Reducing the risk of carotid surgery: A 7-year audit of the role of monitoring and quality control assessment

Background and Purpose: The current risk of stroke after carotid endarterec tomy may be worse than reported in the international trials. Because studie s have suggested that most operative strokes follow surgeon error, the aim of the current study was to audit the impact of introducing a strategy of p erioperative monitoring and quality control assessment on outcome. Methods: A total of 500 patients underwent carotid endarterectomy with intr aoperative transcranial Doppler scan monitoring, completion angioscopy, and 3 hours of postoperative transcranial Doppler scan monitoring. The last of these guided selective dextran therapy in patients with high rates of post operative embolization, which in previous series has been shown to be highl y predictive of progression to thromboembolic stroke. Results: Intimal flaps were repaired in 3% of patients and luminal thrombus removed in 4% of patients. The rate of intraoperative stroke was 0.2%. A t otal of 313 patients had more than one embolus detected postoperatively (96 % within 2 hours of now restoration), but only 22 patients had sustained em bolization requiring dextran. Embolization ceased in all but one patient re ceiving dextran, although the dose had to be increased in seven patients (3 6%). One patient was unable to receive adequate dextran therapy because of severe cardiac failure. Overall, the 30-day death/stroke rate was 2.2%, no patient had a perioperative stroke because of carotid thrombosis, and the r ate of ipsilateral embolic stroke was 0.8%. Most complications resulted fro m cardiac pathology or intracranial hemorrhage. Conclusions: A program of monitoring and quality control assessment has bee n associated with a 60% decrease in the operative risk in comparison with t hat observed before implementation of the protocol.