Key result
Carotid endarterectomy at an inner-city hospital had comparable rates of postoperative stroke (1.1% vs 1.6%) and death (1.1% vs 0%) compared to a private hospital, despite higher patient risk.
Why the study?
Does carotid endarterectomy performed at an inner-city hospital yield comparable outcomes to a private hospital when performed by the same high-volume surgeons?
Observational (n=536)
Yes
Does carotid endarterectomy performed at an inner-city hospital yield comparable outcomes to a private hospital when performed by the same high-volume surgeons?
Absolute Event Rate: 1.1% vs 1.6%
p-value: p=NS
Carotid endarterectomy can be performed safely in a high-risk inner-city population with comparable outcomes to a private hospital when performed by high-volume surgeons, though aggressive preoperative cardiac workup is necessary.
CEA may be performed safely at inner-city hospitals by high-volume surgeons; extends evidence but should not yet change practice.
This is a retrospective review of all carotid endarterectomies (CEA) (n=91) done from 1993 to 2002 at an inner-city hospital (Group I). This group was compared to a randomly selected group of patients (n=445) treated at a private hospital (Group II). The same high-volume surgeons performed CEAs at both hospitals. The majority of Group I patients (71.4%) were members of racial minority groups. They were also more likely to be younger (p<0.001), hypertensive (p<0.03), diabetic (p<0.001), and current smokers (p<0.001); have contralateral carotid artery occlusion (p=0.04); and present with stroke (p<0.001) than Group II patients. Despite this, the incidence of postoperative myocardial infarction (2.2% vs 0.2%, p=0.08), stroke (1.1% vs 1.6%, NS), and death (1.1% vs 0%, NS) was comparable between the 2 groups. Aggressive preoperative workup for occult cardiac disease in Group I revealed an incidence of 25.9% (n=15). Of these, 5 (33.3%) were found to have coronary artery disease severe enough to warrant intervention before CEA. In an inner-city population with increased medical comorbidities, more severe cerebrovascular disease, and relatively low volume of carotid surgery, the results of CEA were comparable to those in patients treated at a high-volume private hospital. The presence of high-volume surgeons, operating at the low-volume municipal hospital, may contribute to the low complication rate. Finally, aggressive preoperative cardiac workup in this underserved population revealed a meaningful incidence of occult coronary artery disease requiring intervention before CEA.
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Maldonado et al. (2004) conducted an observational in Carotid Stenosis (n=536). Carotid endarterectomy at an inner-city hospital vs. Carotid endarterectomy at a private hospital was evaluated on Postoperative stroke (p=NS). Carotid endarterectomy at an inner-city hospital had comparable rates of postoperative stroke (1.1% vs 1.6%) and death (1.1% vs 0%) compared to a private hospital, despite higher patient risk.
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