Modifiable Risk Factors for the Occurrence of Ipsilateral Ischemic Events After Carotid Endarterectomy Beyond the Perioperative Period
Matthew Blecha, Matthew DeJong, Janice Nam, Ashley Penton
Loyola University Chicago, MAYWOOD, IL
Objective : The purpose of this study is to quantify the impact of several modifiable variables on the occurrence of stroke following the initial perioperative period for patients who have undergone carotid endarterectomy.
Methods : The primary outcome for this study was the development of an ischemic stroke or transient ischemic event (TIA) in the cerebral hemisphere ipsilateral to carotid endarterectomy after initial procedural hospitalization. All carotid endarterectomies in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEA in the database. Exclusion criteria included : lack of follow up beyond 30 days; concomitant coronary artery bypass surgery; concomitant proximal or distal carotid intervention at the time of CEA; other arterial intervention at the time of CEA; and stroke or TIA at the time of initial procedural hospital admission leaving 126,290 meeting inclusion. The first step in statistical analysis was chi-squared testing for the outcome of ipsilateral ischemic stroke or TIA after initial CEA procedural hospital admission for relevant variables. Age was evaluated using student t-test. Variables with a P-value of 0.05 or less on univariate analysis were then utilized for multivariable Cox Regression time to event analysis for the primary outcome. Kaplan Meier curves were constructed for the most significant variables.
Results : The following variables achieved significance on Cox Regression for association with development of ipsilateral hemispheric ischemic events after index CEA hospital admission over time : lack of patch placement at endarterectomy site (HR 18.24, P<.0001); lack of antiplatelet therapy at time of long term follow-up (HR 9.75, P<.0001); lack of statin at the time of long term follow-up (HR 3.18, P<.001); lack of statin at time of hospital discharge (HR 1.25, P=.015); Anticoagulation at the time of long term follow up (HR 1.53, P<.001); development of greater than 70% recurrent stenosis (HR 2.15, P<.001); and shunt use at surgery (HR 1.20, P=.007).
Patients with placement of patch at the time of surgery and with confirmed antiplatelet therapy at the time of long term follow up had 99.8% and 99.6% respective freedom from ischemic event ipsilateral to the side of their CEA in long term follow up. This stands in opposition to 5.7% positivity for ischemic event for those without patch at surgery and 4.7% in those not on antiplatelet at long term follow up (P<.0001 for both). Freedom from event curves can be seen in figures 1 and 2.
Conclusions : Performance of patch angioplasty arterial closure is remarkably protective against ipsilateral cerebral ischemic events in the years following carotid endarterectomy. Discharging and maintaining patients on antiplatelet and statin medications after CEA significantly reduces future ipsilateral ischemic events. There is significant opportunity for enhanced outcomes with improved implementation of these measures. 
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