PC112 Statins Reduce Mortality and Failure to Rescue Following Carotid Artery Stenting

Journal of Vascular Surgery

Abstracts

169S

Volume 65, Number 6S

PC112. Statins Reduce Mortality and Failure to Rescue Following Carotid Artery Stenting Muhammad Rizwan, Hanaa N. Dakour Aridi, Besma Nejim, Muhammad Faateh, Mahmoud B. Malas. Johns Hopkins School of Medicine, Baltimore, Md Objectives: The benefit of statins has been well-established following lower extremity revascularization and carotid endarterectomy. However, the potential advantage of statin use in patients undergoing carotid artery stenting (CAS) remains largely unknown. The purpose of this study was to evaluate the effect of statins on postoperative outcomes following CAS. Methods: We performed a retrospective analysis of all patients who underwent CAS in the Premier Database from 2009 to 2015. Univariate (c2 test, t-test) and multivariate (logistic regression models) adjusting for patients’ demographics and characteristics were used to evaluate postoperative stroke, death, myocardial infarction (MI), and the composite outcomes of stroke/death and stroke/death/myocardial infarction (MI). Results: A total of 18,275 patients underwent CAS during the study period. Mean age was 69.8 6 10.5 years. Most patients were men (60.2%), white (80.3%), and on statins (12,885 patients [70.5%]). Statin users had significantly more comorbidities and were more likely to

be symptomatic (36.8% vs 27.1%; P < .001; Table I). Postoperative mortality rate was lower in the statin group (1.1 % vs 1.9%; P < .001), despite higher rates of stroke (2.7% vs 1.8%; P ¼ .001) and MI (1.1% vs 0.4%; P < .001). This continued to be the case after stratifying by symptomatic status (Table II). After adjusting for potential confounders, statins use was associated with a 66% reduction in the odds of death (odds ratio [OR], 0.34; 95% confidence interval [CI], 0.26-0.45; P < .001) and 21% reduction in the odds of stroke/death (OR, 0.79; 95% CI, 0.66-0.95; P ¼ .001). Nonstatin users who had a stroke or MI had significantly higher failure to rescue compared to statin users (mortality: 16.4 vs 8.5%; P ¼ .01). Statins use was associated with 52% reduction in mortality in patients who developed major complications (OR, 0.48; 95% CI, 0.26-0.90; P ¼ .02). Conclusions: We have shown in this study higher rate of stroke and MI in statin users undergoing CAS, which could be explained by their higher prevalence of symptomatic status and severe comorbid conditions. However, statins use has strong protective effect in these patients manifested by lower overall mortality and dramatic rescue in patients who develop major complications. This could be related to statins role in plaque stabilization and its anti-inflammatory effect, possibly reducing the magnitude and impact of stroke and MI. Further prospective studies needed to confirm the benefit of statins and its proper dose.

Table I. Patient characteristics Patient characteristicsa

CAS with statins (n ¼ 12,885)

CAS without statins (n ¼ 5390)

P valueb

Age, mean (SD) years

70.0 (10.03)

69.3 (11.52)

.0001

Male gender

7846 (60.9)

3160 (58.6)

.004

10,282 (79.8)

4401 (81.7)

Black

662 (5.1)

4401 (81.7)

Other

1941 (15.1)

4401 (81.7)

Obesity

1434 (11.1)

446 (8.3)

Race White

.009

<.001

History of Smoking

5542 (43.0)

2212 (41.0)

.01

HTN

10,349 (80.3)

3985 (73.9)

<.001

DM

4665 (36.2)

1533 (28.4)

<.001

Stroke

2217 (17.2)

393 (7.3)

<.001

TIA

2699 (21.0)

1086 (20.2)

.23

CAD

7143 (55.4)

2303 (42.7)

<.001

PAD

3688 (28.6)

1401 (26.0)

<.001

MI

1626 (12.6)

511 (9.5)

<.001

CHF

1562 (12.1)

418 (7.8)

<.001

COPD

2522 (19.6)

942 (17.5)

.001

Dyslipidemia

8923 (69.3)

2796 (51.9)

<.001

CKD Symptomatic

1870 (14.5)

533 (9.9)

<.001

4739 (36.8)

1458 (27.1)

<.001

8068 (62.6)

4130 (76.6)

<.001

Emergency Elective Urgent Emergent

1857 (14.4)

618 (11.5)

2960 (23.0)

642 (11.9)

CAD, Coronary artery disease; CAS, carotid artery stenting; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; HTN, hypertension; MI, myocardial infarction; PAD, peripheral artery disease; TIA, transient ischemic attack. a Data are shown as number (%) unless indicated otherwise as mean (standard deviation). b P < .05 indicates statistical significance.

170S

Journal of Vascular Surgery

Abstracts

June Supplement 2017 Table II. Postoperative outcomes after carotid artery stenting (CAS) stratified by symptomatic status Asymptomatic patients Postoperative outcomes

CAS with statins, No. (%)

CAS without statins, No. (%)

Multivariatea (logistic regression) statins vs no statins

Symptomatic patients

P valueb

CAS with statins, No. (%)

CAS without Statins, No. (%)

P valueb

OR (95% CI)

P valueb

40 (1.0)

.02

87 (1.8)

64 (4.4)

<.001

0.34 (0.26-0.45)

<.001

70 (1.8)

<.001

90 (1.9)

29 (2.0)

.83

1.25 (0.99-1.58)

0.06

67 (0.8)

8 (0.2)

<.001

68 (1.4)

11 (0.8)

.04

2.21 (1.35-3.60)

Stroke/death

282 (3.5)

99 (2.5)

.005

171 (3.6)

88 (6.0)

<.001

0.79 (0.66-0.95)

Stroke/MI/death

327 (4.0)

104 (2.6)

<.001

231 (4.9)

97 (6.7)

.008

0.89 (0.75-1.06)

.18

.06

13 (8.3)

.09

0.48 (0.26-0.90)

.02

Death Stroke MI

Death after stroke or MI

51 (0.6) 251 (3.1)

26 (8.6)

12 (15.8)

7 (17.5)

.002 0.01

CI, Confidence interval; MI, myocardial infarction; OR, odds ratio. a Adjusted for age, gender, race, hypertension, diabetes, smoking, history of congestive heart failure, history of ischemic heart disease, history of chronic obstructive pulmonary disease, history of chronic kidney disease, symptomatic, and emergency status. b P < .05 indicates statistical significance.

Author Disclosures: H. N. Dakour Aridi: Nothing to disclose; M. Faateh: Nothing to disclose; M. B. Malas: Nothing to disclose; B. Nejim: Nothing to disclose; M. Rizwan: Nothing to disclose.

PC114. Predictors of Poor Outcome After Carotid Intervention Rustambek Askarbek o’g’li. Karimov. Tashkent Medical Academy, Tashkent, Uzbekistan Objectives: A variety of patient factors are known to adversely impact outcomes after carotid endarterectomy (CEA) or carotid artery stenting (CAS). However, their specific impact on complications and mortality and how they differ between CEA and CAS is unknown. The purpose of this study was to identify patient and hospital factors that adversely impact outcomes. Methods: Patients who underwent CEA or CAS between 1998 and 2012 (n ¼ 1,756,445) were identified using the Agency for Healthcare Research and Quality National Inpatient Sample and State Ambulatory Services Databases. A multivariate analysis was completed to evaluate the impact of demographics, patient factors, type of symptoms (transient ischemic attack or cerebrovascular accident), volume of cases (3 per year vs 1 to 2 interventions), and interventions upon outcomes, perioperative complications (stroke, myocardial infarction, and bleeding), duration of stay, inpatient mortality, and cost. Significant factors were then used as part of a multivariate regression analysis to determine odds ratios. A subgroup analysis using propensity matching evaluating 1:1 risk-matched asymptomatic and symptomatic patients was completed. Patient cohorts were matched on the basis of Charlson scores. Results: Over the study period, a total of 1,583,614 asymptomatic CEA, 7317 asymptomatic CAS, 162,362 symptomatic CEA, and 3149 symptomatic CAS patients were included. Symptomatic disease portends a worse outlook after either CEA or CAS. Costs of the procedure increased with complications with stroke adding the most significant cost burden. For risk-matched asymptomatic and symptomatic patients, female gender (P < .001) and performing one or two cases per year (P < .05) were associated with higher cerebrovascular accident risk. In asymptomatic and symptomatic patients, predictors of myocardial infarction included congestive heart failure (P < .001) and peripheral artery disease (P < .05), and predictors of bleeding included peripheral artery disease (P < .05) and chronic obstructive pulmonary disease (P < .01) for symptomatic patients only.

Conclusions: Higher rates of postoperative stroke and inpatient mortality for women undergoing CAS are an unexpected finding, and may indicate that this population is vulnerable to complications after endovascular management. Low volume is a predictor of complications and subsequent mortality primarily for CAS. Patients who undergo CEA continue to have superior outcomes compared with matched cohorts who undergo CAS. Author Disclosures: R. Askarbek o’g’li. Karimov: Nothing to disclose.

PC116. Predisposing Factors to Postoperative Hypotension Following Carotid Artery Stenting Gustavo A. Rubio,1 John Karwowski,1 Hilene DeAmorim,2 Lee Goldstein,3 Arash Bornak1. 1University of Miami Miller School of Medicine, Miami, Fla; 2Miami Veterans Affairs, Miami, Fla; 3The Vascular Experts, LLC, Easton, Conn Objectives: This study determined factors associated with hypotension following carotid artery stenting (CAS). In particular, this study evaluated whether involvement of the carotid bifurcation/bulb and degree of calcification can predict postoperative hypotension. Methods: A retrospective review of 90 CAS performed in 88 patients (1 female, 87 males) at a single academic center was performed. Site of carotid stenosis was confirmed on angiography at time of CAS. In patients with proximal internal carotid stenosis involving the carotid bifurcation, extent of bifurcation/bulb calcification on preoperative computed angiogram (CTA) was assessed using a scoring system. A single operator reviewed all CTA to ensure reproducibility. Calcium scores were assigned based on percentage of circumferential calcification of carotid bifurcation as follows: grade 1, <10%; grade 2, 10% to 50%; grade 3, 50% to 90%; grade 4, >90%. Preoperative blood pressure and number of hypertensive medications were recorded. Postoperatively, systolic blood pressure was monitored by arterial line and maintained within 20% of baseline with absolute parameters between 110 and 170 mm Hg. Perioperative factors associated with postoperative hypotension requiring vasopressor were analyzed. Results: Overall, postoperative hypotension requiring vasopressors occurred in 26 (28.9%) of CAS. Mean duration of vasopressor infusion was 21.4 hours (standard deviation, 10.9). There were no differences in baseline demographics, comorbidities, or CAS indication between patients that required postoperative vasopressors for hypotension and