Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival
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Authors
Wallaert, Jessica B.Cronenwett, Jack L.
Bertges, Daniel J.
Schanzer, Andres
Nolan, Brian W.
De Martino, Randall R.
Eldrup-Jorgensen, Jens
Goodney, Philip P.
UMass Chan Affiliations
Department of SurgeryDocument Type
Journal ArticlePublication Date
2013-07-01Keywords
AgedAged, 80 and over
Asymptomatic Diseases
Carotid Artery, Internal
Carotid Stenosis
*Decision Support Techniques
*Endarterectomy, Carotid
Female
Humans
Male
Multivariate Analysis
*Patient Selection
Proportional Hazards Models
Registries
Risk Assessment
Risk Factors
Severity of Illness Index
Time Factors
Treatment Outcome
United States
Surgery
Metadata
Show full item recordAbstract
OBJECTIVE: Although carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis. METHODS: Prospectively collected data from 4114 isolated CEAs performed for asymptomatic stenosis across 24 centers in the Vascular Study Group of New England between 2003 and 2011 were used for this analysis. Late survival was determined with the Social Security Death Index. Cox proportional hazard models were used to identify risk factors for mortality within the first 5 years after CEA and to calculate a risk score for predicting 5-year survival. RESULTS: Overall 3- and 5-year survival after CEA in asymptomatic patients were 90% (95% CI 89%-91%) and 82% (95% CI 81%-84%), respectively. By multivariate analysis, increasing age, diabetes, smoking history, congestive heart failure, chronic obstructive pulmonary disease, poor renal function (estimated glomerular filtration rate dependence), absence of statin use, and worse contralateral ICA stenosis were all associated with worse survival. Patients classified as low (27%), medium (68%), and high risk (5%) based on number of risk factors had 5-year survival rates of 96%, 80%, and 51%, respectively (P < .001). CONCLUSIONS: More than four out of five asymptomatic patients selected for CEA in the Vascular Study Group of New England achieved 5-year survival, demonstrating that, overall, surgeons in our region selected appropriate patients for carotid revascularization. However, there were patients selected for surgery with high risk profiles, and our models suggest that the highest risk patients (such as those with multiple major risk factors including age >/= 80, insulin-dependent diabetes, dialysis dependence, and severe contralateral ICA stenosis) are unlikely to survive long enough to realize a benefit of prophylactic CEA for asymptomatic stenosis. Predicting survival is important for decision making in these patients.Source
Wallaert JB, Cronenwett JL, Bertges DJ, Schanzer A, Nolan BW, De Martino R, Eldrup-Jorgensen J, Goodney PP; Vascular Study Group of New England. Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival. J Vasc Surg. 2013 Jul;58(1):112-8. doi:10.1016/j.jvs.2012.12.056. Link to article on publisher's site
DOI
10.1016/j.jvs.2012.12.056Permanent Link to this Item
http://hdl.handle.net/20.500.14038/49707PubMed ID
23478502Related Resources
Link to Article in PubMedae974a485f413a2113503eed53cd6c53
10.1016/j.jvs.2012.12.056