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Objective: Race-based disparities in health care have been related to a myriad of prevailing factors among minorities in the United States. This study aims to study the race-based differences in the outcomes of carotid endarterectomy (CEA)., Methods: The PROSPERO database registered the review protocol (CRD42023428253). A systematic English literature review was performed using literature databases PubMed and Scopus from inception till June 2023. The review was designed on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included studies reporting mortality, stroke, or composite outcome of mortality and stroke after CEA for carotid artery disease, regardless of any degree of stenosis including both symptomatic and asymptomatic patients. The risk of bias was evaluated utilizing the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for the overall mortality was computed, and a P value of < .05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I 2 statistics., Results: Twelve studies were identified which included a total of 574,055 patients who underwent CEA from 1998 to 2022. Eleven of 12 studies reported 30-day mortality as an outcome for patients undergoing CEA in which 524,708 patients (92.5%) were White and 42,797 (7.5%) were non-White. The overall pooled OR indicated a statistical significance in 30-day mortality between White and non-White patients undergoing CEA (OR, 1.73; 95% confidence interval [CI], 1.37-2.18; P = .011) with substantial heterogeneity (I 2  = 56.3%). Eleven of 12 studies reported stroke as an outcome for patients undergoing CEA in which 524,708 patients (92.5%) were White and 42,801 (7.5%) were non-White. The overall pooled OR indicated no statistical significance in stroke between White and non-White patients undergoing CEA (OR, 1.46; 95% CI, 1.28-1.65; P = .111) with moderate heterogeneity (I 2  = 35.9%). Five of 12 studies reported composite mortality or stroke as an outcome for patients undergoing CEA. The overall pooled OR indicated no statistical significance in composite mortality or stroke between White and non-White patients undergoing CEA (OR, 1.40; 95% CI, 1.24-1.59; P = .467) with no heterogeneity (I 2  = 0.0%)., Conclusions: Non-White patients have a relatively higher risk of mortality; however, no significant difference was observed between the racial groups in terms of stroke or a composite outcome of mortality or stroke. The odds of mortality in non-White patients have been persistent throughout recent studies., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Outcomes for weekend surgical interventions are associated with higher rates of mortality and complications than weekday interventions. Although prior investigations have reported the "weekend effect" for carotid endarterectomy (CEA), this association remains unclear for transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS). We investigated the weekend effect for all three carotid revascularization methods., Methods: We queried the Vascular Quality Initiative for patients who underwent CEA, TCAR, and TFCAS between 2016 and 2022. χ 2 and logistic regression modeling analyzed outcomes including in-hospital stroke, death, myocardial infarction, and 30-day mortality by weekend vs weekday intervention. Backward stepwise regression was used to identify significant confounding variables and was ultimately included in each final logistic regression model. Logistic regression of outcomes was substratified by symptomatic status. Secondary multivariable analysis compared outcomes between the three revascularization methods by weekend vs weekday interventions., Results: A total of 155,962 procedures were analyzed including 103,790 CEA, 31,666 TCAR, and 20,506 TFCAS. Of these, 1988 CEA, 246 TCAR, and 820 TFCAS received weekend interventions. Logistic regression demonstrated no significant differences for TCAR and increased odds of in-hospital stroke/death/myocardial infarction for CEA (odds ratio [OR]: 1.31, 95% confidence interval [CI]: 1.04-1.65) and TFCAS (OR: 1.46, 95% CI: 1.09-1.96) weekend procedures. Asymptomatic TCAR patients had nearly triple the odds of 30-day mortality (OR: 2.85, 95% CI: 1.06-7.68, P = .038). Similarly, odds of in-hospital death were nearly tripled for asymptomatic CEA (OR: 2.89, 95% CI: 1.30-6.43, P = .009) and asymptomatic TFCAS (OR: 2.78, 95% CI: 1.34-5.76, P = .006) patients. Secondary analysis demonstrated that CEA and TCAR had no significant differences for all outcomes. TFCAS was associated with increased odds of stroke and death compared with CEA and TCAR., Conclusions: In this observational cohort study, we found that weekend carotid revascularization is associated with increased odds of complications and mortality. Furthermore, asymptomatic weekend patients perform worse in the CEA and TFCAS procedural groups. Among the three revascularization methods, TFCAS is associated with the highest odds of perioperative stroke and mortality. As such, our findings suggest that TFCAS procedures should be avoided over the weekend in favor of CEA or TCAR. In patients who are poor candidates for CEA, TCAR offers the lowest morbidity and mortality for weekend procedures., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Atherosclerosis is a dynamic process. There is little evidence regarding whether quantification of atherosclerosis extent and progression, particularly in the carotid artery, in asymptomatic individuals predicts all-cause mortality., Objectives: This study sought to evaluate the independent predictive value (beyond cardiovascular risk factors) of subclinical atherosclerosis burden and progression and all-cause mortality., Methods: A population of 5,716 asymptomatic U.S. adults (mean age 68.9 years, 56.7% female) enrolled between 2008 and 2009 in the BioImage (A Clinical Study of Burden of Atherosclerotic Disease in an At Risk Population) study underwent examination by vascular ultrasound to quantify carotid plaque burden (cPB) (the sum of right and left carotid plaque areas) and by computed tomography for coronary artery calcium (CAC). Follow-up carotid vascular ultrasound was performed on 732 participants a median of 8.9 years after the baseline exam. All participants were followed up for all-cause mortality, the primary outcome. Trend HRs are the per-tertile increase in each variable., Results: Over a median 12.4 years' follow-up, 901 (16%) participants died. After adjustment for cardiovascular risk factors and background medication, baseline cPB and CAC score were both significantly associated with all-cause mortality (fully adjusted trend HR: 1.23; 95% CI: 1.16-1.32; and HR: 1.15; 95% CI: 1.08-1.23), respectively (both P < 0.001), thus providing additional prognostic value. cPB performed better than CAC score. In participants with a second vascular ultrasound evaluation, median cPB progressed from 29.2 to 91.3 mm 3 . cPB progression was significantly associated with all-cause mortality after adjusting for cardiovascular risk factors and baseline cPB (HR: 1.03; 95% CI: 1.01-1.04 per absolute 10-mm 3 change; P = 0.01)., Conclusions: Subclinical atherosclerosis burden (cPB and CAC) in asymptomatic individuals was independently associated with all-cause mortality. Moreover, atherosclerosis progression was independently associated with all-cause mortality., Competing Interests: Funding Support and Author Disclosures The High-Risk Plaque BioImage initiative was a precompetitive industry collaboration funded by BG Medicine, Abbott Vascular, AstraZeneca, Merck & Co., Philips, and Takeda. These funders had no role in the present study. Dr Ibanez was supported by the European Commission (grant numbers H2020-HEALTH 945118 and ERC-CoG 819775), La Caixa Foundation (HR22-00533, DIREQT2Heart), the Spanish Ministry of Science and Innovation (PID2022-140176OB-I00), and the Red Madrileña de Nanomedicina en Imagen Molecular–Comunidad de Madrid (2022/BMD-7403 RENIM-CM). Dr García-Álvarez was supported by the Instituto de Salud Carlos III (PI20/00742 and PI23/01341) and La Fundació la Marató TV3 (202314-30/31). Dr Devesa is an Alfonso Martin Escudero fellow and was scientifically supported by la La Caixa Foundation. The CNIC is supported by the Instituto de Salud Carlos III (ISCIII), the Ministerio de Ciencia, Innovación y Universidades (MICIU) and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (grant CEX2020-001041-S funded by MICIU/AEI/10.13039/501100011033). Dr Sánchez-González is an employee of Philips. Dr Muntendam is CEO of SQ innovation. Philips and SQ innovation had no role in the present study. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization., Methods: Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure., Results: A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05)., Conclusions: A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization., Competing Interests: Disclosures H.A. is a 2022-2023 trainee in the Society for Vascular Surgery Patient Safety Organization Quality Fellowship in Training (FIT) program. M.M. has an educational grant from Silk Road Medical to the University of California, San Diego, outside the submitted work. G.W. is a member of the Women of Transcarotid Artery Revascularization advisory board. R.L.M. is a principal investigator for the Diffusion-weighted Magnetic Resonance Imaging Transcarotid Artery Revascularization study. No other competing interests were reported., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Hypertension (HTN) has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled HTN (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population., Methods: We studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from the Vascular Quality Initiative. Patients were stratified into two groups: those with cHTN and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure of <130/80 mm Hg. Patients with uHTN had a blood pressure of ≥130/80 mm Hg. Our primary outcomes were in-hospital stroke, death, myocardial infarction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension or HTN, reperfusion syndrome, prolonged length of stay (LOS) (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis., Results: A total of 34,653 CEA (uHTN, 11,347 [32.7%]), 8199 TFCAS (uHTN, 2307 [28.1%]), and 17,309 TCAR (uHTN, 4990 [28.8%]) patients were included in this study. There was no significant difference in age between patients with cHTN and patients with uHTN for each carotid revascularization procedure. However, compared with patients with cHTN, patients with uHTN had significantly more comorbidities. uHTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR], 1.56; 95% confidence interval [CI], 1.30-1.87; P < .001), TFCAS (aOR, 1.59; 95% CI, 1.21-2.08; P < .001), and TCAR (aOR, 1.39; 95% CI, 1.12-1.73; P = .003) compared with cHTN. Additionally, uHTN was associated with a prolonged LOS after all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR, 1.82; 95% CI, 1.39-2.37; P < .001), in-hospital death (aOR, 3.73; 95% CI, 2.25-6.19; P < .001), reperfusion syndrome (aOR, 6.24; 95% CI, 3.57-10.93; P < .001), and extended LOS (aOR, 1.87; 95% CI, 1.51-2.32; P < .001) compared with CEA. There was no statistically significant difference between the outcomes of TCAR compared with CEA., Conclusions: The results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with cHTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. Additionally, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be safer interventions. Patients with uTHN with symptomatic carotid disease treated with CEA or TCAR have better outcomes compared with those treated with TFCAS., Competing Interests: Disclosures None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: While existing literature reports no benefit of locoregional anesthesia (LRA) over general anesthesia (GA) in patients undergoing carotid endarterectomy (CEA), the effect of LRA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this population., Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2022 and the procedural targeted ACS-NSQIP database for CEA between 2011-2022, all patients receiving CEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ 2 or Fischer's exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. Mortality, stroke, myocardial infarction (MI), and major adverse cardiac events (MACE) were compared between patients receiving GA and LRA using univariate analysis., Results: A total of 3,040 patients (2,733 undergoing GA, 307 undergoing LRA) with a diagnosis of CHF undergoing CEA were identified. No difference in mortality (GA 3.1% vs. LRA 4.6%, P = 0.162), MI (GA 3.0% vs. LRA 2.3%, P = 0.478), stroke (2.4% vs. 2.6%, P = 0.805) or MACE (GA 7.4% vs. LRA 8.1%, P = 0.654) was observed. LRA patients had a significantly lower hospital stay compared to GA patients (1 day [interquartile range (IQR) 1-3] vs. 2 days [IQR 1-4], P < 0.001). Shunt was more commonly used in patients receiving GA (32.9% vs. 12.5%, P < 0.001) compared to LRA., Conclusions: While utilizing LRA compared to GA during CEA in patients with CHF is associated with a shorter hospital stay and less intraoperative shunting, the choice of anesthesia did not impact the outcomes of mortality, MI or stroke. Further research is needed to determine the effect of LRA on the outcomes of CEA among patients with different stages of heart failure., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: With the recent expansion of the Centers for Medicare and Medicaid Services coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. Because approximately 30% of perioperative strokes/deaths post-CAS occur after discharge, appropriate thresholds for in-hospital event rates have been suggested to be <4% for symptomatic and <2% for asymptomatic patients. This study evaluates the tfCAS learning curve using Vascular Quality Initiative (VQI) data., Methods: We identified VQI patients who underwent tfCAS between 2005 and 2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. The primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/myocardial infarction (MI), 30-day mortality, in-hospital stroke/transient ischemic attack (stroke/TIA), and access site complications. The relationship between outcomes and procedure counts was analyzed using the Cochran-Armitage test and a generalized linear model with restricted cubic splines. Our results were then validated using a generalized estimating equations model to account for the variability between physicians., Results: We analyzed 43,147 procedures by 2476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2%-1.7%), in-hospital stroke/death/MI (5.8%-1.7%), 30-day mortality (4.6%-2.8%), in-hospital stroke/TIA (5.0%-1.1%), and access site complications (4.1%-1.1%) as physician experience increased (all P values < .05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1%-1.6%), in-hospital stroke/death/MI (2.6%-1.6%), 30-day mortality (1.7%-0.4%), and in-hospital stroke/TIA (2.8%-1.6%) with increasing physician experience (all P values <.05). The in-hospital stroke/death rate remained above 2% until 13 procedures., Conclusions: In-hospital stroke/death and 30-day mortality rates after tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. Nevertheless, a substantially high rate of in-hospital stroke/death was found in physicians' first 25 procedures. With the recent Centers for Medicare and Medicaid Services coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased postoperative complications., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Objective: The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in preoperative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease., Methods: We used a 20% Medicare sample from 2006 to 2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated preoperative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use., Results: A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8 ± 7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4 ± 1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5 ± 2.1 ultrasounds, 0.95 ± 0.86 neck CTs and 0.47 ± 0.7 MRIs per patient. The average payment for ultrasound was $140 ± 40, $282 ± 94 for CT and $410 ± 146 for MRI. The average inpatient reimbursements were $7,413 ± 4,215 for patients without CSI compared with $7,792 ± 3,921 for patients with CSI, P < 0.001. The average LOS during CEA admission was 2.5 ± 3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by postoperative day 2 compared with ultrasound alone (88.9% vs. 91.5%, respectively, P < 0.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups., Conclusions: Our analysis found preoperative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Transcarotid artery revascularization (TCAR) using a flow-reversal neuroprotection system has gained popularity for the endovascular treatment of carotid artery atherosclerotic disease owing to its lower risk of stroke or death compared with transfemoral carotid artery stenting. However, specific risk factors associated with stroke or death complications after TCAR have yet to be defined., Methods: All patients undergoing TCAR for the treatment of asymptomatic or symptomatic atherosclerotic carotid disease were identified between September 2016 and September 2019 in the Vascular Quality Initiative TCAR Surveillance Project. Our primary outcome was 30-day stroke or death. We created a risk model for 30-day stroke or death using multivariable fractional polynomials and internally validated the model using bootstrapping., Results: During the study period 7633 patients underwent TCAR, of which 4089 (53.6%) were treated for symptomatic and 3544 (46.4%) for asymptomatic disease. The average age of patients undergoing TCAR was 73.3 ± 9.1 years and 63.7% were male. Stroke or death events within 30 days of the index operation occurred in 153 patients (2.0%). Factors independently associated with a higher odds of 30-day stroke or death included the severity of presenting stroke symptoms (cortical transient ischemic attack, odds ratio [OR], 2.17 [95% confidence interval (CI), 1.21-3.90; P = .009]; stroke, OR, 3.30; 95% CI, 2.25-4.85; P < .001), advancing age (OR, 1.03 per year; 95% CI, 1.01-1.06; P = .003), and history of unstable angina or myocardial infarction within the past 6 months (OR, 2.20; 95% CI, 1.29-3.77; P = .004), moderate or severe congestive heart failure (OR, 2.44; 95% CI, 1.31-4.55; P = .005), chronic obstructive pulmonary disease (on medications, OR, 1.61 [95% CI, 1.06-2.43; P = .024]; on home oxygen, OR, 2.52 [95% CI, 1.44-4.41; P = .001]), and prior ipsilateral carotid endarterectomy (OR, 1.56; 95% CI, 1.09-2.25; P = .016), whereas preoperative P2Y 12 use was associated with a lower odds of 30-day stroke or death (OR, 0.57; 95% CI, 0.39-0.85; P = .005). A 30-point risk prediction model created based on these criteria produced a C statistic of 0.72 and Hosmer-Lemeshow goodness of fit of 0.97. Internal validation demonstrated good discrimination with a bias corrected area under the receiver operating characteristic curve of 0.70 with a calibration slope of 1.00., Conclusions: This Vascular Quality Initiative TCAR risk score calculator can be used to estimate the risk of stroke or death within 30 days of the procedure. Because TCAR is commonly used to treat patients with high surgical risk for carotid endarterectomy, this risk score will help to guide treatment decisions in patients being considered for TCAR., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The choice of anesthetic for carotid endarterectomy (CEA) continues to be controversial. Recent literature suggests improved outcomes with the use of regional anesthesia (RA) compared with general anesthesia (GA). The objective of this study was to examine the utilization and outcomes of RA for CEA using a national database., Methods: The targeted CEA files of the American College of Surgeons' National Surgical Quality Improvement Program (2011-2017) were reviewed. Patients were stratified based on anesthesia type into RA and GA, and patients' characteristics were compared between the 2 groups. The outcomes of CEA under GA and RA were compared after 2:1 propensity matching., Results: There were 26,206 CEAs, and 14% (n = 3,664) were performed under RA, with no change in relative utilization during the study period (P = 0.557). Patients treated under RA were more likely to be older than 65 years (80.6% vs. 75.8%; P < 0.001) and White (90.8% vs. 83.5%; P < 0.001) but less likely to have diabetes (28.2% vs. 31.2%; P = 0.001), chronic obstructive pulmonary disease (10.2% vs. 10.5%; P < 0.001), and heart failure (1.0% vs. 1.5%; P = 0.02) and be symptomatic (37.4% vs. 42.7%; P < 0.001). After matching, there was no significant difference in baseline characteristics between the 2 groups. Patients undergoing RA were less likely to experience the combined end point of stroke, myocardial infarction, or mortality compared with GA. GA patients were more likely to have longer operating time and hospital length of stay., Conclusions: CEA performed under RA is associated with improved outcomes compared with GA. RA is underutilized in carotid surgery, and strategies to optimize its use are needed., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Randomized controlled trials (RCTs) show that carotid endarterectomy (CEA) and carotid stenting (CAS) reduce long-term stroke risk in symptomatic and asymptomatic patients with carotid artery stenosis. Historical RCTs may not represent contemporary practice and administrative datasets may estimate procedural risks more reliably. We studied procedural risks after carotid intervention in a novel, international administrative data set of 18,997 patients admitted to 28 hospitals across 7 countries., Methods: Symptomatic and asymptomatic patients undergoing CEA (n = 16,220) and CAS (n = 2,777) between 2011 and 2015 were studied retrospectively. The primary outcome was in-hospital death within seven days. The secondary outcome was the proportion of patients whose length of hospital stay (LOS) exceeded 2 days. We also describe the rate of computerized tomography brain imaging within 2 days of CEA and CAS (proxy for stroke) as procedural strokes were not reliably recorded., Results: In symptomatic patients after CEA, mortality was 0.2% [5/2,118] (95% confidence interval: 0.1-0.5), and 57.0% [628/1,101] (54.1-60.0) had prolonged LOS. In asymptomatic patients after CEA, mortality was 0.1% [21/14,102] (0.1-0.2), and 28.5% [2,864/10,039] (27.7-29.4) had prolonged LOS. In symptomatic patients after CAS, mortality was 3.3% [10/307] (1.3-5.2), and 64.3% [144/224] (58.0-70.5) had prolonged LOS. In asymptomatic patients after CAS, mortality was 0.7% [18/2,470] (0.4-1.1), and 27.5% [601/2,187] (25.6-29.4) had prolonged LOS. After CEA, 8.1% [89/1,101] (6.5-9.7) symptomatic patients and 2.1% [207/10,039] (1.8-2.3) asymptomatic patients underwent brain imaging. After CAS, 7.1% [16/224] (4.0-10.7) symptomatic patients and 3.2% [71/2,187] (2.5-4.0) asymptomatic patients underwent brain imaging., Conclusions: Death and LOS after CEA and CAS were higher in symptomatic than asymptomatic patients. Symptomatic patients undergoing CAS had particularly increased risk of death. This may be partly explained by case selection, with more comorbid patients preferentially undergoing CAS. While RCTs effectively compare long-term efficacy of CEA versus CAS, administrative datasets can provide reliable estimates of contemporary procedural risks., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation (Afib) is a major contributor to cerebrovascular events. Coexisting carotid artery disease is not uncommon in Afib patients, yet they have been excluded from major randomized clinical trials. Therefore, the aim of this study was to evaluate the safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Afib patients., Methods: The Premier Healthcare Database was queried (2009-2015). Patients who underwent CEA or CAS were captured by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic modeling was implemented to examine the outcomes: in-hospital stroke, intracerebral hemorrhage (ICH), mortality, and stroke/death., Results: There were 86,778 patients included. The majority were asymptomatic (n = 82,128 [94.6%]). Afib was reported in 6743 patients (7.8%). In terms of absolute outcomes in both asymptomatic and symptomatic patients, Afib patients (vs non-Afib patients) had higher mortality and stroke/death (asymptomatic: mortality, 0.4% vs 0.2%; stroke/death, 1.7% vs 1.2%; symptomatic: mortality, 6.9% vs 2.1%; stroke/death, 10.6% vs 4.5%; all P < .05). Adjusted analysis yielded higher odds of ICH (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.00-1.67), mortality (aOR, 1.59; 95% CI, 1.11-2.26), and stroke/death (aOR, 1.30; 95% CI, 1.08-1.58) in Afib patients. Although univariable analysis found Afib to be a statistically significant predictor of ischemic stroke, similar results could not be elucidated in the multivariable analysis (aOR, 1.17; 95% CI, 0.93-1.47). In Afib patients, important predictors of stroke/death included CAS (aOR, 1.80; 95% CI, 1.21-2.68) and symptomatic presentation (aOR, 5.00; 95% CI, 3.20-7.83). Other important predictors were type of preoperative medication use, age, and hospital size., Conclusions: Afib was associated with worse postoperative outcomes in patients with carotid artery disease. Symptomatic status in Afib patients is associated with a stroke/death risk that is higher than in recommended guidelines for CEA and particularly for CAS. Overall, CEA was associated with lower periprocedural ICH, mortality, and stroke/death in Afib patients compared with CAS., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Recent studies have found that transcarotid artery revascularization (TCAR) is associated with lower risk of stroke or death compared with transfemoral carotid artery stenting but higher risk of bleeding complications, presumably associated with the need for an incision. Heparin anticoagulation is universally used during TCAR, so protamine use may reduce bleeding complications. However, the safety and effectiveness of protamine use in TCAR are unknown. We therefore evaluated the impact of protamine use on perioperative outcomes after TCAR in the Vascular Quality Initiative TCAR Surveillance Project., Methods: We performed a retrospective review of patients undergoing TCAR in the Vascular Quality Initiative TCAR Surveillance Project from September 2016 to April 2019. We assessed in-hospital outcomes using propensity score-matched cohorts of patients who did and did not receive protamine. The primary efficacy end point was access site bleeding complications, and the primary safety end point was in-hospital stroke or death. Secondary end points included the individual end points of stroke, death, transient ischemic attack, myocardial infarction, congestive heart failure exacerbation, and hemodynamic instability., Results: Of the 5144 patients undergoing TCAR, all patients received heparin and 4072 (79%) patients received protamine. We identified 944 matched pairs of patients who did and did not receive protamine. Protamine use was associated with a significantly lower risk of bleeding complications (2.8% vs 8.3%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.21-0.52; P < .001), including bleeding that resulted in interventional treatment (1.0% vs 3.6%; RR, 0.26; 95% CI, 0.13-0.54; P < .001) and in blood transfusion (1.2% vs 3.9%; RR, 0.30; 95% CI, 0.15-0.58; P <.001). There were no statistically significant differences in in-hospital stroke or death for patients who received protamine and those who did not (1.6% vs 2.2%; RR, 0.71; 95% CI, 0.37-1.39; P = .32); however, there was a trend toward lower risk of stroke for patients who received protamine (1.1% vs 2.0%; RR, 0.53; 95% CI, 0.24-1.13; P = .09). There were also no statistically significant differences in the rates of transient ischemic attack (0.4% vs 1.1%; RR, 0.40; 95% CI, 0.13-1.28; P = .11), myocardial infarction (0.4% vs 0.8%; RR, 0.50; 95% CI, 0.15-1.66; P = .25), heart failure exacerbation (0.4% vs 0.3%; RR, 1.33; 95% CI, 0.30-5.96; P = .71), or postoperative hypotensive hemodynamic instability (16% vs 15%; RR, 1.06; 95% CI, 0.83-1.35; P = .50) with protamine use., Conclusions: Protamine can be safely used in TCAR to reduce the risk of perioperative bleeding complications without increasing the risk of thrombotic events., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background Sudden cardiac death (SCD) is associated with severe coronary heart disease in the great majority of cases. Whether carotid intima-media thickness (C-IMT), a known surrogate marker of subclinical atherosclerosis, is associated with risk of SCD in a general population remains unknown. The objective of this study was to investigate the association between C-IMT and risk of SCD. Methods and Results We examined a total of 20 862 participants: 15 307 participants of the ARIC (Atherosclerosis Risk in Communities) study and 5555 participants of the CHS (Cardiovascular Health Study). C-IMT and common carotid artery intima-media thickness was measured at baseline by ultrasound. Presence of plaque was judged by trained readers. Over a median of 23.5 years of follow-up, 569 participants had SCD (1.81 cases per 1000 person-years) in the ARIC study. Mean C-IMT and common carotid artery intima-media thickness were associated with risk of SCD after adjustment for traditional risk factors and time-varying adjustors: hazard ratios (HRs) with 95% CIs for fourth versus first quartile were 1.64 (1.15-2.63) and 1.49 (1.05-2.11), respectively. In CHS, 302 participants developed SCD (4.64 cases per 1000 person-years) over 13.1 years. Maximum C-IMT was associated with risk of SCD after adjustment: HR (95% CI) for fourth versus first quartile was 1.75 (1.22-2.51). Presence of plaque was associated with 35% increased risk of SCD: HR (95% CI) of 1.37 (1.13-1.67) in the ARIC study and 1.32 (1.04-1.68) in CHS. Conclusions C-IMT was associated with risk of SCD in 2 biracial community-based cohorts. C-IMT may be used as a marker of SCD risk and potentially to initiate early therapeutic interventions to mitigate the risk.

Objective: Previously, we described a Vascular Study Group of New England (VSGNE) risk predictive model to predict composite adverse outcomes (postoperative death, stroke, myocardial infarction, or discharge to extended care facilities) after carotid endarterectomy (CEA). The goal of this study was to externally validate this model using an independent database., Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) CEA-targeted database (2010-2014) was used to externally validate the risk predictor model of adverse outcomes after CEA previously created using the VSGNE carotid database. Emergent cases and those in which CEA was combined with another operation were excluded. Cases in which a discharge destination cannot be determined were also excluded. To assess the predictive power of our VSGNE prediction score within this sample, a receiver operating characteristic curve was constructed. Risk scores for each NSQIP patient were also computed using beta weights from the VSGNE CEA model. To further assess the construct validity of our VSGNE prediction score, the observed proportion of adverse outcomes was examined at each level of our prediction scale and within five roughly equally sized risk groups formed on the basis of our VSGNE prediction scores., Results: In this database, 10,889 cases met our inclusion criteria and were used in this analysis. The overall rate of adverse outcomes in this cohort was 8.5%. External validation of the VSGNE model on this sample showed moderately good predictive ability (area under the curve = 0.745). Patients in progressively higher risk groups, based on their VSGNE model scores, exhibited progressively higher rates of observed adverse outcomes, as predicted., Conclusions: The VSGNE CEA risk predictive model was externally validated on an NSQIP CEA-targeted sample and showed a fairly accurate global predictive ability for adverse outcomes after CEA. Although this model has a good population concordance, the lack of cut point indicates that individual risk prediction requires more evaluation. Further studies should be geared toward identification of variables that make this risk predictive model more robust., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In the pivotal U.S. Food and Drug Administration approval trial, ROADSTER, transcarotid artery revascularization (TCAR) using the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical Inc, Sunnyvale, Calif) was shown to have one of the lowest reported complication rates, not only for carotid artery stent placement, but also for any carotid intervention, including endarterectomy. The number of cases required for a surgeon to gain the proficiency to realize these outcomes has not been studied. Our objective was to determine the learning curve for vascular surgeons performing the TCAR procedure. We examined the effect of surgeon procedural experience on intraoperative data and postoperative outcome., Methods: This retrospective review analyzed data from a prospectively maintained database of 188 consecutive patients from three large academic centers who underwent TCAR. Procedures were ordered chronologically for each surgeon and grouped into bins of five. Operative times and flow reversal times were analyzed by analysis of variance. Results led to comparison of surgeons' early experience (cases 1-15) with their later experience (cases 16-50). The primary outcome was postoperative stroke and death., Results: The mean procedural time for all cases was 75.0 ± 23.8 minutes. When the procedural time of cases 1 through 15 (mean, 79.0 ± 28.3 minutes) were compared with cases 16 through 50 (mean, 71.8 ± 19.0 minutes), a significant difference was noted (P = .02). The mean flow reversal time was 10.6 ± 6.8 minutes. When flow reversal times were compared using analysis of variance testing, cases 1 through 15 were statistically similar and cases 11 through 50 were also similar, but the two groups differed from each other (P < .001). For flow reversal, cases 1 through 15 had mean reversal times of 13.3 ± 8.8 minutes compared with 8.5 ± 3.5 minutes for cases 16 through 50 (P < .001). Postoperative stroke rates were similar in the 1 through 15 and 16 through 50 case groups (2.4% vs 1.0%; P = .59), as were death rates (0.0% vs 1.0%; P > .99). The combined stroke/death rates were also comparable at 2.4% in the early cohort vs 1.9% in the late cohort (P > .99)., Conclusions: There seems to be a relatively short learning curve for the TCAR procedure. After 15 cases, surgeons are able to reduce procedural decrease by 10% (from 79.0 to 71.8 minutes), and flow reversal times by an average of 40% (from 13.3 to 8.5 minutes). More important, the rates of stroke and death do not differ between early and late experience with TCAR. The TCAR procedure may be quickly and safely adopted by vascular surgeons for carotid intervention., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Transcarotid artery revascularization (TCAR) is a novel approach to carotid intervention that uses a direct carotid cut-down approach coupled with cerebral blood flow reversal to minimize embolic potential. The initial positive data with TCAR indicates that it may be an attractive alternative to trans-femoral carotid artery stenting and possibly carotid endarterectomy (CEA) for high-risk patients. The purpose of this study was to present 30-day and 1-year outcomes after treatment by TCAR and to compare these outcomes against a matched control group undergoing CEA at the same institutions., Methods: A retrospective review of all patients who underwent TCAR at four institutions between 2013 and 2017 was performed to evaluate the use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Inc, Sunnyvale, Calif). TCAR patients had high-risk factors and were either enrolled in prospective trials or treated with a commercially available TCAR device after US Food and Drug Administration approval. Contemporaneous patients undergoing CEA at each institution were also reviewed. Patients were propensity matched in a 1:1 (CEA:TCAR) fashion with respect to preoperative comorbidities. Data were analyzed using statistical models with a P value of less than .05 considered significant. Individual and composite stroke, myocardial infarction, and death at 30 days and 1 year postoperatively were assessed., Results: Consecutive patients undergoing TCAR or CEA were identified (n = 663) and compared. Patients undergoing the TCAR procedure (n = 292) had higher rates of diabetes (P = .01), hyperlipidemia (P = .02), coronary artery disease (P < .01), and renal insufficiency (P < .01) compared with unmatched CEA patients (n = 371). Stroke rates were similar at 30 days (1.0% TCAR vs 1.1% CEA) and 1 year (2.8% TCAR vs 3.0% CEA) in the unmatched groups. After propensity matching by baseline characteristics including gender, age, symptom status (36.3%, 35.3%) and diabetes, 292 TCAR patients were compared with 292 CEA patients. TCAR patients were more likely to be treated preoperative and postoperatively with clopidogrel (preoperatively, 82.2% vs 39.4% [P < .01]; postoperatively, 98.3% vs 36.0% [P < .01]) and statins (preoperatively, 88.0% vs 75.0% [P < .01]; postoperatively, 97.8% vs 78.8% [P < .01]). Stroke (1.0% TCAR vs 0.3% CEA; P = .62) and death (0.3% TCAR vs 0.7% CEA; P = NS) rates were similar at 30 days and comparable at 1 year (stroke, 2.8% vs 2.2% [P = .79]; death 1.8% vs 4.5% [P = .09]). The composite end point of stroke/death/myocardial infarction at 1 month postoperatively was 2.1% vs 1.7% (P = NS). TCAR was associated with a decreased rate of cranial nerve injury (0.3% vs 3.8%; P = .01)., Conclusions: These early data suggest that patients undergoing TCAR, even those with high-risk comorbidities, achieve broadly similar outcomes compared with patients undergoing CEA while mitigating cranial nerve injury. Further comparative studies are warranted., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The timing of carotid revascularization in symptomatic patients is a matter of ongoing debate. Current evidence indicates that carotid endarterectomy (CEA) within 2 weeks of symptoms is superior to delayed treatment. However, there is little evidence on the outcomes of emergent CEA (eCEA). The purpose of this study was to compare outcomes of emergency eCEA vs nonemergent CEA (non-eCEA), stratified by type of presenting symptoms., Methods: We analyzed the Vascular Targeted-National Surgical Quality Improvement Program dataset from 2011 to 2016. Symptomatic patients were divided into two groups: eCEA and non-eCEA. Univariable and multivariable methods were used to compare patient characteristics and to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days of surgery adjusting for all potential confounders. A further subgroup analysis was done to compare the outcomes of eCEA vs non-eCEA stratified by the type of presenting symptoms (amaurosis, transient ischemic attack [TIA], and stroke)., Results: A total of 9271 patients were identified, of which 10.7% were eCEA vs 89.3% non-eCEA. Comparing eCEA vs non-eCEA, the two groups were similar in age (70.8 vs 70.5), female gender (36.3% vs 36.9%), diabetes (26.2% vs 28.9%), and smoking status (31.9% vs 28.7%; all P > .05). Patients undergoing eCEA were less likely to be hypertensive (76.2% vs 80.2%; P = .025), but more likely to belong to non-white race (51.5% vs 20.5%; P < .001). The eCEA patients were less likely to be on preprocedural medication vs non-eCEA (antiplatelets, 76.8% vs 89.2%; statins, 74.2% vs 79.9%; beta-blockers, 44.6% vs 50.4%; all P < .05). The 30-day outcomes comparing eCEA vs non-eCEA were: stroke, 6.2% vs 3.1%; death, 2% vs 1%; and stroke/death, 6.9% vs 3.7% (all P < .05). After risk adjustment, perioperative stroke (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.36-3.0), stroke/death (OR, 1.66; 95% CI, 1.13-2.45), and stroke/death/MI (OR, 1.58; 95% CI, 1.18-2.23) were higher after eCEA (all P < .01). When stratified by the type of presenting symptom, eCEA vs non-eCEA stroke outcomes were similar in patients who presented with stroke or amaurosis fugax. However, in the subset of patients presenting with TIA, eCEA had much worse outcomes compared with non-eCEA (stroke, 8.3% vs 2.5%; stroke/death, 8.3% vs 3.2%) and had significantly higher odds of stroke (OR, 3.12; 95% CI, 1.71-5.68) and stroke/death (OR, 2.24; 95% CI, 1.25-4.03) in the adjusted analysis (all P < .05)., Conclusions: In patients presenting with stroke, eCEA does not seem to add significant risk compared with non-eCEA. However, patients presenting with TIA might be better served with non-emergent surgery as their risk of stroke is tripled when CEA is performed emergently., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The value of carotid intervention is predicated on long-term survival for patients to derive a stroke prevention benefit. Randomized trials report no significant difference in survival after carotid endarterectomy (CEA) vs carotid artery stenting (CAS), whereas observational studies of "real-world" outcomes note that CEA is associated with a survival advantage. Our objective was to examine long-term mortality after CEA vs CAS using a propensity-matched cohort., Methods: We studied all patients who underwent CEA or CAS within the Vascular Quality Initiative from 2003 to 2013 (CEA, n = 29,235; CAS, n = 4415). Long-term mortality information was obtained by linking patients in the registry to their respective Medicare claims file. We assessed the long-term rate of mortality for CEA and CAS using Kaplan-Meier estimation. We assessed the crude, adjusted, and propensity-matched (total matched pairs, n = 4261) hazard ratio (HR) of mortality for CEA vs CAS using Cox regression., Results: The unadjusted Kaplan-Meier estimated 5-year mortality was 14.0% for CEA and 18.3% for CAS. The crude HR of all-cause mortality for CEA vs CAS was 0.75 (95% confidence interval [CI], 0.70-0.81), indicating that patients who underwent CEA were 25% less likely to die before those who underwent CAS. This survival advantage persisted after adjustment for age, sex, and comorbidities (adjusted HR, 0.75; 95% CI, 0.69-0.82). This effect was confirmed on a propensity-matched analysis, with an HR of 0.76 (95% CI, 0.69-0.85). Finally, these findings were robust to subanalyses that stratified patients by presenting symptoms and were more pronounced in symptomatic patients (adjusted HR, 0.69; 95% CI, 0.61-0.79) than in asymptomatic patients (adjusted HR, 0.80; 95% CI, 0.71-0.90)., Conclusions: During the last 15 years, patients who underwent CEA in the Vascular Quality Initiative have a long-term survival advantage over those who underwent CAS in real-world practice. Despite no difference in long-term survival in randomized trials, our observational study demonstrated a survival benefit for CEA that did not diminish with risk adjustment., (Published by Elsevier Inc.)

Objective: Black patients undergoing carotid endarterectomy (CEA) in the United States are more often symptomatic at presentation and have more comorbidities compared with white patients. However, the impact of race on outcomes after CEA is largely unknown., Methods: We identified CEA patients in the Vascular Quality Initiative registry (2012-2017) and compared them by race (black vs white). All other nonwhite races (891 [1.4%]) and Hispanics (2222 [3.4%]) were excluded. We used multilevel logistic regression to account for differences in demographics and comorbidities. We assessed long-term survival using multivariable Cox regression. The primary outcome was perioperative stroke/death, with long-term survival as a secondary outcome., Results: We included 57,622 CEA patients; 2909 (5.0%) were black, of whom 983 (34%) were symptomatic. Of the 54,713 white patients, 16,132 (30%) were symptomatic. Black patients, compared with white patients, had a higher vascular disease burden and were less likely to be operated on in a high-volume hospital or by a high-volume surgeon. In addition, black symptomatic patients, compared with white symptomatic patients, were more often operated on <2 weeks after the index neurologic symptom (47% vs 40%; P < .001). Perioperative stroke/death was comparable between black and white patients (symptomatic, 2.8% vs 2.2% [P = .2]; asymptomatic, 1.6% vs 1.3% [P = .2]), as was unadjusted survival at 3 years (93% vs 93%; P = .7). However, after adjustment, black patients did experience better long-term survival compared with white patients (hazard ratio, 0.8; 95% confidence interval, 0.7-0.9; P = .01). On multilevel logistic regression, race was not associated with perioperative stroke/death (odds ratio, 1.0; 95% confidence interval, 0.8-1.3; P = .98)., Conclusions: Despite the greater prevalence of vascular risk factors in black patients and racial inequalities in surgical treatment, rates of perioperative stroke/death and unadjusted survival were similar between white and black patients. Moreover, black patients experienced better adjusted long-term survival after CEA., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to identify the optimal endovascular approach in patients with acute stroke with tandem lesions., Background: At present, there is no consensus about the ideal technical strategy for the endovascular treatment of patients with acute ischemic stroke with tandem lesions of the extracranial internal carotid artery (ICA) and intracranial cerebral arteries., Methods: This was an international, multicenter registry with a total of 482 patients with acute ischemic stroke and tandem lesions. Patients were treated by intracranial thrombectomy as well as 1 of the following 4 strategies: 1) acute carotid artery stenting of the extracranial ICA with antithrombotic agents; 2) acute carotid artery stenting of the extracranial ICA without antithrombotic agents; 3) balloon angioplasty of the extracranial ICA; and 4) intracranial thrombectomy alone. The main outcome endpoints of the study were the degree of recanalization and the 90-day clinical outcome. The safety endpoints were symptomatic intracerebral hemorrhage and all causes of mortality at 90 days., Results: Using univariate analysis, the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction grades 2B and 3) and favorable clinical outcome after 90 days were significantly higher after acute carotid stenting with antithrombotic therapy and thrombectomy compared with the group with thrombectomy alone. After adjusting for confounding variables, acute stenting with antithrombotic therapy was independently associated with successful recanalization (odds ratio: 2.4; 95% confidence interval: 1.25 to 4.59; p = 0.008). The rates of symptomatic intracerebral hemorrhage and 90-day mortality were comparable among all 4 treatment groups., Conclusions: Acute stenting of the extracranial ICA with antithrombotic therapy in combination with intracranial thrombectomy is associated with higher recanalization rates in treatment of patients with acute stroke with tandem lesions., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Race has been associated with inferior outcomes after multiple procedures, but the association of socioeconomic status with procedures for cerebrovascular disease is not well established., Materials and Methods: Elective carotid artery stenting (CAS) and carotid endarterectomy (CEA) procedures were identified in the National Inpatient Sample, 2012 to 2014. Median household income was estimated from patient ZIP codes. Chi-square and multivariable logistic regression analysis evaluated outcomes, accounting for age, race, gender, comorbidities, procedure, income, insurance, and hospital characteristics., Results: We identified 234 825 carotid procedures (205 835 CEA and 28 990 CAS). Blacks and Hispanics were more likely to be among the lowest quartile income patients (LQIPs) compared to whites (53.5% and 38.7% vs 27.0%, respectively; P < .0002). Compared to highest income quartile patients, LQIP had lower rates of private insurance (16.3% vs 22.0%) and higher Medicaid use (4.7% vs 2.0%; all P < .0002). Lowest quartile income patients were more likely to receive CAS (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.27-1.37), as were blacks and Hispanics (OR = 1.09, 95% CI: 1.02-1.26; OR = 1.31, 95% CI: 1.24-1.40, respectively). In multivariable regression, postoperative stroke was associated with LQIP, black race, and Hispanic ethnicity (OR = 1.16, 95% CI: 1.06-1.28; OR = 1.52, 95% CI: 1.33-1.73; OR = 1.43, 95% CI: 1.24-1.64, respectively). Subgroup analysis demonstrated that whites also had higher odds of stroke in the lower income quartile (OR = 1.2, 95% CI: 1.1-1.4). Mortality was associated with LQIP (OR = 1.6, 95% CI: 1.2-2.1), black race (OR = 1.8, 95% CI: 1.4-2.5), and CAS (OR = 1.3, 95% CI: 1.1-1.6). Length of stay in the lowest income quartile was longer than in patients with the highest income ( P < .0001)., Conclusions: Race was associated with increased hospital mortality, postoperative stroke, and overall complications after carotid procedures. Lower income was significantly associated with increased stroke and mortality irrespective of race. Disparate utilization and outcomes for carotid procedures are multifactorial. Efforts to reduce disparities will need to focus on race and other socioeconomic factors.

Background: Stroke is a serious complication of both transcatheter aortic valve replacement (TAVR) and carotid artery disease (CD). The implications of CD in patients undergoing TAVR are unclear., Methods and Results: The Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapies Registry, consisting of data from consecutive US TAVR cases during the years 2013 to 2015, was linked to Medicare claims data to ascertain 30-day and 1-year cumulative incidence rates of stroke and all-cause mortality. We compared 30-day and 1-year stroke and mortality outcomes between patients with no-CD and patients with moderate, severe, and occlusive CD and adjusted for baseline covariates using proportional hazards models. Among 29 143 patients undergoing TAVR across 390 US sites, 22% had CD. Patients with CD had higher rates of prior hypertension, diabetes mellitus, stroke, and myocardial infarction. Observed in-hospital stroke rates were 2.0% among no-CD, 2.5% among moderate CD, 3.0% among severe CD, and 2.6% among occlusive CD. There was no association between the presence of CD and 30-day stroke (adjusted hazard ratio, 1.16; 95% confidence interval, 0.94-1.43) or mortality (adjusted hazard ratio, 1.10; 95% confidence interval, 0.95-1.28). There was no association between CD and 1-year stroke (adjusted hazard ratio, 1.03; 95% confidence interval, 0.86-1.24) or mortality (adjusted hazard ratio, 1.02; 95% confidence interval, 0.93-1.12). Furthermore, there was no significant risk-adjusted association between severity of CD and 30-day or 1-year stroke or mortality., Conclusions: CD is common among TAVR patients, present in 1 of 5. CD was not associated with an increased risk of stroke or mortality at 30 day or 1 year. Post-TAVR stroke seems to be because of mechanisms other than CD., (© 2018 American Heart Association, Inc.)

Background: The Physician Quality Reporting System (PQRS) created by the Centers for Medicare and Medicaid Services financially penalizes providers who fail to meet expected quality of care measures. The purpose of this study is to evaluate the factors that predict failure to meet PQRS measures for carotid endarterectomy (CEA)., Methods: PQRS measure 260 (discharge by postoperative day 2 following CEA in asymptomatic patients) and 346 (rate of postoperative stroke or death following CEA in asymptomatic patients) were evaluated using hospital records from the state of Florida from 2008 to 2012. The impact of demographics, comorbidities, hospital factors, admission variables, and individual practitioner data upon timely discharge, and postoperative stroke and death. Odds ratios, 95% confidence intervals, and significance (P < 0.05) were determined through the development of a logistic regression model. Surgeons were identified by national provider identifier number, and practitioner data obtained from the American Medical Association Physician Masterfile., Results: A total of 34,235 patient records and 701 providers were identified over the 5-year period. Significant negative predictors for PQRS measure 260 included weekend admission (odds ratio [OR], 2.9), Medicaid (OR, 2.4), surgeon historical postoperative stroke rate >2.0% (OR, 1.7), African-American race (OR, 2.0), and female gender (OR, 1.3). The presence of any of these factors was associated with a 13.5% rate of failure. The most significant negative predictor for PQRS measure 346 was surgeon postoperative stroke rate >2.0% (OR, 6.2 for stroke and OR, 29.0 for death). Surgeons in this underperforming group had worse outcomes compared to their peers despite having patients with fewer risk factors for poor outcomes. Surgeon specialty, board certification, and case volume do not impact either PQRS measures., Conclusions: Selected groups of patients and surgeons with a disproportionately high rate of postoperative stroke are at risk of failing to meet PQRS pay for performance quality measures. Awareness of these risk factors may help mitigate and minimize the risk of adversely impacting the value stream. Further evaluation of the causative factors that lead to surgeon underperformance could help to improve the quality of care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The risk-adjusted outcomes by hospital of elective carotid endarterectomy that is inclusive of inpatient and 90-day postdischarge adverse outcomes have not been studied., Methods: We studied Medicare inpatients to identify hospitals with 25 or more qualifying carotid endarterectomy cases between 2012-2014. Risk-adjusted prediction models were designed for adverse outcomes of inpatient deaths, 3-sigma prolonged duration-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day postdischarge associated readmissions. Standard deviations of predicted overall adverse outcomes were computed for each hospital. Hospital-specific z scores and risk-adjusted adverse outcomes were calculated., Results: There were 77,086 carotid endarterectomy patients from 960 hospitals complicated by 191 inpatient deaths (0.25%), 4,436 prolonged duration of stay (5.8%), 457 90-day postdischarge deaths (0.6%), and 7,956 90-day postdischarge associated readmissions (10.3%). In the 90-day postdischarge associated readmission patients, an additional 561 patients died after readmission, for total deaths of 1,209 (1.6%) for the study period, and 11,928 (15.5%) patients had one or more adverse outcomes. There were 29 best-performing hospitals (3.0%) with z scores of -2.0 or less (P < .05) with a median rate of risk-adjusted adverse outcomes of 7.1%. A total of 61 suboptimal performers (6.3%) had z scores of +2.0 or greater (P < .05) with a median rate of risk-adjusted adverse outcome rate of 26.4%., Conclusion: Hospital risk-adjusted adverse outcome rates for carotid endarterectomy are highly variable. Comparisons of hospital performance define the opportunity for improvement., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Since the 2004 approval by the United States Food and Drug Administration of carotid artery stenting (CAS), there have been two seminal publications about CAS reimbursement (Centers for Medicare and Medicaid Services guidelines; 2008) and clinical outcomes (Carotid Revascularization Endarterectomy versus Stent Trial [CREST]; 2010). We explored the association between these publications and national trends in CAS use among high-risk symptomatic patients., Methods: The most recent congruent data sets of the Nationwide Inpatient Sample (NIS) were queried for patients undergoing carotid revascularization. The sample was limited to include only patients who were defined as "high-risk" if they had a Charlson Comorbidity Score of ≥3.0. Subgroup analyses were performed of high-risk patients with symptomatic carotid stenosis. Utilization proportions of CAS were calculated quarterly from 2005 to 2011 for NIS. Three time intervals related to Centers for Medicare and Medicaid Services guidelines and CREST publication were selected: 2005 to 2008, 2008 to 2010, and after 2010. Logistic regression with piecewise linear trend for time was used to estimate different trends in CAS use for the overall high-risk sample and for neurologically asymptomatic and symptomatic cases. Multivariate logistic regression was used to compare odds of postoperative mortality and stroke between these two procedures at different time intervals independent of confounding variables., Results: During the study period, 20,079 carotid endarterectomies (CEAs) and 3447 CAS procedures were performed in high-risk patients in the NIS database. CAS utilization constituted 20.5% of carotid revascularization procedures among high-risk symptomatic patients, with a significant increase from 18.6% to 24.4% during the study period (P < .001). There was an initial increase during 2005 to 2008 in the rate of CAS compared with CEA, CAS utilization significantly decreased during 2008 to 2010 by a 3.3% decline in the odds ratio (OR) of CAS per quarter (OR, 0.967; 95% confidence interval [CI], 0.943-0.993; P = .002), and after CREST (after 2010), CAS utilization continued to increase significantly from the prepublication to the postpublication time interval. The odds of in-hospital mortality (OR, 2.56; 95% CI, 1.17-5.62; P = .019) and postoperative in-hospital stroke (OR, 1.53; 95% CI, 1.09-3.68; P = .024) were independently and significantly higher for CAS patients in the overall sample., Conclusions: The use of CAS for carotid revascularization in a high-risk cohort of patients has significantly increased from 2005 to 2011. Compared with CEA, CAS independently increased the odds of perioperative in-hospital stroke in all high-risk patients and of in-hospital mortality in symptomatic high-risk patients., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Proper selection of patients for carotid artery stenting (CAS) remains controversial despite multiple controlled trials. This relates in part to differences in interpretation of the relative importance of myocardial vs stroke complications after the procedure by different specialties and a lack of granular clinical data to analyze outcomes outside the large clinical trials. The objective of this study was to assess the effect of preoperative medications, procedure parameters, and patient characteristics on outcomes of CAS performed in a multispecialty national database., Methods: We analyzed all patients who underwent CAS between 2005 and 2014 in the Vascular Quality Initiative. A multivariate logistic regression model was built to assess the effects of age, gender, comorbidities, smoking, preprocedure medications, procedure details, and hypotension or hypertension that required intravenous medication on 30-day death or stroke rates., Results: A total of 5263 patients underwent CAS (mean age, 70 years; 63% male). The 30-day stroke/death rate was 3.4% (1.5% minor stroke, 0.9% major stroke, and 1.2% death; 40% of patients who had major strokes died within 30 days), and the myocardial infarction rate was 0.8%. Postprocedural hypertension requiring treatment occurred in 519 cases (9.9%), and it was associated with a 3.4-fold increase in stroke/death (odds ratio, 3.39; 95% confidence interval, 2.30-5.00; P < .0001). Preprocedural beta-blocker use for >30 days was associated with a 34% reduction in the stroke/death risk (odds ratio, 0.66; 95% confidence interval, 0.46-0.95; P = .025) compared with nonuse. Beta-blocker use was not associated with postprocedural hypotension. Other predictors of postoperative stroke and death included age, symptomatic status, diabetes (type 1 or type 2), and postprocedural hypotension, whereas prior carotid endarterectomy and distal embolic protection use were protective., Conclusions: Postprocedural hypertension and hypotension that require treatment are both strongly associated with periprocedural stroke/death after CAS. Beta blockers significantly reduce the stroke/death risk associated with carotid stenting and should be investigated prospectively for potential use during CAS., Competing Interests: Author conflict of interest: none., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Longitudinal, risk-adjusted measurement of outcomes of carotid artery (CA) surgery is necessary for the evaluation of quality performance and for the assessment of strategies of quality improvement., Methods: Patients from quality coding hospitals who underwent CA surgery and met procedural and diagnostic coding requirements in the Medicare Inpatient Limited Data Set from 2009 to 2011 were used to design logistic prediction models for the Adverse Outcomes (AOs) of inpatient deaths, 3-sigma prolonged length-of-stay outliers (prLOS) among live discharges, 90-day post-discharge deaths without readmission (PD-90), and 90-day post-discharge readmissions (ReAdm-90)., Results: A total of 653 quality coding hospitals had 54,183 CA surgery cases. There were 122 inpatient deaths (0.23%) and 3,337 (6.2%) prLOS. After discharge, there were 258 patients that were PD-90 and 9,804 patients (18.1 % of live discharges) were readmitted. Among all readmissions, 1,592 (13.3%) were judged to be totally unrelated to the index operation. A total of 495 patients died during readmission to the hospital. The rate of total adverse outcome was 22.6% with all ReAdm-90 cases counted., Conclusion: In CA surgery, more AOs occur in the 90 days after discharge than during the inpatient period of care. ReAdm-90 remains the major cause for AOs and represents the greatest opportunity for improvement in the care of CA surgery patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to examine variation in outcomes for patients receiving carotid artery stenting (CAS) across a sample of U.S. hospitals and assess the extent to which this variation was attributable to differences in case mix and procedural volume., Background: As CAS is increasingly being used throughout the United States, assessing hospital variation in CAS outcomes is critical to understanding and improving the quality of care for patients with carotid artery disease., Methods: Hospitals participating in the National Cardiovascular Data Registry-Carotid Artery Endarterectomy and Revascularization Registry contributing more than 5 CAS procedures from 2005 through 2013 were eligible for inclusion. We estimated unadjusted and risk-standardized rates of in-hospital stroke or death for each participating hospital using a previously validated prediction model and applying hospital-level random effects., Results: There were 188 hospitals contributing 19,381 CAS procedures during the period of interest. Unadjusted and risk-standardized in-hospital stroke or death rates ranged from 0% to 18.8% and 1.2% to 4.7%, respectively. Operator and hospital volumes were not significant predictors of outcomes after adjustment for case mix (p = 0.15 and p = 0.09, respectively)., Conclusions: CAS outcomes vary 4-fold among hospitals, even after adjustment for differences in case mix. Future work is needed to identify the sources of this variation and develop initiatives to improve patient outcomes., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation is a common comorbid condition among patients undergoing carotid endarterectomy (CEA) and carotid artery stent placement (CAS); however, the outcomes of patients with atrial fibrillation undergoing CAS have not been fully examined. We sought to investigate the impact of atrial fibrillation on outcomes of CEA and CAS in general practice., Methods: We analyzed the data from the National Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2009. The primary end point was postoperative stroke, cardiac complication, postoperative mortality, and composite of these end points. Univariate and multivariate regression analyses were performed to determine, first, the association of atrial fibrillation (compared to without atrial fibrillation) and, second, the association of CEA (compared with CAS) in patients with atrial fibrillation with the occurrence of postoperative stroke, cardiac complication, or death. Covariates included in the logistic regression were the patient's gender, age, race/ethnicity, comorbid conditions, and symptom status (symptomatic vs asymptomatic status) and the hospital's characteristics., Results: Of the total 672,074 patients who underwent CAS or CEA, 8.8% (95% confidence interval [CI], 8.7-8.9) of the procedures were performed in patients with atrial fibrillation. Atrial fibrillation was associated with an increased risk of postoperative stroke in patients undergoing CEA (n = 879 [1.7%]; P < .0001; odds ratio [OR], 1.57; 95% CI, 1.32-1.86) but not in patients undergoing CAS. The relative risk of the composite end point of postoperative stroke, cardiac complications, and mortality was increased in patients with atrial fibrillation undergoing CAS (OR, 1.43; 95% CI, 1.18-1.74) and in those undergoing CEA (OR, 3.18; 95% CI, 2.89-3.49). After adjustment for potential confounders, the odds of the composite end point of postoperative stroke, cardiac complications, and mortality (OR, 1.31; 95% CI, 1.08-1.59) in atrial fibrillation patients were significantly higher among patients who underwent CEA (compared with those who underwent CAS). An opposite relationship was seen in patients without atrial fibrillation, in whom the composite end point was significantly lower in patients undergoing CEA., Conclusions: Our analysis suggests that almost 10% of CAS and CEA is performed in patients with atrial fibrillation in general practice, and higher rates of adverse events are observed among these patients, particularly those undergoing CEA., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Rapid and objective preoperative assessment of patients undergoing carotid endarterectomy (CEA) remains problematic. Preoperative variables correlate with increased morbidity and mortality, yet no easily implemented tool exists to stratify patients. We determined the relationship between our fully implemented frailty-based bedside Risk Analysis Index (RAI) and complications after CEA., Methods: Patients undergoing CEA in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2011 were included. Variables of frailty RAI were matched to preoperative NSQIP variables, and outcomes including stroke, mortality, myocardial infarction (MI), and length of stay were analyzed. We further analyzed patients who were symptomatic and asymptomatic before CEA., Results: With use of the NSQIP database, 44,832 patients undergoing CEA were analyzed (17,696 [39.5%] symptomatic; 27,136 [60.5%] asymptomatic). Increasing frailty RAI score correlated with increasing stroke, death, and MI (P < .0001) as well as with length of stay. RAI demonstrated increasing risk of stroke and death on the basis of risk stratification (low risk [0-10], 2.1%; high risk [>10], 5.0%). Among patients undergoing CEA, 88% scored low (<10) on the RAI. In symptomatic patients, the risk of stroke and death for patients with a score of ≤10 is 2.9%, whereas if the RAI score is 11 to 15, it is 5.0%; 16 to 20, 6.9%; and >21, 8.6%. In asymptomatic patients, the risk of stroke and death for patients with a score of ≤10 is 1.6%, whereas if the RAI score is 11 to 15, it is 2.9%; 16 to 20, 5.2%; and >21, 6.2%., Conclusions: Frailty is a predictor of increased stroke, mortality, MI, and length of stay after CEA. An easily implemented RAI holds the potential to identify a limited subset of patients who are at higher risk for postoperative complications and may not benefit from CEA., (Copyright © 2015 Society for Vascular Surgery. All rights reserved.)

Background: The objective was to evaluate the difference in timing (if any) of in-hospital carotid endarterectomy (CEA) or outcomes of CEA based on sex among men and women hospitalized for carotid artery disease., Methods: This was a retrospective cross-sectional study using the Nationwide Inpatient Sample Database. All patients from 2000-2009 who underwent CEA during their hospitalization were examined. International Classification of Diseases, 9th revision codes were used to identify patients who underwent CEA during hospitalization, stratify asymptomatic and symptomatic patients, determine time in days from admission to CEA, and examine in-hospital complications, including perioperative stroke, cardiac events, and death. Statistical analysis was performed with chi-squared and t-tests. Linear and logistic regression models were used to evaluate relationships between sex and outcomes. The main outcome measures were time from admission to surgery, in-hospital mortality, complications, mean duration of stay, and discharge disposition., Results: Two hundred twenty-one thousand two hundred fifty three patients underwent CEA during hospitalization. More than 9% (9.2%) had symptomatic carotid artery disease. Among symptomatic patients, bivariate analysis found that women had a longer mean time from admission to surgery (2.8 vs. 2.6 days; P < 0.001) and a longer duration of hospital stay (6.4 vs. 5.9 days; P < 0.001) than their male counterparts. However, there was no difference between men and women with regard to rates of perioperative stroke, cardiac complications, myocardial infarction, or death. Among asymptomatic patients, women had a longer mean time from admission to surgery (0.53 vs. 0.48 days; P < 0.001) and a trend toward increased perioperative stroke (0.6% vs. 0.5%; P = 0.06), but a lower rate of cardiac complications (1.5% vs. 1.7%; P = 0.01) and in-hospital mortality (0.26% vs. 0.31%; P = 0.05). However, on multivariable analysis adjusting for differences in age, elective status, insurance, race, hospital location, hospital region, and hospital teaching status, there was no sex disparity in time from admission to surgery, regardless of symptomatic status. In addition, asymptomatic women were less likely than men to have a cardiac complication (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) or in-hospital mortality (OR: 0.83; 95% CI: 0.70-0.98). Symptomatic women were also less likely than men to have a cardiac complication (OR: 0.78; 95% CI: 0.63-0.97)., Conclusions: In this decade-long national population-based study of hospitalized patients undergoing CEA, women had lower perioperative cardiac morbidity and mortality rates than men. After adjusting for patient, clinical, and hospital factors, there is no discernible difference in timing of CEA based on sex., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Administrative data are often hampered by coding errors, absent data, and the difficulty of distinguishing pre-existing conditions from perioperative complications. We evaluated whether the introduction of the present on admission (POA) indicator improved outcome analysis of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) using administrative data., Methods: State inpatient databases from California (2005-2008), New York (2008), and New Jersey (2008) were used to identify patients undergoing CAS and CEA. We first analyzed morbidity data without the POA indicator, using International Classification of Diseases, Ninth Revision complication codes (eg, 997.02, iatrogenic cerebrovascular infarction or hemorrhage, postoperative stroke) and diagnosis codes (eg, 433.11, occlusion and stenosis of the carotid artery with cerebral infarction). Then, we applied the POA indicator to both diagnosis and complication codes and calculated the proportion of events that were labeled POA. Symptom status and perioperative stroke rate were compared using these coding approaches., Results: We identified 21,639 patients who underwent CEA and 3688 patients who underwent CAS. Without the POA indicator, the complication code for stroke indicated a postoperative stroke rate of 1.4% for CEA and 2.4% for CAS. After applying the POA indicator, 54% (CEA) and 62% (CAS) of these strokes were labeled POA. These POA strokes were either preoperative or intraoperative events. Proportion of symptomatic patients ranged from 7% to 16% for CEA and from 5% to 22% for CAS. Perioperative stroke rate was the lowest in the POA method (1.1% CEA, 1.8% CAS) compared with two other methods without POA information (1.4% and 9.5% CEA and 2.4% and 16.4% CAS). Kappa indicated a poor (0.2) to fair (0.7) agreement between these approaches., Conclusions: Administrative data has known limitations for assignment of symptom status and nonfatal perioperative outcomes. Given the uncertain timing of POA events as preoperative vs intraoperative and its apparent underestimation of the perioperative stroke rate, the use of administrative data even with the POA indicator for symptom status and non-fatal outcomes after CEA and CAS is hazardous., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: To examine the risk of femoral access site complications in patients undergoing carotid stent placement who were treated with a closure device compared with patients who were not treated with a closure device., Materials and Methods: A national, multihospital patient database, the Premier Perspective database, was used to identify patients hospitalized for carotid stent placement from 2006-2011. To reduce potential selection bias, a propensity score was generated for each patient using relevant clinical variables. Propensity score adjustment via 1:1 matching was performed on patients who did and did not receive a closure device. Primary outcomes were minor femoral access site complications and major complications requiring procedural intervention. Secondary outcomes included in-hospital mortality, stroke, and blood transfusion., Results: Among 12,287 patients who underwent carotid stent placement at 217 hospitals, 6,398 (52%) received a closure device on the day of the procedure. After propensity score matching, patients who received a closure device had a lower likelihood of minor access site complications (4.2% vs 5.4%; odds ratio = 0.77; 95% confidence interval, 0.55-0.93; P = .0071) compared with patients who did not receive a closure device; however, this difference was small and likely not clinically relevant. Both groups had a similar risk of major access site complications (P = .32), in-hospital mortality (P = .0520), and stroke (P = .31)., Conclusions: Use of a closure device was not associated with a substantially reduced risk of major adverse events after carotid stent placement and was associated with only a small improvement in minor access site complications., (Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: The Centers for Medicare and Medicaid Services (CMS) require high-risk (HR) criteria for carotid artery stenting (CAS) reimbursement. The impact of these criteria on outcomes after carotid endarterectomy (CEA) and CAS remains uncertain. Additionally, if these HR criteria are associated with more adverse events after CAS, then existing comparative effectiveness analysis of CEA vs CAS may be biased. We sought to elucidate this using data from the SVS Vascular Registry., Methods: We analyzed 10,107 patients undergoing CEA (6370) and CAS (3737), stratified by CMS HR criteria. The primary endpoint was composite death, stroke, and myocardial infarction (MI) (major adverse cardiovascular event [MACE]) at 30 days. We compared baseline characteristics and outcomes using univariate and multivariable analyses., Results: CAS patients were more likely to have preoperative stroke (26% vs 21%) or transient ischemic attack (23% vs 19%) than CEA. Although age ≥ 80 years was similar, CAS patients were more likely to have all other HR criteria. For CEA, HR patients had higher MACEs than normal risk in both symptomatic (7.3% vs 4.6%; P < .01) and asymptomatic patients (5% vs 2.2%; P < .0001). For CAS, HR status was not associated with a significant increase in MACE for symptomatic (9.1% vs 6.2%; P = .24) or asymptomatic patients (5.4% vs 4.2%; P = .61). All CAS patients had MACE rates similar to HR CEA. After multivariable risk adjustment, CAS had higher rates than CEA for MACE (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0-1.5), death (OR, 1.5; 95% CI, 1.0-2.2), and stroke (OR, 1.3; 95% CI,1.0-1.7), whereas there was no difference in MI (OR, 0.8; 95% CI, 0.6-1.3). Among CEA patients, age ≥ 80 (OR, 1.4; 95% CI, 1.02-1.8), congestive heart failure (OR, 1.7; 95% CI, 1.03-2.8), EF <30% (OR, 3.5; 95% CI, 1.6-7.7), angina (OR, 3.9; 95% CI, 1.6-9.9), contralateral occlusion (OR, 3.2; 95% CI, 2.1-4.7), and high anatomic lesion (OR, 2.7; 95% CI, 1.33-5.6) predicted MACE. Among CAS patients, recent MI (OR, 3.2; 95% CI, 1.5-7.0) was predictive, and radiation (OR, 0.6; 95% CI, 0.4-0.8) and restenosis (OR, 0.5; 95% CI, 0.3-0.96) were protective for MACE., Conclusions: Although CMS HR criteria can successfully discriminate a group of patients at HR for adverse events after CEA, certain CMS HR criteria are more important than others. However, CEA appears safer for the majority of patients with carotid disease. Among patients undergoing CAS, non-HR status may be limited to restenosis and radiation., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Racial disparities in the outcomes of patients undergoing carotid endarterectomy (CEA) have been reported. We sought to examine the contemporary relationship between race and outcomes and to report postdischarge events after CEA., Methods: The American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were reviewed to identify all CEAs performed from 2005 to 2010 by vascular surgeons. The influence of race on outcomes was examined. Multivariate analysis was performed using variables found to be significant on bivariate analysis. The primary outcomes were stroke and mortality. Secondary outcomes were other 30-day complications, including postdischarge events., Results: CEA was performed on 29,114 white patients (95.7%) and on 1316 black patients (4.3%); the overall stroke and mortality rates were 1.65% and 0.7%, respectively. The stroke rate was 1.6% for whites and 2.5% blacks (P = .009). The 30-day mortality rate was 0.7% for whites and 1.4% for blacks (P = .002). There was a longer operating time (P < .001) and total length of stay (P < .001), more postoperative pneumonias (P = .049), unplanned intubations (P < .001), ventilator dependence (P < .001), cardiac arrests (P < .001), bleeding requiring transfusions (P = .024), and reoperations within 30 days (P = .021) among black patients. Multivariate logistic regression modeling identified black race as an independent risk factor for 30-day mortality (odds ratio, 1.9; P = .007). Black patients also had a greater proportion of in-hospital deaths than white patients (73.7% vs 43.1%; P = .01). There was no between-group difference in the rate of postdischarge strokes. Thirty-six percent of all strokes occurred after discharge at a mean of 8.3 days, and 54.3% of deaths occurred after discharge at a mean of 11 days., Conclusions: Black race is an independent risk factor for 30-day mortality after CEA. A significant proportion of strokes and deaths occur after discharge in both racial groups evaluated., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Cost-effectiveness has become an important end point in comparing therapies that may be considered to have clinical equipoise. While controversial, some feel that recent multicenter randomized controlled trials have codified clinical equipoise between carotid endarterectomy (CEA) and carotid artery stenting (CAS)., Methods: A retrospective analysis of hospital cost and 30-day clinical outcomes was performed on patients undergoing CEA and CAS between January 1, 2008 and September 30, 2010 at a single tertiary referral institution. Cost, not charges, of the index hospitalization was divided into supply, labor, facility, and miscellaneous categories. All costs were normalized to 2010 values., Results: A total of 306 patients underwent either CEA (n = 174) or CAS (n = 132). Mean hospital cost for CAS was $9426 ± $5776 while CEA cost was $6734 ± $3935 (P < .0001). This cost differential was driven by the significantly higher direct supply costs for CAS ($5634) vs CEA ($1967) (P ≤ .0001). The higher costs for CAS were seen consistently in symptomatic, asymptomatic, elective, and urgent subgroups. Patients undergoing CAS who were enrolled in a trial or registry (53.8%) incurred significantly less cost ($7779 ± $3525) compared to those who were not ($11,279 ± $7114; P = .0004). Patients undergoing CEA trended toward a higher prevalence of being symptomatic (44.8%) compared to CAS (34.0%; P = .058). Age was not significantly different between patients undergoing CEA and CAS (70.2 vs 72.0, respectively; P = .36). Coronary artery disease was more common in patients undergoing CAS (60.3% vs 39%; P = .0001). The prevalence of chronic obstructive pulmonary disease, renal failure, hypertension, and diabetes was not significantly different between cohorts. Thirty-day combined stroke/death/myocardial infarction rate was 2.3% (4 of 174) in the CEA group and 3.8% (5 of 132) in the CAS group, P = .5. Overall length of stay (LOS) was 2.1 days in both groups (P = .9). LOS was higher for urgent interventions (7.3-7.5 days) and symptomatic status (2.9-3.5 days) when compared to patients treated electively (1.3-1.4 days)., Conclusions: Treatment of carotid disease with CAS was 40% more costly than CEA and did not provide better clinical outcomes or a reduction in LOS. These trends were consistent in symptomatic, asymptomatic, urgent, and elective subgroups At present, CAS cannot be considered a cost-effective treatment for carotid disease., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Introduction: Although obesity is a risk factor for vascular disease, previous studies have shown an obesity paradox with decreased mortality in obese patients undergoing vascular surgery. This study examined the relationship between body mass index (BMI) and outcomes after carotid endarterectomy (CEA)., Methods: The 2005-2009 American College of Surgeons National Surgical Quality Improvement Program database was queried to evaluate 30-day outcomes after isolated CEA across National Institutes of Health-defined obesity classes. χ(2) analysis was used to assess the unadjusted relationship of BMI category to postoperative outcomes. The independent association of BMI with morbidity and mortality was assessed with multivariable logistic regression, adjusting for preoperative and operative characteristics., Results: In the cohort of 23,652 CEA, 1.8% of patients were underweight (BMI <18.5), 26.6% were normal weight (BMI 18.5-24.9), 39.4% were overweight (BMI 25.0-29.9), 21.1% were class I obese (BMI 30.0-34.9), 7.5% were class II obese (BMI 35.0-39.9), and 3.5% were class III obese (BMI ≥ 40). The overall stroke and mortality rates were 1.4% and 0.6%, respectively. On univariable analysis, there were U-shaped relationships between death (P = .017) and stroke (P = .029), with the lowest incidence in overweight and class I obese patients. The incidence of surgical site infection (SSI) (P = .021) increased incrementally with increasing BMI. On multivariable analysis, class I obesity was the only variable associated with decreased risk of stroke (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.31-0.83; P = .007). Independent risk factors for stroke were previous transient ischemic attack (OR, 1.97; P = .006), American Society of Anesthesiologists class 4 to 5 (OR, 1.62; P = .010), surgery performed by a nonvascular surgeon (OR, 1.85; P = .015), and hemiplegia (OR, 1.97; P = .018). There was also a trend, although not statistically significant, toward decreased mortality risk associated with class I obesity (OR, 0.53; 95% CI, .26-1.08; P = .080). Class II obesity was associated with an increased risk of SSI compared with normal weight (OR, 2.21; 95% CI, 1.01-4.82; P = .047). BMI category was not associated with the risk of myocardial infarction., Conclusions: An obesity paradox exists for stroke and mortality after CEA; for stroke, but not mortality, this protective association was independent of patient demographics and comorbidities. Obesity is not a contraindication to CEA, and surgeons may safely undertake CEA in obese patients when indicated., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Recent randomized controlled trials have shown that age significantly affects the outcome of carotid revascularization procedures. This study used data from the Society for Vascular Surgery Vascular Registry (VR) to report the influence of age on the comparative effectiveness of carotid endarterectomy (CEA) and carotid artery stenting (CAS)., Methods: VR collects provider-reported data on patients using a Web-based database. Patients were stratified by age and symptoms. The primary end point was the composite outcome of death, stroke, or myocardial infarction (MI) at 30 days., Results: As of December 7, 2010, there were 1347 CEA and 861 CAS patients aged < 65 years and 4169 CEA and 2536 CAS patients aged ≥ 65 years. CAS patients in both age groups were more likely to have a disease etiology of radiation or restenosis, be symptomatic, and have more cardiac comorbidities. In patients aged <65 years, the primary end point (5.23% CAS vs 3.56% CEA; P = .065) did not reach statistical significance. Subgroup analyses showed that CAS had a higher combined death/stroke/MI rate (4.44% vs 2.10%; P < .031) in asymptomatic patients but there was no difference in the symptomatic (6.00% vs 5.47%; P = .79) group. In patients aged ≥ 65 years, CEA had lower rates of death (0.91% vs 1.97%; P < .01), stroke (2.52% vs 4.89%; P < .01), and composite death/stroke/MI (4.27% vs 7.14%; P < .01). CEA in patients aged ≥ 65 years was associated with lower rates of the primary end point in symptomatic (5.27% vs 9.52%; P < .01) and asymptomatic (3.31% vs 5.27%; P < .01) subgroups. After risk adjustment, CAS patients aged ≥ 65 years were more likely to reach the primary end point., Conclusions: Compared with CEA, CAS resulted in inferior 30-day outcomes in symptomatic and asymptomatic patients aged ≥ 65 years. These findings do not support the widespread use of CAS in patients aged ≥ 65 years., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Introduction: The impact of resident surgeon participation during vascular procedures on postoperative outcomes is incompletely understood. We characterized resident physician participation during carotid endarterectomy (CEA) procedures within the 2005-2009 American College of Surgeons National Surgical Quality Improvement Participant Use Datafile and evaluated associations with procedural characteristics and perioperative adverse events., Methods: CEAs were identified using primary current procedural terminology codes; those performed simultaneously with other major procedures or unknown resident participation status were excluded. Group-wise comparisons based on resident participation status were performed using χ(2) or Fisher's exact test for categorical variables and t tests or nonparametric methods for continuous variables. Associations with perioperative adverse events (major = stroke, death, myocardial infarction, or cardiac arrest; minor = peripheral nerve injury, bleeding requiring transfusion, surgical site infection, or wound disruption) were assessed using multivariable logistic regression models adjusting for other known risk factors., Results: A total of 25,280 CEA procedures were analyzed, of which residents participated in 13,705 (54.2%), while residents were absent in 11,575 (45.8%). Among CEAs with resident physician participation, resident level was categorized as junior (postgraduate year [PGY] 1-2) in 21.9%, senior (PGY 3-5) in 52.7%, and fellow (PGY ≥6) in 25.3%. Major adverse event rates with and without resident participation were 1.9% versus 2.1%, and minor adverse event rates with and without resident participation were 0.9% versus 1.0%, respectively. In multivariable models, resident physician participation was not associated with perioperative risk for major adverse events (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.75-1.08) or minor adverse events (OR, 0.93; 95% CI, 0.72-1.21)., Conclusions: Resident surgeon participation during CEA is not associated with risk of adverse perioperative events., (Published by Mosby, Inc.)

The Nationwide Inpatient Sample (NIS) contains information from discharge abstracts submitted by hundreds of community hospitals across the United States, and it frequently has been used as a resource for population-based research comparing the safety of carotid artery stenting (CAS) to that of carotid endarterectomy (CEA). However, at least two findings from the NIS dataset seem open to question. First, several NIS studies have indicated that more than 90% of CEAs and CAS procedures now are being done in asymptomatic patients, a figure that substantially exceeds the prevalence of asymptomatic patients that has been reported elsewhere. Second, these studies also have suggested that the periprocedural stroke rate for CEA and CAS is lower at community hospitals contributing to the NIS than it was in the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST), even though the surgeons and interventionalists participating in CREST were stringently selected according to their previous experience and results. Neither of these two findings seems to pass the test of face validity. Furthermore, some unexpectedly low stroke-to-death (STD) ratios are present in the NIS data, especially for CAS. These issues may be related to poor documentation of preprocedural symptoms and periprocedural strokes in the medical records and to subsequent coding errors in the hospital discharge abstracts on which the NIS is based., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

The American Heart Association liberalised guidelines for carotid stenting (CAS) into average risk patients based on the following interpretations and assumptions; (i) CAS doubles the risk of procedural stroke; (ii) CEA doubles the risk of procedural myocardial infarction (MI); (iii) peri-operative MI significantly reduces long-term survival; (iv) poorer long-term survival is attributable to a greater proportion of CEA patients dying after their peri-operative MI. (v) reduced survival in CEA patients suffering a peri-operative MI offsets any benefit conferred by the lower procedural stroke risk so that; (vi) CAS is considered equivalent to CEA and may even be safer in those considered high risk for procedural MI. However, this much publicised rationale is flawed by the simple fact that the poorer survival rates observed in CREST were not attributable to a greater proportion of CEA patients dying following their procedural MI. In fact, a relatively higher proportion of CAS patients suffering a peri-operative MI died during follow-up. This observation changes how the literature should be interpreted. The clinical reality is that up to 10% of patients will suffer a stroke within seven days of their index TIA and the benefits of intervening in the hyperacute period after onset of symptoms (ie offering greater stroke prevention) will far outweigh any potential consequences of peri-operative MI and reduced life expectancy. Peri-operative MI should inform, but not drive the current debate. More importantly, it should not deflect attention away from the most important management priority; the prevention of stroke. This is one situation where the heart should not rule the head!, (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Data derived from prospective randomized clinical trials suggest differential comparative benefit between carotid angioplasty and stent (CAS) placement and carotid endarterectomy (CEA) in various age strata. We sought to investigate the impact of age on outcomes of CAS and CEA in general practice., Methods: We analyzed the data from the Nationwide Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2008. The primary end point was occurrence of stroke, cardiac complications, or death during the postprocedural period. Outcomes of interest were compared between patients aged ≥70 years and <70 years, undergoing CEA and CAS. Multivariate logistic regression was performed to determine the effect of age on occurrence of postoperative stroke, cardiac complications, or death. Covariates included in the logistic regression were patient's age, gender, comorbid conditions, including hypertension, diabetes mellitus (DM), chronic lung disease, coronary artery disease (CAD), congestive heart failure (CHF), and renal failure; symptom status (symptomatic vs asymptomatic status), and hospital characteristics., Results: Of the total 495,331 estimated patients who received treatment for CAD during the study period, 88% underwent CEA and the remaining 12% underwent CAS. Of the total procedures, 41% of the procedures were performed in patients aged <70 years compared to the remaining 59% that were performed among patients aged ≥70 years. For patients undergoing CAS, age ≥70 years was an important predictor of postoperative stroke (P = .0025; odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.5) and cardiac complications postprocedure (P = .045; OR, 1.3; 95% CI, 1.0-1.6). For patients undergoing CEA, age ≥70 years was associated with higher cardiac complications (P < .001; OR, 1.5; 95% CI, 1.3-1.7) and higher postoperative mortality risk (P = .0008; OR, 1.4; 95% CI, 1.1-1.8) compared to patients aged <70 years. The increased risk of composite end point (postoperative stroke/cardiac complications/mortality) among patients aged ≥70 years was a significant factor for patients undergoing either CAS or CEA (OR of 1.3 for both procedures)., Conclusion: Our analysis suggests that most CAS and CEAs are performed in patients aged ≥70 years in general practice, and higher rates of postoperative complications are observed among these patients regardless of procedure choice., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The Society for Vascular Surgery (SVS) Vascular Registry (VR) collects data on outcomes of carotid endarterectomy and carotid artery stenting (CAS). The purpose of this study was to evaluate the impact of open vs closed cell stent design on the in-hospital and 30-day outcome of CAS., Methods: The VR collects provider-reported data on patients using a Web-based database. Data were analyzed both in-hospital and at 30 days postprocedure. The primary outcome is combined death/stroke/myocardial infarction (MI)., Results: As of October 14, 2009, there were 4337 CAS with discharge data and 2397 with 30-day data. Open cell stents (OPEN) were used in 3451 patients (79.6%), and closed cell stents (CLOSED) were used in 866 patients (20.4%). Baseline demographics showed no differences in age, gender, race, and ethnicity. However, the OPEN group had more patients with atherosclerosis (74.5% vs 67.4%; P = .0003) as the etiology of carotid artery disease. The OPEN group also had a higher prevalence of preprocedural stroke (25.8% vs 21.4%; P = .0079), chronic obstructive pulmonary disease (COPD; 21.0% vs 17.6%; P = .0277), cardiac arrhythmia (14.7% vs 11.4%; P = .0108), valvular heart disease (7.4% vs 3.7%; P < .0001), peripheral vascular disease (PVD; 40.0% vs 35.3%; P = .0109), and smoking history (59.0% vs 54.1%; P = .0085). There are no statistically significant differences in the in-hospital or 30-day outcomes between the OPEN and CLOSED patients. Further subgroup analyses demonstrated symptomatic patients had a higher event rate than the asymptomatic cohort in both the OPEN and CLOSED groups. Among symptomatic patients, the OPEN patients had a lower (0.43% vs 1.41%; P = .0349) rate of in-hospital mortality with no difference in stroke or transient ischemic attack (TIA). There were no differences in 30-day event rates. In asymptomatic patients, there were also no statistically significant differences between the OPEN and CLOSED groups. After risk adjustment, there remained no statistically significant differences between groups of the primary endpoint (death/stroke/MI) during in-hospital or 30 days., Conclusion: In-hospital and 30-day outcomes after CAS were not significantly influenced by stent cell design. Symptomatic patients had higher adverse event rates compared to the asymptomatic cohort. As there is no current evidence of differential outcome between the use of open and closed cell stents, physicians should continue to use approved stent platforms based on criteria other than stent cell design., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Carotid endarterectomy (CEA) is among the most commonly performed vascular operations in both academic and community hospital settings. The excellent results of the large prospective studies (North American Symptomatic Carotid Endarterectomy Trial, Asymptomatic Carotid Atherosclerosis Study) have been criticized because of a widely held impression that community hospitals could not duplicate the excellent surgical results achieved in high volume university hospitals or clinics. The purpose of this study was to use the National Surgical Quality Improvement Program data to evaluate the outcomes of CEA in academic versus community hospitals., Methods: All patients undergoing CEA were identified in the National Surgical Quality Improvement Program database conducted between January 1, 2005 and October 30, 2009. The patients were stratified on the basis of the hospital of care: academic hospital or community hospital. All postoperative outcomes were analyzed., Results: A total of 17,388 CEAs met the inclusion criteria, among which 9,649 cases were performed at an academic institution and 7,739 cases were performed at a community hospital. There were more women in the community hospital cohort (42.5% vs. 40.2%, p = 0.0197). Preoperatively, the community hospital cohort had more patients with dyspnea (22.8% vs. 18.1%, p < 0.0001), chronic obstructive pulmonary disease (COPD) (10.7% vs. 9.7%, p = 0.0322), angina (2.6% vs. 1.9%, p = 0.0021), previous stroke with no deficit (9.0% vs. 7.6%, p = 0.0009), and past transient ischemic attacks (28.3% vs. 25.1%, p < 0.0001). The academic hospital cohort had more patients with recent alcohol use (4.5% vs. 3.8%, p = 0.0245), cardiac surgery (24.0% vs. 22.5%, p = 0.0206), and hemiplegia (4.8% vs. 4.1%, p = 0.0288). Postoperatively, there was no difference in the two groups in 30-day stroke rate (1.2% vs. 1.5%, p = 0.1035), 30-day myocardial infarction rate (0.5% vs. 0.6%, p = 0.2149), or 30-day mortality rate (0.5% vs. 0.6%, p = 0.6335). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (2.2% vs. 2.7%, p = 0.0568). In the asymptomatic patient cohort, there were a total of 9,285 cases, with 5311 cases performed at an academic institution and the remainder at community hospitals. Preoperatively, the community hospitals had more patients with dyspnea (78.3% vs. 82.1%, p < 0.0001). The academic cohort had more patients with acute renal failure (0.3% vs. 0.1%, p = 0.0426). Postoperatively, there was no difference in the two groups in 30-day stroke rate (0.9% vs. 1.1%, p = 0.2899), 30-day myocardial infarction rate (0.4% vs. 0.5%, p = 0.4348), or 30-day mortality rate (0.5% vs. 0.4%, p = 0.6370). The overall combined 30-day stroke, myocardial infarction, and mortality rates were not different between the two groups (1.8% vs. 2.0%, p = 0.4394)., Conclusion: CEA is widely performed in both academic and community hospital settings. This study demonstrates that the results are equivalent and have equally good 30-day outcomes in both asymptomatic and combined populations., (Copyright © 2011. Published by Elsevier Inc.)

Objective: This study compared, at a national level, trends in utilization, mortality, and stroke after carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA) from 2005 to 2007., Methods: The Nationwide Inpatient Sample (NIS) was queried for patient discharges with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CAS and CEA. The primary outcomes were in-hospital mortality, stroke, hospital charges, and discharge disposition. Subgroup analyses were performed to evaluate these outcomes by neurologic presentation using χ(2) and multivariable logistic regression., Results: Of the 404,256 discharges for carotid revascularization, CAS utilization was 66% higher in 2006 than in 2005 (9.3% vs 14%, P = .0004). Crude mortality, stroke, and median charges remained higher for CAS than for CEA; discharge to home was more common after CEA. Results improved from 2005 to 2007. By logistic regression of the total cohort from 2005 to 2006, CAS was independently predictive of mortality (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; P < .0001). Independent predictors of stroke included CAS (OR, 1.43; 95% CI, 1.18-1.73; P < .0001) and symptomatic disease (OR, 2.4; 95% CI, 2.06-2.93;P < .0001). Among subgroups based on neurological presentation, regression showed that CAS significantly increased the odds of stroke in asymptomatic patients (OR, 1.6; 95% CI, 1.2-2.0; P = .0003). Among symptomatic patients, CAS increased the odds of in-hospital death (OR, 3.0; 95% CI, 1.7-5.1, P < .0001) and trended toward significance for stroke (OR, 1.7; 95% CI, 1.0-2.8; P = .0569)., Conclusion: Utilization of CAS has increased from the years 2005 to 2007 with some improvements in the outcome. Despite improvements in outcome, resource utilization remains significantly higher for CAS than CEA., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: The aim of this study was to analyze the CAPTURE 2 (Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events) study for physician- or site-related variables associated with differential outcomes for carotid artery stenting (CAS)., Background: The CAPTURE 2 trial is an ongoing, prospective, nonrandomized, independently adjudicated, multicenter clinical study enrolling high-surgical-risk patients undergoing CAS., Methods: In this assessment of the CAPTURE 2 study, the American Heart Association carotid endarterectomy guideline limits were used to define acceptable site and physician CAS outcomes; therefore, the resulting population of nonoctogenarian, asymptomatic subjects in this analysis is confined to 3,388 (of the total 5,297) subjects treated at 180 U.S. hospitals by 459 operators between March 2006 and January 2009., Results: The rates of death, stroke, and myocardial infarction and death and stroke (DS) at 30 days were 3.5% and 3.3%, respectively, for the full CAPTURE 2 study cohort and 2.9% and 2.7%, respectively, for the asymptomatic, nonoctogenarian subgroup. In this subgroup, two-thirds of sites (118 of 180, 66%) had no DS events. Within the remaining sites, an inverse relationship between event rates and hospital patient volume as well as between event rates and individual operator volume was observed. The DS rates trended lower for interventional cardiologists compared with other specialties., Conclusions: Outcomes from the largest prospectively gathered, independently adjudicated, multicenter CAS study indicate that CAS can be safely performed in a variety of hospital settings by physicians with various specialties. The most important determinant of perioperative CAS outcomes was both site and operator CAS volume. A threshold of 72 cases was found to be necessary for consistently achieving a DS rate below 3% in this later-phase single arm study; background era and non-study operator experience will affect this determination. (Second Phase of "Carotid RX ACCULINK/RX ACCUNET Post-Approval Trial to Uncover Unanticipated or Rare Events"; NCT00302237)., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Relatively little is known about trends in the utilization or outcomes of carotid endarterectomy (CEA) in the very elderly. We determined trends in the rates of CEA and perioperative (in-hospital and 30-day) and long-term (1-, 2-, 3-, 4- and 5-year) mortality in a US national sample of patients >or=80 years of age., Methods: All fee-for-service Medicare patients (80-89 and >or=90 years of age) who had a CEA [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): 38.12] from 1993 to 1999 were identified using the Centers for Medicare and Medicaid Services Inpatient Standard Analytic Files. Demographic characteristics and comorbid conditions were determined using ICD-9-CM diagnostic codes within the year prior to the index hospitalization for CEA., Results: A total of 140,376 CEA were performed in patients aged 80-89 years and 6,446 in those aged >or=90 years during this 7-year period. The annual number of operations increased from 13,115 in 1993 to 21,582 in 1999 for octogenarians, and from 481 in 1993 to 1,257 in 1999 for nonagenarians. Perioperative mortality was 2.2% in octogenarians and 3.3% in nonagenarians. Long-term mortality increased by approximately 10% per year after the operation, and was 43% in octogenarians and 56% in nonagenarians at 5 years. Perioperative mortality rates remained relatively stable over the 7-year period for both age groups although comorbidities increased., Conclusions: The number of CEA performed in the very elderly in the USA increased from 1993 to 1999. Perioperative mortality rates were high compared with trial results, while long-term survivorship was comparable to that of similarly-aged peers in the USA., ((c) 2009 S. Karger AG, Basel.)

Background and Purpose: Information about the expression of atherosclerosis in different arteries is important. The impact of cardiovascular risk factors is artery-related, and the assessment of arterial structure and function in peripheral arteries are increasingly used as surrogate markers for coronary atherosclerosis and the risk of developing heart attack., Methods: In an autopsy study, we analyzed the coronary, carotid and superficial femoral arteries from 100 individuals (70 men; 20 to 82 years of age) of which 27 died from coronary atherosclerosis. Microscopic sections (n=4756) were analyzed blindly using a modification of the histological classification endorsed by the American Heart Association (AHA)., Results: We found distinct artery-dependent patterns of atherosclerosis with a high prevalence of foam cell lesions and lipid core plaques in the carotid arteries. The femoral arteries were least affected by atherosclerosis, foam cell lesions were rare, and the development of advanced atherosclerosis was strongly age-dependent and dominated by fibrous plaques. Plaques were most common in the left anterior descending coronary artery and the carotid bifurcation. In coronary (versus noncoronary) death, lipid core plaques were more prevalent in all arteries., Conclusions: The initiation, speed of development, and phenotypic expression of atherosclerotic plaques are artery-related. Foam cell lesions are frequent in the carotid arteries, probably explaining the dynamics in carotid intima-media thickness. Atherosclerosis develops slowly in femoral arteries, and severe atherosclerosis is dominated by fibrous plaques. The higher prevalence of lipid core plaques in all arteries in coronary death indicates a systemically more vulnerable expression of atherosclerosis in these individuals.

We determined hospital mortality and postoperative stroke rates after combined carotid endarterectomy (CEA) and coronary artery bypass graft surgery (CABG) vs CABG alone, using the US Nationwide Inpatient Sample. CEA-CABG combined was 1.06%. After correcting for comorbidities, the odds ratio for postoperative stroke or death for CEA-CABG was 1.38 (95% CI 1.27 to 1.50) vs CABG. With the increase in postoperative stroke and death, a randomized, controlled clinical trial of combined CEA-CABG is indicated.