Long-term Outcomes of Carotid Endarterectomy With Simultaneous Proximal Common Carotid Endovascular Intervention

Carotid bifurcation stenosis may coexist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in aortic arch. Obtaining long-term outcomes data is vital to making any definitive conclusions on efficacy of performing this dual treatment. Four cohorts were created for perioperative outcome analysis and Kaplan-Meier freedom from event analysis: endarterectomy (CEA) isolation asymptomatic disease; CEA symptomatic patients; CCA endovascular intervention stenosis; patients. Binary logistic multivariable regression was performed a neurological 90-day mortality risk determination, Cox cumulative ischemic analysis. Symptomatology type surgery (CEA or without intervention) individual variables The study encompassed transient attack stroke combined. We noted statistically significant (P < .001) progressive escalation rates (Fig 3) event, myocardial infarction, re-exploration, combined moving (A) (B) (C) (D) combination intervention. After surgery, cerebral ischemia patients undergoing closely aligned (Figs 1 2), indicating quality protection adverse events. Comparison baseline characteristics listed Table I. Multivariable (Table II), neuro III), IV), V) presented. Despite high treatment, there likely reduction benefit approach based strength North American Symptomatic Endarterectomy Trial (NASCET) event-free seen herein after initial hospital discharge. treating ICA lesions remains vague as lack natural history improved medical therapy makes challenging.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3View (PPT)Table IComparison across cohortsVariableAsymptomatic (N = 109,511)Symptomatic 56,743)Asymptomatic + Tx 608)Symptomatic 339)P valueMean age, years70.6470.4669.4470.45<.001Male64.962.25244.8<.001Race<.001 Native American0.20.30.00.6 Asian1.01.00.80.3 Black4.15.63.12.7 Hawaiian Pacific Islander0.10.10.00.0 White91.488.992.894.4 Unknown0.10.10.00.0 Multiracial3.14.03.32.1Hx smoking75.472.188.386.7<.001Hypertension89.888.089.889.1<.001Diabetes mellitus36.435.329.330.7<.001CAD28.922.434.529.2<.001CHF11.310.514.515.6<.001COPD23.021.632.737.2<.001CRI19.816.417.815.0<.001Anemia (Hgb <10)91.293.090.889.1<.001No preoperative antiplatelet11.110.68.19.7.02No statin17.515.415.116.2<.001Symptomatic lesion within 6 months0.0100.00.0100.0N/ALocal/regional anesthesia8.56.44.13.8<.001Yes patch used88.886.293.384.4<.001Shunt used49.352.642.845.1<.001Protamine used70.072.174.878.5<.001Yes EEG used28.831.532.733.0<.001Stump pressure used11.210.011.911.5<.001CAD, Coronary CCA, artery; CEA, endarterectomy; CHF, congestive heart failure; COPD, chronic obstructive pulmonary CRI, renal insufficiency; EEG, electroencephalogram; Hgb, hemoglobin; Hx, of; N/A, not applicable; Tx, treatment.Data are presented % unless otherwise specified. Open table new tab IIRisks neurologic event—binary using univariable risks all included studyPerioperative (n/N)Univariable P valueAdjusted odds ratio (95% CI)Multivariable valueSimultaneous Yes3.6 (34/947)<.0015.84 (4.80-7.11)<.001 No1.7 (2880/165,869)Age, years Yes event71.25<.011.007 (1.003-1.011).001 No event70.56Sex Male1.7 (566/41,391).597 Female1.8 (1164/65,904)Race American2.4 (10/419).570 Asian2.0 (34/1661).917 Black2.5 (191/7690).648 Isles1.7 (2/118).267 White1.7 (2551/151,357).736 Unknown2.8 (6/217).672 Multiracial2.2 (124/5630).683History smoking Active former smoker1.7 (2122/124,317.042 Never smoker1.9 (796/42,884)History HTN Yes1.8 (2692/149,162)<.0011.42 (1.23-1.63)<.001 No1.3 (226/18,039)Hx DM Yes1.9 (1169/60,146)<.0011.15 (1.07-1.25)<.001 No1.6 (1749/107,055)Hx CAD (817/44,684).117 (2101/122,517)CHF (348/18,495).133 (2570/148,706)Hx COPD Yes1.7 (655/37,770).85 (2263/129,431)Hx CRI (572/31,163).177 (2346/136,038)Hx anemia (2666/153,510).374 No1.8 (252/13,691)Preoperative antiplatelet (2520/148,970)<.0011.27 (1.14-1.42)<.001 Not2.2 (398/18,231)Preoperative statin (2375/139,164).0071.14 (1.03-1.25).01 Not1.9 (543/28,037)Local anesthesia (2710/154,283).217 Not1.6 (208/12,918)Patch (2467/147,002)<.0011.38 (1.24-1.54)<.001 No2.2 (451/20,199)Shunt Yes1.5 (1276/83,006)<.0011.31 (1.21-1.41)<.001 No2.0 (1642/84,195)Protamine (1978/118,044)<.0011.14 (1.5-1.23).002 No1.9 (934/48,802)EEG (2025/117,128).442 (884/49,583)Stump used (2641/148,666).0061.09 (0.96-1.24).184 No1.5 (269/18,004)Symptomatic months (1476/56,812)<.0011.98 (1.84-2.14)<.001 (1442/0389)Postoperative MI Yes4 (117/1224)<.0015.84 (2801/165,977)CAD, CI, confidence interval; DM, diabetes mellitus; HTN, hypertension; MI, infarction; IIICombined mortality—binary eventVariableCombined rate, valueProximal Yes2.8 (4651/165,869)<.0012.13 (1.62-2.80)<.001 No2.8 (59/947)Age, event72.19<.0011.02 (1.01-1.02)<.001 event70.53Sex Male2.8 (2831/101,295).415 Female2.9 (1887/65,904)Race American3.6 (15/419) Asian2.8 (47/1661) Black3.7 (288/7690).431 Hawaiian3.4 (4/118) White2.8 (4184/151,357) Multiracial3.7 (8/217) Other3.0 (171/5630History smoker2.9 (3544/124,317).23 smoker2.7 (1174/42,884)History Yes2.9 (4359/149,162)<.0011.31 (1.17-1.46)<.001 (359/18,039)Hx Yes3.3 (1984/60,146)<.0011.19 (1.19-1.26)<.001 No2.6 (2734/107,055)Hx (1496/44,684)<.0011.14 (1.07-1.22)<.001 (3222/122,517)Hx Yes3.5 (1314/37,770)<.0011.26 (1.18-1.35)<.001 (3404/129,431)Hx (1136/31,163)<.0011.18 (1.10-1.27)<.001 (3582/136,038)Hx Yes4.4 (605/13,691)<.0011.53 (1.40-1.67)<.001 No2.7 (4113/153,510)Hx CHF Yes4.5 (838/18,495)<.0011.41 (1.30-1.53)<.001 (3880/148,706)Preoperative (652/18,231)<.0011.29 (1.18-1.40)<.001 Not2.7 (4066/148,970)Preoperative Yes3.2 (887/28,037)<.0011.16 Not2.8 (3831/139,164)Local regional Yes2.6 (334/12,918) (4384/154,283).098No Yes3.4 (690/20,199)<.0011.28 (1.17-1.40)<.001 (4028/147,002)Shunt (2662/84,195)<.0011.29 (1.21-1.37)<.001 No2.5 (2056/83,006)Protamine Yes2.7 (3213/118,044) No3.1 (1496/48,802)<.0011.13 (1.06-1.21)<.001EEG (1383/49,583).615 (3321/117,128)Stump (4273/148,666)<.0011.10 (0.99-1.22)<.001 No2.4 (432/18,004)Symptomatic Yes4.1 (2318/56,812)<.0011.96 (1.85-2.08)<.001 (2400/110,389)Postoperative Yes19.6 (240/1224)<.0017.58 (6.53-8.79)<.001 (4478/165,977)CAD, infarction. IVRisks follow-up—Cox risksVariableMortality LTFU, valueHazard Yes11.8 (112/947).0091.40 (1.16-1.69)<.001 No9.3 (15,461/165,866)Age, LTF73.3<.0011.04 (1.04-1.04)<.001 LTF70.3Sex Male9.5 (9671/101,292)<.0011.07 (1.03-1.12)<.001 Female9.0 (5959/65,901)Race American7.6 (32/419) Asian5.5 (91/1661) Black9.9 (759/7690) Hawaiian9.3 (11/118) White9.5 (14,398/151,351)1.07 (1.03-1.10)<.001 Multiracial5.1 (11/217) Other5.7 (321/5630)History smoker10.0 (12,438/124,315)<.0011.33 (1.27-1.40)<.001 smoker7.4 (3192/42,880)History Yes9.6 (14,340/149,159)<.0011.08 (1.01-1.16).027 No7.2 (1290/18,036)History Yes11.1 (6652/60,145)<.0011.30 (1.25-1.35)<.001 No8.4 (8978/107,050)History Yes12.5 (5603/44,684)<.0011.20 (1.15-1.25)<.001 No8.2 (10,027/122,511)History Yes13.4 (5045/37,770)<.0011.60 (1.53-1.67)<.001 (10,585/129,425)History Yes14.7 (4577/31,160)<.0011.33 (1.27-1.39)<.001 No8.1 (11,053/136,035)History Yes23.6 (3228/13,688)<.0011.97 (1.86-2.09)<.001 (12,402/153,507)History Yes17.0 (3145/18,495)<.0011.76 (1.68-1.85)<.001 (12,485/148,700)Preoperative Yes9.1 (13,603/1,148,967) Not11.1 (2027/18,228)<.0011.11 (1.05-1.18)<.001Preoperative Yes8.9 (12,397/139,161) Not11.5 (3233/28,034)<.0011.20 (1.12-1.29)<.001Local Yes10.4 (1349/12,915)<.0011.00 (0.93-1.08).968 (14,281/154,280)Patch Yes9.2 (13,466/146,999) No10.7 (2164/20,196)<.0011.11 (1.04-1.18)<.001Shunt (8107/84,194)<.0011.07 (1.02-1.12).004 No9.1 (7523/83,001)Protamine use (10,452/118,042) No10.5 (5126/48,801)<.0011.01 (0.97-1.05).639EEG Yes10.1 (5000/49,580)<.0011.00 (0.95-1.05).986 No9.0 (10,563/117,128)Stump Yes6.8 (1227/18,004) No9.6 (14,332/148,663)<.0011.13 (1.06-1.21)<.001Symptomatic Yes8.4 (4797/56,810) No9.8 (10,833/110,385)<.0011.38 (1.32-1.46)<.001Postoperative Yes26.2 (321/1224)<.0012.20 (1.91-2.52)<.001 No9.2 (15,309/165,971)Antiplatelet discharge (7092/73,726)<.0011.15 (1.10-1.19)<.001 (8538.93,469)Statin Yes8.3 (12,151/146,227) No16.6 (3479/20,968)<.0011.71 (1.59-1.84)<.001Smoking LTF (1640/18,010)<.0011.00 (0.95-1.06).929 No8.3 (9119/110,242)Antiplatelet (11,765/128,825) No10.1 (3865/38,361)<.0011.15 (1.09-1.21)<.001Anticoagulation (10,209/121,933) No12.0 (5421/45,253)<.0011.07 (0.98-1.17).114Statin (7810/84,458) No9.5 (7820/82,728).1511.01 (0.96-1.06).688Ipsilateral recurrent >70% (257/3059).9771.10 (0.97-1.25).128 (10,502/125,193)Postoperative Yes21.5 (627/2918)<.0012.44 (2.22-2.69)<.001 (15,003/164,277)CAD, LTF, follow-up; VRisks risksVariableNeurologic (34/947).0621.62 (1.14-2.29).007 (4357/165,869)Age, event71.2<.0011.006 (1.00-1.01)<.001 event70.6Sex Male2.6 (2645/101,294) Female2.7 (1750/65,904).584Race American2.9 (12/419) Asian2.6 (43/1661) Black3.5 (268/7690) White2.6 (3868/151,356) Multiracial4.1 (9/217)<.0011.67 (0.62-2.21).647 Other3.4 (191/5630)History smoker2.6 (3197/124,317).0131.01 (0.94-1.08).826 (1198/42,883)History (3994/149,162)<.0011.13 (1.01-1.26).03 (401/18,038)History (1694/60,146)<.0011.08 (1.01-1.15).028 (2701/107,054)History (1180/44,684).85 (3215/122,516)History (977/37,770) (3418/129,430).57History (805/31,163).595 (3590/136,037)History (351/13,690).653 (4044/153,510)History (514/18,495).179 (3881/148,705)Preoperative (3836/148,970) (559/18,230)<.0011.13 (1.02-1.25).016Preoperative (3649/139,164) (746/28,036).714Local Yes2.4 (308/12,917) (4087/154,283).073Patch Yes2.5 (3739/147,002) No3.2 (6565/20,198)<.0011.27 (1.16-1.40)<.001Shunt (2402/84,195)<.0011.16 (1.09-1.24)<.001 (1993/83,005)Protamine (3019/118,044) (1368/48,802).0051.11 (1.04-1.19).003EEG (1351.49,583).119 (3035/117,128)Stump Yes2.3 (406/18,004) (3981/148,666)<.0011.10 (0.98-1.23).093Symptomatic (2584/56,812)<.0013.07 (2.83-3.34)<.001 (1811/110,388)Postoperative Yes10.3 (126/1224)<.0013.17 (2.58-3.89)<.001 (4269/165,976)Antiplatelet (2352/73,730)<.0011.27 (1.19-1.35)<.001 (2043/93,470)Statin (3756.146,231) No3.0 (639/20,969)<.0011.24 (1.13-1.37)<.001Smoking (3756/146,231)<.0011.08 (0.99-1.17).102 No2.9 (3169/110,243)Antiplatelet (3102/128,831) No3.4 (1293/38,361)<.0011.34 (1.24-1.44)<.001Anticoagulation (3471/121,935)<.0011.75 (1.56-1.96)<.001 (924/45,257)Statin (2888/84,460)<.0011.08 (0.99-1.18).087 (1507/82,732)Ipsilateral Yes5.2 (159/3059)<.0011.60 (1.36-1.87)<.001 (3639/125,195)CAD,