Higher Stroke Risk following Carotid Endarterectomy and Transcarotid Artery Revascularization is Associated with Relative Surgeon Volume Ratio.

Adoption of transcarotid artery revascularization (TCAR) by surgeons has been variable, with some still performing traditional carotid endarterectomy (CEA), while others have shifted to mostly TCAR. Our goal was to evaluate the association of relative surgeon volume of CEA to TCAR with perioperative outcomes. The Vascular Quality Initiative (VQI) CEA and carotid artery stent (CAS) registries were analyzed from 2021-2023 for symptomatic and asymptomatic interventions. Surgeons participating in both registries were categorized in the following CEA to CEA+TCAR volume percentage ratios: 0.25 (majority TCAR), 0.26-0.50 (more TCAR), 0.51-0.75 (more CEA), 0.76-1.00 (majority CEA). Primary outcomes were rates of perioperative ipsilateral stroke, death, cranial nerve injury (CNI), and return to the operating room (RTOR) for bleeding. There were 50,189 patients who underwent primary carotid revascularization (64.3% CEA and 35.7% TCAR). CEA patients were younger (71.1 vs 73.5 years, P<.001), with more symptomatic cases, less coronary artery disease, diabetes, and lower antiplatelet and statin use (all P<.001). TCAR patients had lower rates of smoking, obesity, and dialysis or renal transplant (all P<.001). Post-operative stroke after CEA was significantly impacted by operator CEA to TCAR volume ratio (P=.04), with surgeons who perform majority TCAR and more TCAR having higher post-operative ipsilateral stroke (majority TCAR OR 2.15, 95% CI 1.16-3.96, P=.01; more TCAR 1.42 95% CI 1.02, 1.96, P=.04), as compared to those who perform majority CEA. Similarly, post-operative stroke after TCAR was significantly impacted by CEA to TCAR volume ratio (P=.02), with surgeons who perform majority CEA and more CEA having higher stroke (majority CEA OR 1.51, 95% CI 1.00-2.27, P=.05; more CEA OR 1.50, 95% CI 1.14-2.00, P=.004), as compared to those who perform majority TCAR. There was no association between surgeon ratio and perioperative death, cranial nerve injury, and RTOR for bleeding for either procedure. Relative surgeon CEA to TCAR ratio is significantly associated with perioperative stroke rate. Surgeons who perform a majority of one procedure have a higher stroke rate in the other. Surgeons offering both operations should maintain a balanced practice and have a low threshold to collaborate as needed.

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Copyright © 2024. Published by Elsevier Inc.