Predictors of Prolonged Length of Stay after Elective Carotid Revascularization

Hanaa Aridi; Brandon Leon; Michael P Murphy; Mahmoud Malas; Marc Schermerhorn; Vikram S Kashyap; Grace Wang; Jens Eldrup-Jorgensen; Andrew Gonzalez; Raghu Motaganahalli

doi:10.1016/j.jvs.2024.05.022

Predictors of Prolonged Length of Stay after Elective Carotid Revascularization

J Vasc Surg. 2024 May 17:S0741-5214(24)01201-1. doi: 10.1016/j.jvs.2024.05.022. Online ahead of print.

Authors

Affiliations

¹ Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
² Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
³ Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
⁴ Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids MI.
⁵ Division of Vascular and Endovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
⁶ Tufts University School of Medicine, Boston, MA.
⁷ Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN. Electronic address: rmotagan@iupui.edu.

PMID: 38763455
DOI: 10.1016/j.jvs.2024.05.022

Abstract

Objective: Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of > 1 day, after elective carotid revascularization.

Methods: Patients undergoing carotid endarterectomy (CEA), Transcarotid artery revascularization (TCAR) and Transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of > 1 day, after each procedure.

Results: A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the 3 procedures. Age, female sex, nonwhite race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday and postoperative hypo- or hypertension were significantly associated with pLOS across all 3 procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (< 11 cases/year) and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all 3 procedures; CEA (HR,1.64; 95%CI, 1.49-1.82), TCAR (HR,1.56; 95%CI, 1.35-1.80), and TFCAS (HR,1.33; 95%CI,1.08-1.64) (all P<0.05).

Conclusions: A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients are risk for pLOS highlight quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.

Keywords: Length of stay; Transcarotid artery revascularization; carotid endarterectomy; carotid revascularization; quality improvement; risk factors; transfemoral carotid artery stenting.