Impact of Surgical Specialty on Outcomes Following Carotid Endarterectomy

• Published in: Neurosurgery Vol. 80; no. 2; pp. 217 - 225
• Main Authors: Lieber, Bryan A., Henry, Jensen K., Agarwal, Nitin, Day, John D., Morris, Thomas W., Stephens, Marcus L., Abla, Adib A.
• Format: Journal Article
• Language: English
• Published: United States Oxford University Press 01.02.2017; Copyright by the Congress of Neurological Surgeons; Wolters Kluwer Health, Inc
• Subjects: Endarterectomy, Carotid - adverse effects; Endarterectomy, Carotid - statistics & numerical data; Humans; Mortality; Multivariate analysis; Prospective Studies; Specialties, Surgical - statistics & numerical data; Stroke; Surgeons - statistics & numerical data; Treatment Outcome; NSQIP; Surgical specialty; Carotid endarterectomy
• ISSN: 0148-396X; 1524-4040
• DOI: 10.1093/neuros/nyw027

Abstract BACKGROUND: The impact of surgeon specialty on outcomes following carotid endarterectomy (CEA) has been widely debated within the literature. Previous studies on this subject are often limited by small sample sizes, single-intuition designs, variability in patients and procedures, and potential confounding factors such as institution type and volume. OBJECTIVE: To identify similarities and differences between surgeon specialties in postoperative stroke and mortality rates for patients undergoing unilateral CEAs by utilizing a large, multicenter prospective database. METHODS: We utilized a large national prospective database (National Surgical Quality Inpatient database) and investigated all patients with a 1-sided, surgically naïve CEA, performed by either a general, vascular, cardiothoracic, or neurological surgeon. We employed a logistic regression analysis to control for the most salient variables identified via univariate analysis. Our primary outcomes were all-cause mortality and stroke. RESULTS: There were 42 369 patients included across all specialties. Patients from each specialty were similar in demographics but varied in medical history. Multivariate analysis demonstrated that among the specialties only general surgeons had significantly greater postoperative stroke rates (2.3%) when compared to vascular surgeons (1.5%; P = .003, odds ratio [OR] 1.574, confidence interval [CI]: 1.168-2.121). In contrast, surgical specialty was not a significant risk factor for 30-d postoperative mortality (0% in cardiothoracic surgeons; 0.8% in vascular surgeons; 1.1% in general surgeons; 1.8% in neurosurgeons; Cardiothoracic surgeons: P = .995, OR: 0 [no incidences of mortality]; neurosurgeon: P = .118, OR: 0.2057, CI: 0.833-2.057; general surgeon P = .210, OR: 1.326, CI: 1.853-2.062). Most secondary outcomes (myocardial infarction, infection, reoperation, pneumonia) were similar between specialties (P = .339-.816). However, length of stay (P < .001), operative duration (P < .001), incidence of venous thromboembolism (P < .001), and the postoperative requirement for a ventilator greater than 48 h (P = .004) were all the greatest among neurosurgeons. CONCLUSION: Multidisciplinary approaches with improved communication among surgical specialties may enhance patient management and improve success after CEA. Though there were differences in postoperative stroke and other secondary outcomes, no differences were observed among specialties in mortality after unilateral CEA in more than 40 000 patients.