Prediction Models for Clinical Outcome After a Carotid Revascularization Procedure: An External Validation Study
behalf of the Carotid Stenosis Trialists' Collaboration
(2018) Stroke, volume 49, issue 8, pp. 1880 - 1885
(Article)
Abstract
Background and Purpose: Prediction models may help physicians to stratify patients with high and low risk for periprocedural complications or long-term stroke risk after carotid artery stenting or carotid endarterectomy. We aimed to evaluate external performance of previously published prediction models for short- and long-term outcome after carotid revascularization in
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patients with symptomatic carotid artery stenosis. Methods: From a literature review, we selected all prediction models that used only readily available patient characteristics known before procedure initiation. Follow-up data from 2184 carotid artery stenting and 2261 carotid endarterectomy patients from 4 randomized trials (EVA-3S [Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis], SPACE [Stent-Protected Angioplasty Versus Carotid Endarterectomy], ICSS [International Carotid Stenting Study], and CREST [Carotid Revascularization Endarterectomy Versus Stenting Trial]) were used to validate 23 short-term outcome models to estimate stroke or death risk ≤30 days after the procedure and the original outcome measure for which the model was developed. Additionally, we validated 7 long-term outcome models for the original outcome measure. Predictive performance of the models was assessed with C statistics and calibration plots. Results: Stroke or death ≤30 days after the procedure occurred in 158 (7.2%) patients after carotid artery stenting and in 84 (3.7%) patients after carotid endarterectomy. Most models for short-term outcome after carotid artery stenting (n=4) or carotid endarterectomy (n=19) had poor discriminative performance (C statistics ranging from 0.49-0.64) and poor calibration with small absolute risk differences between the lowest and highest risk groups and overestimation of risk in the highest risk groups. Long-term outcome models (n=7) had a slightly better performance with C statistics ranging from 0.59 to 0.67 and reasonable calibration. Conclusions: Current models did not reliably predict outcome after carotid revascularization in a trial population of patients with symptomatic carotid stenosis. In particular, prediction of short-term outcome seemed to be difficult. Further external validation of existing prediction models or development of new prediction models is needed before such models can be used to support treatment decisions in individual patients.
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Keywords: Angioplasty, Carotid endarterectomy, Carotid stenosis, Myocardial infarction, Prognosis, Thromboembolism, Carotid Stenosis/diagnosis, Predictive Value of Tests, Models, Biological, Humans, Treatment Outcome, Endarterectomy, Carotid/statistics & numerical data, thromboembolism, myocardial, infarction, carotid stenosis, calibration, angioplasty, Clinical Neurology, Cardiology and Cardiovascular Medicine, Advanced and Specialised Nursing, Review, Research Support, Non-U.S. Gov't, Journal Article, Research Support, N.I.H., Extramural
ISSN: 0039-2499
Publisher: Lippincott Williams & Wilkins
Note: Funding Information: This study was funded by the Rudolf Magnus Young Talent Fellowship (University Medical Center Utrecht; grant to Dr Greving). Dr Halliday’s research is funded by the National Institute for Health Research, Oxford Biomedical Research Center. Dr Bonati’s research was funded by the Swiss National Science Foundation (grant 32003B_156658). Drs Howard and Brott are funded by the National Institutes of Health/ National Institute of Neurological Disorders and Stroke. Publisher Copyright: © 2018 The Authors. Stroke is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc.
(Peer reviewed)