Investigating Factors That Delay Carotid Endarterectomy in Patients With Symptomatic Carotid Artery Stenosis

Investigating Factors That Delay Carotid Endarterectomy in Patients With Symptomatic Carotid Artery Stenosis

Abstracts from the 2016 Canadian Society for Vascular Surgery Annual Meeting PAPER SESSION I: CAROTID DISEASE: CHALLENGES AND CONTROVERSIES Investigat...

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Abstracts from the 2016 Canadian Society for Vascular Surgery Annual Meeting PAPER SESSION I: CAROTID DISEASE: CHALLENGES AND CONTROVERSIES Investigating Factors That Delay Carotid Endarterectomy in Patients With Symptomatic Carotid Artery Stenosis Daniel Meyer,1 Erwin Karreman,2 David Kopriva2,3. 1College of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada; 2 Regina Qu’Appelle Health Region, Regina, Saskatchewan, Canada; 3 Department of Surgery, Section of Vascular Surgery, University of Saskatchewan, Regina, Saskatchewan, Canada Objective: The objectives of this study were to identify the proportion of patients in southern Saskatchewan meeting the Canadian Best Practice Recommendations for Stroke Care (2008) that “patients with transient ischemic attack or non-disabling stroke and ipsilateral 70% to 99% internal carotid artery stenosis . should be offered carotid endarterectomy within 2 weeks of the incident transient ischemic attack or stroke unless contraindicated” and to identify those factors associated with failure to meet the guideline. Methods: We reviewed patients who underwent carotid endarterectomy (CEA) in our center between January 1, 2009, and December 31, 2014, who had presented with neurologic symptoms ipsilateral to an internal carotid artery (ICA) stenosis of 70% to 99% (North American Symptomatic Carotid Endarterectomy Trial) or meeting carotid Doppler velocity criteria for severe stenosis. Results: There were 244 patients with symptomatic severe ICA stenosis included. Only 31.6% of patients met the guideline for CEA within 14 days of symptom onset. Fifteen percent of patients waited longer than 14 days to present to a health care provider. After entry into the health care system, the following factors were associated with meeting the guideline. Patients presenting to an emergency department were more likely to receive surgery within 14 days compared with patients who first presented to a primary care provider’s office (P < .001). After presentation, patients who were referred to a vascular surgeon with fewer intervening consultations were more likely to meet the 14-day guideline than those who were referred to multiple specialists (P ¼ .015). Patients presenting with a minor stroke were more likely to receive surgery within 14 days compared with patients who presented with hemispheric sensory symptoms or amaurosis fugax (P ¼ .005). Conclusions: Improvements in meeting the goal of CEA within 14 days of symptom onset, in patients with severe ipsilateral ICA stenosis, should be directed at patient and provider education to enhance recognition of

symptoms. A system for rapid referral of symptomatic patients directly to a vascular surgeon should be established. Author Disclosures: D. Mayer: Nothing to disclose; E. Karreman: Nothing to disclose; D. Kopriva: Nothing to disclose.

The Fall of Carotid Endarterectomy and Rise of Carotid Artery Stenting in Ontario from 2002 to 2014 Mohamad A. Hussain,1,2 Muhammad Mamdani,3 Gustavo Saposnik,3,4 Subodh Verma,1,3,5 Jack V. Tu,6 Mohammed Al-Omran1,2,3. 1Department of Surgery, University of Toronto, Toronto, Ontario, Canada; 2 Division of Vascular Surgery, St. Michael’s Hospital, Toronto, Ontario, Canada; 3Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada; 4Division of Neurology, St. Michael’s Hospital, Toronto, Ontario, Canada; 5Division of Cardiac Surgery, St. Michael’s Hospital, Toronto, Ontario, Canada; 6Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Objective: We sought to determine the utilization rates of carotid endarterectomy and stenting in the clinical setting and to examine the impact of major clinical trials on these rates. Methods: We conducted a population-based time-series analysis of all individuals who underwent carotid endarterectomy and stenting in Ontario between April 1, 2002, and March 31, 2014, using validated databases. We used exponential smoothing modeling to examine trends in rates per 100,000 adults 40 years of age or older. We also compared procedure rates before and after publication of major trials by conducting interrupted time-series analyses using autoregressive integrated moving average models. Results: A total of 16,772 patients were studied (n ¼ 14,394 endarterectomy [86%]; n ¼ 2378 stenting [14%]). The overall rate of carotid revascularization decreased from 6.0 procedures per 100,000 in April 2002 to 4.3 procedures per 100,000 in the first quarter of 2014 (29% decrease; P < .001; Fig). The rate of endarterectomy decreased by 36% from 5.6 to 3.6 procedures per 100,000 (P < .001), whereas the rate of stenting increased by 72% from 0.39 to 0.67 procedure per 100,000 (P < .001). Neurosurgeons performed less endarterectomy and more stenting, whereas the rates did not significantly change among vascular surgeons. We observed a marked increase (P < .001) in the rate of stenting following publication of the Stenting and Angioplasty with Protection in Patients with High Risk for Endarterectomy (SAPPHIRE) trial in 2004, whereas the rate of stenting remained unchanged following publication of subsequent trials in 2006 and 2010. In contrast,

Fig. Rates of carotid artery revascularization in Ontario, Canada, from 2002 to 2014 in relation to publication of major clinical trials. CREST, Carotid Revascularization Endarterectomy vs Stenting Trial; EVA-3S, Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; ICSS, International Carotid Stenting Study; SAPPHIRE, Stenting and Angioplasty with Protection in Patients with High Risk for Endarterectomy; SPACE, Stent-Protected Angioplasty vs Carotid Endarterectomy.

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