Evolution of carotid endarterectomy in two community hospitals: Springfield revisited--seventeen years and 2243 operations later.

PURPOSE

The purpose of this study was to evaluate and update the results of carotid endarterectomy (CEA) in two community hospitals over a 17-year period and to determine whether there had been any reduction in the unacceptably high incidence of complications previously reported from these same two hospitals.

METHODS

We retrospectively reviewed the records of 1981 patients who underwent 2243 CEAs from July 1976 to November 1993.

RESULTS

There were 36 operative deaths (1.6%) and 120 operative strokes (5.3%), for a combined stroke-mortality rate of 6.3%. The mortality, stroke, and combined stroke-mortality rates all decreased significantly (p < 10(-5)) compared with the rates reported in the original study (6.6%, 14.5%, and 21.1%, respectively). Nonfatal stroke rates decreased significantly for patients diagnosed with asymptomatic carotid artery disease, 18.2% to 2.9% (p = 0.04); transient ischemic attacks, 17.8% to 3.9% (p < 10(-6)); and prior stroke, 15.2% to 8.0% (p = 0.04). Improvement in combined stroke-mortality rates occurred for all operative indications, but was significant only in the transient ischemic (p < 10(-8)) and prior stroke groups (p = 0.00002). Surgical experience varied, with 31 surgeons performing one to 236 CEAs. Although results were not significantly correlated with individual operative activity, 10 surgeons who performed more than 12 CEAs per year had a statistically lower incidence of operative stroke (4.1%) compared with 21 surgeons who performed fewer procedures (7.2%) (p = 0.009). The incidence of stroke (2.7%) and the combined stroke-mortality rate (3.7%) of surgeons with additional vascular training was superior to the stroke rate (6.8%) and combined stroke-mortality rate (7.9%) of surgeons who did not (p = 0.0014 and p = 0.0006); but several surgeons in the latter group had results that were comparable to those of the vascular group.

CONCLUSIONS

Although overall operative complication rates in these two community hospitals have declined dramatically compared with previously reported results, they are still not optimal and probably will remain high as long as individual surgeons with high complication rates continue to perform CEAs.