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A Risk Prediction Model for Determining Appropriateness of CEA in Patients with Asymptomatic Carotid Artery Stenosis
Mark F Conrad*, Jean W Kang*, Shankha Mukhopadjyay*, Virendra I Patel*, Glenn M LaMuraglia, Richard P Cambria
Massachusetts General Hospital, Boston, MA

Objective: The benefit of CEA over medical therapy in patients with asymptomatic carotid artery stenosis(ACAS) is predicated upon a 5-year post-procedure life expectancy. The study goal was to create a scoring system that predicts 5-year survival after CEA for triage of patients with ACAS.
Methods:All patients who underwent CEA for ACAS From 1989-2005 were identified. Long-term survival was obtained from the social security death index. All patients had 5+ year follow-up. A logistic regression predicting actual 5-year survival(not actuarial) was performed and a prediction score was derived from the odds ratios. This was validated within the cohort using the Hosmer-Lemeshow Test and a derivation/validation Receiver Operating Characteristic(ROC) curve.
Results:There were 2004 CEA(1791pts) performed. Average follow-up was 130+/-49mo. The 30-day stroke rate was 1.1%, death rate was 0.7%. The actual 5-year survival was 73%. Logistic regression yielded the following predictors of mortality:Age(OR=1.8,p<0.0001),CAD(OR=1.5,p=0.0007),
COPD(OR=2.5;p<0.0001),diabetes(OR=1.7,p<0.0001),neck radiation(OR=2.6,p=0.005), no statin(OR=2.1,p<0.0001),Creatinine>1.5(OR=2.6,p<0.0001). The scoring system is detailed in Table 1. The system was validated(p=0.26) with no difference in ROC curves.
Conclusions:This scoring system can identify which patients are likely to benefit from CEA based on 5-year survival probability. Since 5-year survival of patients in the medical arm of the asymptomatic CEA trials was 60-70%, we conclude that patients who score 0-8 points are excellent candidates for CEA while most patients with >12 points have limited longevity so as to preclude benefit from prophylactic CEA.
Table 1
Age<50years0 pointsCAD2 points
50-59years2 pointsCOPD3 points
60-69years4 pointsDiabetes2 points
70-79years6 pointsNeck Rad3 points
80-89years8 pointsNo Statin2 points
90+years10 pointsCr >1.53 points
Score Range% SurvivalScore Range% Survival
0-5 points92.5%12-14 points46.5%
6-8 points83.6%15+ points33.8%
9-11 points63.7


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