Carotid endarterectomy (CEA) yields better short-term results than carotid artery stenting (CAS) in patients with carotid artery disease, according to a 30-day outcomes report from the Society for Vascular Surgery (SVS) Vascular Registry for Carotid Procedures, published in the January 2009 issue of the Journal of Vascular Surgery®, by the Society for Vascular Surgery.
Carotid artery disease is marked by stenosis (narrowing) of the carotid artery, located on either side of the neck, which supplies blood to the brain. Typically, this has been treated by performing an open repair surgery (CEA). An endovascular procedure (CAS) treats patients who are at risk for complications such as prior carotid artery surgery (i.e., CEA), neurological conditions (i.e., prior stroke), or exposure to radiation at the neck.
The SVS Outcomes Committee developed the Vascular Registry for Carotid Procedures in response to the 2005 Centers for Medicare and Medicaid Services National Coverage Decision on carotid artery stenting. The SVS Vascular Registry went live on July 2005, as the first societal registry to enroll CAS and CEA patients. Data are allocated to visit intervals of 30-day, six-month, one-year, and subsequent annual evaluations.
"As of December 26, 2007, 6,403 procedures with discharge data were entered by 287 providers at 56 centers," said Flora Siami, MPH, director, regulatory affairs and principal research scientist at New England Research Institutes, Inc. in Watertown, Mass. "In addition there were 1,450 CAS patients and 1,368 CEA patients with 30-day outcomes."
"Our primary outcome of interest was combined death, stroke, and myocardial infarction at 30-days post-procedure," said senior author Anton Sidawy, MD, MPH, FACS, chief of vascular surgery at Veterans Affair Medical Center in Washington, D.C. and professor of surgery at both Georgetown and George Washington University Schools of Medicine, in Washington, D.C. "The SVS Outcomes Committee also reviewed demographics, comorbidities, intra-operative complications."
"The majority of patients were treated because of atherosclerotic disease," said Dr. Sidawy. "In general, there was a greater proportion of CAS patients with pre-procedure lateralizing neurological symptoms, as well as higher prevalence of cardiac comorbidities compared with CEA patients."
Dr. Sidawy added that after risk-adjustment for age, history of stroke, diabetes and the American Society of Anesthesiologists' grade (i.e., factors found to be significant confounders in outcomes using backwards elimination) logistic regression analysis suggested better outcomes following CEA. When CAS and CEA were compared in the treatment of atherosclerotic disease only, the difference in outcomes between the two procedures was more pronounced, with death/stroke/MI 6.42 percent after CAS vs. 2.62 percent following CEA, p<0.0001. Thus, following best possible risk adjustment of these unmatched groups, symptomatic and asymptomatic CAS patients had significantly higher 30-days post-procedure incidence of death/stroke/myocardial infarction when compared to CEA patients.
Dr. Sidawy explained, "Given the trend observed in the Vascular Registry, there is no justification to expand the use of CAS until the results of the randomized CREST trial are published providing level one evidence."
"This initial report from the Vascular Registry provides proof of concept that a specialty society-based vascular registry can succeed in meeting regulatory and scientific goals," said Gregorio Sicard, MD, chair, SVS Outcomes Committee, and chief of vascular surgery and professor of surgery at Washington University in St. Louis. "With continued enrollment and follow-up, analysis of SVS Vascular Registry will supplement randomized trials by providing real-world comparisons of CAS and CEA with sufficient numbers to serve as an outcome assessment tool of important patient subsets and across the spectrum of peripheral vascular procedures."
The SVS Vascular Registry for Carotid Procedures currently has 77 participating clinical facilities and over 9,700 patients. The SVS Vascular Registry provides semi-annual institutional benchmarking reports to participating facilities on outcomes by procedure. New England Research Institutes, Inc. serves as the independent data coordinating center, maintaining the database and performing statistical analysis. The SVS designed the Vascular Registry with potential for expansion to procedures involving other vascular beds.
Tuesday, March 3, 2009
Carotid Endarterectomy Yields Better Short-Term Results Than Stenting
Wednesday, December 31, 2008
Statins May Decrease Incidence of Delirium After Cardiac Surgery
Newswise — The use of cholesterol-lowering statins before cardiac surgery decreases the odds of postoperative delirium in elderly patients. Previous studies have demonstrated that statins decrease the incidence of morbidity and mortality after cardiac and major non-cardiac surgery. Statins have also been shown to be protective in central nervous system injury.
But this new study could be the first to provide proof of a link between statin use in cardiac surgery and a decrease in delirium. Such findings could be a boon to physicians who are dealing with an aging population known to be more susceptible to post-surgical delirium, a confounding condition that is not well understood.
"The underlying mechanism of delirium is unknown," said Dr. Katznelson. "However, identifying factors that can stop or provoke this condition may help to understand the disease better and create strategies to prevent it."
Delirium is a common complication after cardiac surgery associated with prolonged length of stay in the hospital, increased health costs and higher mortality. It has been estimated that about $6.9 billion of Medicare hospital expenditures are attributable to delirium, said Dr. Katznelson.
The incidence rate of delirium after cardiac surgery is thought to be in the range of 3-47 percent, but depends on several variables, including older age, preoperative depression and the complexity of the surgery, among others.
³Of the 1,059 patients we analyzed, 11.5 percent had delirium at any time during their cardiovascular intensive care stay,² said Dr. Katznelson. ³After adjusting for several variables in these patients, we found that the administration of statins had a statistically significant protective effect, reducing the odds of delirium by 46 percent.²
Dr. Katznelson¹s data offer very real evidence that statins may someday improve patient outcomes, but she cautioned that her findings will need to be confirmed with further clinical trials before statins can be used for the purpose of controlling delirium in cardiac surgery patients.
Anesthesiologists: Physicians providing the lifeline of modern medicine. Founded in 1905, the American Society of Anesthesiologists is an educational, research and scientific association with 43,000 members organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.
For more information visit the American Society of Anesthesiologists Web site at www.asahq.org.
