Time to Intervention Effect on Discharge Outcomes in Carotid Endarterectomy

This study aimed to analyze the effect of time to intervention on the postoperative course and discharge outcomes of patients undergoing carotid endarterectomy (CEA). A single-institution retrospective study analyzing all patients undergoing CEA between January 1, 2016, and October 30, 2022, using National Surgical Quality Improvement Program data. Time to intervention after cerebrovascular accident (CVA) and demographics were analyzed for their impact on length of stay (LOS), discharge destination, as well as 30-day mortality, stroke, myocardial infarction (MI), and readmission rates. LOS was subsequently analyzed as a continuous variable to determine other contributing factors. A total of 398 patients underwent CEA: 134 were symptomatic, and 262 were asymptomatic. Data from symptomatic patients were analyzed. Sixty-four patients were female, and 70 were White. Average age was 71.5 years (standard deviation [SD], 10.5 years). Early vs late CEA groups (n=102 and 34, respectively) were compared (Table I). The majority of late CEAs (76%) presented >14 days after their CVA. There were no differences in age (P = .61), National Institute of Health Stroke Scale (NIHSS) (P = .14), or prior stroke rates (P = .10). Thirty-day perioperative stroke occurrence was 2% vs 2.6% (early vs late, respectively), MI 0% vs 2.6%, and mortality 1% vs 5.2%. There were no differences in discharge destination (P = .85), 30-day readmissions (P = .10), or reoperations (P = .66). Early intervention patients had higher American Society of Anesthesiologist scores (mean, 3.35; SD, 0.50 vs mean, 3.16; SD, 0.37; P = .015) and were less functionally independent (85% vs 95%; P = .05). Early intervention patients had longer postoperative hospital LOS (mean, 5.5; SD, 3.7 vs mean, 1.6; SD, 4.0; P < .01). All symptomatic patients were analyzed for factors contributing to extended LOS (Table II). Longer LOS was associated with higher initial NIHSS score (P < .01), selective shunting (P < .01), more functional dependence (P < .01), and lower preoperative albumin (P < .01). Age (P = .10), body mass index (BMI) (P = .15), and prior stroke (P = .48) did not significantly affect postoperative LOS. Via continuous variable analysis, LOS was associated with discharge to a facility (P < .01), but not 30-day stroke (P = .15) and mortality (P = .95) rates. Symptomatic carotid stenosis patients undergoing early CEA had equivalent outcomes of stroke, death, and MI as those undergoing late CEA despite having worse American Society of Anesthesiologists score, NIHSS, and functional status. Patients undergoing CEA after 14 days had shorter postoperative LOS and were discharged to home more frequently. Due to low perioperative stroke rate, we could not determine optimal timing between initial CVA and CEA. Further study is needed to determine optimal timing with more granularity.Table IDifferences in preoperative factors and outcomes for patients who underwent early vs late carotid endarterectomy (CEA)Early (0-14 days)Late (>14 days)P-valueDemographics Age, years71.2 (11.2)72.8 (8.7).61 GenderFemale: 49 (48)Male: 43 (52)Female: 11 (39)Male: 23 (61).35 EthnicityWhite: 48 (47)Other: 44 (53)White: 22 (58)Other: 16 (42).21 OriginHome: 69 (67)Facility: 33 (34)Home: 29 (76)Facility: 9 (24).14Preoperative factors Arrival NIHSS3.5 (5.0)2.1 (2.9).14 Prior stroke17 (16)11 (27).10 ASA classificationI00I00–II11.0II00–III6462.4III3284.2.02IV3736.2IV615.8.02 Functionally independent87 (85)36 (95).05 BMI26.4 (4.1)26.7 (5.1).64 Preoperative LOS, days5.5 (3.7)1.6 (4.0)< .01Outcomes Postoperative LOS, days4.11 (4.6)2.5 (3.4).03 Discharged to facility28 (27.4)11 (28.9).85 Readmission7 (6.8)6 (18.4).10 Reoperation4 (3.9)2 (5.2).66 Postoperative stroke2 (2)1 (2.6).41 MI01 (2.6)– Mortality1 (1)2 (5.2).10ASA, American Society of Anesthesiologists, BMI, body mass index; LOS, length of stay; MI, myocardial infarction; NIHSS, National Institute of Health Stroke Scale.Data are presented as number (%) or mean (standard deviation). Open table in a new tab Table IIAssociation of preoperative and postoperative factors with length of stay (LOS) for all symptomatic patientsStatistic (χ2a or estimate)P-valueDemographics Age, years−0.210.10 Gendera0.26a0.61 Ethnicitya0.08a0.96 Origina12.91a0.01Preoperative factors Arrival NIHSS0.56<0.01 Prior strokea0.49a0.48 ASA classificationa12.39a<0.01 Functionally independenta11.08a<0.01 BMI0.200.15 Albumin−5.92<0.01 Elective interventiona33.38a<0.01 Early vs late interventiona30.88a<0.01 Preoperative LOS, days1.43<0.01 Shunt7.36a<0.0130-Day outcomes Discharged to facilitya52.88a<0.01 Readmissiona0.73a0.39 Reoperationa1.09a0.30 Postoperative strokea2.09a0.15 MI–– Mortalitya0.00a0.95ASA, American Society of Anesthesiologists, BMI, body mass index; LOS, length of stay; MI, myocardial infarction; NIHSS, National Institute of Health Stroke Scale.LOS was analyzed as a continuous variable. Due to skewness >0.5, LOS was analyzed when possible using negative binomial (marked a). In other cases, LOS was analyzed using a generalized linear model (unmarked). Test statistic was included in this table as either a χ2 (for negative binomial) or the estimate (for generalized linear model). Open table in a new tab