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• W4233283595 abstract "Quality improvement initiatives at The Ottawa Hospital (TOH) have aimed to reduce time between symptom onset and carotid endarterectomy (CEA) delivery; however, recent evidence suggests that perioperative stroke risk may be higher in the hyperacute setting (<48 hours from symptom onset). The study objective was to identify factors—such as timing—that are associated with adverse outcomes after CEA. This is a cohort study of patients receiving CEA by vascular surgeons at TOH between 2003 and 2018. Clinical and ultrasound surveillance data were obtained from electronic medical records (vOACIS; Telus Health, Montreal, Quebec, Canada) and TOH’s ultrasound database (VascuBase; Consensus Medical Systems, Richmond, BC, Canada). Patients’ demographics, timing and perioperative data, and postoperative complications and restenosis rates were recorded. Adverse outcomes were stratified by six variables: age, timing from symptom onset to surgery, anesthetic, operative technique, preoperative stenosis, and symptomatic status. Statistical analyses were performed to determine which variables were associated with higher rates of adverse outcomes using χ2 and Fisher exact tests. During the study period, 1190 CEAs were performed in 1129 patients. The majority were symptomatic (78.0%), with stenosis ranging from 70% to 99% (93.3%), and received patch arterioplasty (83.6%), without a shunt (84.9%), under regional anesthetic (88.3%). Overall 30-day stroke, stroke/death, and stroke/death/myocardial infarction (MI) rates were 2.1%, 2.6%, and 2.8%. Hyperperfusion syndrome and nerve injury rates were 4.0% and 5.3% (Table). Among symptomatic patients, CEA was performed within 48 hours in 10.9%, 2 to 14 days in 34.8%, and >14 days in 54.2%. Rate of nerve injury was higher among asymptomatic patients than symptomatic (P = .044). When stratified by anesthetic, combined rate of stroke, death, and MI was highest among patients who received a general anesthetic (7.4% vs 2.3% [regional anesthetic] and 0.0% [local anesthetic]; P = .016). When stratified by timing, combined stroke, death, and MI was highest among patients who received CEA within 48 hours of symptom onset (P = .007). This signal was predominantly driven by the stroke rate, which was also highest among those who received CEA within 48 hours (Fig; P = .038). Eversion endarterectomy was associated with the highest rate of postoperative ipsilateral restenosis >80% (17.9% vs 3.6% [patch angioplasty] and 2.8% [primary repair]; P = .014). Neither preoperative ipsilateral stenosis nor age was associated with adverse outcomes. Despite improvement in CEA delivery for stroke prevention after symptom onset, there is an association between hyperacute CEA (<48 hours) and worse outcomes. Further investigation should determine whether this represents a higher risk population who will benefit from expedient surgery or whether a “cool-down” period is warranted.TableOverall short-term (30-day) outcomesOutcomeNo.Rate, %Stroke/TIA252.1Death60.5MI40.3Combined stroke + death292.6Combined stroke + death + MI312.8Nerve injury635.3Intracranial bleed40.3Hyperperfusion syndrome484.0MI, Myocardial infarction; TIA, transient ischemic attack.Nerve injury and hyperperfusion syndrome were the two most common adverse outcomes. Unit of analysis varied between carotid and patient, depending on the outcome observed. Open table in a new tab" @default.
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• W4233283595 date "2019-06-01" @default.
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• W4233283595 title "PC056. Quality Improvement in Timing and Delivery of Carotid Endarterectomies at the Ottawa Hospital: Is the Pendulum Swinging Too Far?" @default.
• W4233283595 doi "https://doi.org/10.1016/j.jvs.2019.04.321" @default.
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