Characterization of Perioperative Contralateral Stroke After Carotid Endarterectomy

Journal of Vascular Surgery

Abstracts

1183

Volume 64, Number 4 Table. Univariate discriminants of perioperative contralateral stroke after carotid endarterectomy (CEA) Factor

P value

Preoperative Urgency of operation

Fig. Limb salvage (%).

[interquartile range, 95-340]). The need for operative foot débridement, minor amputation, and use of revascularization increased with increasing WIfI stage (Table). The proportion with complete wound healing decreased and the proportion requiring major amputation increased with increasing WIfI stage (Table). On Kaplan-Meier analysis, increasing WIfI stage was associated with decreased 1-year limb salvage (P ¼ .003; Fig) and amputationfree survival (P ¼ .007). Stage 4 WIfI independently predicted amputation (hazard ratio, 12; 95% confidence interval, 1.6-94). Ambulatory and independent living status deteriorated from baseline in stage 4 patients (Table). Mortality was not significantly different between stages (Table). Conclusions: In patients treated aggressively for limb salvage, WIfI correlated with intensity of multimodal limb treatment as well as with limb salvage and patient-centered outcomes at 1 year. These data support the Society for Vascular Surgery WIfI system as a powerful tool to risk stratify patients with threatened limbs. Author Disclosures: W. P. Robinson: None; L. Loretz: None; C. Hanesian: None; J. M. Flahive: None; J. A. Bostrom: None; N. Lunig: None; A. Schanzer: None; L. M. Messina: None.

Characterization of Perioperative Contralateral Stroke After Carotid Endarterectomy W. Darrin Clouse, Emel Ergul, Virendra I. Patel, R. Todd Lancaster, Glenn M. LaMuraglia, Richard P. Cambria, Mark F. Conrad. Massachusetts General Hospital, Boston, Mass Objective: Contralateral stroke is an infrequent cause of perioperative stroke after carotid endarterectomy (CEA). Whereas the risks of ipsilateral stroke complicating CEA have been discriminated, factors that lead to contralateral stroke are poorly defined. The goal of this study was to identify the risk of perioperative (30-day) contralateral stroke after CEA as well as predisposing preoperative and operative factors. Methods: The Vascular Study Group of New England was queried from April 1, 2003, to February 29, 2016, for all CEAs. Duplicated patients and those without complete data were excluded. Those patients sustaining contralateral stroke in the postoperative period were identified. Demographic, preoperative, and operative factors were analyzed to identify discriminators between those with and without contralateral stroke. Logistic regression modeling was performed to identify factors independently associated with contralateral stroke. Results: There were 10,837 CEAs performed during the study. Average age was 70.4 6 9.3 years, and 6605 patients (61%) were male; 40% (n ¼ 4324) were performed for symptoms. Most were current or former smokers (n ¼ 8619 [80%]); 8% (n ¼ 831) had serum creatinine concentration $1.8 mg/dL, and dialysis dependence was present in 162 (2%). Coronary artery disease and congestive heart failure were identified in 31% and 8.6%, respectively; 59 patients (0.5%) were identified having

.0001

Degree of ipsilateral (operated) carotid stenosis

.004

Stress test performance

.02

Preoperative facility need

.03

Beta blocker use

.04

Contralateral occlusion

.06

Degree of contralateral carotid stenosis

.14

Symptomatic

.23

Aspirin use

.26

Clopidogrel use

.43

Dual antiplatelet therapy

.46

ACE inhibitor/ARB

.57

Statin use

.62

Operative CEA with coronary bypass (P ¼ .001)

.0001

Length of operation

.0001

CEA with other open arterial component (P ¼ .01)

.01

Ipsilateral proximal endovascular procedure (P ¼ .02)

.02

Shunt

.19

Dextran

.45

Protamine

.85

Type of CEA (eversion/longitudinal)

.91

Postoperative Dysrhythmia (P ¼ .0001)

.0001

Return to OR (P ¼ .0001)

.0001

Reperfusion syndrome (P ¼ .006)

.006

ACE, Angiotensin-converting enzyme; ARB, angiotensin receptor blocker; OR, operating room.

contralateral perioperative stroke. Preoperative, operative, and postoperative significant univariate factors along with notable factors not affecting perioperative contralateral stroke are presented in Table. After logistic regression analysis of significant factors, with and without contralateral occlusion represented, length of procedure (odds ratio [OR], 1.01/minute; 95% confidence interval [CI], 1.008-1.009; P ¼ .02), urgency of operation (OR, 2.5; 95% CI, 1.3-4.6; P ¼ .006), and concomitant proximal endovascular procedure (OR, 8.7; 95% CI, 4.5-31.2; P ¼ .001) remain predictors of contralateral stroke after CEA. Conclusions: Contralateral stroke after CEA is rare, affecting 0.5% of patients. Traditional risk reduction medical therapy does not affect occurrence. Degree of contralateral stenosis, including contralateral occlusion, does not predict perioperative contralateral stroke. Urgency of operation, length of operation, and performance of a concomitant, ipsilateral endovascular procedure predict risk of contralateral stroke with CEA. Author Disclosures: W. Clouse: None; E. Ergul: None; V. I. Patel: None; R. Lancaster: None; G. M. LaMuraglia: None; R. P. Cambria: None; M. F. Conrad: None.

Peroneal Artery Endovascular Revascularization Is an Effective Alternative to Open Bypass for Critical Limb Ischemia With Tissue Loss Courtney J. Warner, Nikolaos Zacharias, Jeffery C. Hnath, Yaron Sternbach, R. Clement Darling III. Albany Medical College, Albany, NY Objective: Peroneal artery bypass is an effective treatment for tissue loss; however, the efficacy of peroneal endovascular intervention is less