ramsay Group, Champigny sur Marne, France (J.-P.B.).
Bonati LH Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland.
Bulbulia R Clinical Trial Service Unit and Epidemiological Studies Unit (R.B., D.R.M.), Nuffield Department of Population Health, University of Oxford, United Kingdom.
Calvet D INSERM U1266, Paris, France (D.C., J.-L.M.).
Fraedrich G Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.).
Gregson J Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.).
Halliday A Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.).
Hendrikse J Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands.
Howard G Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.).
Jansen O Department of Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.).
Malas MB Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, Health System (M.B.M.).
Ringleb PA Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.).
Brown MM Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.).
Mas JL INSERM U1266, Paris, France (D.C., J.-L.M.).
Brott TG Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.).
Morris DR Clinical Trial Service Unit and Epidemiological Studies Unit (R.B., D.R.M.), Nuffield Department of Population Health, University of Oxford, United Kingdom.
Lewis SC Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (S.C.L.).
Eckstein HH From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany.

2019-11-19

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Stroke. - 2019

English Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7% men). The 30-day stroke or death rate was 4.3%. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95% CI, 0.50-0.99]). Shunting (aRR, 1.43 [95% CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95% CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95% CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.

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