Jornal Vascular Brasileiro
Jornal Vascular Brasileiro
Original Article

Association between Hospital Carotid Endarterectomy Procedure Volumes and In-Hospital Mortality in São Paulo State

Associação do volume hospitalar de endarterectomia carotídea com a mortalidade intra-hospitalar no estado de São Paulo

Renato Luís Pessôa

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Background: Previous studies indicate an inverse relationship between hospital volume and mortality after carotid endarterectomy. However, data at the level of Brazil are lacking.

Objectives: To assess the relationship between hospital carotid endarterectomy procedure volumes and mortality in the state of São Paulo.

Methods: Data from the São Paulo State Hospital Information System on all carotid endarterectomies performed between 2015 and 2019 were analyzed. Hospitals were categorized into clusters by annual volume of surgeries (1-10, 11-25, and ≥26). Multiple logistic regression models were used to determine whether the volume of carotid endarterectomy procedures was an independent predictor of in-hospital mortality among patients undergoing this procedure.

Results: Crude in-hospital mortality was nearly 60 percent lower in patients who underwent carotid endarterectomy at the highest volume hospitals than among those who underwent endarterectomy at the lowest volume hospitals (unadjusted OR of survival to hospital discharge, 2.41; 95% CI, 1.11-5.23; p = 0.027). Although this lower rate represents 1.5 fewer deaths per 100 patients treated, high-volume centers are more likely than low-volume centers to perform elective procedures, thus the analysis did not retain statistical significance when adjusted for admission character (OR, 1.69; 95% CI, 0.74-3.87; p = 0.215).

Conclusions: In a contemporary Brazilian registry, higher volume carotid endarterectomy centers were associated with lower in-hospital mortality than lower volume centers. Further studies are needed to verify this relationship considering the presence of symptoms in patients.


carotid arteries, endarterectomy, mortality, health policy, vascular surgery


Resumo: Contexto: Estudos indicam uma relação inversa entre volume hospitalar e mortalidade após endarterectomia carotídea. Entretanto, não há dados a nível brasileiro.

Objetivos: Avaliar a relação entre volume hospitalar de endarterectomia carotídea e mortalidade no estado de São Paulo.

Métodos: Foram analisados dados do Sistema de Informação Hospitalar do Estado de São Paulo de todas as endarterectomias carotídeas realizadas entre 2015 e 2019. Os hospitais foram categorizados em grupos de acordo com o volume anual de cirurgias (1-10, 11-25 e ≥26). Modelos de regressão logística múltipla foram usados para determinar se o volume de endarterectomias carotídeas era um preditor independente de mortalidade intra-hospitalar entre os pacientes submetidos a esse procedimento.

Resultados: A mortalidade intra-hospitalar foi quase 60% menor nos pacientes submetidos a endarterectomia carotídea nos hospitais de maior volume em comparação aos pacientes submetidos a endarterectomia nos hospitais de menor volume (OR não ajustado de sobrevida após alta hospitalar, 2,41; IC 95%, 1,11-5,23; p = 0,027). Embora essa taxa mais baixa represente 1,5 menos mortes por 100 pacientes tratados, os centros de alto volume são mais propensos do que os centros de baixo volume a realizarem procedimentos eletivos; portanto, a análise não reteve significância quando ajustada para o caráter de admissão (OR, 1,69; IC 95%, 0,74-3,87; p = 0,215).

Conclusões: Em um registro brasileiro contemporâneo, centros com maior volume de endarterectomia carotídea foram associados a menor mortalidade intra-hospitalar em comparação aos centros de menor volume. Mais estudos são necessários para verificar essa relação considerando a presença de sintomas em pacientes.


artérias carótidas, endarterectomia, mortalidade, política de saúde, cirurgia vascular


1 Joviliano EE. Estenose carotídea: conceitos atuais e perspectivas futuras Carotid stenosis: current concepts and future prospects. J Vasc Bras. 2015;14(2):107-9.

2 Bonamigo TP, Lucas ML. Análise crítica das indicações e resultado do tratamento cirúrgico da doença carotídea. J Vasc Bras. 2007;6(4):366-77.

3 Hannan EL, Popp AJ, Tranmer B, Fuestel P, Waldman J, Shah D. Relationship between provider volume and mortality for carotid endarterectomies in New York state. Stroke. 1998;29(11):2292-7. PMid:9804636.

4 Cowan JA Jr, Dimick JB, Thompson BG, Stanley JC, Upchurch GR Jr. Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume. J Am Coll Surg. 2002;195(6):814-21. PMid:12495314.

5 Huibers A, de Waard D, Bulbulia R, de Borst GJ, Halliday A, ACST collaborative group. Clinical Experience amongst Surgeons in the Asymptomatic Carotid Surgery Trial-1. Cerebrovasc Dis. 2016;42(5-6):339-45. PMid:27322379.

6 Kuehnl A, Tsantilas P, Knappich C, et al. Significant Association of Annual Hospital Volume with the Risk of Inhospital Stroke or Death Following Carotid Endarterectomy but Likely Not after Carotid Stenting: Secondary Data Analysis of the Statutory German Carotid Quality Assurance Database. Circ Cardiovasc Interv. 2016;9(11):e004171. PMid:27815343.

7 Holt PJE, Poloniecki JD, Loftus IM, Thompson MM. Meta-analysis and systematic review of the relationship between hospital volume and outcome following carotid endarterectomy. Eur J Vasc Endovasc Surg. 2007;33(6):645-51. PMid:17400005.

8 Nazarian SM, Yenokyan G, Thompson RE, Griswold ME, Chang DC, Perler BA. From the Southern Association For Vascular Surgery Statistical modeling of the volume-outcome effect for carotid endarterectomy for 10 years of a statewide database. J Vasc Surg. 2008;48(2):343-50, discussion 50. PMid:18644481.

9 Bosiers M, Kleinsorge GHD, Koen D, Navarro TP. Carotid artery surgery: back to the future. J Vasc Bras. 2011;10(1):44-9.

10 Canto JG, Every NR, Magid DJ, et al. The volume of primary angioplasty procedures and survival after acute myocardial. N Engl J Med. 2000;342(21):1573-80. PMid:10824077.

11 Ho KJ, Madenci AL, McPhee JT, et al. Contemporary predictors of extended postoperative hospital length of stay after carotid endarterectomy. J Vasc Surg. 2014;59(5):1282-90. PMid:24447544.

12 Mulatti GC, Puech-Leão P, de Luccia N, da Silva ES. Characterization and natural history of patients with internal carotid occlusion: a comparative study. Ann Vasc Surg. 2018;53:44-52. PMid:30053548.

13 Batagini NC, da Silva ES, Pinto CAV, Puech-Leão P, de Luccia N. Analysis of risk factors and diseases associated with atherosclerosis in the progression of carotid artery stenosis. Vascular. 2016;24(1):59-63. PMid:25687720.

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