Southern Association For Vascular Surgery

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National Update on the Use of Completion Imaging after Carotid Endarterectomy
Hanaa Dakour Aridi, Mohamed Gamal Mohamed Gaber, Satinderjit Locham, Mahmoud Malas
University of California San Diego, La Jolla, CA

Background: The use of intraoperative completion imaging (CI) (completion duplex or angiography) to confirm the technical adequacy of carotid endarterectomy (CEA) remains a matter of controversy. The purpose of this study is to assess different CI practice patterns and to study the association between CI and postoperative stroke/death and high-grade restenosis (>70%) after CEA.
Methods: Patients who underwent CEA in the VQI database (2003-2018) were included. Surgeons' practice patterns were defined as rare (CI performed for <5% of CEA cases), selective (5% to 90%), or routine (≥90%). Multivariable logistic models, Kaplan-Meier survival estimates and Cox proportional hazards models were used adjusting for patients' demographics, symptomatic status, comorbidities (CHF, COPD, diabetes), prior vascular procedures, Preoperative medication use (P2Y12 inhibitors, aspirin, statin, beta blockers), urgency, shunt use, eversion vs. conventional CEA and patching.
Results: Out of 98,055 CEA cases, 26,716 (27.3%) were performed with CI. Difference in baseline characteristics of patients who underwent CI vs. those who did not, are shown in Table 1. On univariable analysis, no difference in pre-discharge, 30-day and 2-year stroke, and stroke or death rates were seen between patients who had CI and those who did not. However, patients who underwent CI had higher rates of intraoperative immediate re-exploration compared to those with no CI (3.5% vs. 0.9%, p<0.001). They were also more likely to return to the OR (RTOR) for bleeding or neurological causes (1.6% vs.1.2%, p<0.001) and had longer operative times [mean (SD), 12546 vs.11243 minutes, p<0.001]. After multivariable adjustment, CI use was associated with 3.8 times the odds of immediate re-exploration (OR, 3.8, 95%CI, 2.7-5.4, p<0.001) and 24% higher odds of RTOR (OR, 1.24, 95%CI:1.1-1.4, p<0.01). There was a trend towards lower restenosis rates at 2 years in patients who received CI (Freedom from restenosis, 93.7% vs. 92.8%, p=0.04); however, the difference disappeared on multivariable adjustment (HR, 0.93, 95%CI, 0.82-1.07, p=0.32)(Table 2). When different surgeon practice patterns were compared, 45% out of 1,920 surgeons in our cohort were shown to not perform CI, 15.8% rarely performed CI, whereas CI was performed selectively by 22.8% and routinely by 16.5%. Among the three difference practice patterns, performing CI rarely had higher rates of immediate re-exploration(7.5% vs. 3.3% vs.3.4%,p<0.001) and RTOR for bleeding and neurological events (4.3% vs.1.6% vs.1.5%, p<0.001) compared to CI performed selectively and routinely, respectively. On multivariable analysis, rarely performing CI was also associated with almost 3 times higher odds of 30-day stroke/death and repeat revascularization compare to not performing [OR, 3.38, 95%CI, (2.37-4.84),and 3.02 (2.16-4.25), respectively] (both p<0.001).Conclusion: Our findings suggest that surgeon practice patterns with CI vary widely across the US. The performance of CI during CEA increases the odds of immediate re-exploration but does not seem to offer an advantage in reducing postoperative stroke and death or restenosis. Selective CI based on operative course might be warranted.
Table 1. Baseline Characteristics of Patients underwent Completion Imaging (Duplex or angiography) during CEA vs. those who did not

No Completion Imaging PerformedCompletion ImagingP value
Number of Patients(N=71,339, 72.8%)(N=26,716, 27.3%)
Age, years71 (64-77)71 (64-77)0.26
Females28205 (39.5)10554 (39.5)0.93
White Race65409 (91.9)24414 (91.4)<0.001
ASA class<0.001
I/II4335 (6.4)1424 (5.7)
III50424 (74.2)19120 (76.7)
IV/V13,211 (19.4)4,383(17.5)
Symptomatic Carotid Stenosis15989 (22.4)5886 (22.0)0.2
Diabetes25377 (35.6)9259 (34.7)0.01
HTN63509 (89.1)23751 (88.9)0.63
CAD19569 (27.5)7186 (26.9)0.1
CHF7238 (10.2)2875 (10.8)0.01
COPD15703 (22.0)6208 (23.3)<0.001
CKD24481 (35.1)9013 (34.5)0.11
Pre-operative medications
Aspirin58869 (82.6)22718 (85.1)<0.001
Beta blocker41340 (58.0)15687 (58.8)0.02
Statin57,352 (80.4)21.953 (82.2)<0.001
P2Y12 Inhibitors20516 (28.8)9289 (34.8)<0.001
Transfer from
Hospital3502 (4.9)1135 (4.3)<0.001
Rehabilitation Unit397 (0.6)114 (0.3)
Elective62497 (87.6)23507 (79.0)
Urgent8361 (11.7)3037 (11.4)
Emergent464 (0.65)171 (0.6)
Patching42,073 (89.1)16,497 (88.8)0.27
Eversion CEA5,652 (12.0)2,959 (15.9)<0.001
None32316 (45.4)12387 (46.4)
Routine36180 (40.8)12870 (48.2)
Selective (Pre-/Intraoperative Indication)2765 (3.9)1433 (5.4)

Table 2. Association between Completion Imaging and Post-Operative Outcomes after CEA
Unadjusted AnalysisAdjusted Analysis
No Completion Imaging Performed Completion ImagingP valueCompletion vs No-CI
In-hospital Outcomes(N=71,339, 72.8%)(N=26,716, 27.3%)OR (95%CI)p-value
Death198 (0.28)84 (0.31)0.341.15 (0.90-1.48)0.24
Stroke704 (1.15)286 (1.29)0.101.16 (1.00-1.35)0.06
Stroke/Death840 (1.2)343 (1.3)0.171.12 (0.96-1.30)0.15
Immediate Re-exploration670 (0.9)935 (3.5)<0.0013.84(2.74-5.38)<0.001
Return to the OR for bleeding or neuro causes885 (1.2)421 (1.6)<0.0011.24 (1.08-1.42)<0.01
Operative time, mean (SD)112 (43.0)125 (46.1)<0.001-
Thirty-Day Outcomes
Stroke/Death1181 (1.7)479 (1.8)0.141.13 (1.0-1.27)0.04
Repeat Revascularization1350 (3.2)552 (3.3)0.521.02(.837-1.24)0.84
Two-Year Outcomes% Freedom from outcomes (95%CI)% Freedom from outcomes (95%CI)P-valueHR (95%CI)p-value
Stroke/Death84.9% (84.1-85.6)85.9 (84.8-87.0)0.100.96 (0.88-1.06)0.43
High-Grade Restenosis92.8 (92.3-93.2)93.7(93.1-94.3)0.040.93 (0.82-1.07)0.32

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