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The Need for Treatment of Hypotension or Hypertension after Carotid Endarterectomy is Associated with Increased Perioperative Mortality and Morbidity
Tze-Woei Tan1, Mohammad Eslami1, Denis Rybin1, Jeffrey Kalish1, Robert Eberhardt1, Naomi Hamburg1, Gheorghe Doros1, Philip Goodney2, Jack Cronenwett2, Alik Farber1
1Boston University Medical Center, Boston, MA;2Dartmouth-Hitchcock Medical Center, Lebanon, NH

The objective of this study was to evaluate the outcomes of patients with significant hypotension or hypertension after carotid endarterectomy (CEA) that required the administration of intravenous vasoactive medications (IVMED).
We examined consecutive primary, isolated CEA performed by 128 surgeons within the Vascular Study Group of New England (VSGNE) database (2003-2010) and compared outcomes of patients who required postoperative IVMED to treat hypo- or hypertension with those who did not. Non-elective CEA (969), patients who required IVMED for both postoperative hypo and hypertension (57), and those without IVMED information (8) were excluded. Outcomes included perioperative death, stroke, myocardial infarction (MI), congestive heart failure (CHF), and hospital length of stay (LOS). Propensity score matching was performed for risk adjusted comparisons. Multivariable logistic regression models were used to compare the association between IVMED use and composite outcome of MI, stroke, or death.
There were 7,677 CEAs in the study cohort, with 11% requiring IVMED for hypertension and 16% for hypotension. Symptomatic status (20%) was similar across cohorts; other clinical differences were eliminated with propensity score matching (Table). In both crude and propensity-matched analyses, need for IVMED for
hypertension was associated with increased 30-day mortality, MI, CHF, stroke and LOS. Similarly, need for IVMED for hypotension after CEA was associated with increased rates of each of these factors (Table). In multivariable analysis, IVMED for hypertension was associated with increased MI, stroke or death rate (Odds Ratio (OR) 2.7, 95% Confidence Interval (CI) 1.7-4.2, p<.001). Similarly, IVMED for hypotension was associated with increased MI, stroke or death rate (OR 3.6, 95% CI 2.4-5.4, p<.001).
Post-operative hypotension or hypertension requiring intravenous vasoactive medications after CEA is associated with increased perioperative mortality, stroke and cardiac complications. This marker of poor outcome can be used to identify at-risk patients that may benefit from more intense medical management to reduce these complications.
CEA Full SampleCEA Propensity Matched Sample
No IVMed
IVMed Hypertension
IVMed Hypotension (n=942)p-
IVMed Hypertension
IVMed Hypotension (n=629)*p-value
Current Smoking29.4%35.4%.00230.3%.47434.5%.91532%.290
General Anesthesia88%87.6%.78392.1%<.00189.7%.08691.7%.437
Eversion CEA10.2%6.2%<.00115.1%<.0017.4%.78111.4%.888
30-day Outcomes
MI, stroke, or death1.6%4.4%<.0015.5%<.0014.5%<.0015.7%<.001
LOS, (day) (Median, 25th & 75th percentile)1 (1-1)1 (1-2)@<.0011 (1-2)@<.0011 (1-3)@<.0011 (1-2)@<.001

*p-value reflects comparison to propensity matched sample
@gamma regression was used to compared length of stay

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