Title: Delayed Carotid Endarterectomy After Admission in Symptomatic Carotid Artery Disease Is Associated With Lower Postoperative Stroke Rates in the Medicare Population
Abstract: The appropriate timing of carotid endarterectomy (CEA) in symptomatic carotid artery disease is still controversial. Despite guideline recommendations to perform CEA within 14 days, recent studies have favored delayed CEA to decrease the risk of postoperative stroke. The goal of this study was to evaluate the timing of CEA for symptomatic disease in the Medicare population and its effects on postoperative stroke rates. A 20% Medicare sample was queried to identify CEAs performed during inpatient hospitalizations. Patients were considered symptomatic if they had an admitting diagnosis of stroke/infarct, transient ischemic attack (TIA), or amaurosis fugax according to previously published literature. A postoperative stroke was noted if the patients had an International Classification of Diseases, Ninth Revision code noting iatrogenic causes. Multivariable logistic regression was used to evaluate risk factors for in-hospital stroke and reported as odds ratios (ORs) with 95% confidence intervals (95% CIs). A total of 133,069 CEAs were performed in 120,754 patients. The majority of CEAs were performed for asymptomatic disease (84.1%), with rates increasing for symptomatic disease in recent years (Table I). The majority of symptomatic disease was previous stroke/infarct (74.6%), followed by TIA (14.1%), then amaurosis fugax (11.2%). The rates of in-hospital stroke were significantly higher for symptomatic disease than for asymptomatic disease (6.1% vs 0.5%; P < .001). The majority of CEAs for symptomatic disease were performed within 2 days of hospitalization (65.9%), followed by 3 to 7 days (28.3%), 8 to 14 days (5.2%), and >14 days (0.7%). Delay of CEA by 3 to 7 days after hospitalization was associated with lower postoperative stroke (OR, 0.43; 95% CI, 0.37-0.41); however, waiting >14 days was not associated with a lower risk (Table II). Compared with TIA, amaurosis fugax was associated with a lower rate (OR, 0.15; 95%, CI, 0.08-0.30), and previous infarct/stroke was associated with a higher stroke rate (OR, 3.5; 95% CI, 2.68-4.51). Although this study found a significant association between lower postoperative stroke and CEA with delayed timing after admission up to 2 weeks, further studies including randomized controlled trials are needed to define the optimal timing of CEA for symptomatic carotid artery disease.Table ITrends in carotid endarterectomy (CEA) indication and in-hospital strokeYearSymptomatic indication for CEA, %In-hospital stroke rateAsymptomatic disease, %Symptomatic disease, %200614.10.84.8200713.90.84.9200814.90.57.3200915.20.56.6201015.10.46.6201116.80.47.1201217.20.36.1201317.80.45.6201418.60.45.2Total15.90.56.1 Open table in a new tab Table IIFactors affecting in-hospital stroke rate for carotid endarterectomies (CEAs) performed for symptomatic diseaseFactorOR95% CIP valueTiming of CEA (compared with hospital days 0-2) Hospital day 3-70.440.37-0.51<.001 Hospital day 8-140.500.37-0.67<.001 Hospital day >140.890.48-1.65.71Female sex1.161.03-1.30.01Type of symptoms (compared with TIA) Amaurosis fugax0.150.08-0.30<.001 Stroke/infarct3.482.68-4.51<.001CI, Confidence interval; OR, odds ratio; TIA, transient ischemic attack. Open table in a new tab