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Carotid endarterectomy: Who should perform it?
Eur J VascEndovascSurg 10, 263-264 (1995)
LEADING ARTICLE
Carotid Endarterectomy: Who Should Perform it? Marc A. Cairols
Hospital Universitari de Bellvitge, Universitat de Barcelona, Spain
Carotid endarterectomy has proved superior to medical treatment in symptomatic high grade carotid stenosis (ECST, NASCET). 1'2 One important question is how the results of these international multicentre studies apply to the average district hospital. Trials are often carried out in tertiary referral hospitals, while the clinical policy is adopted in all kind of institutions. Relatively little attention has been given to the question: Who performs carotid surger~ and where should it be performed? This question raises many issues including: what qualifications should the specialist have to perform carotid endarterectomy? Are too many surgeons performing carotid endarterectomies and what is the optimal caseload to maintain proficiency? Also important is the institution where carotid surgery is performed, i.e. what are the standards for diagnostic and postoperative care? The setting in which carotid surgery is performed plays an important role. While more than half of the total secondary healthcare is performed in small institutions, most carotid surgery takes place in urban hospitals with a larger range of specialists, each covering his/her own field and with better ancillary support by appropriate equipment, medical and paramedical staff to reliably achieve a correct diagnosis as well as proper intra and postoperative care. The results of the Rand Corporation of 1032 carotid endarterectomies performed in different hospitals showed a 9.8% combined postoperative deaths/major stroke rate, and hospitals with a larger surgical caseload had better results. 3 Hospitals should bear a responsibility for evaluating the vascular training of applicants taking positions on its vascular staff. It is the author's impression that many regional hospitals in Europe today, certainly in Spain, still perform vascular surgery without proper evaluation of the
surgeon's training. One consequence is that results, at times, are below acceptable standards. This may result in restriction in referrals or diversion of patients to other hospitals. Of all factors pertaining to good quality carotid surgery the responsible surgeon is the most important. Since good results are more likely to be published than poor outcomes, literature reports may provide results that are superior to those obtained in settings that do not contribute to trials, or otherwise convey their results to the medical community. Even from centres that do publish their results, subgroup analysis and selective category reporting may provide an overoptimistic view on the results of carotid endarterectomy as a whole. Thompson has reported certain patterns of presentation that he observed in publications: lower mortality and morbidity rates usually being reported by single institutional or single surgeon series compared to the results from multicentre studies. 4 In the latter, individual surgeons remain anonymous and rates as high as 7.7% for permanent deficits and 3.5% for deaths are reported in the joint study, published by Fields et al.5 These figures do not differ from the NASCET and the ECST results (5.8% and 7.5% for major stroke respectively and 2.1% and 3.2% for mortality). It should also be mentioned that the track record of surgeons was scrutinized in greater depth in NASCET than it was in ECST. In reviewing the results of the same surgeon in different hospitals Gibbs and Guzzetta concluded that the key to good results resides in the surgeon and not in the hospital. 6 Abu Rahma and Robinson demonstrated that adequate training in vascular surgery diminished the frequency of complications. 7 An important but controversial aspect is the surgical caseload needed to maintain acquired skills. Although
1078-5884/95/070263 + 02 $12.00/0 © 1995 W. B. Saunders CompanyLtd.
264
M.A. Cairols
Friedman et al. found no significant correlation References between surgical outcomes and the number of proce1 NORTH AMERICANSYMPTOMATICCAROTID ENDARTERECTOMYTRIAL dures performed, it is likely that a relationship COLLABORATORS. Beneficial effect on carotid endarterectomy in between caseload and success rate procedure exists. 8 symptomatic patients with high grade carotid stenosis. N Engl ] Med 1991; 325: 445-453. Leape et al. examined the relationship between the 2 EUROPEAN CAROTID SURGERY TRIALIST'S COLLABORATIVE GROUP. number of operative procedures performed by indiMRC European Carotid Surgery Trial: interim results of symptovidual surgeons and the variation in the rate of carotid matic patients with severe (70-99%) or with mild (0-29%) carotid Stenosis. Lancet 1991; 337: 1235-1243. endarterectomies among Medicare beneficiaries in 3 MERRICK NJ, FINK a~ BROOK RH et al. Indications for selected areas of high, average and loW, use. 9 The great medical and surgical procedures - - a literature review and majority performed three endarterectomies and 24% ratings of appropriateness: carotid endarterectomy. Santa Monica, California: RAND corporation, 1986. Rand publication no. carried out just one endarterectomy in 1981. There is R-3204 / 6-CWF / HF / PMT / RWJ. little doubt that too many surgeons are performing 4 THOMPSONJE. Cerebral complications of carotid endarterectomy. carotid endarterectomies. This unacceptable situation Correlation with methods of cerebral protection. In: Bernhard and Towne, eds. Complications in Vascular Surgery, New York: persists, as recently shown by Murie and Morris in. Grune & Stratton, 1980: 228. Great Britain and Estevan et al. in Spain. 1°'11 There is 5 FIELDS WS, MASLENIKOVV, MEYERJS et al. Joint study of extra little doubt that surgeons operating on these small cranial arterial occlusion V. progress report of prognosis following surgery or nonsurgical treatment for transient cerebral numbers of patients with carotid artery disease should ischemic attacks and cervical carotid artery lesions. JAMA 1970; not be performing this operation. How many opera211: 1993-2003. tions per annum are optimal for good results? Moore 6 GIBBS BF, GUZZETTAVJ. Carotid endarterectomy in community practice: surgeons-specific versus institutional results. Ann Vasc reported the experience of 4~ fellows in 32 approved Surg 1989; 3: 307-312. training programs in which the caseload averaged 28 7 ABURAHMA AF, ROBINSON P. Indications and complications of (range 5-64). 12 The author personally regards this carotid endarterectomy as performed by four different surgical speciality groups. J Cardiovasc Surg 1988; 29: 277-282. number as a minimum requirement to obtain suffi8 FRIEDMANP/GARBJL, BERMANJ, SULLIVANC, CELORIAG, RHEESW. cient experience not only in the technical aspects, but Carotid endarterectomy. Clinical results in a community-based also to gain familiarity with the indications and teaching hospital. Stroke 1988; 19: 1323-1327. 9 LEAPE LL, PARK RE, SOLOMON DH, CHASSIN MR, KOSECOFF J~ complications of this operation. The matter of periodic BROOK RH. Relation between surgeon's practice volumes and auditing by national or international professional geographic variation in the rate of carotid endarterectomy. N organisations needs to be studied carefully as well as Engl J Med 1989; 321: 653-674. 10 MUR1EJ, MORRISP. Carotid endarterectomy in Great Britain and the issue of accreditation. Ireland. Trends and current practice. Br J Surg 1991; 78: In summary, postoperative stroke and death rates 397-400. are influenced by the indications for surgery, training 11 ESTEVANJM, GONZALEZMA, VALLEA, CAIROLSM, MARco-LuQuE MA, NAVARROR. Ciugia carotldea en Espa~a. An~lisis de dos and workload of the surgeon, as well as by the size nacionales. Neurologia 1992; 7: 260-265. and the type of hospital. 13'14 To address the question 12 encuestas MOORE WS. Vascular surgery, a continuing quest for excellence. posed in the title of this leading article: carotid f Vasc Surg 1988; 7: 185-189. endarterectomy should be carried out by skilled and 13 BROTT T, THALINGER K. The practice of CEA in a large metropolitan area. Stroke 1984; 15: 950-954. well-trained vascular surgeons who use their wisdom 14 HslA DC, KRUSHATWM, MOSCOE LM. Epidemiology of carotid to treat patients on the basis of sound indications, and endarterectomies among medicare beneficiaries. J Vasc Surg 1992; 16: 201-288. exercise their skills in hospitals with the necessary ancillary equipment, having as their only objective the Accepted 12 December 1994 well being of their patients.
Eur J Vasc Endovasc Surg Vol 10, October 1995
LEADING ARTICLE
Carotid Endarterectomy: Who Should Perform it? Marc A. Cairols
Hospital Universitari de Bellvitge, Universitat de Barcelona, Spain
Carotid endarterectomy has proved superior to medical treatment in symptomatic high grade carotid stenosis (ECST, NASCET). 1'2 One important question is how the results of these international multicentre studies apply to the average district hospital. Trials are often carried out in tertiary referral hospitals, while the clinical policy is adopted in all kind of institutions. Relatively little attention has been given to the question: Who performs carotid surger~ and where should it be performed? This question raises many issues including: what qualifications should the specialist have to perform carotid endarterectomy? Are too many surgeons performing carotid endarterectomies and what is the optimal caseload to maintain proficiency? Also important is the institution where carotid surgery is performed, i.e. what are the standards for diagnostic and postoperative care? The setting in which carotid surgery is performed plays an important role. While more than half of the total secondary healthcare is performed in small institutions, most carotid surgery takes place in urban hospitals with a larger range of specialists, each covering his/her own field and with better ancillary support by appropriate equipment, medical and paramedical staff to reliably achieve a correct diagnosis as well as proper intra and postoperative care. The results of the Rand Corporation of 1032 carotid endarterectomies performed in different hospitals showed a 9.8% combined postoperative deaths/major stroke rate, and hospitals with a larger surgical caseload had better results. 3 Hospitals should bear a responsibility for evaluating the vascular training of applicants taking positions on its vascular staff. It is the author's impression that many regional hospitals in Europe today, certainly in Spain, still perform vascular surgery without proper evaluation of the
surgeon's training. One consequence is that results, at times, are below acceptable standards. This may result in restriction in referrals or diversion of patients to other hospitals. Of all factors pertaining to good quality carotid surgery the responsible surgeon is the most important. Since good results are more likely to be published than poor outcomes, literature reports may provide results that are superior to those obtained in settings that do not contribute to trials, or otherwise convey their results to the medical community. Even from centres that do publish their results, subgroup analysis and selective category reporting may provide an overoptimistic view on the results of carotid endarterectomy as a whole. Thompson has reported certain patterns of presentation that he observed in publications: lower mortality and morbidity rates usually being reported by single institutional or single surgeon series compared to the results from multicentre studies. 4 In the latter, individual surgeons remain anonymous and rates as high as 7.7% for permanent deficits and 3.5% for deaths are reported in the joint study, published by Fields et al.5 These figures do not differ from the NASCET and the ECST results (5.8% and 7.5% for major stroke respectively and 2.1% and 3.2% for mortality). It should also be mentioned that the track record of surgeons was scrutinized in greater depth in NASCET than it was in ECST. In reviewing the results of the same surgeon in different hospitals Gibbs and Guzzetta concluded that the key to good results resides in the surgeon and not in the hospital. 6 Abu Rahma and Robinson demonstrated that adequate training in vascular surgery diminished the frequency of complications. 7 An important but controversial aspect is the surgical caseload needed to maintain acquired skills. Although
1078-5884/95/070263 + 02 $12.00/0 © 1995 W. B. Saunders CompanyLtd.
264
M.A. Cairols
Friedman et al. found no significant correlation References between surgical outcomes and the number of proce1 NORTH AMERICANSYMPTOMATICCAROTID ENDARTERECTOMYTRIAL dures performed, it is likely that a relationship COLLABORATORS. Beneficial effect on carotid endarterectomy in between caseload and success rate procedure exists. 8 symptomatic patients with high grade carotid stenosis. N Engl ] Med 1991; 325: 445-453. Leape et al. examined the relationship between the 2 EUROPEAN CAROTID SURGERY TRIALIST'S COLLABORATIVE GROUP. number of operative procedures performed by indiMRC European Carotid Surgery Trial: interim results of symptovidual surgeons and the variation in the rate of carotid matic patients with severe (70-99%) or with mild (0-29%) carotid Stenosis. Lancet 1991; 337: 1235-1243. endarterectomies among Medicare beneficiaries in 3 MERRICK NJ, FINK a~ BROOK RH et al. Indications for selected areas of high, average and loW, use. 9 The great medical and surgical procedures - - a literature review and majority performed three endarterectomies and 24% ratings of appropriateness: carotid endarterectomy. Santa Monica, California: RAND corporation, 1986. Rand publication no. carried out just one endarterectomy in 1981. There is R-3204 / 6-CWF / HF / PMT / RWJ. little doubt that too many surgeons are performing 4 THOMPSONJE. Cerebral complications of carotid endarterectomy. carotid endarterectomies. This unacceptable situation Correlation with methods of cerebral protection. In: Bernhard and Towne, eds. Complications in Vascular Surgery, New York: persists, as recently shown by Murie and Morris in. Grune & Stratton, 1980: 228. Great Britain and Estevan et al. in Spain. 1°'11 There is 5 FIELDS WS, MASLENIKOVV, MEYERJS et al. Joint study of extra little doubt that surgeons operating on these small cranial arterial occlusion V. progress report of prognosis following surgery or nonsurgical treatment for transient cerebral numbers of patients with carotid artery disease should ischemic attacks and cervical carotid artery lesions. JAMA 1970; not be performing this operation. How many opera211: 1993-2003. tions per annum are optimal for good results? Moore 6 GIBBS BF, GUZZETTAVJ. Carotid endarterectomy in community practice: surgeons-specific versus institutional results. Ann Vasc reported the experience of 4~ fellows in 32 approved Surg 1989; 3: 307-312. training programs in which the caseload averaged 28 7 ABURAHMA AF, ROBINSON P. Indications and complications of (range 5-64). 12 The author personally regards this carotid endarterectomy as performed by four different surgical speciality groups. J Cardiovasc Surg 1988; 29: 277-282. number as a minimum requirement to obtain suffi8 FRIEDMANP/GARBJL, BERMANJ, SULLIVANC, CELORIAG, RHEESW. cient experience not only in the technical aspects, but Carotid endarterectomy. Clinical results in a community-based also to gain familiarity with the indications and teaching hospital. Stroke 1988; 19: 1323-1327. 9 LEAPE LL, PARK RE, SOLOMON DH, CHASSIN MR, KOSECOFF J~ complications of this operation. The matter of periodic BROOK RH. Relation between surgeon's practice volumes and auditing by national or international professional geographic variation in the rate of carotid endarterectomy. N organisations needs to be studied carefully as well as Engl J Med 1989; 321: 653-674. 10 MUR1EJ, MORRISP. Carotid endarterectomy in Great Britain and the issue of accreditation. Ireland. Trends and current practice. Br J Surg 1991; 78: In summary, postoperative stroke and death rates 397-400. are influenced by the indications for surgery, training 11 ESTEVANJM, GONZALEZMA, VALLEA, CAIROLSM, MARco-LuQuE MA, NAVARROR. Ciugia carotldea en Espa~a. An~lisis de dos and workload of the surgeon, as well as by the size nacionales. Neurologia 1992; 7: 260-265. and the type of hospital. 13'14 To address the question 12 encuestas MOORE WS. Vascular surgery, a continuing quest for excellence. posed in the title of this leading article: carotid f Vasc Surg 1988; 7: 185-189. endarterectomy should be carried out by skilled and 13 BROTT T, THALINGER K. The practice of CEA in a large metropolitan area. Stroke 1984; 15: 950-954. well-trained vascular surgeons who use their wisdom 14 HslA DC, KRUSHATWM, MOSCOE LM. Epidemiology of carotid to treat patients on the basis of sound indications, and endarterectomies among medicare beneficiaries. J Vasc Surg 1992; 16: 201-288. exercise their skills in hospitals with the necessary ancillary equipment, having as their only objective the Accepted 12 December 1994 well being of their patients.
Eur J Vasc Endovasc Surg Vol 10, October 1995