Risk Factors For Stroke, Myocardial Infarction, or Death Following Carotid Endarterectomy: Results From the International Carotid Stenting Study

D Doig; E L Turner; J Dobson; R L Featherstone; G J de Borst; G Stansby; J D Beard; S T Engelter; T Richards; M M Brown; ICSS Investigators

doi:10.1016/j.ejvs.2015.08.006

Risk Factors For Stroke, Myocardial Infarction, or Death Following Carotid Endarterectomy: Results From the International Carotid Stenting Study

Eur J Vasc Endovasc Surg. 2015 Dec;50(6):688-94. doi: 10.1016/j.ejvs.2015.08.006. Epub 2015 Oct 14.

Authors

D Doig¹, E L Turner², J Dobson³, R L Featherstone¹, G J de Borst⁴, G Stansby⁵, J D Beard⁶, S T Engelter⁷, T Richards⁸, M M Brown⁹; ICSS Investigators

Collaborators

ICSS Investigators:
A Algra, J Bamford, J Beard, M Bland, A W Bradbury, M M Brown, A Clifton, P Gaines, R Collins, A Molyneux, R Naylor, C Warlow, J M Ferro, D Thomas, L H Bonati, L Coward, J Dobson, J Ederle, R F Featherstone, H Tindall, D J McCabe, A Wallis, M Brooks, B Chambers, A Chan, P Chu, D Clark, H Dewey, G Donnan, G Fell, M Hoare, M Molan, A Roberts, N Roberts, B Beiles, C Bladin, C Clifford, G Fell, M Grigg, G New, R Bell, S Bower, W Chong, M Holt, A Saunder, P G Than, S Gett, D Leggett, T McGahan, J Quinn, M Ray, A Wong, P Woodruff, R Foreman, D Schultz, R Scroop, B Stanley, B Allard, N Atkinson, W Cambell, S Davies, P Field, P Milne, P Mitchell, B Tress, B Yan, A Beasley, D Dunbabin, D Stary, S Walker, P Cras, O d'Archambeau, J M Hendriks, P Van Schil, A Z St Blasius, M Bosiers, K Deloose, E van Buggenhout, J De Letter, V Devos, J Ghekiere, G Vanhooren, P Astarci, F Hammer, V Lacroix, A Peeters, J Verbist, J F Blair, J L Caron, N Daneault, M F Giroux, F Guilbert, S Lanthier, L H Lebrun, V Oliva, J Raymond, D Roy, G Soulez, A Weill, M Hill, W Hu, M Hudion, W Morrish, G Sutherland, J Wong, A Albäck, H Harno, P Ijäs, M Kaste, M Lepäntalo, S Mustanoja, T Paananen, M Porras, J Putaala, M Railo, T Sairanen, L Soinne, A Vehmas, P Vikatmaa, M Goertler, Z Halloul, M Skalej, P Brennan, C Kelly, A Leahy, J Moroney, J Thornton, M J Koelemay, P J Nederkoorn, J A Reekers, Y B Roos, J M Hendriks, P J Koudstaal, P M Pattynama, A van der Lugt, L C van Dijk, M R van Sambeek, H van Urk, H J Verhagen, C M Bruijninckx, S F de Bruijn, R Keunen, B Knippenberg, A Mosch, F Treurniet, L van Dijk, H van Overhagen, J Wever, F C de Beer, J S van den Berg, B A van Hasselt, D J Zeilstra, J Boiten, J C van Otterloo, A C de Vries, G J Lycklama a Nijeholt, B F van der Kallen, J D Blankensteijn, F E De Leeuw, L J Kool, J A van der Vliet, G J de Borst, G A de Kort, L J Kapelle, T H Lo, W P Mali, F Moll, H B van der Worp, H Verhagen, P A Barber, R Bourchier, A Hill, A Holden, J Stewart, S J Bakke, K Krohg-Sørensen, M Skjelland, B Tennøe, P Bialek, Z Biejat, W Czepiel, A Czlonkowska, A Dowzenko, J Jedrzejewska, A Kobayashi, M Lelek, J Polanski, J Kirbis, Z Milosevic, B Zvan, J Blasco, A Chamorro, J Macho, V Obach, V Riambau, L San Roman, J Branera, D Canovas, J Estela, A G Gaibar, J Perendreu, K Björses, A Gottsater, K Ivancev, T Maetzsch, B Sonesson, B Berg, M Delle, J Formgren, P Gillgren, T B Kall, P Konrad, N Nyman, R Takolander, T Andersson, J Malmstedt, M Soderman, C Wahlgren, N Wahlgren, S Binaghi, L Hirt, P Michel, P Ruchat, L H Bonati, S T Engelter, F Fluri, L Guerke, A L Jacob, E Kirsch, P A Lyrer, E W Radue, P Stierli, M Wasner, S Wetzel, C Bonvin, A Kalangos, K Lovblad, M Murith, D Ruefenacht, R Sztajzel, N Higgins, P J Kirkpatrick, P Martin, K Varty, D Adam, J Bell, A W Bradbury, P Crowe, M Gannon, M J Henderson, D Sandler, R A Shinton, J M Scriven, T Wilmink, S D'Souza, A Egun, R Guta, S Punekar, D M Seriki, G Thomson, J A Brennan, T P Enevoldson, G Gilling-Smith, D A Gould, P L Harris, R G McWilliams, H C Nahser, R White, K G Prakash, F Serracino-Inglott, G Subramanian, J V Symth, M G Walker, M Clarke, M Davis, S A Dixit, P Dorman, A Dyker, G Ford, A Golkar, R Jackson, V Jayakrishnan, D Lambert, T Lees, S Louw, S Macdonald, A D Mendelow, H Rodgers, J Rose, G Stansby, M Wyatt, T Baker, N Baldwin, L Jones, D Mitchell, E Munro, M Thornton, D Baker, N Davis, G Hamilton, D McCabe, A Platts, J Tibballs, J Beard, T Cleveland, D Dodd, P Gaines, R Lonsdale, R Nair, A Nassef, S Nawaz, G Venables, A Belli, A Clifton, G Cloud, A Halliday, H Markus, R McFarland, R Morgan, A Pereira, A Thompson, J Chataway, N Cheshire, R Gibbs, M Hammady, M Jenkins, I Malik, J Wolfe, M Adiseshiah, C Bishop, S Brew, J Brookes, M M Brown, R Jäger, N Kitchen, R Ashleigh, S Butterfield, G E Gamble, C McCollum, A Nasim, P O'Neill, J Wong, R D Edwards, K R Lees, A J MacKay, J Moss

Affiliations

¹ Institute of Neurology, University College London, UK.
² Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC, USA.
³ Department of Medical Statistics, London School of Hygiene and Tropical Medicine, UK.
⁴ Department of Vascular Surgery, University Medical Centre Utrecht, The Netherlands.
⁵ Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne, UK.
⁶ Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK.
⁷ Department of Neurology and Stroke Center, University Hospital Basel, Basel, Switzerland.
⁸ Division of Surgery and Interventional Science, University College London, UK.
⁹ Institute of Neurology, University College London, UK. Electronic address: martin.brown@ucl.ac.uk.

Abstract

Objectives: Carotid endarterectomy (CEA) is standard treatment for symptomatic carotid artery stenosis but carries a risk of stroke, myocardial infarction (MI), or death. This study investigated risk factors for these procedural complications occurring within 30 days of endarterectomy in the International Carotid Stenting Study (ICSS).

Methods: Patients with recently symptomatic carotid stenosis >50% were randomly allocated to endarterectomy or stenting. Analysis is reported of patients in ICSS assigned to endarterectomy and limited to those in whom CEA was initiated. The occurrence of stroke, MI, or death within 30 days of the procedure was reported by investigators and adjudicated. Demographic and technical risk factors for these complications were analysed sequentially in a binomial regression analysis and subsequently in a multivariable model.

Results: Eight-hundred and twenty-one patients were included in the analysis. The risk of stroke, MI, or death within 30 days of CEA was 4.0%. The risk was higher in female patients (risk ratio [RR] 1.98, 95% CI 1.02-3.87, p = .05) and with increasing baseline diastolic blood pressure (dBP) (RR 1.30 per +10 mmHg, 95% CI 1.02-1.66, p = .04). Mean baseline dBP, obtained at the time of randomization in the trial, was 78 mmHg (SD 13 mmHg). In a multivariable model, only dBP remained a significant predictor. The risk was not related to the type of surgical reconstruction, anaesthetic technique, or perioperative medication regimen. Patients undergoing CEA stayed a median of 4 days before discharge, and 21.2% of events occurred on or after the day of discharge.

Conclusions: Increasing diastolic blood pressure was the only independent risk factor for stroke, MI, or death following CEA. Cautious attention to blood pressure control following symptoms attributable to carotid stenosis could reduce the risks associated with subsequent CEA.

Keywords: Carotid artery stenosis; Carotid atherosclerosis; Carotid endarterectomy.

Publication types

Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Angioplasty / instrumentation*
Blood Pressure
Carotid Stenosis / complications
Carotid Stenosis / diagnosis
Carotid Stenosis / mortality
Carotid Stenosis / surgery*
Endarterectomy, Carotid / adverse effects*
Endarterectomy, Carotid / mortality
Female
Humans
Hypertension / etiology
Hypertension / physiopathology
Male
Middle Aged
Multivariate Analysis
Myocardial Infarction / diagnosis
Myocardial Infarction / etiology*
Myocardial Infarction / mortality
Myocardial Infarction / physiopathology
Odds Ratio
Risk Assessment
Risk Factors
Severity of Illness Index
Stents*
Stroke / diagnosis
Stroke / etiology*
Stroke / mortality
Stroke / physiopathology
Time Factors
Treatment Outcome

Associated data

ISRCTN/ISRCTN25337470

Grants and funding

G0300411/Medical Research Council/United Kingdom