Carotid endarterectomy: previous MI, TIA or non-North American/European graduate physician increased the risk of complications after carotid endarterectomy.

Clinical bottom line (level 2b)

  1. A tenth of patients who have had a carotid endarterectomy and are over 65 years old suffered an in-hospital stroke, MI or death at 30 days.
  2. Patients who had carotid endarterectomy and were over 65 years old were at an increased risk of complications if they had: an evolving or recent stroke, an MI within the past 6 months, non-North American/European graduate physician or a carotid transient ischaemic attack.
Brook et al: Annals of Internal Medicine 1990; 113: 747-753
Expires November 2002

The study

Retrospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: 3 geographic areas (states or large parts of states), USA

1302 patients (aged >65 years old, ?% male) had undergone carotid endarterectomy in 1981

Excluded if
  • <65 years old



    • Factors studied:
  • in-hospital complications
  • evolving stroke
  • myocardial infarction within past 6 months
  • recent stroke
  • non-North American/European graduate physician (excludes graduates of Western Europe, American or Canadian medical schools)
  • carotid transient ischaemic attack


    • surgery

    Logistic regression was used to adjust for confounding factors.

    followed for 30 days
    Outcomes studied:
  • in-hospital complications death, stroke and myocardial infarction

    • Data about physician's was obtained from the Directory of Medical Specialists and the American Medical Association's Directory of Physicians.

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    in-hospital complications 30 days 147/1302 11.29%
    (9.57% to 13.01%)

    prognostic factor for
    in-hospital complications     		time to outcome adjusted RR
    (95% CI)
    evolving stroke 30 days 7.58
    (1.54 to 15.0)
    myocardial infarction within past 6 months 30 days 2.87
    (1.09 to 6.41)
    recent stroke 30 days 2.42
    (1.10 to 4.84)
    non-North American/European graduate physician 30 days 1.91
    (1.12 to 3.13)
    carotid transient ischaemic attack 30 days 1.74
    (1.06 to 2.79)

    • Relative risks were calculated for adverse outcomes after carotid endarterectomy when each independent variable goes from a low to a high value.

    Comments

    1. A disadvantage is that the surgeons were classified according to how many carotid endarterectomies (CEA) they perform per year on patients 65 years or older, instead of classifying them according their real total number of CEAs per year.

    Citation

    1. Brook RH, Park RE, Chassin MR, et al: Carotid endarterectomy for elderly patients: Predicting complications. Annals of Internal Medicine 1990; 113: 747-753
    Contributor: Clare Wotton and Musab Hayatli, November 1999
    Reviewer: Martin Mueller

    Clinical Question.
    Patient carotid endarterectomy
    Intervention or Exposure presence of risk factors
    Comparison absence of risk factors
    Outcome complications