Establishing Benchmarks for Cardiac Surgery at Minority Serving versus Non-Minority Serving Hospitals in the United States: Are We Bridging the Racial Disparity Gap?
Paige Newell MD1, Sameer Hirji MD MPH1, Alexis Okoh MD2, Supreet Singh MD2, Shivangi Goel BS1, Stephanie Cohen BA3, Edward Percy MD1, Morgan Harloff MD1, Farhang Yazdchi MD1, Tsuyoshi Kaneko MD1
1Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; 2Cardiovascular Research Institute, RWJ Barnabas Health, Newark, New Jersey; 3Tufts University School of Medicine, Boston, MA
Background: Shunting during eversion carotid endarterectomy (eCEA) may be technically challenging. Whether shunting practice patterns modify perioperative stroke risk after eCEA is unclear. We aimed to compare eCEA outcomes based on whether surgeons prospectively planned or planned not to shunt. Secondarily, we sought to compare outcomes based on shunting indication.
Methods: The Vascular Quality Initiative (2011-2019) was queried for eCEAs. Outcomes were compared based on 1) whether surgeons planned or planned not to shunt and 2) whether shunting was routine practice, preoperatively indicated, intraoperatively indicated, or not performed.
Results: Among 13,207 eCEAs, surgeons planned to shunt in 3,605 (27.2%) cases. When surgeons planned to shunt, compared with planned not to shunt, patients experienced similar 30-day stroke (.7% vs .8%, P=.49) and mortality (.6% vs .6%, P=.68), but longer operative duration (116.8±49.4 vs 107.1±44.6 minutes, P<.001). On multivariable analysis, planning compared with planning not to shunt was associated with similar stroke and mortality risk, but with increased operative duration (OR 1.2, 95% CI 1.14-1.18, P<.001). Among eCEAs, shunting was routine in 25.4%, preoperatively indicated in 1.9%, intraoperatively indicated in 4.7%, and not performed in 68%. Compared to no shunting, routine and preoperatively indicated shunting were each associated with similar stroke risk, but intraoperatively indicated shunting was associated with increased stroke risk (OR 2.74, 95% CI 1.41-5.3, P.003).
Conclusion: In eCEA, there is no difference in perioperative stroke risk when surgeons prospectively plan or plan not to shunt. When shunting is performed, shunting planned in advance is associated with lower stroke risk.
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