Regional performance of carotid endarterectomy - Appropriateness, outcomes, and risk factors for complications

Background and Purpose Guided by the findings of randomized controlled trials evaluating carotid endarterectomy (CEA), we examined the appropriateness of CEAs performed in our city and determined the incidences and risk factors for postoperative stroke, death, and cardiac complications. Methods Using health records, we retrospectively reviewed 291 consecutive CEAs performed in our region over 18 months. Based on randomized controlled trial results and standardized remeasurements of angiographic carotid stenoses, indications for CEA were considered appropriate for symptomatic carotid stenoses greater than or equal to 70%, uncertain for <70% symptomatic or greater than or equal to 60% asymptomatic stenoses, or inappropriate for <6O% asymptomatic stenoses and for patients with preoperative neurological or medical instability. Results We found that 41% of patients (118/291) were asymptomatic. Surgical indications were appropriate in 33% of cases (92/281), uncertain in 49% (138/281), and inappropriate in 18% (51/281). Stroke or death occurred within 30 days postoperatively in 5.2% (9/174) of symptomatic patients and 5.1% (6/117) of asymptomatic patients. At least one cardiac complication (angina, congestive heart failure, dysrhythmia, or myocardial infarction) developed in 8.9% (26/291). Independent preoperative risk factors for stroke or death were histories of angina or congestive heart failure and lack of antiplatelet medication; for cardiac complications, risk factors were age >75 years and a history of congestive heart failure. Conclusions Almost 1 in 5 patients underwent CEA inappropriately, which was most commonly due to apparent overestimation of stenosis severity, and half had uncertain indications. Our high complication rate possibly negated any overall surgical benefit in the large group of asymptomatic patients.