The Effect of Glycemic Control on Outcomes After Carotid Artery Stenting
Huong Truong, MD, Viktor Dombrovskiy, MD, PhD, Khanjan Nagarsheth, MD, MBA, Randy Shafritz, MD, Saum Rahimi, MD.
Robert Wood Johnson Rutgers, New Brunswick, NJ, USA.
Many studies have evaluated the post-operative outcomes of carotid endarterectomy in patients with and without diabetes, with data showing that diabetes does increase post-operative complications. With this known, our study attempts to evaluate whether glycemic control in a diabetic (UCDM vs WCDM) would decrease adverse postoperative outcomes and if these rates are comparable to non-diabetics (NDM) in patients who underwent CAS. A secondary goal of the study was to evaluate hospital costs and length of stay (LOS) among these groups.
Using the ICD-9-CM diagnosis codes in the National Inpatient Sample 2006-2013 with revised weights in 2006-2011 for computing national estimates, patients were selected with UCDM codes 250.x2 and 250.x3, WCDM with codes 250.x0 and 250.x1, and all others were qualified as NDM. Rates of postoperative complications including stroke, cerebral artery occlusion (CAO), transient cerebral ischemia (TCI), and hospital mortality were compared between all these groups. Chi-square and multivariable logistic regression were used for analysis. Hospital LOS and total hospital cost were also compared with non-parametric Wilcoxon rank sum test.
A total of 98,749 patients undergoing CAS were evaluated with 1,181 (1.2%) UCDM, 30,760 (31.2%) WCDM, and 66,812 (67.7%) NDM. Patients with UCDM and WCDM had higher rates of postoperative stroke (6.61%, 1.79%, 1.86% respectively; p<0.0001), CAO (7.48%, 2.47%, 2.12% respectively; p<0.0001), and hospital mortality (4.05%, 0.53%, and 0.46% respectively; p<0.0001) than NDM patients. UCDM patients had significantly lower rates of TCI than WCDM and NDM patients (0.36%, 1.37%, 1.10% respectively; p<0.0001). This was confirmed in the multivariable analysis. UCDM compared to CDM counterparts was more likely to develop post-op stroke (OR [odds ratio]=3.69; 95%CI [confidence interval] 2.89-4.72), occlusion of cerebral arteries (OR=3.28; 95%CI 2.60-4.15), and mortality (OR=7.50; 95%CI 5.38-10.44). LOS and hospital costs are also notably less for WCDM than UCDM (2.4 days and 5.8 day, $10,342 and $17,446 respectively; p<0.0001). This was also true for CDM versus UCDM (2.4 days and 6.4 days, $15,097 and $25,073 respectively; p<0.0001) in terms of LOS and cost.
Strict hyperglycemic control prior to CAS is valuable, as it has been shown to abate post-operative stroke, CAO, hospital mortality, LOS, and cost. Interestingly, TCI is more prevalent in NDM than UCDM and must be further evaluated to provide greatest pre-operative optimization.
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