Intraoperative completion studies and their associations with carotid endarterectomy outcomes

Objective:

This study aimed at assessing outcomes after carotid endarterectomy (CEA) in dependence of center policy with respect to imaging intraoperative completion study (ICSⁱ) usage.

Summary background data:

Although randomized controlled studies are missing, a beneficial effect was shown for ICSⁱ techniques (i.e., angiography and intraoperative duplex ultrasound) after CEA.

Methods:

This secondary data analysis is based on the German statutory quality assurance database. Research was funded by Germany’s Federal Joint Committee Innovation Fund (G-BA Innovations fonds, 01VSF19016 ISAR-IQ). According to their ICSⁱ policy, hospitals were categorized as routine ICSⁱ (>90%), selective ICSⁱ (10–90%), or sporadic ICSⁱ (<10%) centers. Primary study outcome was in-hospital stroke or death. Multivariable regression analyses were performed.

Results:

Between 2012 and 2016, a total of 119,800 patients underwent CEA. In-hospital stroke or death rates were lower in routine ICSⁱ centers (1.7%) compared to selective (2.1%) and sporadic ICSⁱ centers (2.0%). The multivariable regression analysis showed, that in routine ICSⁱ centers, ICSⁱ use was associated with lower rates of stroke or death (aOR 0.64; 95% CI 0.44–0.93). In selective ICSⁱ centers, ICSⁱ was not associated with the occurrence of either of the assessed outcomes. In sporadic ICSⁱ centers, ICSⁱ was associated with higher rates of stroke or death (aOR 1.91; 95% CI 1.26–2.91).

Conclusions:

Lowest in-hospital stroke or death rates are achieved in routine ICSⁱ centers. While ICSⁱ is associated with a lower perioperative risk in routine ICSⁱ centers, it might act as a surrogate marker for worse outcomes due to intraoperative irregularities in sporadic ICSⁱ centers. Routine use of ICSⁱ is advisable.