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

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Abstract

Background and Purpose-This analysis was performed to assess the association between perioperative and clinicalvariables 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 CarotidStenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomaticstenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type ofanesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Strokeor death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimatedin 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 multivariableregression 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 orocclusion (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 significantlyassociated with the perioperative stroke or death risk.Conclusions-The current results indicate lower perioperative stroke or death rates in patients operated upon under localanesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion wereidentified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findingsmight 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

Keywords

  • Anesthesia
  • Death
  • Endarterectomy, carotid
  • Humans
  • Stroke

ASJC Scopus subject areas

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

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    Knappich, C., Kuehnl, A., Haller, B., Salvermoser, M., Algra, A., Becquemin, J. P., Bonati, L. H., Bulbulia, R., Calvet, D., Fraedrich, G., Gregson, J., Halliday, A., Hendrikse, J., Howard, G., Jansen, O., Malas, M. B., Ringleb, P. A., Brown, M. M., Mas, J. L., ... 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