Patients who undergo carotid revascularization at the weekend have increased odds of complications and mortality, with transfemoral carotid artery stenting (TFCAS) posing the highest risk and transcarotid artery revascularization (TCAR) the lowest, compared to carotid endarterectomy (CEA). This is one of the key findings of new observational research published online ahead of print in the Journal of Vascular Surgery (JVS).
Lead author Mokhshan Ramachandran, MD, senior author Mahmoud Malas, MD, and colleagues—all from UC San Diego in San Diego, California—state in their research article that outcomes for weekend surgical interventions are known to be associated with higher rates of complications and mortality compared to weekday interventions. The aim of their study was to assess the ‘weekend effect’ for the three available carotid revascularization methods—CEA, TCAR and TFCAS—noting that research on the topic is currently only available regarding CEA.
To do this, the researchers queried the Vascular Quality Initiative (VQI) for patients undergoing CEA, TCAR and TFCAS over a six-year period, from 2016–2022. They employed Chi-square and logistic regression modelling to analyze outcomes including in-hospital stroke, death, myocardial infarction (MI), and 30-day mortality by weekend versus weekday intervention.
Providing more details on their study methods, Ramachandran et al write that they used backward stepwise regression to identify significant confounding variables, and that logistic regression of outcomes was substratified by symptomatic status. Furthermore, they used secondary multivariable analysis to compare outcomes between the three revascularization methods by weekend versus weekday interventions.
Overall, Ramachandran and colleagues analyzed 155,962 procedures in their study, comprising 103,790 CEA, 31,666 TCAR and 20,506 TFCAS. Of these, the authors specify, 1,988 CEA, 246 TCAR and 820 TFCAS received weekend interventions.
In JVS, the authors report that they observed no significant differences for TCAR, and increased odds of in-hospital stroke, death and MI for CEA and TFCAS procedures conducted at weekends.
In addition, Ramachandran et al share that asymptomatic TCAR patients had nearly triple the odds of 30-day mortality, and that odds of in-hospital mortality were nearly tripled for asymptomatic CEA and asymptomatic TFCAS patients.
Finally, they reveal that CEA and TCAR had no significant differences for all outcomes, while TFCAS was associated with increased odds of stroke and death compared to CEA and TCAR.
In the conclusion of their findings, Ramachandran and colleagues summarize that weekend carotid revascularization is associated with increased odds of complications and mortality, adding that asymptomatic weekend patients perform worse in the CEA and TFCAS groups.
“Among the three revascularization methods, TFCAS is associated with the highest odds of perioperative stroke and mortality. As such, our findings suggest that TFCAS procedures should be avoided over the weekend, in favor of CEA or TCAR,” the authors write. They continue that, in patients who are poor candidates for CEA, TCAR offers the lowest morbidity and mortality for weekend procedures.
Sharing the take-home message from their research, Ramachandran et al posit that CEA and TCAR procedures should be the “first-line” interventions for weekend carotid revascularization.
