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Drain Placement Confers No Benefit Following Carotid Endarterectomy in the Vascular Quality Initiative
Christopher J. Smolock, MD1, Jeanwan Kang, MD1, James F. Bena1, Nayara Cioffi Batagini, MD2, Rebecca Kelso, MD1, Daniel Clair, MD1.
1The Cleveland Clinic, Cleveland, OH, USA, 2Clinicas Hospital, University of Sao Paulo Medical School, Sao Paulo, Brazil.
While bleeding complications requiring a return to the operating room (OR) after carotid endarterectomy (CEA) are infrequent (1%), they are associated with increased 30-day combined postoperative stroke/death rate. Drain placement (DR) following CEA varies among vascular surgeons and there is limited data to support the practice. The goal of this study is to evaluate factors leading to DR and the effect of DR on postoperative outcomes including return to OR for bleeding, stroke and death.
We identified 47,752 patients undergoing CEA using the VQI registry from 2011 to 2015. Demographic, preoperative and intraoperative factors between patients who underwent CEA with DR (n=19,425) and without DR (n=28,327) were compared. End points included return to the OR for bleeding, stroke, death, postoperative wound infection, and hospital length of stay. Postoperative outcomes between groups were then compared using mixed effect logistic regression models to control for correlation within center. Similar methods were used to show relationship between return to OR for bleeding and other variables. Subgroup analysis of patients with DR was compared among centers with high DR (>66.7% of cases), medium DR (33.3-66.7%), and low DR (<33.3%).
Patients with DR were more likely to be on a preoperative P2Y12 antagonist (P2A) (P<.001), have prior CEA/CAS (P<.001), use dextran (P<.001), have a concomitant procedure/CABG (P<.001) and less likely to use protamine (P<.001) compared to those without DR. DR did not prevent return to the OR for bleeding (P<.22). Re-exploration of the carotid artery after closure in the OR (P<.001), preoperative P2A (P<.001) and no protamine use (P<.001) were predictors for return to the OR for bleeding among those with DR. Of patients requiring return to the OR for bleeding, DR did not influence 30-day stroke (P=.82), 30-day mortality (P=0.43), nor 30-day combined stroke/mortality (p=0.42) compared to those without DR. DR did not influence postoperative wound infection (P < .3). Hospital length of stay was increased in patients with DR (P<.001). Return to OR for bleeding (P=.24), wound infection (P=.16) and length of stay (P=.94) did not differ among the high, medium and low DR groups.
DR following CEA reduces neither return to OR for bleeding nor perioperative stroke and death in such circumstances. DR is associated with increased length of stay.
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