Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival

Jessica B. Wallaert, Jack L. Cronenwett, Daniel J. Bertges, Andres Schanzer, Brian W. Nolan, Randall R De Martino, Jens Eldrup-Jorgensen, Philip P. Goodney

Research output: Contribution to journalArticle

45 Citations (Scopus)

Abstract

Objective: Although carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis. Methods: Prospectively collected data from 4114 isolated CEAs performed for asymptomatic stenosis across 24 centers in the Vascular Study Group of New England between 2003 and 2011 were used for this analysis. Late survival was determined with the Social Security Death Index. Cox proportional hazard models were used to identify risk factors for mortality within the first 5 years after CEA and to calculate a risk score for predicting 5-year survival. Results: Overall 3- and 5-year survival after CEA in asymptomatic patients were 90% (95% CI 89%-91%) and 82% (95% CI 81%-84%), respectively. By multivariate analysis, increasing age, diabetes, smoking history, congestive heart failure, chronic obstructive pulmonary disease, poor renal function (estimated glomerular filtration rate <60 or dialysis dependence), absence of statin use, and worse contralateral ICA stenosis were all associated with worse survival. Patients classified as low (27%), medium (68%), and high risk (5%) based on number of risk factors had 5-year survival rates of 96%, 80%, and 51%, respectively (P <.001). Conclusions: More than four out of five asymptomatic patients selected for CEA in the Vascular Study Group of New England achieved 5-year survival, demonstrating that, overall, surgeons in our region selected appropriate patients for carotid revascularization. However, there were patients selected for surgery with high risk profiles, and our models suggest that the highest risk patients (such as those with multiple major risk factors including age ≥80, insulin-dependent diabetes, dialysis dependence, and severe contralateral ICA stenosis) are unlikely to survive long enough to realize a benefit of prophylactic CEA for asymptomatic stenosis. Predicting survival is important for decision making in these patients.

Original languageEnglish (US)
Pages (from-to)112-119
Number of pages8
JournalJournal of Vascular Surgery
Volume58
Issue number1
DOIs
StatePublished - Jul 2013
Externally publishedYes

Fingerprint

Carotid Endarterectomy
Patient Selection
Survival
Carotid Stenosis
New England
Blood Vessels
Dialysis
Pathologic Constriction
Hydroxymethylglutaryl-CoA Reductase Inhibitors
Social Security
Glomerular Filtration Rate
Proportional Hazards Models
Chronic Obstructive Pulmonary Disease
Decision Making
Multivariate Analysis
Survival Rate
Heart Failure
Smoking
History
Stroke

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival. / Wallaert, Jessica B.; Cronenwett, Jack L.; Bertges, Daniel J.; Schanzer, Andres; Nolan, Brian W.; De Martino, Randall R; Eldrup-Jorgensen, Jens; Goodney, Philip P.

In: Journal of Vascular Surgery, Vol. 58, No. 1, 07.2013, p. 112-119.

Research output: Contribution to journalArticle

Wallaert, JB, Cronenwett, JL, Bertges, DJ, Schanzer, A, Nolan, BW, De Martino, RR, Eldrup-Jorgensen, J & Goodney, PP 2013, 'Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival', Journal of Vascular Surgery, vol. 58, no. 1, pp. 112-119. https://doi.org/10.1016/j.jvs.2012.12.056
Wallaert, Jessica B. ; Cronenwett, Jack L. ; Bertges, Daniel J. ; Schanzer, Andres ; Nolan, Brian W. ; De Martino, Randall R ; Eldrup-Jorgensen, Jens ; Goodney, Philip P. / Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival. In: Journal of Vascular Surgery. 2013 ; Vol. 58, No. 1. pp. 112-119.
@article{4a093445f9df4b83a97fafd5e12ec5c9,
title = "Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival",
abstract = "Objective: Although carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis. Methods: Prospectively collected data from 4114 isolated CEAs performed for asymptomatic stenosis across 24 centers in the Vascular Study Group of New England between 2003 and 2011 were used for this analysis. Late survival was determined with the Social Security Death Index. Cox proportional hazard models were used to identify risk factors for mortality within the first 5 years after CEA and to calculate a risk score for predicting 5-year survival. Results: Overall 3- and 5-year survival after CEA in asymptomatic patients were 90{\%} (95{\%} CI 89{\%}-91{\%}) and 82{\%} (95{\%} CI 81{\%}-84{\%}), respectively. By multivariate analysis, increasing age, diabetes, smoking history, congestive heart failure, chronic obstructive pulmonary disease, poor renal function (estimated glomerular filtration rate <60 or dialysis dependence), absence of statin use, and worse contralateral ICA stenosis were all associated with worse survival. Patients classified as low (27{\%}), medium (68{\%}), and high risk (5{\%}) based on number of risk factors had 5-year survival rates of 96{\%}, 80{\%}, and 51{\%}, respectively (P <.001). Conclusions: More than four out of five asymptomatic patients selected for CEA in the Vascular Study Group of New England achieved 5-year survival, demonstrating that, overall, surgeons in our region selected appropriate patients for carotid revascularization. However, there were patients selected for surgery with high risk profiles, and our models suggest that the highest risk patients (such as those with multiple major risk factors including age ≥80, insulin-dependent diabetes, dialysis dependence, and severe contralateral ICA stenosis) are unlikely to survive long enough to realize a benefit of prophylactic CEA for asymptomatic stenosis. Predicting survival is important for decision making in these patients.",
author = "Wallaert, {Jessica B.} and Cronenwett, {Jack L.} and Bertges, {Daniel J.} and Andres Schanzer and Nolan, {Brian W.} and {De Martino}, {Randall R} and Jens Eldrup-Jorgensen and Goodney, {Philip P.}",
year = "2013",
month = "7",
doi = "10.1016/j.jvs.2012.12.056",
language = "English (US)",
volume = "58",
pages = "112--119",
journal = "Journal of Vascular Surgery",
issn = "0741-5214",
publisher = "Mosby Inc.",
number = "1",

}

TY - JOUR

T1 - Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival

AU - Wallaert, Jessica B.

AU - Cronenwett, Jack L.

AU - Bertges, Daniel J.

AU - Schanzer, Andres

AU - Nolan, Brian W.

AU - De Martino, Randall R

AU - Eldrup-Jorgensen, Jens

AU - Goodney, Philip P.

PY - 2013/7

Y1 - 2013/7

N2 - Objective: Although carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis. Methods: Prospectively collected data from 4114 isolated CEAs performed for asymptomatic stenosis across 24 centers in the Vascular Study Group of New England between 2003 and 2011 were used for this analysis. Late survival was determined with the Social Security Death Index. Cox proportional hazard models were used to identify risk factors for mortality within the first 5 years after CEA and to calculate a risk score for predicting 5-year survival. Results: Overall 3- and 5-year survival after CEA in asymptomatic patients were 90% (95% CI 89%-91%) and 82% (95% CI 81%-84%), respectively. By multivariate analysis, increasing age, diabetes, smoking history, congestive heart failure, chronic obstructive pulmonary disease, poor renal function (estimated glomerular filtration rate <60 or dialysis dependence), absence of statin use, and worse contralateral ICA stenosis were all associated with worse survival. Patients classified as low (27%), medium (68%), and high risk (5%) based on number of risk factors had 5-year survival rates of 96%, 80%, and 51%, respectively (P <.001). Conclusions: More than four out of five asymptomatic patients selected for CEA in the Vascular Study Group of New England achieved 5-year survival, demonstrating that, overall, surgeons in our region selected appropriate patients for carotid revascularization. However, there were patients selected for surgery with high risk profiles, and our models suggest that the highest risk patients (such as those with multiple major risk factors including age ≥80, insulin-dependent diabetes, dialysis dependence, and severe contralateral ICA stenosis) are unlikely to survive long enough to realize a benefit of prophylactic CEA for asymptomatic stenosis. Predicting survival is important for decision making in these patients.

AB - Objective: Although carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis. Methods: Prospectively collected data from 4114 isolated CEAs performed for asymptomatic stenosis across 24 centers in the Vascular Study Group of New England between 2003 and 2011 were used for this analysis. Late survival was determined with the Social Security Death Index. Cox proportional hazard models were used to identify risk factors for mortality within the first 5 years after CEA and to calculate a risk score for predicting 5-year survival. Results: Overall 3- and 5-year survival after CEA in asymptomatic patients were 90% (95% CI 89%-91%) and 82% (95% CI 81%-84%), respectively. By multivariate analysis, increasing age, diabetes, smoking history, congestive heart failure, chronic obstructive pulmonary disease, poor renal function (estimated glomerular filtration rate <60 or dialysis dependence), absence of statin use, and worse contralateral ICA stenosis were all associated with worse survival. Patients classified as low (27%), medium (68%), and high risk (5%) based on number of risk factors had 5-year survival rates of 96%, 80%, and 51%, respectively (P <.001). Conclusions: More than four out of five asymptomatic patients selected for CEA in the Vascular Study Group of New England achieved 5-year survival, demonstrating that, overall, surgeons in our region selected appropriate patients for carotid revascularization. However, there were patients selected for surgery with high risk profiles, and our models suggest that the highest risk patients (such as those with multiple major risk factors including age ≥80, insulin-dependent diabetes, dialysis dependence, and severe contralateral ICA stenosis) are unlikely to survive long enough to realize a benefit of prophylactic CEA for asymptomatic stenosis. Predicting survival is important for decision making in these patients.

UR - http://www.scopus.com/inward/record.url?scp=84879417582&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84879417582&partnerID=8YFLogxK

U2 - 10.1016/j.jvs.2012.12.056

DO - 10.1016/j.jvs.2012.12.056

M3 - Article

C2 - 23478502

AN - SCOPUS:84879417582

VL - 58

SP - 112

EP - 119

JO - Journal of Vascular Surgery

JF - Journal of Vascular Surgery

SN - 0741-5214

IS - 1

ER -