Postoperative delirium and cognitive outcomes in elderly patients undergoing carotid endarterectomy: a subgroup analysis of the PAWEL Study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Elective surgery in elderly patients (carotid endarterectomy, vascular surgery, or non-vascular surgery) (n=730). Intervention: Carotid endarterectomy (CEA) vs. Vascular surgery without carotid intervention (VAS) and non-vascular surgery (SUR). Primary outcome: Occurrence of postoperative delirium (POD) assessed via CAM (daily, days 1-9) or NuDESC (days 2 and 6) (p=0.101).

Q: What does this research mean for the field?

Elderly patients undergoing carotid endarterectomy exhibit numerically lower rates of postoperative delirium compared with other surgical cohorts, with comparable rates of postoperative cognitive impairment and decline. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Martin Breitkopf; Juliane Spank; Gerhard Wilhelm Eschweiler; Gerhard Schneider; Christoph Mattmann; Dominik Hahn; Manfred Roessle; Marc Fernandes; Andreas Walther; Christine Thomas; Soeren Wagner

doi:10.21203/rs.3.rs-11284481/v1

November 12, 2026Open Access

Postoperative delirium and cognitive outcomes in elderly patients undergoing carotid endarterectomy: a subgroup analysis of the PAWEL Study

View Full Paper

Ask AI

Bookmark

Share

Key result

Carotid endarterectomy had a 0% incidence of postoperative delirium compared to 24.0% in vascular and 13.9% in non-vascular surgery, with comparable cognitive impairment rates.

Why the study?

Patients undergoing carotid endarterectomy may represent a unique subgroup regarding postoperative delirium and cognitive impairment due to advanced cerebrovascular disease and intensified neurological monitoring, but neurocognitive outcomes following the procedure remain incompletely understood.

Does carotid endarterectomy affect the risk of postoperative delirium and postoperative cognitive impairment compared with other vascular and non-vascular surgeries in elderly patients aged ≥70 years?

Key Points

To assess the incidence of postoperative delirium and cognitive outcomes in elderly patients undergoing carotid endarterectomy compared with non-carotid vascular and non-vascular surgical cohorts.
Post hoc subgroup analysis of 730 patients aged ≥ 70 years from the untreated baseline cohort of the multicenter PAWEL study across five tertiary academic medical centers in Germany (DRKS00013311).
Patients were categorized using procedure codes into carotid endarterectomy (CEA, n = 15), non-carotid vascular surgery (VAS, n = 25), and non-vascular surgery (SUR, n = 690) cohorts.
Delirium was evaluated using the CAM daily (days 1–9) and NuDESC (days 2 and 6); cognitive impairment (MoCA < 26) and cognitive decline (ΔMoCA) were evaluated preoperatively and on postoperative day 9.
Postoperative delirium occurred in 0% (0/15) of patients in the CEA group, compared with 24.0% in the VAS cohort and 13.9% in the SUR cohort (p = 0.101).
Postoperative cognitive impairment was observed in 86.7% of CEA patients, 84.2% of VAS patients, and 86.3% of SUR patients, showing no significant difference between groups (p = 0.922).
Postoperative cognitive decline assessed by ΔMoCA did not differ significantly across cohorts (p = 0.709), with comparable results in sensitivity analyses of patients with preserved baseline cognition.

Study Design

Type

Cohort (n=730)

Multicenter

Yes

Structured PICO

Does carotid endarterectomy affect the risk of postoperative delirium and postoperative cognitive impairment compared with other vascular and non-vascular surgeries in elderly patients aged ≥70 years?

P

Population

730 elderly adults (mean age 78.15 years, 50.5% female) undergoing elective surgery (15 carotid endarterectomy, 25 non-carotid vascular surgery, 690 non-vascular surgery) at five tertiary academic medical centers in Germany, followed through postoperative day 9.

E

Exposure

Carotid endarterectomy (CEA, OPS codes 5-381.00 to 5-381.06, n=15)

C

Comparator

Vascular surgery without carotid intervention (VAS, n=25) and non-vascular surgery (SUR, n=690) from the untreated baseline cohort without multimodal delirium prevention intervention

O

Outcome

Occurrence of postoperative delirium (POD), defined as at least one positive Confusion Assessment Method (CAM, assessed daily from postoperative day 1 to day 9) or Nursing Delirium Screening Scale (NuDESC, assessed on postoperative days 2 and 6) assessment during the 9-day postoperative observation periodhard clinical

Main Result

Absolute Event Rate: 0% vs 24%

p-value: p=0.101

In this exploratory subgroup analysis of elderly surgical patients, those undergoing carotid endarterectomy had numerically lower rates of postoperative delirium (0%) compared with other vascular (24.0%) and non-vascular (13.9%) surgeries, while rates of postoperative cognitive impairment and decline were similarly high across all groups.

Limitations

Exploratory post hoc subgroup analysis of prospectively collected data
Small carotid endarterectomy subgroup (n=15) limiting statistical power and increasing the risk of type II error
Postoperative cognitive assessment relied on MoCA screening rather than comprehensive neuropsychological testing
Postoperative MoCA assessments were missing in a relevant proportion of patients (17.5% of SUR and 24.0% of VAS)
Detailed intraoperative physiological and neuromonitoring parameters were unavailable
Small sample size in the carotid endarterectomy subgroup (n=15), limiting statistical power and increasing the risk of type II error
Missing postoperative MoCA assessments in 17.5% of SUR patients and 24.0% of VAS patients
Use of a MoCA cutoff value of <26 points may overestimate postoperative cognitive impairment rates in elderly multimorbid surgical populations

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Should not yet change practice in elderly surgical patients; leaves open whether carotid endarterectomy confers delirium protection in larger prospective studies.

Abstract

Background Postoperative delirium (POD) and postoperative cognitive impairment are common perioperative neurocognitive complications in elderly surgical patients. Patients undergoing carotid endarterectomy (CEA) may represent a unique subgroup because of advanced cerebrovascular disease and intensified perioperative neurological monitoring. However, neurocognitive outcomes following CEA remain incompletely understood. Methods This study represents a post hoc subgroup analysis of prospectively collected data from the multicenter PAWEL study. Elderly patients (≥ 70 years) undergoing elective surgery were included from the untreated baseline cohort. Patients were assigned to CEA, vascular surgery (VAS) without carotid intervention, or non-vascular surgery (SUR) cohorts based on OPS procedure codes. POD was assessed using the Confusion Assessment Method (CAM) and Nursing Delirium Screening Scale (NuDESC). Cognitive performance was assessed preoperatively and postoperatively using the Montreal Cognitive Assessment (MoCA). Postoperative cognitive impairment was defined as postoperative MoCA < 26. Cognitive decline was additionally assessed using postoperative changes in MoCA performance (ΔMoCA). Results A total of 730 patients were included, comprising 15 patients undergoing CEA, 25 patients in the VAS cohort, and 690 patients in the SUR cohort. POD was not observed in the CEA group, compared with 24.0% in the VAS group and 13.9% in the SUR group, without a statistically significant overall difference between groups (p = 0.101). Postoperative cognitive impairment rates were comparable between groups (CEA: 86.7%, VAS: 84.2%, SUR: 86.3%; p = 0.922). Likewise, no significant differences were observed regarding postoperative cognitive decline measured by ΔMoCA (p = 0.709). Sensitivity analyses restricted to patients with preserved baseline cognition demonstrated similar findings. Conclusions In this exploratory subgroup analysis, patients undergoing CEA demonstrated numerically lower rates of POD compared with vascular and non-vascular surgical cohorts, whereas postoperative cognitive impairment and postoperative cognitive decline were comparable between groups. These hypothesis-generating findings warrant confirmation in larger prospective studies incorporating detailed perioperative hemodynamic and neuromonitoring data. Trial registration German Clinical Trials Register, DRKS00013311, registered on 10 November 2017.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Breitkopf et al. (2026) conducted a cohort in Elective surgery in elderly patients (carotid endarterectomy, vascular surgery, or non-vascular surgery) (n=730). Carotid endarterectomy (CEA) vs. Vascular surgery without carotid intervention (VAS) and non-vascular surgery (SUR) was evaluated on Occurrence of postoperative delirium (POD) assessed via CAM (daily, days 1-9) or NuDESC (days 2 and 6) (p=0.101). Carotid endarterectomy had a 0% incidence of postoperative delirium compared to 24.0% in vascular and 13.9% in non-vascular surgery, with comparable cognitive impairment rates.

synapsesocial.com/papers/6af73ada9badce7b6084db6b https://doi.org/10.21203/rs.3.rs-11284481/v1

View Full Paper

Ask AI

Bookmark

Share

Postoperative delirium and cognitive outcomes in elderly patients undergoing carotid endarterectomy: a subgroup analysis of the PAWEL Study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Postoperative delirium and cognitive outcomes in elderly patients undergoing carotid endarterectomy: a subgroup analysis of the PAWEL Study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading