Objective: This study aimed at assessing outcomes after carotid endarterectomy (CEA) in dependence of center policy with respect to imaging intraoperative completion study (ICSⁱ) usage. Background: Although randomized controlled studies are missing, a beneficial effect was shown for ICSⁱ techniques (ie, angiography and intraoperative duplex ultrasound) after CEA. Methods: This secondary data analysis is based on the German statutory quality assurance database. The research was funded by Germany’s Federal Joint Committee Innovation Fund (G-BA Innovationsfonds, 01VSF19016 ISAR-IQ). According to their ICSⁱ policy, hospitals were categorized as routine ICSⁱ (>90%), selective ICSⁱ (10%–90%), or sporadic ICSⁱ (<10%) centers. Primary study outcome was in-hospital stroke or death. Multivariable regression analyses were performed. Results: Between 2012 and 2016, a total of 119,800 patients underwent CEA. In-hospital stroke or death rates were lower in routine ICSⁱ centers (1.7%) compared with selective (2.1%) and sporadic ICSⁱ centers (2.0%). The multivariable regression analysis showed, that in routine ICSⁱ centers, ICSⁱ use was associated with lower rates of stroke or death (adjusted odds ratio: 0.64; 95% CI: 0.44–0.93). In selective ICSⁱ centers, ICSⁱ was not associated with the occurrence of either of the assessed outcomes. In sporadic ICSⁱ centers, ICSⁱ was associated with higher rates of stroke or death (adjusted odds ratio: 1.91; 95% CI: 1.26–2.91). Conclusions: Lowest in-hospital stroke or death rates are achieved in routine ICSⁱ centers. Although ICSⁱ is associated with a lower perioperative risk in routine ICSⁱ centers, it might act as a surrogate marker for worse outcomes due to intraoperative irregularities in sporadic ICSⁱ centers. Routine use of ICSⁱ is advisable.

Abdominal aortic aneurysms (AAA) are the most frequent aortic dilation, with considerable morbidity and mortality. Inflammatory (infl) and IgG4-positive AAAs represent specific subtypes of unclear incidence and clinical significance. Here, histologic and serologic analyses with retrospective clinical data acquisition are investigated via detailed histology, including morphologic (HE, EvG: inflammatory subtype, angiogenesis, and fibrosis) and immunhistochemic analyses (IgG and IgG4). In addition, complement factors C3/C4 and immunoglobulins IgG, IgG2, IgG4 and IgE were measured in serum samples and clinical data uses patients’ metrics, as well as through semi-automated morphometric analysis (diameter, volume, angulation and vessel tortuosity). A total of 101 eligible patients showed five (5%) IgG4 positive (all scored 1) and seven (7%) inflammatory AAAs. An increased degree of inflammation was seen in IgG4 positive and inflAAA, respectively. However, serologic analysis revealed no increased levels of IgG or IgG4. The operative procedure time was not different for those cases and the short-term clinical outcomes were equal for the entire AAA cohort. Overall, the incidence of inflammatory and IgG4-positive AAA samples seems very low based on histologic and serum analyses. Both entities must be considered distinct disease phenotypes. Short-term operative outcomes were not different for both sub-cohorts.

Background: The aim of this study was to analyze the association between center quality certifications and patients’ characteristics, clinical management, and outcomes after carotid revascularization. Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the Bavarian subset of the nationwide German statutory quality assurance carotid database. Hospitals were classified as to whether a certified vascular center (cVC) or a certified stroke unit (cSU) was present on-site or not. The primary outcome event was any stroke or death until discharge from the hospital. Results: In total, 31,793 cases were included between 2012 and 2018. The primary outcome rate in asymptomatic patients treated by CEA ranged from 0.7% to 1.5%, with the highest rate in hospitals with cVC but without cSU. The multivariable regression analysis revealed a significantly lower primary outcome rate in centers with cSU in asymptomatic patients (aOR 0.69; 95% CI 0.56–0.86; p < 0.001). In symptomatic patients needing emergency treatment, the on-site availability of a cSU was associated with a significantly lower primary outcome rate (aOR 0.56; 95% CI 0.40–0.80; p < 0.001), whereas the presence of a cVC was associated with higher risk (aOR 3.07; 95% CI 1.65–5.72). Conclusions: This study provides evidence of statistically significant better results in some sub-cohorts in certified centers. In centers with cSU, the risk of any stroke or death was significantly lower in asymptomatic patients receiving CEA or symptomatic patients treated by emergency CEA.

Background This study analyses the determinants of prehospital (index event to admission) and in-hospital delay (admission to carotid endarterectomy (CEA)). In addition, the analysis addresses the association between prehospital or in-hospital delay and outcomes after CEA for symptomatic patients in German hospitals. Materials and methods This retrospective analysis is based on the nationwide German statutory quality assurance database. 55 437 patients were included in the analysis. Prehospital delay was grouped as follows: 180–15, 14–8, 7–3, 2–0 days or ‘in-hospital index event’. In-hospital delay was divided into: 0–1, 2–3 and >3 days. The primary outcome event (POE) was in-hospital stroke or death. Univariate and multivariable regression analyses were performed for statistical analysis. The slope of the linear regression line is given as the β-value, and the rate parameter of the logistic regression is given as the adjusted OR (aOR). Results Prehospital delay was 0–2 days in 34.9%, 3–14 days in 29.5% and >14 days in 18.6%. Higher age (β=−1.08, p<0.001) and a more severe index event (transitory ischaemic attack: β=−4.41, p<0.001; stroke: β=−6.05, p<0.001, Ref: amaurosis fugax) were determinants of shorter prehospital delay. Higher age (β=0.28, p<0.001) and female sex (β=0.09, p=0.014) were associated with a longer in-hospital delay. Index event after admission (aOR 1.23, 95% CI: 1.04 to 1.47) and an intermediate in-hospital delay of 2–3 days (aOR 1.15, 95% CI: 1.00 to 1.33) were associated with an increased POE risk. Conclusions This study revealed that older age, higher American Society of Anesthesiology (ASA) stage, increasing severity of symptoms and ipsilateral moderate stenosis were associated with shorter prehospital delay. Non-specific symptoms were associated with a longer prehospital delay. Regarding in-hospital delay, older age, higher ASA stage, contralateral occlusion, preprocedural examination by a neurologist and admission on Fridays or Saturdays were associated with lagged treatment. A very short (<2 days) prehospital and intermediate in-hospital delay (2–3 days) were associated with increased risk of perioperative stroke or death.

Various studies have failed to detect a difference in outcomes between carotid endarterectomy (CEA) with patch angioplasty and eversion CEA. This study aimed to assess whether surgical technique and related department policy are associated with in hospital outcomes after CEA. This was a secondary data analysis based on the German statutory quality assurance database. According to surgical technique policy, hospitals were categorised as routine eversion (> 90%), selective eversion (10 - 90%), or sporadic eversion (< 10%) centres. The primary outcome event (POE) was in hospital stroke or death. Uni- and multivariable regression analyses were performed. A total of 119 800 patients underwent CEA between 2012 and 2016. Multivariable regression analysis showed eversion technique to be associated with a lower POE rate (adjusted odds ratio 0.78, 95% confidence interval 0.69 - 0.88). Routine eversion centres showed statistically significantly lower in hospital stroke or death rates compared with selective eversion and sporadic eversion centres (1.7% vs. 1.9% vs. 2.0%; p = .004). After risk adjustment, centre surgical technique policy did not show a significant association with any of the assessed outcomes. Eversion CEA compared to CEA with patch angioplasty was independently associated with a lower in hospital stroke or death rate. The centre policy with respect to surgical technique did not show an association with the primary or either of the secondary outcomes.