Abstract
Intraoperative neuromonitoring (IONM) is used to detect neurological complications during carotid endarterectomy (CEA), and current data show mixed results in clinical outcomes. This study aimed to examine health care utilization metrics and outcomes relating to the use of IONM in CEA using a large national database in the USA.
Data were abstracted from the 2016 to 2021 Nationwide Readmissions Database. The primary aim was to evaluate whether adverse neurological events, hospital costs, length of stay (LOS), and routine discharge differed by the presence of IONM. We additionally evaluated whether all-cause 30-day and 90-day readmissions, and in-hospital mortality differed by IONM. We adjusted outcomes to control for age, comorbidity burden, left-sided surgery, and elective admission.
There were an estimated 283,045 hospitalizations for CEA, of which 13,469 (4.79%) had IONM. IONM was associated with 12% longer adjusted stays, 16% higher adjusted costs and 35% lower odds of routine discharge (P<0.001). In addition, IONM was associated with increased odds of an adverse neurological event, which included ischemic and hemorrhagic cerebrovascular complications (IONM: 19.40% vs. 12.65%, aOR: 1.31, 95% CI: 1.18-1.45, P<0.001). Lower income quartiles and rural/nonteaching facilities were associated with lower odds of IONM use. There were no differences in mortality or all-cause readmissions.
Our findings showed worse outcomes associated with IONM use during CEA. IONM is typically utilized in high-surgical-risk patients, largely accounting for our findings. The higher costs, longer hospital stays, and lower odds of routine discharge associated with IONM use need to be balanced with potential benefits. We also found significant disparities based on facility type and income. Detailed procedural risk factors, which are lacking from this data, limit the results of this study.