Background: Carotid endarterectomy (CEA) has long been known to be an effective procedure for stroke prevention in patients with symptomatic carotid artery stenosis. However, its best practice has been in evolution with more recent evidence regarding optimal surgical timing, patient selection and choice of endovascular intervention versus surgery. Understanding the changes in CEA practice over time provides insights into how successfully evidence from research is translated into clinical practice.
Objective: To investigate changes in practice and outcome of CEA over time in an Australian stroke centre hospital.
Hypothesis: We hypothesized that the practice of CEA would change in line with new evidence in medical literature.
Methods: All patients who underwent CEA from 2004-14 and carotid angioplasty and stenting (CAS) from 2003-08 were included. Clinical data were analysed to identify time trends in choice of intervention, patient selection, pre-operative imaging utilization, surgical timing and outcome. Chi square test, Mann-Whitney U test and multivariable logistic regression models were used in statistical analysis.
Results: There were 510 CEA performed in 2004-14 and 95 CAS in 2003-08. The proportion of patients undergoing CEA increased from 60% to 90% from 2004-08 (p<0.001). CAS patients were more likely to have cardiac comorbidities and have restenosis as an indication. From 2004-14, the proportion of CEA patients >80 years old increased (p=0.001) and the proportion of asymptomatic patients decreased (OR 0.9 [0.87,0.99] p=0.003) over time. Median time from symptom onset to surgery decreased from 52 days (Q1: 25, Q3: 74) in 2004 to 8 days (Q1: 5, Q3: 37) in 2014 (p<0.001). Use of pre-operative ultrasonography decreased whilst CT angiography and the number of imaging modalities applied to each patient increased over time (p<0.001). Overall 5.9% of CEA were complicated by death, stroke, or acute myocardial infarction with no change over time.
Conclusions: The trends in CEA practice at our institute align with international trends and guidelines. This result may provide a representative indicator of Australian hospital practice.