Citations

Background Expansion of the endovascular and surgical workforce in the USA might lead to carotid revascularization procedures being carried out at low volume centers. Objective To evaluate trends in the treatment of carotid stenosis at high volume centers in the USA and compare outcomes by hospital volume. Methods Using the Nationwide Inpatient Sample, we evaluated trends in the proportion of carotid revascularization procedures performed at high volume centers in the USA from 2005 to 2011. High volume was defined as combined endarterectomy/stenting volume ≥130 patients/year, carotid endarterectomy volume ≥117 cases/year and carotid stenting volume ≥38 cases/year. In-hospital mortality, discharge to a long-term facility, intracranial hemorrhage, and postoperative stroke rates were compared between high and low volume centers. Results A total of 181 972 patients were included in this study. Overall, 63 442 patients (34.9%) were treated at high volume centers. The proportion of patients treated at high volume carotid revascularization centers decreased from 38.3% in 2005–2006 to 30.2% in 2010–2011. The proportion of patients treated at high volume centers decreased from 35.7% to 30.0% for carotid endarterectomy (p<0.0001) and 45.2% to 35.1% for carotid stenting. Patients treated at low volume centers had significantly higher rates of discharge to a long-term facility than high volume center patients (6.3% vs 5.0%, p<0.0001). The same was true for endarterectomy patients (6.0% vs 4.7%, p<0.0001) and stenting patients (8.3% vs 6.5%, p<0.0001). Conclusions A trend toward a lower proportion of patients with carotid stenosis being treated in high volume centers from 2005 to 2011 is concerning as these high volume centers had lower complication rates.

Background and purpose A recent expansion of the neurointerventional workforce in the USA could lead to a trend toward cerebral aneurysms being increasingly treated at low volume centers. Such a trend could have a negative impact on patient care as higher volume centers are known to have better outcomes. Methods Using the Nationwide Inpatient Sample, we evaluated trends in aneurysm treatment in the USA from 2001 to 2010. Annual volumes of both ruptured and unruptured aneurysms were counted, as well as annual percentages of cases treated at high volume centers (≥50 aneurysms/year clipped or coiled). Results The number of ruptured aneurysms treated per year has fluctuated between 9000 and 12 000 from 2003 to 2010. In 2001–2002, 27.4% of intracranial aneurysm patients were treated with clipping or coiling at high volume centers, with a peak of 70.1% in 2007–2008. This proportion dropped to 61.8% in 2009–2010. The proportion of patients clipped at high volume centers was 23.3% in 2001–2002 and peaked at 65.0% in 2007–2008. In 2009–2010, the proportion dropped to 58.6%. For coiling patients, 46.4% were treated at high volume centers in 2001–2002, with a peak of 70.1% in 2007–2008, and a drop to 61.8% in 2009–2010. Conclusion A trend toward less cerebral aneurysms being treated in high volume centers in 2009 and 2010 is worrisome because high volume centers are known to tend to have better outcomes. This trend is likely due to recent expansion of the neurointerventional workforce.

Background and Purpose— Use of endovascular coiling for treatment of ruptured and unruptured intracranial aneurysms (IAs) in the elderly is increasing. We performed a meta-analysis of the literature examining clinical and angiographic outcomes for treatment of IAs in the elderly. Methods— We performed a comprehensive review of the literature from 1995 to 2012, reporting series of patients ≥65 years of age with ruptured or unruptured IAs treated with endovascular approach. Event rates were pooled across studies using random effects meta-analysis. Results— A total of 21 studies reporting on 1511 patients were included. Long-term aneurysm occlusion rates were 79% (95% confidence interval [CI], 70%–85%). Perioperative stroke occurred in 4% (95% CI, 3%–6%), with similar rates between patients with ruptured (5%; 95% CI, 3%–7%) and unruptured aneurysms (4%; 95% CI, 1%–14%; P =0.68). Intraprocedural rupture occurred in 1% (95% CI, 0%–3%) and 4% (95% CI, 2–6%; P =0.04) of patients with unruptured and ruptured aneurysms, respectively. Perioperative mortality rate for patients with ruptured aneurysms was 23% (95% CI, 17%–30%) and 1% (95% CI, 0%–6%) for patients with unruptured aneurysms ( P <0.01). Rates of good clinical outcome at 1 year were 93% (95% CI, 88%–96%) and 66% (95% CI, 59%–72%) in patients with unruptured and ruptured aneurysms, respectively. Conclusions— This study suggests that endovascular treatment of IAs in the elderly is associated with high long-term occlusion rates. Given the morbidity and mortality associated with endovascular treatment of IAs in the elderly, careful patient selection, especially in the case of patients with unruptured aneurysm, is recommended.

Background and Purpose— Acute intraprocedural thrombus formation complicating endovascular cerebral aneurysm treatment is often treated with intra-arterial or intravenous administration of thrombolytic agents or glycoprotein IIb/IIIa (GpIIb/IIIa) inhibitors. We sought to evaluate the morbidity and mortality associated with such treatments using a large multihospital database. Methods— Using the Premier Perspective Database, we examined outcomes for patients receiving endovascular coiling for ruptured and unruptured aneurysms requiring rescue therapy, defined as treatment with GpIIb/IIIa inhibitors and fibrinolytic therapy. We compared discharge status, length of stay, and complication rates across 3 groups: (1) patients receiving GpIIb/IIIa inhibitors only, (2) patients receiving fibrinolytic therapy only, and (3) patients receiving both GpIIb/IIIa inhibitors and fibrinolytics. Student t test was used to compare continuous variables, and Fisher exact test was used to compare categorical variables. Results— Seven-percent (254/3627) of patients treated for unruptured aneurysms received rescue therapy. When compared with patients receiving GpIIb/IIIa inhibitors alone, patients receiving only fibrinolytics had significantly higher rates of discharge to institutions other than home (37.5% [9/24] versus 7.4% [15/201]; P <0.0001). Eight-percent of patients (338/4204) treated for ruptured aneurysms received rescue therapy. When compared with patients receiving GpIIb/IIIa inhibitors alone, patients receiving only fibrinolytics had significantly higher rates of mortality (26.0% [18/69] versus 14.5% [35/241]; P =0.02) and discharge to institutions other than home (59.4% [41/69] versus 36.5% [88/241]; P <0.0001). Conclusions— Pharmacological rescue therapy occurred in 7% to 8% of endovascular coiling patients with unruptured and ruptured intracranial aneurysms. Rescue therapy with thrombolytic agents resulted in significantly more morbidity and mortality than rescue therapy with GpIIb/IIIa inhibitors.

Background and Purpose— Flow diverters are important tools in the treatment of intracranial aneurysms. However, their impact on aneurysmal occlusion rates, morbidity, mortality, and complication rates is not fully examined. Methods— We conducted a systematic review of the literature searching multiple databases for reports on the treatment of intracranial aneurysms with flow-diverter devices. Random effects meta-analysis was used to pool outcomes of aneurysmal occlusion rates at 6 months, and procedure-related morbidity, mortality, and complications across studies. Results— A total of 29 studies were included in this analysis, including 1451 patients with 1654 aneurysms. Aneurysmal complete occlusion rate was 76% (95% confidence interval [CI], 70%–81%). Procedure-related morbidity and mortality were 5% (95% CI, 4%–7%) and 4% (95% CI, 3%–6%), respectively. The rate of postoperative subarachnoid hemorrhage was 3% (95% CI, 2%–4%). Intraparenchymal hemorrhage rate was 3% (95% CI, 2%–4%). Perforator infarction rate was 3% (95% CI, 1%–5%), with significantly lower odds of perforator infarction among patients with anterior circulation aneurysms compared with those with posterior circulation aneurysms (odds ratio, 0.01; 95% CI, 0.00–0.08; P <0.0001). Ischemic stroke rate was 6% (95% CI, 4%–9%), with significantly lower odds of perforator infarction among patients with anterior circulation aneurysms compared with those with posterior circulation aneurysms (odds ratio, 0.15; 95% CI, 0.08–0.27; P <0.0001). Conclusions— This meta-analysis suggests that treatment of intracranial aneurysms with flow-diverter devices is feasible and effective with high complete occlusion rates. However, the risk of procedure-related morbidity and mortality is not negligible. Patients with posterior circulation aneurysms are at higher risk of ischemic stroke, particularly perforator infarction. These findings should be considered when considering the best therapeutic option for intracranial aneurysms.

Background and Purpose— Minorities in the United States have less access to healthcare system resources, especially preventative treatments. We sought to determine whether racial and sex disparities existed in the treatment of unruptured intracranial aneurysms. Methods— Using the Nationwide Inpatient Sample, hospitalizations for clipping and coiling of intracranial aneurysms from 2001 to 2009 were identified by cross-matching International Classification of Diseases, 9th Revision codes for diagnosis of unruptured aneurysm and subarachnoid hemorrhage (SAH) with procedure codes for clipping or coiling of cerebral aneurysms. Demographic information analyzed included age (<50, 50–64, 65–79, and ≥80 years), race (white, black, Hispanic, Asian/Pacific Islander), sex, income quartile, primary payer (Medicare, Medicaid, private insurance, self-pay, no charge, other), and Charlson comorbidity index. Results— When compared with patients treated for SAH, those treated for unruptured intracranial aneurysm were significantly more likely to be women (75.0% versus 69.0%; P <0.0001). In all, 9.7% of patients receiving treatment for SAH were self-payers versus 3.0% of patients being treated for unruptured intracranial aneurysm ( P <0.0001). In all, 62.2% of patients receiving treatment for SAH were white compared with 76.4% of patients being treated for unruptured intracranial aneurysm ( P <0.0001). There was a higher proportion of black, Hispanic, and Asian patients in the SAH treatment group when compared with the unruptured aneurysm treatment group ( P <0.0001 for all groups). Conclusions— When compared with patients undergoing treatment for SAH, patients undergoing surgical and endovascular treatment for unruptured intracranial aneurysm are generally from higher socioeconomic strata and are more likely to be insured, women, and white. Future studies are needed to determine the underlying causes and solutions for this disparity.

Background Evaluating recombinant tissue plasminogen activator utilization rates is important, as many studies have demonstrated that administration of recombinant tissue plasminogen activator to qualified patients significantly improves prognosis. Aims We investigated recent trends in the utilization and outcomes of administration of intravenous recombinant tissue plasminogen activator in the United States using the National Inpatient Sample between 2001 and 2008. Methods We identified patients with a primary diagnosis of acute ischemic stroke who underwent treatment with intravenous recombinant tissue plasminogen activator and studied utilization rates and clinical outcomes: discharge to long-term facility (morbidity), in-hospital death (mortality), and intracranial hemorrhage. Information on demographics, hospital characteristics, and comorbidities was collected. A multivariate logistic regression analysis was performed to determine independent predictors of morbidity, mortality, and intracranial hemorrhage. Results Intravenous recombinant tissue plasminogen activator utilization increased from 1·3% in 2001 to 3·5% in 2008. On multivariate analysis, variables associated with increased morbidity after intravenous recombinant tissue plasminogen activator administration included advanced age ( P < 0·001), female gender ( P < 0·001), and comorbidities of atrial fibrillation ( P < 0·001) and hypertension ( P < 0·001). Increased mortality was associated with increased age ( P < 0·001) and comorbidities of atrial fibrillation, congestive heart failure, coronary artery disease, and diabetes ( P < 0·001 for all comorbidities). Conclusions Intravenous recombinant tissue plasminogen activator utilization rates increased between 2001 and 2008. Advanced age and atrial fibrillation were significantly associated with increased morbidity and mortality among patients treated with intravenous recombinant tissue plasminogen activator.

Background— Despite several advances in postresuscitation care over the past decade, population-based mortality rates for patients hospitalized with cardiac arrest in the United States have not been studied over this time period. The aim of this study was to determine the annual in-hospital mortality rates of patients with cardiac arrest from 2001 to 2009. Methods and Results— The US mortality rates for hospitalized patients with cardiac arrest were determined using the 2001 to 2009 US National Inpatient Sample, a national hospital discharge database. Using the International Classification of Diseases , 9 th Edition, code 427.5, we identified patients hospitalized in the United States with cardiac arrest from 2001 to 2009. The main outcome measure was in-hospital mortality. A total of 1 190 860 patients were hospitalized with a diagnosis of cardiac arrest in the United States from 2001 to 2009. The in-hospital mortality rate decreased each year from 69.6% in 2001 to 57.8% in 2009. In multivariable analysis, when controlling for age, sex, race, and comorbidities, earlier year was a strong independent predictor of in-hospital death. The mortality rate declined across all analyzed subgroups, including sex, age, race, and stratification by comorbidity. Conclusions— The in-hospital mortality rate of patients hospitalized with cardiac arrest in the United States decreased by 11.8% from 2001 to 2009.