- Using a large national patient registry (12,336 asymptomatic and 8,727 symptomatic patients), researchers at Massachusetts General Hospital assessed the influence of surgical specialty on perioperative outcomes of carotid endarterectomy (CEA)
- Asymptomatic patients undergoing CEA by a vascular surgeon had significantly lower rates of stroke (1.3% vs. 2.4%; P = .02) and stroke/death (1.7% vs. 3.2%; P = .006) than those whose procedure was performed by a non-vascular surgeon
- Those differences persisted in multivariable analyses
- Among symptomatic patients, there was no difference between the vascular surgeon and non-vascular surgeon cohorts in stroke or stroke/death, but the non-vascular surgeon cohort had a significantly higher rate of major complications
Surgeons from multiple medical specialties regularly perform carotid endarterectomy (CEA). Multiple studies have assessed the impact of a surgeon's specialty on outcomes, but the results have been inconsistent.
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Notably, few researchers have stratified their analyses by symptom status even though some types of surgeons (e.g., neurosurgeons) are more likely to treat symptomatic patients who are at higher risk of stroke. In addition, many studies have lacked data about covariates that should be considered in multivariable analyses, such as degree of stenosis, high-risk anatomic features and preoperative medications.
Using a database that has such information available, Laura T. Boitano, MD, clinical fellow in surgery, Samuel I. Schwartz, MD, vascular surgeon, and colleagues of the Division of Vascular and Endovascular Surgery at Massachusetts General Hospital, determined that asymptomatic patients have better outcomes when CEA is performed by a vascular surgeon. Their report appears in the Journal of Vascular Surgery.
The research team reviewed records of 12,336 asymptomatic patients and 8,727 symptomatic patients who underwent CEA between 2001 and 2016 in the "vascular targeted participant use data files" maintained by the American College of Surgeons.
Ninety-five percent of asymptomatic and 90% of symptomatic patients had the procedure performed by a vascular surgeon (VS). The other cases were performed by a neurosurgeon, cardiac surgeon, thoracic surgeon or general surgeon (non-vascular surgeons; NVS).
The two primary outcomes of the study were stroke within 30 days and the composite endpoint of stroke or death within 30 days.
- Asymptomatic patients — The median stroke rate was significantly lower in the VS cohort than in the NVS cohort (1.3% vs. 2.4%; P = .02), as was the rate of stroke/death (1.7% vs. 3.2%; P = .006)
- Symptomatic patients — The stroke rate (3.1% vs. 4.2%) and the rate of stroke/death (3.8% vs. 4.6%) were similar in the VS and NVS cohorts. However, the NVS cohort had a significantly higher rate of major complications (21% vs. 17%; P = .02)
Results of Multivariable Analyses
- Asymptomatic patients — The NVS cohort was at almost two times the odds of stroke compared with the VS cohort (OR, 1.8; 95% CI, 1.1–3.1; P = .03). When each individual surgical subspecialty was compared with VS, neurosurgery was associated with three times the odds of stroke (OR, 3.1; 95% CI, 1.3–7.2; P = .008)
- Symptomatic patients — The odds of stroke were similar whether CEA was performed by an NVS or VS
- Asymptomatic patients — The NVS cohort was at almost two times the odds of stroke/death compared with the VS cohort (OR, 1.8; 95% CI, 1.1–2.9; P = .01). Neurosurgery was associated with 2.5-fold increased odds compared with VS (OR, 2.5; 95% CI, 1.1–5.7; P = .04)
- Symptomatic patients — The odds of stroke/death were similar whether CEA was performed by an NVS or VS
Continued Scrutiny Expected
In 2011, both the Society for Vascular Surgery and the American Heart Association published guidelines that stated appropriate perioperative stroke/death rates for CEA: less than 3% in asymptomatic patients and less than 6% in symptomatic patients. In this study, NVS failed to meet the benchmark for asymptomatic patients.
The use of statins has decreased the risk of stroke enough that some experts believe CEA is no longer indicated for asymptomatic patients. The Society for Vascular Surgery is developing new guidelines for CEA, and the CREST-2 trial, which is comparing carotid revascularization plus medical management against medical management alone. It is expected to be completed in 2020.
It's likely that the outcomes of CEA in asymptomatic patients will continue to be reviewed closely, with rigorous benchmarks for surgeons. The real-world differences in outcomes by subspecialty that this study identified will presumably be a focus of continued critical examination.
Learn more about the Division of Vascular and Endovascular Surgery
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