Surgical Risk Calculator

Carotid Endarterectomy Risk Index for Asymptomatic Patients

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Estimates the combined risk of stroke, myocardial infarction or death within 30 days of surgery, for asymptomatic patients having elective carotid endarterectomy.

Who this applies to

Use this only for asymptomatic patients having elective carotid endarterectomy. The study left out patients with a past stroke or transient ischemic attack, emergency cases, and several other acutely ill or high-risk groups, such as patients with a do-not-resuscitate order, ventilator dependence, disseminated cancer or sepsis.

Dyspnea at moderate exertion or at rest Within 30 days before surgery. Moderate exertion means, for example, unable to climb one flight of stairs without shortness of breath.
Previous peripheral revascularization or amputation Any angioplasty, stent or revascularization for atherosclerotic peripheral vascular disease, or any amputation for peripheral vascular disease. Not amputation for trauma.
COPD Emphysema or chronic bronchitis with functional disability, past hospitalization for COPD, chronic bronchodilator therapy, or FEV1 below 75% of predicted. Not asthma alone, diffuse interstitial fibrosis or sarcoidosis.
Recent angina Within 1 month before surgery
Dependent functional status Needs some help from another person with activities of daily living, in the 30 days before surgery

About this model

  • Built from 17,692 asymptomatic patients having elective carotid endarterectomy in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), 2005–2010.
  • The outcome is combined: stroke, myocardial infarction or death within 30 days. It happened in 324 patients (1.8%). Stroke happened in 0.9%, myocardial infarction in 0.6% and death in 0.4%.
  • A myocardial infarction counted only with qualifying ECG changes, or a new troponin above 3 times the upper reference limit with suspected myocardial ischemia.
  • The model separates patients only moderately well: C statistic 0.64, and 0.64 after bootstrap correction. It was validated by bootstrapping, not on a separate group of patients.
  • Patients under 60 score higher than patients aged 60 to 79. The paper traced this to a higher risk of perioperative stroke in the younger group.
  • The data have no information on degree of stenosis, side of disease, contralateral occlusion, surgical technique, surgeon, or medications such as antiplatelets and statins.

Points (Table III of the paper)

Risk factorPoints
Age: under 60 years0
Age: 60 to 69 years−1
Age: 70 to 79 years−1
Age: 80 years or older2
Dyspnea at moderate exertion or at rest2
Previous peripheral revascularization or amputation3
COPD3
Recent angina4
Dependent functional status5

Risk by total points (Table IV of the paper)

Total pointsEstimated riskRisk group
−11.18%Low
01.44%Low
11.75%Low
22.13%Low
32.60%Low
43.15%Intermediate
53.82%Intermediate
64.63%Intermediate
75.60%Intermediate
86.75%High
98.13%High
109.75%High
1111.66%High
1213.88%High
1316.45%High
1419.38%High
1522.70%High
1626.40%High
1730.47%High
1834.86%High
1939.53%High

Citation

Gupta PK, Ramanan B, Mactaggart JN, Sundaram A, Fang X, Gupta H, Johanning JM, Pipinos II. Risk index for predicting perioperative stroke, myocardial infarction, or death risk in asymptomatic patients undergoing carotid endarterectomy. J Vasc Surg. 2013;57(2):318-26. doi:10.1016/j.jvs.2012.08.116 · PubMed 23159474

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