RS07 - Association between Ambulatory Status and Outcomes of Carotid Endarterectomy

Objectives: Ambulatory status of patients plays a pivotal role in surgical decision-making. Carotid Endarterectomy (CEA) is the established gold standard for addressing carotid artery disease. We assessed the impact of ambulatory status on CEA outcomes, stratifying our analysis by symptomatic and asymptomatic status, in order to evaluate ambulatory status as a surrogate for surgical fitness.

Methods: We identified all patients who had undergone CEA from 2012 to 2023 in the Vascular Quality Initiative Database. We categorized patients by independent ambulatory status and non-ambulatory (with wheelchair and bedridden). We performed logistic regression to compare between procedures, adjusting for confounding variables such as demographics (age, gender, race, BMI), comorbidities (hypertension, diabetes, COPD, CHF, CAD, CKD, dialysis, active smoking, ASA class 4/5, 80% or greater degree of ipsilateral stenosis), urgency (elective, emergent, urgent), and preoperative medications (P2Y inhibitor, statin, aspirin, beta blocker, ace inhibitor, anticoagulant). Our primary outcomes were in-hospital stroke, death, 30-day mortality, and combined stroke/death.

Results: We identified 176,167 patients undergoing CEA of which 173,884 (98.7%) were ambulatory and 2283 (1.2%) were non-ambulatory . Non-ambulatory patients had more comorbidities such as hypertension (p < 0.001), diabetes (p < 0.001), COPD (p < 0.001), CHF(p < 0.001) , CAD(p < 0.001) , CKD (p < 0.001), and were more likely to be symptomatic (p < 0.001). Compared to ambulatory patients, non-ambulatory patients had significantly worse outcomes for stroke (aOR=1.7, 95%CI:1.2-2.3, p< 0.001), death(aOR=2.2, 95%CI:1.4-3.5, p< 0.001), 30-day mortality(aOR=2.6, 95%CI:2.0-3.4, p< 0.001), and combined stroke-death (aOR=1.8, 95%CI:1.4-2.5, p< 0.001). Symptomatic non-ambulatory patients had over double the risk of stroke (aOR=2.2, 95%CI:1.5-3.1, p< 0.001), death(aOR=2.4, 95%CI:1.3-4.3, p=0.003), 30-day mortality(aOR=2.6, 95%CI:1.8-3.8, p< 0.001) and stroke/death(aOR=2.2, 95%CI:1.6-3.1, p< 0.001). Asymptomatic non-ambulatory patients had over two times the risk for 30-day mortality (aOR= 2.6, 95%CI:1.8-3.8, p< 0.001).

Conclusions: Patient selection is crucial for CEA to optimize outcomes. Non-ambulatory status was associated with worse outcomes, especially when observing outcomes of symptomatic patients. Careful consideration must be given for non-ambulatory asymptomatic patients as they had significant increased 30-day mortality with CEA. While surgical intervention may be imperative for non-ambulatory symptomatic patients, non-ambulatory asymptomatic patients might be better served with aggressive medical management.