There Is No Such Thing As A Patient Who Is Prohibitively High-Risk For CEA Based On Medical Comorbidities
Alexander Kraev, M.D., Gregg Landis, M.D.
Background: The landmark studies, specifically the SAPPHIRE trial, on carotid artery stenosis shunned high risk patients to the current standard of therapy with endovascular treatment only. Recent small reviews and expert opinion have observed that carotid endarterectomy (CEA) is a much safer operation that previously thought. The 2005-2006 National Surgical Quality Improvement Project (NSQIP) is a database containing over 170,000 surgical cases. NSQIP is a powerful tool in outcomes analysis, used here to question if risk factors exist in CEA surgery.
Methods: The 2005-2006 NSQIP database was queried for patients undergoing CEA. Stepwise logistic regression analysis was then used to identify pre-operative risk factors. Logistic regression analysis was then used to test if high risk definitions in the SAPPHIRE trial – age over eighty, significant pulmonary disease and significant cardiovascular disease, were predictive of mortality.
Results: The final database consisted of 4142 patients. There were 31 deaths (.74% mortality). There were 10 post-operative non-fatal myocardial infarctions (.24%). There were 69 post-operative strokes (1.6%). Pre-operative predictors of mortality were dyspnea (p-value <.0001), wound infection (p-value <.0001) and recent surgery (p-value .0012). SAPPHIRE defined risk factors for CEA were not predictors of mortality in NSQIP.
Conclusion: Current techniques in CEA have reached a high level of safety nationally. Due to excellent outcomes CEA should not be contraindicated due to medical comorbidities. Current prospective trials such as CREST are looking to evaluate this notion demonstrated.