Hostname: page-component-76fb5796d-22dnz Total loading time: 0 Render date: 2024-04-29T19:36:45.328Z Has data issue: false hasContentIssue false
  • English
  • Français

Auditing Carotid Endarterectomy: A Regional Experience

Published online by Cambridge University Press:  02 December 2014

J. Max Findlay ,
Linda Nykolyn ,
Tracey B. Lubkey ,
John H. Wong ,
Mikael Mouradian  and
Ambikaipakan Senthilselvan
J. Max Findlay
Affiliation:
Division of Neurosurgery, University of Alberta, Clinical Quality Resource and Risk Management Department, Capital Health Authority, Alberta, Canada
Linda Nykolyn
Affiliation:
Division of Neurosurgery, University of Alberta, Clinical Quality Resource and Risk Management Department, Capital Health Authority, Alberta, Canada
Tracey B. Lubkey
Affiliation:
Division of Neurosurgery, University of Alberta, Clinical Quality Resource and Risk Management Department, Capital Health Authority, Alberta, Canada
John H. Wong
Affiliation:
Division of Neurosurgery, University of Calgary, Alberta, Canada
Mikael Mouradian
Affiliation:
Division of Neurology, University of Alberta, Alberta, Canada
Ambikaipakan Senthilselvan
Affiliation:
Epidemiology Program, Department of Public Health, University of Alberta, Alberta, Canada
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Background:

Proof from randomized controlled trials that carotid endarterectomy (CEA) is efficacious in stroke prevention has resulted in a large resurgence of its use in recent years. We wished to determine if patients in our region were being selected and treated with complication rates consistent with the randomized trials.

Methods:

We have completed four audits of CEAs performed in our region since 1994, each followed by feed-back of results to the participating surgeons. Operations for > 70% symptomatic stenosis were considered appropriate, those for 50%-69% symptomatic and > 60% asymptomatic stenosis were considered uncertain and all others, including those in medically or neurologically unstable patients, were designated inappropriate. In part 4, the referral source and nature of the patients was also determined.

Results:

Part 1 (April 1994 - September 1995) found that of 291 CEAs performed 33% were appropriate, 48% were uncertain and 18% were inappropriate, and 40% of patients who underwent CEA were asymptomatic. In part 2 (September 1996 - September 1997) appropriate indications significantly improved to 49% of 184 CEAs (P=0.005), uncertain indications remained nearly the same at 47%, inappropriate indications fell to 4% (P=0.00002), and asymptomatic patients remained at 40%. The results of part 3 (October 1997 - October 1998) remained nearly the same as part 2 (249 CEAs, 47% appropriate, 51% uncertain, 2% inappropriate, 45% asymptomatic). Part 4 (October 1999 - October 2000) results were significantly better than part 3, appropriate indications increasing from 47% to 58% of 222 CEAs (P=0.02), and an elimination of inappropriate operations (P=0.03). Stroke and death complications declined over the study period from an overall rate of 5.2% in part 1 to 2.3% in part 4. In part 4 the majority of patients (69%) were referred to surgeons directly from general practitioners, including 58 (73%) of the 80 asymptomatic patients who underwent CEA.

Interpretation:

Regular auditing and feedback of results and information to surgeons has resulted in significant and continued improvements in the surgical performance of CEAin our region. Since the majority of patients are referred directly to surgeons by general practitioners, it is important that this group of physicians be familiar with current CEA guidelines.

Résumé:

RÉSUMÉ:Introduction:

La preuve basée sur des études contrôlées randomisées que l’endartérectomie carotidienne (EAC) est efficace dans la prévention de l’accident vasculaire cérébral a entraîné une augmentation importante de son utilisation ces dernières années. Nous voulions déterminer si le taux de complications en relation avec le choix et le traitement des patients de notre région était comparable à celui des études randomisées.

Méthodes:

Nous avons complété 4 évaluations d’EACs effectuées dans notre région depuis 1994, chacune étant suivie de la communication des résultats aux chirurgiens participants. Les chirurgies effectuées pour des sténoses symptomatiques de plus de 70% étaient considérées comme appropriées, celles effectuées pour des sténoses symptomatiques de 50% à 69% et pour des sténoses asymptomatiques de plus de 60% étaient considérées comme incertaines et toutes les autres, incluant celles effectuées chez des patients instables au point de vue neurologique étaient considérées comme inappropriées. Dans la quatrième partie, la source de référence et la nature des patients étaient également examinées.

Résultats:

La première partie de l’étude (avril 1994 à septembre 1997) a montré que, des 291 EACs, 33% étaient appropriées, 48% étaient incertaines et 18% étaient inappropriées. 40% des patients qui ont subi une EAC étaient asymptomatiques. Dans la deuxième partie (septembre 1996 à septembre 1997), le taux d’indications appropriées s’est amélioré significativement, soit 49% de 184 EACs (P = 0,005), celui des indications incertaines est demeuré pratiquement le même, soit 47%, celui des indications inappropriées est tombé à 4% (P= 0,00002) et le taux de patients asymptomatiques est resté à 40%. Les résultats de la troisième partie (octobre 1997 à octobre 1998) sont demeurés pratiquement les mêmes que pendant la deuxième partie (249 EACs, 47% appropriées, 51% incertaines, 2% inappropriées, 45% asymptomatiques). Les résultats de la quatrième partie (octobre 1999 à octobre 2000) étaient significativement améliorés par rapport à ceux de la troisième partie. Cependant, les indications appropriées ont augmenté de 47% à 58% de 222 EACs ( P= 0,02) et on a observé une élimination des chirurgies inappropriées (P = 0,03). Les accidents vasculaires cérébraux et les décès découlant de la chirurgie ont diminué au cours de la période de l’étude, le taux étant passé de 5,2% dans la première partie à 2,3% dans la quatrième. Dans la quatrième partie, la majorité des patients (69%) étaient référés aux chirurgiens directement par les généralistes, dont 58 (73%) des 80 patients asymptomatiques qui ont subi une EAC.

Interprétation:

Une évaluation régulière et une communication des résultats aux chirurgiens a entraîné une amélioration significative et soutenue du succès chirurgical de l’EAC dans notre région. Comme la majorité des patients sont référés directement aux chirurgiens par les généralistes, il est important que ce groupe de médecins soit familier avec les lignes directrices sur l’EAC.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 29 , Issue 4 , November 2002 , pp. 326 - 332
Copyright
Copyright © The Canadian Journal of Neurological 2002

References

1. McCrory, DC, Goldstein, LB, Samsa, GP, et al. Predicting complications of carotid endarterectomy. Stroke 1993;24:1285–1291.Google Scholar
2. Easton, JD, Sherman, DG. Stroke and mortality rate in carotid endarterectomy: 228 consecutive operations. Stroke 1977;8:565–568.Google Scholar
3. European Carotid Surgery Trialists’ Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 1991;337:1235–1243.Google Scholar
4. Hobson, RW, Weiss, DG, Fields, WS, et al, for the Veterans Affairs Cooperative Study Group. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. N Engl J Med 1993;328:221–227.Google Scholar
5. Morasch, MD, Parker, MA, Feinglass, J, Manheim, LM, Pearce, WH. Carotid endarterectomy: characterization of recent increases in procedure rates. J Vasc Surg 2000;31:901–909.Google Scholar
6. Hougaku, H, Matsumoto, M, Handa, N, et al. Asymptomatic carotid lesions and silent cerebral infarction. Stroke 1994;25:566–570.CrossRefGoogle ScholarPubMed
7. Barnett, HJM, Eliasziw, M, Meldrum, HE, Taylor, DW. Do the facts and figures warrant a 10-fold increase in the performance of carotid endarterectomy on asymptomatic patients? Neurology 1996;46:603–608.Google Scholar
8. Autret, A, Pourcelot, L, Saudea, D, et al. Stroke risk in patients with carotid stenosis. Lancet 1987;1:888–890.CrossRefGoogle ScholarPubMed
9. Inzitari, D, Eliasziw, M, Gates, P, et al. The cause and risk of stroke in patients with asymptomatic internal carotid artery stenosis. N Engl J Med 2000;342:1693–1700.Google Scholar
10. Kresowik, TF, Hemann, RA, Grund, SL, et al. Improving the outcomes of carotid endarterectomy: results of a statewide quality improvement project. J Vasc Surg 2000;31:918–926.Google Scholar
11. The European Carotid Surgery Trialist Collaborative Group. Risk of stroke in the distribution of an asymptomatic carotid artery. Lancet 1995;345:209–212.Google Scholar
12. Warlow, C. Carotid endarterectomy: does it work? Stroke 1984;15:1068–1076.CrossRefGoogle ScholarPubMed
13. Findlay, JM, Tucker, WS, Ferguson, GG, et al. Guidelines for the use of carotid endarterectomy: current recommendations from the Canadian Neurosurgical Society. Can Med Assoc J 1997;157(6):653–659.Google Scholar
14. Karp, HR, Flanders, WD, Shipp, CC, Taylor, B, Martin, D. Carotid endarterectomy among medicare beneficiaries. A statewide evaluation of appropriateness and outcome. Stroke 1998;29:46–52.Google Scholar
15. Kistler, JP, Furie, KL. Carotid endarterectomy. (Editorial.) N Engl J Med 2000;342:1743–1745.CrossRefGoogle Scholar
16. Gorelick, PB, Sacco, RL, Smith, DB, et al. Prevention of a first stroke: a review of guidelines and a multidisclipinary consensus statement from the National Stroke Association. JAMA 1999;281:1112–1120.Google Scholar
17. Chaturvedi, S, Meinke, JL, St. Pierre, E, Bertasio, B. Attitudes of Canadian and US neurologists regarding carotid endarterectomy for asymptomatic stenosis. Can J Neurol Sci 2000;27:116–119.Google Scholar
18. Fode, NC, Sundt, TM Jr, Robertson, JT, Peerless, SJ, Shields, CB. Multicenter retrospective review of results and complications of carotid endarterectomy in 1981. Stroke 1986;17:370–376.Google Scholar
19. Hsia, DC, Moscoe, LM, Krushat, WM. Epidemiology of carotid endarterectomy among medicare beneficiaries 1985-1996 update. Stroke 1998;29:346–350.Google Scholar
20. Sarasin, FP, Bounameaux, H, Bogousslavsky, J. Asymptomatic severe carotid stenosis: immediate surgery or watchful waiting? A decision analysis. Neurology 1995;45:2147–2153.CrossRefGoogle ScholarPubMed
21. Barnett, HJM, Haines, SJ. Carotid endarterectomy for asymptomatic carotid stenosis. (Editorial.) New Engl J Med 1993;328:276–278.Google Scholar
22. Sacco, RL. Extracranial carotid stenosis. N Engl J Med 2001;345:1113–1118.Google Scholar
23. Van Ruiswyk, J, Noble, H, Sigmann, P. The natural history of carotid bruits in elderly persons. Ann Intern Med 1990;112:340–346.Google Scholar
24. Wolf, PA, Clagett, GP, Easton, JD, et al. Preventing ischemic stroke in patients with prior stroke and transient ischemic attack: a statement from healthcare professionals from the Stroke Council of the American Heart Association. Stroke 1999;30:1991–1994.Google Scholar
25. Hankey, GJ, Warlow, CP, Molyneus, AJ. Complications of cerebral angiography for patients with mild carotid territory ischemia being considered for carotid endarterectomy. J Neurol Neurosurg Psychiatry 1990;53:542–548.Google Scholar
26. Feasby, TE, Quan, H, Ghalis, WA. Geographic variation in the rate of carotid endarterectomy in Canada. Stroke 2001;32:2417–2422.Google Scholar
27. Qureshi, AI, Suri, FK, Ali, Z, et al. Role of conventional angiography in evaluation of patients with carotid artery stenosis demonstrated by Doppler ultrasound in general practice. Stroke 2001;32:2287–2291.Google Scholar
28. Reilly, LM, Lusby, RJ, Hughes, L, et al. Carotid plaque histology using real-time ultrasonography. Clinical and therapeutic implications. Am J Surg 1983;146:188–193.CrossRefGoogle ScholarPubMed
29. Barnett, HJ, Plum, F, Walton, JN. Carotid endarterectomy: an expression of concern. Stroke 1984;15:941–943.Google Scholar
30. Brott, TG, Labutta, RJ, Kempczinski, RF. Changing patterns in the practice of carotid endarterectomy in a large metropolitan area. JAMA 1986;255:2609–2612.CrossRefGoogle Scholar
31. Winslow, CM, Solomon, DH, Chassin, MR, et al. The appropriateness of carotid endarterectomy. N Engl J Med 1988;318:721–727.Google Scholar
32. Gross, CP, Steiner, CA, Bass, EB, Powe, NR. Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy. JAMA 2000;284:2886–2893.Google Scholar
33. Goldstein, LB, Moore, WS, Robertson, JT, Chaturvedi, S. Complication rates for carotid endarterectomy. A call to action. Stroke 1997;28:889–890.Google Scholar
34. Moore, WS, Boren, C, Malone, JM, et al. Natural history of nonstenotic, asymptomatic ulcerative lesions of the carotid artery. Arch Surg 1978;113:1352–1359.Google Scholar
35. Wilson, PWF, Hoeg, JM, D’Agostino, RB, et al. Cumulative effects of high cholesterol levels, high blood pressure, and cigarette smoking on carotid stenosis. N Engl J Med 1997;337:516–522.Google Scholar
36. Dyken, ML, Pokras, R. The performance of carotid endarterectomy for disease of the extracranial arteries of the head. Stroke 1984;15:948–950.Google Scholar
37. Weschler, LR. Ulceration and carotid artery disease. Stroke 1988;19:650–653.Google Scholar
38. Moore, WS, Barnett, HJM, Beebe, HG, et al. Guidelines for carotid endarterectomy: a multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Stroke 1995;26:188–201.Google Scholar
39. Lanska, DJ, Kryscio, RJ. Endarterectomy for asymptomatic internal carotid artery stenosis. Neurology 1997;48:1481–1490.Google Scholar
40. Block, RW, Grey-Weale, AC, Mock, PA, et al. The natural history of asymptomatic carotid artery disease. J Vasc Surg 1993;17:160–171.Google Scholar
41. Norris, JW, Zhu, CZ, Bornstein, NM, Chambers, BR. Vascular risks of asymptomatic carotid stenosis. Stroke 1992;22:1485–1490.Google Scholar
42. Norris, JW, Zhu, CZ. Silent stroke and carotid stenosis. Stroke 1992;23:483–485.Google Scholar
43. Dixon, S, Pais, SO, Raivola, C, et al. Natural history of nonstenotic, asymptomatic ulcerative lesions of the carotid artery: a further analysis. Arch Surg 1982;117:1493–1498.Google Scholar
44. Mayberg, MR, Wilson, SE, Yatsu, F, et al, for the Veterans Affairs Cooperative Studies Program 309 Trialist Group. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. JAMA 1991;266:3289–3294.Google Scholar
45. European Carotid Surgery Trial. Endarterectomy for moderate symptomatic carotid stenosis: interim results from the MRC European Carotid Surgery Trial. Lancet 1996; 347:1591–1593.Google Scholar
46. Wong, JH, Findlay, JM, Suarez-Almazor, ME. Regional performance of carotid endarterectomy. Appropriateness, outcomes, and risk factors for complications. Stroke 1997;28:891–898.Google Scholar
47. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421–1428.Google Scholar
48. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445–453.Google Scholar
49. Wong, JH, Lubkey, TB, Suarez-Almazor, ME, Findlay, JM. Improving appropriateness of carotid endarterectomy. Results of a prospective city-wide study. Stroke 1999;30:12–15.Google Scholar
50. Barnes, RW, Robertson, JT. Surgical considerations in asymptomatic disease in stroke. Barnett, HJM, Mohr, JP, Stein, BM, Yatsu, FM (Eds): 3rd ed. Churchill Livingstone, 1998:1228–1241.Google Scholar
51. Perry, JR, Szalai, JP, Norris, JW, for the Canadian Stroke Consortium. Consensus against both endarterectomy and routine screening for asymptomatic carotid artery stenosis. Arch Neurol 1997;54:25–28.Google Scholar
52. Moore, WS, Barnett, HJM, Beebe, HG, et al. Guidelines for carotid endarterectomy: a multidiscliplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation 1995;91:566–579.Google Scholar
53. Albers, GW, Hart, RG, Lutsep, HL, Newell, DW, Sacco, RL. Supplement to the guidelines for the management of transient ischemic attacks: a statement from the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. Stroke 1999;30:2502–2511.CrossRefGoogle Scholar
54. Tu, JV, Hannan, EL, Anderson, GM, et al. The fall and rise of carotid endarterectomy in the United States and Canada. N Engl J Med 1998;339:1441–1447.Google Scholar
55. Brott, T, Thalinger, K. The practice of carotid endarterectomy in a large metropolitan area. Stroke 1984;15:950–955.Google Scholar
56. Barnett, HJM, Taylor, DW, Eliaziw, M, et al, for the North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998;339:1415–1425.Google Scholar
57. Holloway, RG Jr, Witter, DM Jr, Mushlin, AI, et al. Carotid endarterectomy trends in the patterns and outcomes of care at academic medical centers, 1990 through 1995. Arch Neurol 1998;55:25–32.Google Scholar
58. Golledge, J, Greenhalgh, RM, Davies, AH. The symptomatic carotid plaque. Stroke 2000;31:774–781.Google Scholar
59. Rutgers, DR, Klijn, CJM, Kappelle, LJ, et al. Sustained bilateral hemodynamic benefit of contralateral carotid endarterectomy in patients with symptomatic internal carotid artery occlusion. Stroke 2001;32:728–734.Google Scholar
60. Liapis, CD, Kakisis, JD, Kostakis, AG. Carotid stenosis: factors affecting symptomatology. Stroke 2001;32:2782–2786.Google Scholar