Stroke surgery overused in sick, older patients

NEW YORK Thu May 31, 2012 12:30pm EDT

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NEW YORK (Reuters Health) - One in five people who get artery-clearing surgery to prevent a stroke are likely too old and sick to live long enough to benefit from the procedure, according to a new study.

"This is not extremely surprising to me, because I had a sense we weren't doing a great job with patient selection," said Dr. Jessica Wallaert, the lead author of the study and a researcher at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.

"But I think 20 percent is still pretty high."

Surgery to prevent stroke, called carotid endarterectomy, involves opening up an artery in the neck and scraping away fatty deposits that can block the flow of blood.

The procedure is typically recommended for people who have narrowed blood vessels and have had symptoms of a stroke, such as dizziness, sudden weakness and confusion. But for those without symptoms or a known prior stroke, some researchers believe such an invasive intervention might be going overboard.

"Especially in light of advancing medical therapy, it's not clear we should be operating on all of them," said Wallaert.

She said most professional medical societies have said patients without symptoms should be expected to live at least three to five more years to be a good candidate for artery-clearing surgery.

But she had noticed anecdotally that some patients getting the operation were quite sick and unlikely to live many more years after the operation.

To find out how often that's the case, Wallaert and her colleagues collected more than 12,000 records from surgeries on asymptomatic patients, done at one of about 200 hospitals.

Looking for evidence of health conditions that would limit patients' life expectancy, such as advanced lung or liver disease, they found one out five had at least one other major health problem.

That included about 10 percent of all patients with severe emphysema and other chronic lung disease and 10 percent who were classified as having "severe systemic disease that is a constant threat to life."

Among people with these conditions, about half will die within five years, the authors note in their report in the journal Stroke.

Wallaert's group also found that patients with a life-limiting condition were more likely to have a stroke or die within 30 days of the surgery than people without such serious health problems.

In total, about one in every 70 people had one of those complications within a month of endarterectomy.

‘UNDUE HARM AND COST'

Guidelines from the American Academy of Neurology recommend that people have at least a five-year life expectancy if they are to get carotid endarterectomy.

"This paper may be useful for reinforcing that message to surgeons," said Dr. Seemant Chaturvedi, a professor of neurology and director of the stroke program at Wayne State University in Detroit who helped write those guidelines.

Wallaert said one reason people are getting surgery inappropriately is that it's difficult for surgeons to assess how long they're likely to live.

"It's very easy to look at the data from afar and say, 'Based on this patient's comorbidity or age or other characteristics they're not going to realize the benefits of this surgery.' But when you get them in clinic and meet them in person, you can say, 'This person looks pretty good,'" she said.

Chaturvedi told Reuters Health there might be a reflex among primary care physicians to recommend surgery for all patients who have narrowing in the arteries.

"So the question is how to stop that train, and I think one way is to get an opinion from a neurologist or a specialist in stroke," he said.

It's possible that medications, such as cholesterol-lowering drugs and blood thinners, might be a better treatment option for patients with severe health conditions, Wallaert said.

They could also be a less expensive approach to lowering the risk of stroke: medications typically cost several hundred dollars a year and a surgery can cost thousands.

Wallaert said it's possible the 20 percent finding could be an overestimate of how many people are getting surgery inappropriately.

"But even if we cut that number in half and say 10 percent of the surgeries are inappropriate and unnecessary, that's still 10 percent of surgeries that could be causing undue harm and cost to society," she said.

SOURCE: bit.ly/L6HomY Stroke, online May 1, 2012.

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