Urgent endarterectomy for symptomatic carotid occlusion is associated with a high mortality

BackgroundInterventions for carotid occlusions are infrequently undertaken and the outcomes are poorly defined. We sought to study patients undergoing urgent carotid revascularization for symptomatic occlusions.MethodsThe Society for Vascular Surgery Vascular Quality Initiative was queried from 2003 to 2020 to identify patients with carotid occlusions undergoing carotid endarterectomy. Only symptomatic patients undergoing urgent interventions, defined within 24 hours of presentation, were included in this analysis. This cohort was compared to patients undergoing urgent intervention for severe stenosis (≥80%). Patients were identified based on computed tomography and magnetic resonance imaging, only. The primary end points were perioperative stroke, death, myocardial infarction (MI), and composite outcomes.ResultsA total of 390 patients were identified who underwent urgent carotid endarterectomy for symptomatic occlusions. The mean age was 67.4 ± 10.2 years with a range from 39 to 90 years. The cohort was predominantly male (60%), and had significant risk factors for cerebrovascular disease, including hypertension (87.4%), diabetes (34.4%), coronary artery disease (21.6%), current smoking (38.7%), chronic obstructive pulmonary disease (21.6%), and congestive heart failure (10.3%). Medications included statin therapy (78.6%), P2Y12 inhibitors (32.0%), aspirin (77.9%) and renin-angiotensin inhibitor use (43.7%). The perioperative rate of neurologic events was 4.9%%, associated mortality was 2.8% and rate of MI was 1.0%. The composite end point of stroke/death/MI was 7.7%. When compared to patients undergoing urgent endarterectomy for severe stenosis (≥80%), the two cohorts were well matched with regards to risk factors, but the severe stenosis cohort appeared to be better medically managed based on reported medications. In the severe stenosis group, the perioperative rate of neurologic events was 3.3%, associated mortality was 0.9% and rate of MI was 1.2%. The perioperative outcomes were significantly worse for the carotid occlusion cohort, primarily driven by the perioperative mortality, which was nearly threefold, 2.8% versus 0.9% (P < .001). The composite end point of stroke/death/MI was also significantly worse in the occlusion cohort (7.7% vs 4.9%; P = .014).ConclusionsRevascularization for symptomatic carotid occlusion constitutes approximately 2% of carotid interventions captured in the Vascular Quality Initiative, affirming the rarity of this undertaking. These patients have acceptable rates of perioperative neurologic events but are at an elevated risk of overall perioperative adverse events, primarily driven by a significantly higher mortality. While intervention for a symptomatic carotid occlusion may be performed with acceptable rate of perioperative complications, judicious patient selection is warranted in this high-risk cohort. BackgroundInterventions for carotid occlusions are infrequently undertaken and the outcomes are poorly defined. We sought to study patients undergoing urgent carotid revascularization for symptomatic occlusions. Interventions for carotid occlusions are infrequently undertaken and the outcomes are poorly defined. We sought to study patients undergoing urgent carotid revascularization for symptomatic occlusions. MethodsThe Society for Vascular Surgery Vascular Quality Initiative was queried from 2003 to 2020 to identify patients with carotid occlusions undergoing carotid endarterectomy. Only symptomatic patients undergoing urgent interventions, defined within 24 hours of presentation, were included in this analysis. This cohort was compared to patients undergoing urgent intervention for severe stenosis (≥80%). Patients were identified based on computed tomography and magnetic resonance imaging, only. The primary end points were perioperative stroke, death, myocardial infarction (MI), and composite outcomes. The Society for Vascular Surgery Vascular Quality Initiative was queried from 2003 to 2020 to identify patients with carotid occlusions undergoing carotid endarterectomy. Only symptomatic patients undergoing urgent interventions, defined within 24 hours of presentation, were included in this analysis. This cohort was compared to patients undergoing urgent intervention for severe stenosis (≥80%). Patients were identified based on computed tomography and magnetic resonance imaging, only. The primary end points were perioperative stroke, death, myocardial infarction (MI), and composite outcomes. ResultsA total of 390 patients were identified who underwent urgent carotid endarterectomy for symptomatic occlusions. The mean age was 67.4 ± 10.2 years with a range from 39 to 90 years. The cohort was predominantly male (60%), and had significant risk factors for cerebrovascular disease, including hypertension (87.4%), diabetes (34.4%), coronary artery disease (21.6%), current smoking (38.7%), chronic obstructive pulmonary disease (21.6%), and congestive heart failure (10.3%). Medications included statin therapy (78.6%), P2Y12 inhibitors (32.0%), aspirin (77.9%) and renin-angiotensin inhibitor use (43.7%). The perioperative rate of neurologic events was 4.9%%, associated mortality was 2.8% and rate of MI was 1.0%. The composite end point of stroke/death/MI was 7.7%. When compared to patients undergoing urgent endarterectomy for severe stenosis (≥80%), the two cohorts were well matched with regards to risk factors, but the severe stenosis cohort appeared to be better medically managed based on reported medications. In the severe stenosis group, the perioperative rate of neurologic events was 3.3%, associated mortality was 0.9% and rate of MI was 1.2%. The perioperative outcomes were significantly worse for the carotid occlusion cohort, primarily driven by the perioperative mortality, which was nearly threefold, 2.8% versus 0.9% (P < .001). The composite end point of stroke/death/MI was also significantly worse in the occlusion cohort (7.7% vs 4.9%; P = .014). A total of 390 patients were identified who underwent urgent carotid endarterectomy for symptomatic occlusions. The mean age was 67.4 ± 10.2 years with a range from 39 to 90 years. The cohort was predominantly male (60%), and had significant risk factors for cerebrovascular disease, including hypertension (87.4%), diabetes (34.4%), coronary artery disease (21.6%), current smoking (38.7%), chronic obstructive pulmonary disease (21.6%), and congestive heart failure (10.3%). Medications included statin therapy (78.6%), P2Y12 inhibitors (32.0%), aspirin (77.9%) and renin-angiotensin inhibitor use (43.7%). The perioperative rate of neurologic events was 4.9%%, associated mortality was 2.8% and rate of MI was 1.0%. The composite end point of stroke/death/MI was 7.7%. When compared to patients undergoing urgent endarterectomy for severe stenosis (≥80%), the two cohorts were well matched with regards to risk factors, but the severe stenosis cohort appeared to be better medically managed based on reported medications. In the severe stenosis group, the perioperative rate of neurologic events was 3.3%, associated mortality was 0.9% and rate of MI was 1.2%. The perioperative outcomes were significantly worse for the carotid occlusion cohort, primarily driven by the perioperative mortality, which was nearly threefold, 2.8% versus 0.9% (P < .001). The composite end point of stroke/death/MI was also significantly worse in the occlusion cohort (7.7% vs 4.9%; P = .014). ConclusionsRevascularization for symptomatic carotid occlusion constitutes approximately 2% of carotid interventions captured in the Vascular Quality Initiative, affirming the rarity of this undertaking. These patients have acceptable rates of perioperative neurologic events but are at an elevated risk of overall perioperative adverse events, primarily driven by a significantly higher mortality. While intervention for a symptomatic carotid occlusion may be performed with acceptable rate of perioperative complications, judicious patient selection is warranted in this high-risk cohort. Revascularization for symptomatic carotid occlusion constitutes approximately 2% of carotid interventions captured in the Vascular Quality Initiative, affirming the rarity of this undertaking. These patients have acceptable rates of perioperative neurologic events but are at an elevated risk of overall perioperative adverse events, primarily driven by a significantly higher mortality. While intervention for a symptomatic carotid occlusion may be performed with acceptable rate of perioperative complications, judicious patient selection is warranted in this high-risk cohort.