One in five patients failed to achieve a textbook outcome after undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR) or transfemoral carotid artery stenting (TF-CAS), a Vascular Quality Initiative (VQI) analysis that tested a novel, patient-centric textbook outcome metric found.
“Having a non-textbook outcome was prognostic of an inferior five-year survival” among asymptomatic carotid stenosis patients who underwent any of the three carotid revascularization procedures, Jesse Columbo, MD, presenting author of the multi-institutional study, told the 2024 New England Society for Vascular Surgery (NESVS) annual meeting in Portland, Maine (Oct. 25–27). “Hospital transfer, non-home living status and severe comorbidities were predictive of a non-textbook outcome.”
The findings come in the wake of the Centers for Medicare & Medicaid Services (CMS) Medicare coverage expansion for carotid stenting to standard-risk patients, with a physician-patient shared decision-making interaction now required to form part of the preoperative assessment process.
The crucially important carotid revascularization effectiveness measures of stroke, death and myocardial infarction (MI) are, of course, “irrefutably important,” Columbo told NESVS 2024, but—referencing his group’s prior work—he pointed to data showing patients prioritize additional aspects of their perioperative care, and drew further reference to another crucial factor: to obtain reimbursement, the required interaction must involve the personal preferences of beneficiaries.
The novel metric—the work of Columbo, a vascular surgeon at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues from the University of Florida in Gainesville, and the University of Alabama Medical Center in Birmingham—includes stroke, transient ischemic attack (TIA), MI, cranial nerve injury, reperfusion syndrome, return to the operating room (OR), access site complications, death within 30 days, discharge to a facility, and a postoperative length of stay of two days or more.
“The context of a textbook outcome composite adjunct has been championed by several other surgical specialties, most notably surgical oncology,” noted Columbo. “It has been documented as capturing a patient-centric snapshot of the anticipated successful outcome of the surgery. However, to date, vascular surgery has not adopted the use of textbook outcomes in clinical practice.”
Aiming to create such a patient-centered outcome measure to inform shared decision-making conversations surrounding carotid revascularization, the research group established a cohort of elective patients in order to evaluate the likelihood of a textbook outcome. Mining VQI data from 2016–2023 resulted in a patient group further divided into CEA (51,000), TCAR (15,000) and TF-CAS (6,000) cohorts.
Patients had a mean age of 71.6 years, approximately 40% of each cohort was female, and most were White, with those who had a recent MI, on home oxygen and with heart failure important minorities in each cohort, Columbo said. “Notably, 1% of patients who underwent CEA had a history of a prior ipsilateral carotid procedure, compared to 14% of TCAR patients and 22% of TF-CAS patients,” he revealed.
“Across the three cohorts, most patients had a textbook outcome, but a slightly higher percentage of patients who underwent TF-CAS achieved a textbook outcome.”
Stroke and MI were found to be low across the three groups, while return to the OR and access site complications were approximately 2%, while 30-day mortality was low, Columbo pointed out. “Nearly 20% of these asymptomatic patients were discharged on postoperative day two or later.”
Sensitivity analyses showed that the driver of the greater level of textbook outcomes among those treated via TF-CAS—postoperative length of stay—did not endure into days three and four, when the there was no statistically significant difference between the three treatment modalities.
Analysis of five-year survival curve data revealed a rate of 92% among CEA patients who had textbook outcomes versus 86% for those who did not. The data were similar for TCAR and TF-CAS: 91% vs. 85% and 90% vs. 82%, respectively.
“You’ll note that, in each case, the results for patients who underwent elective procedures for asymptomatic carotid stenosis appear roughly similar, and patients who had a textbook outcome had superior survival across the cohorts,” Columbo said.
Columbo acknowledged study limitations, including an inability to quantify the impact of the distinct components of the composite textbook outcome. “A successful textbook outcome after any carotid revascularization in current practice was surprisingly less likely than may have been anticipated, Columbo concluded. “The correlation between textbook outcomes and five-year survival substantiates it as a useful quality measure for patients considering carotid revascularization.”
The novel patient-centric textbook outcome measure at hand may offer value to shared decision-making interactions between physicians and patients as they discuss carotid procedure options in the wake of the CMS coverage expansion, he added.
