Utilization and safety of extracranial–intracranial bypass surgery in symptomatic steno-occlusive disorders

OBJECTIVE: The objective of this study was to investigate patterns of utilization and safety of extracranial–intracranial (EC-IC) bypass in patients with symptomatic cerebrovascular steno-occlusive disorders. METHODS: Patients with one of the steno-occlusive conditions (defined as symptomatic intracranial stenosis, extracranial stenosis, and moyamoya disease) were identified using all nonfederal hospitalizations in New York (2005–2014) and Florida (2005–2015). EC-IC bypass surgery was defined using the corresponding procedure codes. Patients were included if there was a prior history of ischemic stroke or transient ischemic attack. Patients were excluded for any preceding diagnosis of cerebral hemorrhage, aneurysm, or trauma. The primary outcome was perioperative ischemic stroke, cerebral hemorrhage, or mortality occurring within 30 days of surgery. We also determined yearly trends for the volume of EC-IC bypass procedures in the study period. RESULTS: Among 346 patients with steno-occlusive disease treated with EC-IC bypass, median age was 52.5 years and 52.5% were female. Rates of EC-IC bypass surgery procedure increased until 2011 and then decreased coinciding with the publication of the Carotid Occlusion Surgery Study trial. Thirty-day event rates of stroke, hemorrhage, or death decreased in patients treated with EC-IC bypass (odds ratio: 0.2, confidence interval: 0.0.4–0.99; P = 0.03) over the 10-year study period. CONCLUSIONS: Overall utilization of EC-IC bypass procedure is relatively low, whereas the 30-day complication rates for patients with steno-occlusive conditions appear to be relatively low and improving. Further research is needed to confirm these findings and to determine the subset of patients who would most likely benefit from this intervention.