Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis

Christoph Knappich, Andreas Kuehnl, Bernhard Haller, Michael Salvermoser, Ale Algra, Jean Pierre Becquemin, Leo H. Bonati, Richard Bulbulia, David Calvet, Gustav Fraedrich, John Gregson, Alison Halliday, Jeroen Hendrikse, George Howard, Olav Jansen, Mahmoud B. Malas, Peter A. Ringleb, Martin M. Brown, Jean Louis Mas, Thomas G. BrottDylan R. Morris, Steff C. Lewis, Hans Henning Eckstein

Research output: Contribution to journalArticle

Abstract

Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7% men). The 30-day stroke or death rate was 4.3%. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95% CI, 0.50-0.99]). Shunting (aRR, 1.43 [95% CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95% CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95% CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.

Original languageEnglish (US)
Pages (from-to)3439-3448
Number of pages10
JournalStroke
Volume50
Issue number12
DOIs
StatePublished - Dec 1 2019

Fingerprint

Carotid Endarterectomy
Carotid Stenosis
Stroke
Local Anesthesia
Intraoperative Neurophysiological Monitoring
Multilevel Analysis
Mortality
Selection Bias
General Anesthesia
Pathologic Constriction
Anesthesia
Randomized Controlled Trials
Odds Ratio
Regression Analysis
Databases

Keywords

  • anesthesia
  • death
  • endarterectomy, carotid
  • humans
  • stroke

ASJC Scopus subject areas

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing

Cite this

Knappich, C., Kuehnl, A., Haller, B., Salvermoser, M., Algra, A., Becquemin, J. P., ... Eckstein, H. H. (2019). Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis. Stroke, 50(12), 3439-3448. https://doi.org/10.1161/STROKEAHA.119.026320

Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis. / Knappich, Christoph; Kuehnl, Andreas; Haller, Bernhard; Salvermoser, Michael; Algra, Ale; Becquemin, Jean Pierre; Bonati, Leo H.; Bulbulia, Richard; Calvet, David; Fraedrich, Gustav; Gregson, John; Halliday, Alison; Hendrikse, Jeroen; Howard, George; Jansen, Olav; Malas, Mahmoud B.; Ringleb, Peter A.; Brown, Martin M.; Mas, Jean Louis; Brott, Thomas G.; Morris, Dylan R.; Lewis, Steff C.; Eckstein, Hans Henning.

In: Stroke, Vol. 50, No. 12, 01.12.2019, p. 3439-3448.

Research output: Contribution to journalArticle

Knappich, C, Kuehnl, A, Haller, B, Salvermoser, M, Algra, A, Becquemin, JP, Bonati, LH, Bulbulia, R, Calvet, D, Fraedrich, G, Gregson, J, Halliday, A, Hendrikse, J, Howard, G, Jansen, O, Malas, MB, Ringleb, PA, Brown, MM, Mas, JL, Brott, TG, Morris, DR, Lewis, SC & Eckstein, HH 2019, 'Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis', Stroke, vol. 50, no. 12, pp. 3439-3448. https://doi.org/10.1161/STROKEAHA.119.026320
Knappich, Christoph ; Kuehnl, Andreas ; Haller, Bernhard ; Salvermoser, Michael ; Algra, Ale ; Becquemin, Jean Pierre ; Bonati, Leo H. ; Bulbulia, Richard ; Calvet, David ; Fraedrich, Gustav ; Gregson, John ; Halliday, Alison ; Hendrikse, Jeroen ; Howard, George ; Jansen, Olav ; Malas, Mahmoud B. ; Ringleb, Peter A. ; Brown, Martin M. ; Mas, Jean Louis ; Brott, Thomas G. ; Morris, Dylan R. ; Lewis, Steff C. ; Eckstein, Hans Henning. / Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis. In: Stroke. 2019 ; Vol. 50, No. 12. pp. 3439-3448.
@article{738d7b7885534aa6aa9e0251fc6af1bb,
title = "Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis",
abstract = "Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7{\%} men). The 30-day stroke or death rate was 4.3{\%}. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95{\%} CI, 0.50-0.99]). Shunting (aRR, 1.43 [95{\%} CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95{\%} CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95{\%} CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.",
keywords = "anesthesia, death, endarterectomy, carotid, humans, stroke",
author = "Christoph Knappich and Andreas Kuehnl and Bernhard Haller and Michael Salvermoser and Ale Algra and Becquemin, {Jean Pierre} and Bonati, {Leo H.} and Richard Bulbulia and David Calvet and Gustav Fraedrich and John Gregson and Alison Halliday and Jeroen Hendrikse and George Howard and Olav Jansen and Malas, {Mahmoud B.} and Ringleb, {Peter A.} and Brown, {Martin M.} and Mas, {Jean Louis} and Brott, {Thomas G.} and Morris, {Dylan R.} and Lewis, {Steff C.} and Eckstein, {Hans Henning}",
year = "2019",
month = "12",
day = "1",
doi = "10.1161/STROKEAHA.119.026320",
language = "English (US)",
volume = "50",
pages = "3439--3448",
journal = "Stroke",
issn = "0039-2499",
publisher = "Lippincott Williams and Wilkins",
number = "12",

}

TY - JOUR

T1 - Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis

AU - Knappich, Christoph

AU - Kuehnl, Andreas

AU - Haller, Bernhard

AU - Salvermoser, Michael

AU - Algra, Ale

AU - Becquemin, Jean Pierre

AU - Bonati, Leo H.

AU - Bulbulia, Richard

AU - Calvet, David

AU - Fraedrich, Gustav

AU - Gregson, John

AU - Halliday, Alison

AU - Hendrikse, Jeroen

AU - Howard, George

AU - Jansen, Olav

AU - Malas, Mahmoud B.

AU - Ringleb, Peter A.

AU - Brown, Martin M.

AU - Mas, Jean Louis

AU - Brott, Thomas G.

AU - Morris, Dylan R.

AU - Lewis, Steff C.

AU - Eckstein, Hans Henning

PY - 2019/12/1

Y1 - 2019/12/1

N2 - Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7% men). The 30-day stroke or death rate was 4.3%. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95% CI, 0.50-0.99]). Shunting (aRR, 1.43 [95% CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95% CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95% CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.

AB - Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7% men). The 30-day stroke or death rate was 4.3%. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95% CI, 0.50-0.99]). Shunting (aRR, 1.43 [95% CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95% CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95% CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.

KW - anesthesia

KW - death

KW - endarterectomy, carotid

KW - humans

KW - stroke

UR - http://www.scopus.com/inward/record.url?scp=85075812829&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85075812829&partnerID=8YFLogxK

U2 - 10.1161/STROKEAHA.119.026320

DO - 10.1161/STROKEAHA.119.026320

M3 - Article

C2 - 31735137

AN - SCOPUS:85075812829

VL - 50

SP - 3439

EP - 3448

JO - Stroke

JF - Stroke

SN - 0039-2499

IS - 12

ER -