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High risk patients treated with urgent CEA have increased perioperative morbidity: A group to target for carotid stenting?

Objectives: Recent reports from single institutions have confirmed the efficacy of carotid endarterectomy (CEA) performed in the urgent or emergent setting, although with higher perioperative mortality and morbidity. We analyzed a large contemporary series of urgently and emergently performed CEA to determine whether these results reflect outcome of cases performed in the community setting.
Methods: Records of patients undergoing CEA in nonfederal hospitals in the state of Connecticut between 1991 and 2002 (n=12,076) were reviewed, and classified as urgent or emergent, or elective cases. Multivariable logistic regression was used to determine the effect of risk factors on outcome.
Results: Patients undergoing urgent CEA (n=764; 6.3%) had higher perioperative mortality (1.96% vs. 0.33%; p<.0001) and stroke (2.88% vs. 1.13%; p<.0001), but not cardiac complications (3.01% vs. 2.19%; p=0.14), compared to patients undergoing elective CEA (n=11,312). Perioperative mortality was associated with performance in low volume hospitals (OR 51; p=.03). Perioperative stroke was associated with renal insufficiency (OR 7.8; p=.01). Perioperative cardiac complications were associated with diabetes (OR 2.6; p=.03). Urgent admission was associated with renal disease (OR 1.7; p=.05) and cardiac disease (OR 1.3; p=.006).
Conclusions: In community practice, urgently performed CEA has higher perioperative mortality and stroke compared with electively performed cases. Patients with low risk profiles can achieve low rates of perioperative complications with urgently performed CEA. Patients presenting urgently and with risk factors for adverse outcome, such as renal or cardiac disease, may form a high-risk group of patients that should be considered candidates for carotid stenting.