Safety of Carotid Endarterectomy in a High-Risk Population: Lessons from the VA and Connecticut

BackgroundThe safety and efficacy of carotid endarterectomy (CEA) have been demonstrated in randomized trials, but these studies excluded patients thought to be at higher risk for poor outcomes. We sought to determine whether patients undergoing CEA in Veteran Affairs Hospitals (VA) were at higher risk and had different outcomes, compared with patients in nonfederal hospitals.Study DesignRecords of all CEA performed in the VA Connecticut Healthcare System between October 1997 and September 2002 were examined and compared with CEA performed in all nonfederal Connecticut hospitals (CT).ResultsThere were 7,089 CEAs performed (VA, 140; CT, 6,949). VA patients had increased comorbidity scores and symptomatic presentation (39% versus 14%; p < 0.0001). Perioperative mortality rates were 1.4% (VA) and 0.3% (CT) (p = 0.06). Perioperative stroke (VA, 1.4% versus CT, 0.9%; p = 0.15) and cardiac complication (VA, 2.9% versus CT, 2.1%; p = 0.54) rates were similar. Multivariate analysis demonstrated that perioperative mortality correlated with symptomatic presentation (odds ratio 11.7, p < 0.0001), but not performance, in a VA hospital (p = 0.23); patients treated at the VA were also not at higher risk for stroke (p = 0.94) or cardiac complications (p = 0.90).ConclusionsDespite increased severity of illness and symptomatic presentation, VA patients had similar perioperative outcomes compared with patients undergoing CEA in nonfederal hospitals in the state of Connecticut. These results suggest not only that patients undergoing vascular surgery at the VA may form a higher-risk population compared with patients receiving care in non-VA hospitals, but that these high-risk patients can undergo CEA safely.