High rate of inappropriate carotid endarterectomy in an urban medical center.

BACKGROUND: Some studies have reported that the appropriateness of carotid endarterectomy (CEA) has dramatically improved in the last two decades. However, these studies did not include the most recent study results for asymptomatic stenosis. METHODS: We sought to determine the appropriateness of CEA at a large, urban community hospital. A retrospective chart review of all CEA procedures during a 2-year period was conducted. CEA appropriateness was defined according to factors including age, degree of stenosis, symptomatic or asymptomatic status, and presence of high surgical risk comorbidities. RESULTS: During a 2-year period, 51 CEA procedures were performed. For patient characteristics, 73% were asymptomatic, 77% were African American, and 65% had high surgical risk comorbidities. Perioperative stroke or myocardial infarction occurred in 14.3% of symptomatic patients and 18.9% of asymptomatic patients. The rate of inappropriate CEA was 57%, and 14% of cases were of uncertain value. Patients with an inappropriate or uncertain CEA had a 19.4% rate of in-hospital stroke or myocardial infarction. CONCLUSIONS: In an urban hospital, the majority of CEA procedures were either inappropriate or of uncertain value. The periprocedure complication rate was high in these patients. Patient selection in urban hospitals is not adhering to clinical trial criteria.

Higher risk factor burden and worse outcomes in urban carotid endarterectomy patients.

BACKGROUND AND PURPOSE: Previous multicenter carotid endarterectomy (CEA) studies had screening criteria for patient comorbidities and very few blacks. We assessed the hypothesis that CEA results from two urban hospitals would approximate those of the previous multicenter trials. METHODS: A retrospective chart review was completed at two urban hospitals for CEA procedures done in 2003 and 2004. Demographic information and past medical history was recorded. In hospital perioperative complications (stroke or myocardial infarction [MI]) were noted. We calculated an expected perioperative stroke rate based on trial figures and our proportion of symptomatic and asymptomatic patients. RESULTS: Patients in our cohort had significantly higher rates of hypertension, diabetes, smoking, black race, and elderly status compared to previous trials. The expected perioperative stroke was 3.1%, and the observed stroke rate was 4.7% (P=0.36). Observed rates of MI (6.7%, P<0.001)) and stroke or MI (11.3%, P<0.0001) were higher than expected based on the previous trials. The stroke or MI rate in black subjects was higher (15.4% versus 5.6%, P=0.065) and this was significant at the hospital with lower CEA volume. CONCLUSIONS: In two urban hospitals, CEA results were significantly worse than previous trials. Patient selection is likely to play a role because our cohort had higher numbers of hypertensives, diabetics, smokers, blacks, and elderly patients. Clinicians need to carefully consider the risk/benefit ratio of CEA in urban patients because our study shows that these patients have a large number of medical comorbidities and worse outcomes after CEA.