Analysis Reveals Mass General as a National Leader in Treating Carotid Artery Stenosis

A recent internal analysis of procedures performed to address carotid artery stenosis (CAS) revealed that Massachusetts General Hospital is both a regional and national leader in key parameters associated with patient outcomes. The evaluation—targeting different carotid artery procedures from 2016 to 2020—revealed that Mass General demonstrated among the lowest mortality, complication, and readmission rates relative to other comparably sized hospitals.

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"Our analyses focused on parameters that are used as benchmarks for procedures performed to address CAS in hospitals throughout the nation," says Javier Romero, MD, neuroradiologist in the Department of Radiology at Mass General. "The results were extremely encouraging and confirmed our standing at or near the top among both national and regional hospitals in patient outcomes from these life-saving vascular procedures."

Diagnosing and Treating a Silent Killer

The carotid arteries are situated on either side of the neck and provide blood and oxygen to the brain. CAS describes a condition wherein those arteries become narrowed or blocked to a degree that restricts blood flow—increasing the risk of stroke. These blockages result from plaque buildup, marking CAS as a common morbidity alongside systemic atherosclerotic diseases.

Importantly, any cardiovascular risk factor predisposing someone to progressive atherosclerosis can potentially manifest as CAS, with genetics and lifestyle choices as frequent determinants of this outcome.

"In almost 90% of cases, CAS is associated with factors such as hypertension, hyperlipidemia (high cholesterol), and coronary artery disease that directly contribute to cardiovascular diseases," says Dr. Romero.

Patients with CAS are frequently asymptomatic, with definitive diagnosis most often occurring after a stroke. Thus, for asymptomatic patients, careful consideration of the patient's medical history and the presence of clear risk factors are critical first steps in preventive care.

"There are three primary approaches to CAS diagnosis prior to interventions," explains Dr. Romero. "These represent a kind of triage that allows us to determine how CAS treatment proceeds."

• Ultrasound: This is the most frequently used, least invasive diagnostic method. This technique determines whether there is a blockage by showing blood flow through the carotid arteries. "Ultrasound is frequently used to predict incidence in asymptomatic carotid artery narrowing in patients presenting CAS risk factors," says Dr. Romero
• Computed tomography angiography (CTA): This method is slightly more invasive, as it involves using a contrast dye and X-ray radiation to obtain images. However, the results offer a detailed assessment of both the extent and location of the blockage
• Magnetic resonance angiography (MRA): This technique offers similar levels of detail as CTA, without radiation and possibly without the use of a contrast dye
• Digital subtraction angiography: Although still considered the "gold standard" technique for visualizing blood vessels, this method is infrequently used relative to CTA and MRA due to its reliance on contrast dyes and radiation

Dr. Romero advises that although ultrasound primarily qualifies as a preventative measure to assess the presence of CAS, all of these methods yield information that leads to appropriate follow-up. In cases requiring interventions beyond medication and lifestyle changes, the procedure used is determined according to the severity of the blockage and the patient's health status.

There are three common approaches to mitigating CAS-related blockages:

• Endarterectomy: This is a surgical method that involves entry to the artery via an incision in the neck, followed by surgical removal of the plaque. Given the risks associated with surgical procedures, endarterectomy is generally only recommended for moderate to severe blockages (>50%) and patients with no significant comorbidities
• Angioplasty with stenting: Angioplasty involves the delivery of a deflated balloon via a catheter to the affected artery. Inflation of the balloon compresses the plaque against the artery walls, thereby restoring blood flow. In many cases, a mesh surrounding the balloon acts as a scaffold that remains in place after the balloon is inflated and provides structural support to the arterial walls
• Transcatheter revascularization (TCAR): TCAR also employs angioplasty and stenting. However, to avoid complications from stroke caused by loosened plaque reaching the brain, blood flow to the brain is temporarily diverted into the femoral artery in the thigh and filtered during angioplasty/stenting

"Determining the best course of action requires a team with the expertise needed for confident decision-making and talent to consistently provide flawless care, regardless of the procedure being administered," says Dr. Romero.

Benefitting Patients Through a Commitment to Constant Improvement

The results of their analysis highlighted three specific areas in which Mass General demonstrated exceptional outcomes for patients:

• A 33% decrease in readmissions following CAS-related procedures from 2015 to 2020
• The lowest mortality rate associated with these procedures among the top 10 hospitals in the nation based on U.S. News & World Report rankings
• The 6^th lowest complication rate for these procedures in the nation

Notably, the results also presented similar outcomes relative to regional hospitals, which Dr. Romero says highlights an important qualifying factor in this particular analysis: When reporting positive outcomes according to benchmarks that signal a hospital's effectiveness at a particular procedure, context is essential.

"Some regional hospitals may only perform a handful of these procedures annually while being highly selective of the patients that undergo them. We felt that properly evaluating our standing required a fair assessment against outcomes in hospitals with similar patient volumes as Mass General."

To account for this, analyses of Mass General's standing against regional hospitals focused on those performing at least 200 procedures annually. In addition to the national numbers, the data also identified Mass General as having the lowest complication rate related to CAS procedures (3.4%) and the lowest readmission rate of patients following CAS procedures (3.6%) among regional hospitals.

"These results are a testament to the multidisciplinary approach to treating patients with CAS or other life-threatening vascular conditions," explains Dr. Romero.

As one of the only vascular centers in the nation with specialists in all areas of vascular disease, this holistic approach to patient care has paid clear dividends. He specifically highlights the low mortality and readmission rates as singular achievements resulting from selecting the right patients for the correct procedures performed by the best surgeons.

"The specialists in the Fireman Vascular Center are experts in the various fields required not only for accurate and effective diagnosis and treatment but also post-procedure care because the fight is not over when a procedure ends. This analysis offered validation that the kind of comprehensive care provided here is working."

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