Class I obesity is paradoxically associated with decreased risk of postoperative stroke after carotid endarterectomy.

Although obesity is a risk factor for vascular disease, previous studies have shown an obesity paradox with decreased mortality in obese patients undergoing vascular surgery. This study examined the relationship between body mass index (BMI) and outcomes after carotid endarterectomy (CEA). The 2005-2009 American College of Surgeons National Surgical Quality Improvement Program database was queried to evaluate 30-day outcomes after isolated CEA across National Institutes of Health-defined obesity classes. χ(2) analysis was used to assess the unadjusted relationship of BMI category to postoperative outcomes. The independent association of BMI with morbidity and mortality was assessed with multivariable logistic regression, adjusting for preoperative and operative characteristics. In the cohort of 23,652 CEA, 1.8% of patients were underweight (BMI <18.5), 26.6% were normal weight (BMI 18.5-24.9), 39.4% were overweight (BMI 25.0-29.9), 21.1% were class I obese (BMI 30.0-34.9), 7.5% were class II obese (BMI 35.0-39.9), and 3.5% were class III obese (BMI ≥ 40). The overall stroke and mortality rates were 1.4% and 0.6%, respectively. On univariable analysis, there were U-shaped relationships between death (P = .017) and stroke (P = .029), with the lowest incidence in overweight and class I obese patients. The incidence of surgical site infection (SSI) (P = .021) increased incrementally with increasing BMI. On multivariable analysis, class I obesity was the only variable associated with decreased risk of stroke (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.31-0.83; P = .007). Independent risk factors for stroke were previous transient ischemic attack (OR, 1.97; P = .006), American Society of Anesthesiologists class 4 to 5 (OR, 1.62; P = .010), surgery performed by a nonvascular surgeon (OR, 1.85; P = .015), and hemiplegia (OR, 1.97; P = .018). There was also a trend, although not statistically significant, toward decreased mortality risk associated with class I obesity (OR, 0.53; 95% CI, .26-1.08; P = .080). Class II obesity was associated with an increased risk of SSI compared with normal weight (OR, 2.21; 95% CI, 1.01-4.82; P = .047). BMI category was not associated with the risk of myocardial infarction. An obesity paradox exists for stroke and mortality after CEA; for stroke, but not mortality, this protective association was independent of patient demographics and comorbidities. Obesity is not a contraindication to CEA, and surgeons may safely undertake CEA in obese patients when indicated.

Jackson RS ，Black JH 3rd ，Lum YW ，Schneider EB ，Freischlag JA ，Perler BA ，Abularrage CJ ... -  《-》

The influence of body mass index obesity status on vascular surgery 30-day morbidity and mortality.

Davenport DL ，Xenos ES ，Hosokawa P ，Radford J ，Henderson WG ，Endean ED ... -  《-》

Association between minor and major surgical complications after carotid endarterectomy: results of the New York Carotid Artery Surgery study.

Greenstein AJ ，Chassin MR ，Wang J ，Rockman CB ，Riles TS ，Tuhrim S ，Halm EA ... -  《JOURNAL OF VASCULAR SURGERY》

Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy.

The role of obesity as a risk factor after carotid endarterectomy is not well-described. We undertook a study of the association of obesity with 30-day outcomes after carotid endarterectomy. After obtaining Institutional Review Board approval, we retrospectively analyzed prospectively collected data from carotid endarterectomies in the 2005-2006 Veterans Affairs Surgical Quality Improvement Program database. The association of body mass index (BMI; calculated as kg/m(2)) on 30-day outcomes was assessed using multivariable logistic regression. From 3,706 carotid endarterectomies, we excluded 22 for missing BMI and 39 for emergency status; 3,645 carotid endarterectomies were analyzed. BMI was underweight (<18.5) in 1.6%, normal (18.5 to 24.9) in 31.0%, overweight (25.0 to 29.9) in 40.8%, class I obese (30.0 to 34.9) in 19.3%, class II obese (35.0 to 39.9) in 5.8%, and class III obese (≥40) in 1.6%. On multivariable analysis, class II to III (odds ratio = 6.95; 95% CI, 1.89-25.58; p = 0.004) obesity was associated with death, and class II to III obesity was associated with cardiac complications (odds ratio = 3.68; 95% CI, 1.27-10.66; p = 0.02) compared with normal weight. Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy. Surgeons should consider this when evaluating the risks and benefits of carotid endarterectomy in obese patients. Carotid artery stenting was not assessed, and future studies are needed to examine its role in management of obese patients.

Jackson RS ，Sidawy AN ，Amdur RL ，Macsata RA ... -  《-》

National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007.

This study compared, at a national level, trends in utilization, mortality, and stroke after carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA) from 2005 to 2007. The Nationwide Inpatient Sample (NIS) was queried for patient discharges with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CAS and CEA. The primary outcomes were in-hospital mortality, stroke, hospital charges, and discharge disposition. Subgroup analyses were performed to evaluate these outcomes by neurologic presentation using χ(2) and multivariable logistic regression. Of the 404,256 discharges for carotid revascularization, CAS utilization was 66% higher in 2006 than in 2005 (9.3% vs 14%, P = .0004). Crude mortality, stroke, and median charges remained higher for CAS than for CEA; discharge to home was more common after CEA. Results improved from 2005 to 2007. By logistic regression of the total cohort from 2005 to 2006, CAS was independently predictive of mortality (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; P < .0001). Independent predictors of stroke included CAS (OR, 1.43; 95% CI, 1.18-1.73; P < .0001) and symptomatic disease (OR, 2.4; 95% CI, 2.06-2.93;P < .0001). Among subgroups based on neurological presentation, regression showed that CAS significantly increased the odds of stroke in asymptomatic patients (OR, 1.6; 95% CI, 1.2-2.0; P = .0003). Among symptomatic patients, CAS increased the odds of in-hospital death (OR, 3.0; 95% CI, 1.7-5.1, P < .0001) and trended toward significance for stroke (OR, 1.7; 95% CI, 1.0-2.8; P = .0569). Utilization of CAS has increased from the years 2005 to 2007 with some improvements in the outcome. Despite improvements in outcome, resource utilization remains significantly higher for CAS than CEA.

Eslami MH ，McPhee JT ，Simons JP ，Schanzer A ，Messina LM ... -  《-》