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IP079. Characteristics and Outcomes of Patients Younger Than 50 Undergoing Carotid Endarterectomy
JOURNAL OF VASCULAR SURGERY Volume 63, Number 6S
Abstracts 81S
Table. CEA with CEA without P CCO (n ¼ 570) CCO (n ¼ 11,541) value Age, years Male, % BMI >30, % Smoking, % Diabetes, % Congestive heart failure, % Hypertension requiring medication, % End-stage renal disease, % Functional status- not independent, % Recent cardiac events, % Asymptomatic status, % Intraoperative shunt, % Patch angioplasty, % Regional anesthesia, % Postoperative TIA, % 30-day postoperative mortality, % Postoperative stroke, % Asymptomatic subgroup, % Postoperative MI + stroke + death, % Asymptomatic subgroup, % Hospital length of stay, days Discharge to home, %
<.001 <.001 .365 <.001 .631 .019 .034
69.7 (9.2) 69.6 35.1 35.8 29.3 2.5 80.1
71.3 (9.4) 61.1 33.3 26.2 30.0 1.3 84.2
0.9 4.4
1.1 3.0
.654 .059
4.9 60.7 53.0 82.6 14.7 0.9 1.1
4.7 55.9 33.9 77.9 14.7 1.0 0.6
.850 .024 <.001 .007 .965 .750 .224
3.3 2.3 5.3
1.9 1.1 3.6
.021 .037 .034
4.3 3.3 (4.7) 88.4
3.7 2.7 (4.1) 92.9
.516 .001 <.001
BMI, Body mass index; CCO, carotid artery occlusion; CEA, carotid endarterectomy; MI, myocardial infarction; TIA, transient ischemic attack.
should be taken when performing CEA in patients with CCO. Author Disclosures: S. L. Chen: Nothing to disclose; R. M. Fujitani: Bard Peripheral Vascular: consulting fees (eg, advisory boards), speaker’s bureau, other financial or material support, Bolton Medical: contracted research, Endologix and Medtronic: speaker’s bureau, other financial or material support, Terumo Interventional Systems and W. L. Gore: other financial or material support; N. Kabutey: C.R. Bard: speaker’s bureau; I. J. Kuo: Nothing to disclose. IP077. Regional Anesthesia Is Protective Against Postoperative Hypertension in Patients Undergoing Eversion Carotid Endarterectomy Felecia Jinwala, MD1, Justin Oh, BS2, Khanjan Nagarsheth, MD1, Saum Rahimi, MD1. 1Rutgers University, New Brunswick, NJ; 2Rutgers University, Fort Lee, NJ Objectives: Eversion carotid endarterectomy (eCEA) has been effective in reducing stroke risk in patients with carotid artery stenosis. Recent literature shows patients who undergo eCEA are at risk for developing postoperative hypertension requiring intravenous (IV) antihypertensive medication. The purpose of this study was to assess whether the type of anesthesia (regional or general) impacts the incidence of postoperative hypertension requiring IV antihypertensive medication in the surgical intensive care unit (SICU) in patients undergoing eCEA.
Methods: We performed a retrospective chart review from August 2009 to March 2013 and identified 124 patients who underwent eCEA. Patient characteristics, including age, gender, body mass index, smoking status, and preoperative diagnosis of hypertension, were collected; operative data, including the use of shunt and type of anesthesia, were also obtained. Descriptive statistics were used to summarize patient and procedure characteristics. The difference between select groups was tested by c2 analysis with calculating odds ratio and 95% confidence intervals (CIs). Results: A total of 124 patients were analyzed, and 134 eCEA were performed. Of these, 59 (44.0%) were performed under cervical plexus block and 75 (56.0%) were performed under general anesthesia. Thirty-one patients (23.1%) were admitted to the SICU. Of these, 22 (71.0%) were for postoperative hypertension management requiring IV antihypertensive medication. Of the patients admitted to the SICU for postoperative hypertension, 6 patients (27.3%) underwent regional anesthesia compared to 16 patients (72.7%) who had general anesthesia, a statistically significant finding (95% CI, 1.041-8.610). Conclusions: In patients undergoing eCEA, regional anesthesia can be protective against postoperative hypertension, with a reduced requirement for intravenous postoperative antihypertensive medications and SICU admission. Further investigations involving the exact mechanism of this finding and potential cost benefits are warranted. Author Disclosures: F. Jinwala: Nothing to disclose; K. Nagarsheth: Nothing to disclose; J. Oh: Nothing to disclose; S. Rahimi: Nothing to disclose.
IP079. Characteristics and Outcomes of Patients Younger Than 50 Undergoing Carotid Endarterectomy Lauren M. Story, BS1, Matthew R. Smeds, MD1, Cora E. Lewis, MD, MSPH2, Ali A. Ahsan, MD1, Mohammed M. Moursi, MD1, Lyons C. Lewis, MD1, Guillermo A. Escobar, MD1. 1University of Arkansas for Medical Sciences, Little Rock, Ark; 2University of Alabama at Birmingham, Birmingham, Ala Objectives: Less than 10% of all neurovascular events occur in patients aged 18 to 50, and only 25% of these are attributable to carotid disease (2.5% overall). Thirteen percent of young patients do not regain independent living status after a stroke, and about half return to work. Stroke from carotid disease is one of the strongest risk factors for poor outcome, yet there is a paucity of data on young patients undergoing carotid procedures. We examined the clinical characteristics and outcomes of patients aged 18 to 49 who underwent carotid procedures at the University of Arkansas for Medical Sciences (UAMS). Methods: IRB-approved, retrospective review of all patients aged 18 to 49 undergoing carotid surgery from 2005 to 2015 at a single institution. We included demographics,
JOURNAL OF VASCULAR SURGERY June Supplement 2016
82S Abstracts
IP081. Patient-Tailored Postsurgical Survival Information from CARAT (the Carotid Risk Assessment Tool) Did Not Change Surgeons’ Recommendations for Carotid Surgery: A Randomized Survey With Clinical Vignettes Adrienne Faerber1, Renee Roberts2, Karina Newhall, MD3, Kimon Bekelis, MD3, Bjoern D. Suckow, MD, MS3, Philip P. Goodney, MD, MS3. 1Dartmouth Institute, Hanover, NH; 2Hartwick College, Oneonta, NY; 3DartmouthHitchcock Medical Center, Lebanon, NH Objectives: Surgical techniques to improve blood flow through carotid arteries, like carotid angioplasty with stenting (CAS) and carotid endarterectomy (CEA), are effective in reducing stroke risk, but some patients may not be healthy enough for surgery, or not expected to survive long enough to get the full benefit of preventive surgery. The Carotid Risk Assessment Tool (CARAT) calculates a patient’s 2-year mortality rate after carotid surgery based on risk factors and comorbidities and presents a recommendation for or against surgery. Our objective is to evaluate the effectiveness of CARAT to change surgical recommendations when a patient may not be appropriate for surgery.
Is the patient healthy enough for carotid surgery?
Fig. Low Risk
Absolutely Yes
Medium Risk
clinical presentation, and surgical approach/outcomes, all being obtained from a prospectively managed hospital database. Results: A total of 16 patients <50 years old underwent carotid procedures. Average age was 46years (4149), 47% were male and 75% were Caucasian. Prevalence of risk factors were on average: smoking, 94% (mean 1.3 packs per day, and 32 pack-years [range, 10-100]); hypertension, 69% (1.4 medications); diabetes, 31%; a diagnosis of hypercholesterolemia, 61% (mean total cholesterol 195 mg/dL, only one >240 mg/dL); none with creatinine >1.5 mg/dL. A total of 63% were transferred to our institution from an average distance of 142 miles. A total of 13 (81%) had neurologic events before diagnosis (69% stroke, 15% amaurosis, 8% TIA, 8% combination), the rest were asymptomatic. No carotid dissections. Duplex showed 33% had stenosis >90%, 47% had a stenosis >70%, and the rest had a stenosis 50% to 69%. Average time to surgery was 29 days (4-85; median, 15). Patch angioplasty was done in 75%, the rest with eversion. Complications included: 1 hyperperfusion syndrome, 0 new strokes or cranial nerve injuries, 1 DVT (which prolonged hospitalization). Hospitalization averaged 2.6 days (range, 1-12; mode, 1). Conclusions: Carotid endarterectomy in adults <50 most commonly follows a stroke in Caucasian patients, with a carotid stenosis >70%. Both genders are at risk, commonly have hypertension. and average >30 pack-years of smoking. Those treated do well from surgery, comparable to the outcomes published in older adults.
Definitely Yes
Definitely Not
High Risk -40
-30
-20
0
-10
10
20
30
40
Absolutely Yes
Absolutely Not
In the next 2 years, how likely is the patient to have a stroke? Slightly likely
Low Risk Not at all likely
Moderately likely Very likely
Medium Risk
Extremely likely
High Risk -40
-30
-20
-10
0
10
20
Not at all likely
30
40
Extremely Likely
In the next 2 years, how likely is the patient to die from a stroke? Low Risk
Not at all likely
Slightly likely
Medium Risk
likely Moderately likely Very likely
High Risk
-40
-30
-20
-10
0
10
20
30
40
Extremely Likely
Not at all likely
In the next 2 years, how likely is the patient to die from some other cause? Slightly likely
Not at all likely
Low Risk Medium Risk
Moderately likely
High Risk
Very likely -40
-30
-20
-10
0
10
20
Extremely likely 30
40
Extremely Likely
Not at all likely
How effective would surgery be in reducing the patients risk of having a stroke in the next 2 years? Not at all effective
Low Risk
Extremely effective
Slightly effective
Medium Risk
Author Disclosures: A. A. Ahsan: Nothing to disclose; G. A. Escobar: Nothing to disclose; L. C. Lewis: Nothing to disclose; M. M. Moursi: Nothing to disclose; M. R. Smeds: Nothing to disclose; L. M. Story: Nothing to disclose.
Maybe Yes
Maybe Not
Moderately Effective Very effective
High Risk
-40
-30
-20
-10
0
10
20
30
40
Extremely effective
Not at all effective
Fig.
Abstracts 81S
Table. CEA with CEA without P CCO (n ¼ 570) CCO (n ¼ 11,541) value Age, years Male, % BMI >30, % Smoking, % Diabetes, % Congestive heart failure, % Hypertension requiring medication, % End-stage renal disease, % Functional status- not independent, % Recent cardiac events, % Asymptomatic status, % Intraoperative shunt, % Patch angioplasty, % Regional anesthesia, % Postoperative TIA, % 30-day postoperative mortality, % Postoperative stroke, % Asymptomatic subgroup, % Postoperative MI + stroke + death, % Asymptomatic subgroup, % Hospital length of stay, days Discharge to home, %
<.001 <.001 .365 <.001 .631 .019 .034
69.7 (9.2) 69.6 35.1 35.8 29.3 2.5 80.1
71.3 (9.4) 61.1 33.3 26.2 30.0 1.3 84.2
0.9 4.4
1.1 3.0
.654 .059
4.9 60.7 53.0 82.6 14.7 0.9 1.1
4.7 55.9 33.9 77.9 14.7 1.0 0.6
.850 .024 <.001 .007 .965 .750 .224
3.3 2.3 5.3
1.9 1.1 3.6
.021 .037 .034
4.3 3.3 (4.7) 88.4
3.7 2.7 (4.1) 92.9
.516 .001 <.001
BMI, Body mass index; CCO, carotid artery occlusion; CEA, carotid endarterectomy; MI, myocardial infarction; TIA, transient ischemic attack.
should be taken when performing CEA in patients with CCO. Author Disclosures: S. L. Chen: Nothing to disclose; R. M. Fujitani: Bard Peripheral Vascular: consulting fees (eg, advisory boards), speaker’s bureau, other financial or material support, Bolton Medical: contracted research, Endologix and Medtronic: speaker’s bureau, other financial or material support, Terumo Interventional Systems and W. L. Gore: other financial or material support; N. Kabutey: C.R. Bard: speaker’s bureau; I. J. Kuo: Nothing to disclose. IP077. Regional Anesthesia Is Protective Against Postoperative Hypertension in Patients Undergoing Eversion Carotid Endarterectomy Felecia Jinwala, MD1, Justin Oh, BS2, Khanjan Nagarsheth, MD1, Saum Rahimi, MD1. 1Rutgers University, New Brunswick, NJ; 2Rutgers University, Fort Lee, NJ Objectives: Eversion carotid endarterectomy (eCEA) has been effective in reducing stroke risk in patients with carotid artery stenosis. Recent literature shows patients who undergo eCEA are at risk for developing postoperative hypertension requiring intravenous (IV) antihypertensive medication. The purpose of this study was to assess whether the type of anesthesia (regional or general) impacts the incidence of postoperative hypertension requiring IV antihypertensive medication in the surgical intensive care unit (SICU) in patients undergoing eCEA.
Methods: We performed a retrospective chart review from August 2009 to March 2013 and identified 124 patients who underwent eCEA. Patient characteristics, including age, gender, body mass index, smoking status, and preoperative diagnosis of hypertension, were collected; operative data, including the use of shunt and type of anesthesia, were also obtained. Descriptive statistics were used to summarize patient and procedure characteristics. The difference between select groups was tested by c2 analysis with calculating odds ratio and 95% confidence intervals (CIs). Results: A total of 124 patients were analyzed, and 134 eCEA were performed. Of these, 59 (44.0%) were performed under cervical plexus block and 75 (56.0%) were performed under general anesthesia. Thirty-one patients (23.1%) were admitted to the SICU. Of these, 22 (71.0%) were for postoperative hypertension management requiring IV antihypertensive medication. Of the patients admitted to the SICU for postoperative hypertension, 6 patients (27.3%) underwent regional anesthesia compared to 16 patients (72.7%) who had general anesthesia, a statistically significant finding (95% CI, 1.041-8.610). Conclusions: In patients undergoing eCEA, regional anesthesia can be protective against postoperative hypertension, with a reduced requirement for intravenous postoperative antihypertensive medications and SICU admission. Further investigations involving the exact mechanism of this finding and potential cost benefits are warranted. Author Disclosures: F. Jinwala: Nothing to disclose; K. Nagarsheth: Nothing to disclose; J. Oh: Nothing to disclose; S. Rahimi: Nothing to disclose.
IP079. Characteristics and Outcomes of Patients Younger Than 50 Undergoing Carotid Endarterectomy Lauren M. Story, BS1, Matthew R. Smeds, MD1, Cora E. Lewis, MD, MSPH2, Ali A. Ahsan, MD1, Mohammed M. Moursi, MD1, Lyons C. Lewis, MD1, Guillermo A. Escobar, MD1. 1University of Arkansas for Medical Sciences, Little Rock, Ark; 2University of Alabama at Birmingham, Birmingham, Ala Objectives: Less than 10% of all neurovascular events occur in patients aged 18 to 50, and only 25% of these are attributable to carotid disease (2.5% overall). Thirteen percent of young patients do not regain independent living status after a stroke, and about half return to work. Stroke from carotid disease is one of the strongest risk factors for poor outcome, yet there is a paucity of data on young patients undergoing carotid procedures. We examined the clinical characteristics and outcomes of patients aged 18 to 49 who underwent carotid procedures at the University of Arkansas for Medical Sciences (UAMS). Methods: IRB-approved, retrospective review of all patients aged 18 to 49 undergoing carotid surgery from 2005 to 2015 at a single institution. We included demographics,
JOURNAL OF VASCULAR SURGERY June Supplement 2016
82S Abstracts
IP081. Patient-Tailored Postsurgical Survival Information from CARAT (the Carotid Risk Assessment Tool) Did Not Change Surgeons’ Recommendations for Carotid Surgery: A Randomized Survey With Clinical Vignettes Adrienne Faerber1, Renee Roberts2, Karina Newhall, MD3, Kimon Bekelis, MD3, Bjoern D. Suckow, MD, MS3, Philip P. Goodney, MD, MS3. 1Dartmouth Institute, Hanover, NH; 2Hartwick College, Oneonta, NY; 3DartmouthHitchcock Medical Center, Lebanon, NH Objectives: Surgical techniques to improve blood flow through carotid arteries, like carotid angioplasty with stenting (CAS) and carotid endarterectomy (CEA), are effective in reducing stroke risk, but some patients may not be healthy enough for surgery, or not expected to survive long enough to get the full benefit of preventive surgery. The Carotid Risk Assessment Tool (CARAT) calculates a patient’s 2-year mortality rate after carotid surgery based on risk factors and comorbidities and presents a recommendation for or against surgery. Our objective is to evaluate the effectiveness of CARAT to change surgical recommendations when a patient may not be appropriate for surgery.
Is the patient healthy enough for carotid surgery?
Fig. Low Risk
Absolutely Yes
Medium Risk
clinical presentation, and surgical approach/outcomes, all being obtained from a prospectively managed hospital database. Results: A total of 16 patients <50 years old underwent carotid procedures. Average age was 46years (4149), 47% were male and 75% were Caucasian. Prevalence of risk factors were on average: smoking, 94% (mean 1.3 packs per day, and 32 pack-years [range, 10-100]); hypertension, 69% (1.4 medications); diabetes, 31%; a diagnosis of hypercholesterolemia, 61% (mean total cholesterol 195 mg/dL, only one >240 mg/dL); none with creatinine >1.5 mg/dL. A total of 63% were transferred to our institution from an average distance of 142 miles. A total of 13 (81%) had neurologic events before diagnosis (69% stroke, 15% amaurosis, 8% TIA, 8% combination), the rest were asymptomatic. No carotid dissections. Duplex showed 33% had stenosis >90%, 47% had a stenosis >70%, and the rest had a stenosis 50% to 69%. Average time to surgery was 29 days (4-85; median, 15). Patch angioplasty was done in 75%, the rest with eversion. Complications included: 1 hyperperfusion syndrome, 0 new strokes or cranial nerve injuries, 1 DVT (which prolonged hospitalization). Hospitalization averaged 2.6 days (range, 1-12; mode, 1). Conclusions: Carotid endarterectomy in adults <50 most commonly follows a stroke in Caucasian patients, with a carotid stenosis >70%. Both genders are at risk, commonly have hypertension. and average >30 pack-years of smoking. Those treated do well from surgery, comparable to the outcomes published in older adults.
Definitely Yes
Definitely Not
High Risk -40
-30
-20
0
-10
10
20
30
40
Absolutely Yes
Absolutely Not
In the next 2 years, how likely is the patient to have a stroke? Slightly likely
Low Risk Not at all likely
Moderately likely Very likely
Medium Risk
Extremely likely
High Risk -40
-30
-20
-10
0
10
20
Not at all likely
30
40
Extremely Likely
In the next 2 years, how likely is the patient to die from a stroke? Low Risk
Not at all likely
Slightly likely
Medium Risk
likely Moderately likely Very likely
High Risk
-40
-30
-20
-10
0
10
20
30
40
Extremely Likely
Not at all likely
In the next 2 years, how likely is the patient to die from some other cause? Slightly likely
Not at all likely
Low Risk Medium Risk
Moderately likely
High Risk
Very likely -40
-30
-20
-10
0
10
20
Extremely likely 30
40
Extremely Likely
Not at all likely
How effective would surgery be in reducing the patients risk of having a stroke in the next 2 years? Not at all effective
Low Risk
Extremely effective
Slightly effective
Medium Risk
Author Disclosures: A. A. Ahsan: Nothing to disclose; G. A. Escobar: Nothing to disclose; L. C. Lewis: Nothing to disclose; M. M. Moursi: Nothing to disclose; M. R. Smeds: Nothing to disclose; L. M. Story: Nothing to disclose.
Maybe Yes
Maybe Not
Moderately Effective Very effective
High Risk
-40
-30
-20
-10
0
10
20
30
40
Extremely effective
Not at all effective
Fig.