Carotid endarterectomy before and after publication of randomized controlled trials

BACKGROUND: In 1991, the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) demonstrated that carotid endarterectomy (CEA), in addition to best medical therapy, significantly reduces ipsilateral stroke in patients with high-grade (70 per cent or more) carotid artery stenosis compared with best medical therapy alone. In 1995, the Asymptomatic Carotid Atherosclerosis Study demonstrated that CEA was of benefit in asymptomatic patients with stenosis greater than 60 per cent. The aim of this paper was to examine how the practice and outcome of CEA have changed since publication of these data. METHODS: A prospectively gathered computerized database comprising 634 consecutive CEAs was studied. Two time intervals were analysed: 1975-1991 inclusive (17 years) and 1 January 1992 to 1 May 1998 (6 years 4 months). RESULTS: Since 1991, there has been a fourfold increase in the number of CEAs performed annually for symptomatic disease. CEA is now performed almost exclusively for high-grade (more than 70 per cent) stenosis. There has been a significant reduction in the total peri-operative neurological event rate (12.5 versus 5.9 per cent, P < 0.05), and the 30-day combined major stroke (Rankin grade 3-5) and mortality rate has fallen to 2.0 per cent. The number of patients who have CEA for asymptomatic disease remains small with 16 of 30 being randomized within the Asymptomatic Carotid Surgery Trial. CONCLUSION: Publication of ECST and NASCET data has been associated with a major increase in the number of CEAs performed for symptomatic disease in this unit. Despite a greater proportion of high-risk patients, the results have improved progressively.     

Clinical and radiographic risk factors for operative stroke and death in the European carotid surgery trial.

OBJECTIVES: carotid endarterectomy is associated with significant morbidity and mortality. A better understanding of the relationships between baseline characteristics and outcome may help to reduce the risks of surgery. In order to make accurate and unbiased estimates of surgical risk it is important to study cohorts of patients that were established prospectively, where independent physicians assessed outcome, and where the decision to analyse and report the results was not data-dependent. The surgical arm of the European Carotid Surgery Trial (ECST) is such a cohort. METHODS: the 30-day outcome of carotid endarterectomy was analysed in ECST surgery patients in relation to their baseline clinical and angiographic characteristics. The severity of operative strokes was compared with that of strokes that occurred in the medical group. RESULTS: 1729 patients underwent trial surgery. There were 17 deaths (1.0%, 95% CI=0.6-1.6) and 105 non-fatal major strokes (6.1%, 95% CI=5.0-7.3) within 30 days of surgery. The risk of major stroke or death was 7.1% (95% CI=5.9-8.4). The risk of disabling or fatal stroke was 3.0% (95% CI=2.1-3.8). The ratio of disabling to non-disabling operative strokes was similar to that in the medical group. Several baseline characteristics predicted the operative risk of stroke and death in univariate analyses, but only four were independent risk factors in a multiple regression analysis: presentation with cerebral TIA vs ocular ischaemic events only (HR=2.99, 95% CI=1.33-6.69, p=0.008); female sex (HR=2.04, 95% CI=1.37--3.06, p=0.001); systolic hypertension (HR=1.01 per 10 mmHg, 95% CI=1.00-1.02, p=0.03) and peripheral vascular disease (HR=2.17, 95% CI=1.17-2.89, p=0.001). CONCLUSIONS: the operative risk of stroke and death in the ECST was comparable with other prospective studies and trials in which patients were assessed postoperatively by both a physician and a surgeon. Case fatality and disability after operative stroke are similar to strokes that occur on medical treatment only. Several baseline patient characteristics predict surgical risk and it may be possible to use these characteristics to aid patient selection and surgical audit.     

Analysis of factors contributing to improved outcome for carotid endarterectomy

Since carotid endarterectomy was revitalized following the North American Symptomatic Carotid Endarterectomy Trial and Asymptomatic Carotid Atherosclerosis Study, results have improved. However, types of carotid endarterectomy, indications, risk factors, surgical factors, techniques, and other treatment modalities may be associated with outcomes of carotid endarterectomy. The purpose of this study was to identify those factors in a broad-based carotid endarterectomy patient. This study involved review of the data from 3,644 patients undergoing carotid endarterectomy in New York State hospitals. A multivariate statistical model was used to identify significant patient risk factors to examine the association of the process of care and surgical factors, including surgical specialty for outcome of carotid endarterectomy. In-hospital death and stroke rate overall was 1.84%. After adjustment for patient risk factors, specific processes of care, such as eversion endarterectomy, protamine, heparin, or shunt, were associated with lower adverse outcomes relative to patients undergoing carotid endarterectomy without these processes. Similarly, patients undergoing carotid endarterectomy by vascular surgeons had lower adverse outcomes compared to neurosurgeons and general surgeons. This retrospective review showed that processes of care and surgical specialty were significant factors that contributed to outcomes following carotid endarterectomy.     

Carotid artery stenting: to be or not to be?

Carotid endarterectomy (CEA) has been the standard of care for suitable patients with symptomatic or asymptomatic high grade carotid stenosis since the landmark NASCET (North American Symptomatic Carotid Endarterectomy Trial), ECST (European Carotid Surgery Trial) and ACAS (Asymptomatic Carotid Artery Surgery) studies performed in the 1990s and more recently the ACST (Asymptomatic Carotid Surgery Trial). Carotid artery stenting (CAS) in the treatment of both symptomatic and asymptomatic patients with high grade carotid stenosis has recently been investigated as an alternative to CEA. We present a review of the most recent CAS trials and examine some of the controversies that surround them.     

The influence of surgical specialty and caseload on the results of carotid endarterectomy

Carotid endarterectomy is rapidly becoming one of the most commonly performed major surgical operations in the United States, in part because of the greater availability of noninvasive techniques to accurately diagnose extracranial carotid arterial disease and a low reported morbidity and mortality. We retrospectively reviewed the records for all carotid endarterectomies performed in the greater Cincinnati area for a recent 12-month period and examined the impact of surgical specialty and operative caseload on the results. Altogether, 750 operations were performed on 656 patients by 61 surgeons working in 16 general medical-surgical hospitals. Overall, strokes occurred in 5.1% of all patients; 2.3% of patients died. Symptomatic patients had a significantly higher risk of suffering a postoperative stroke compared with asymptomatic patients (6.5% vs. 3.7%), although the risk of death was virtually identical (2.4% vs. 2.1%). When the operating surgeons were classified into four types on the basis of their previous training, no statistically significant differences in either postoperative stroke or death could be identified. Furthermore, when the surgical caseloads of these physicians were grouped into three categories (i.e., less than 12 each year, more than 50 each year, and a group between these two extremes), no significant differences in outcome were seen. We concluded that our community-wide results for carotid endarterectomy were not comparable to those previously published from specialized centers and that these results did not appear to be influenced by the type of formal surgical specialty or operative caseload.     

Behandlung der Karotisstenose durch Stentimplantation

The incidence of arterioarterial stroke originating from the supra-aortic branches is 187/100,000/year.The 90-day prognosis shows a probability of 15% mortality and 19% severe disability. Based on the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST), the indications for endarterectomy have a high level of evidence. Recommendations for carotid endarterectomy depending on the perioperative risk are defined in the American Heart Association (AHA) and European Stroke Initiative (EUSI) proposals. Several trials have shown that stent supported carotid angioplasty is now an almost equivalent alternative for short-term and intermediate-term follow-up, and an even safer alternative technique in surgically high risk patients. However, the following contraindications must be taken into consideration: thrombosis of the internal carotid artery, long stenoses, aneurysms of the aortic arch with involvement of the supra-aortic branches, carotid occlusion in cases of maintenance of the branchial artery coiling of the internal exit area, as well as severe contrast medium allergy. For the endovascular surgeon this implies the need to learn about and to be involved in using this challenging technique. This therapeutic option allows patient oriented therapy and may further reduce the overall complication rate of carotid stenosis therapy.     

Carotid endarterectomy after NASCET and ACAS: A statewide study

Purpose: Since the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Artery Stenosis Study (ACAS) established the efficacy of carotid endarterectomy at large academic centers, there have been two community-based studies of outcomes after this operation. The purpose of this study was to perform a statewide survey to evaluate postoperative morbidity and mortality after carotid endarterectomy among patients throughout Maine. Methods: A statewide registry was established to collect prospective data on carotid operations from January 1 to December 31, 1995. All surgeons and hospitals in the state were solicited to participate. All carotid endarterectomies were intended to be included; the only exclusion criterion was out-of-state residence. Comorbidities, preoperative studies, surgical indications, operative technique, and postoperative outcomes were analyzed. State administrative data were used to assess registry coverage. Results: Ten of 17 hospitals participated, and 58% of all carotid endarterectomies performed in the state were included. Three hundred sixty-four operations were entered into the registry. Forty-four percent of the operations were performed for transient ischemic attack, 37% for asymptomatic stenosis, and 19% for stroke. The postoperative stroke rate was 2.5% with a total neurologic complication rate of 4.7% (transient ischemic attack and stroke). There was one postoperative death (mortality rate 0.3%). Patients with symptoms had a higher incidence of postoperative stroke (4.0% vs 0% asymptomatic; p < 0.05) and transient ischemic attacks (3.8% vs 0.8% asymptomatic). Hospital stroke rates varied from 0% to 7%. Stroke rate did not differ significantly between low-volume hospitals (2 to 28 patients/year, 3.3%) and high-volume hospitals (29 to 101 patients/year, 2.3%) or between low-volume surgeons (fewer than 11 operations/year, 1.7%) and high-volume surgeons (more than 12 operations/year, 2.4%). Among 26 reporting surgeons, stroke rate varied from 0% to 10%; the absolute number of strokes per surgeon varied between zero and two. Conclusion: The statewide registry showed a postoperative stroke plus death rate of 2.8%, comparable with the NASCET and ACAS findings. Although this study had inherent limitations, the results from one state, including a variety of community practices, achieved results comparable with those of landmark trials. (J Vasc Surg 1998;27:1017-23.)     

Comparison of carotid endarterectomy at high- and low-volume hospitals.

BACKGROUND: Population-based studies have demonstrated better outcomes for carotid endarterectomies at high-volume hospitals. METHODS: This is a 2-year retrospective review of carotid procedures at two low-volume hospitals (n = 156) and one high-volume hospital (n = 404) in the metropolitan area of Portland, Oregon. RESULTS: There were no significant differences in 30-day mortality and stroke rates for carotid endarterectomies when comparing low- and high-volume hospitals (P = 0.59). These were comparable rates despite the fact that the low-volume hospitals had significantly older patients (P <0.001), more smokers (P <0.001), more patients with an indication of a previous nondisabling stroke (P <0.01), and fewer patients who were asymptomatic (P <0.01). CONCLUSION: The regionalization of carotid endarterectomy into high-volume hospitals is not justified by the findings of this study. Carotid endarterectomy performed by well-trained, experienced surgeons in low-volume hospitals is a safe procedure.     

Aktueller Status von ECST-2

Background

Carotid endarterectomy (CEA) is a common procedure performed in patients who have suffered a stroke or transient ischaemic attack (TIA) to prevent a recurrent event. Clinical trials have provided evidence for the safety and efficacy of CEA in patients with recently symptomatic stenosis. Carotid artery stenting is an alternative to CEA. However, medical treatment has improved in the last 30 years and trials are ongoing to assess the use of modern medical treatment in selected patients with carotid disease as an alternative to revascularization.

Methods

We have reviewed the published results from clinical trials investigating the best treatment for symptomatic and asymptomatic carotid artery stenosis. In this review we discuss carotid endarterectomy, stenting and medical treatment. We have also included an update on the Second European Carotid Surgery Trial (ECST-2) which is an ongoing trial comparing revascularization to optimized medical therapy in patients with low to intermediate risk of recurrent stroke.

Results

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) both show that patients with high-risk symptomatic carotid stenosis benefit from CEA over medical treatment alone. However, it has been shown that surgery appeared to be harmful or at least not beneficial in patients included in the trials whose characteristics predicted a low risk of recurrent stroke. The Asymptomatic Carotid Surgery Trial (ACST) also showed a small benefit in treating asymptomatic patients with CEA over medical therapy. Several published trials have compared stenting with endarterectomy and although endarterectomy appears safer in the short term, both treatments have similar long-term outcomes; therefore stenting can be used as an alternative to CEA for selected patients.

Conclusion

CEA and stenting can both be offered to patients with recently symptomatic carotid stenosis to prevent recurrent stroke. We await the results of current trials investigating the role of modern medical therapy in selected patients with low to intermediate risk of recurrent stroke as an alternative to revascularization. The English full-text version of this article is available at SpringerLink (under “Supplemental”).     

Natural history of carotid artery occlusion contralateral to carotid endarterectomy

BACKGROUND: The natural history of patients with carotid artery occlusion is controversial. A few studies have concluded that patients with internal carotid artery occlusion carry a high risk of neurologic events. None of these previously reported studies analyze the natural history of internal artery occlusion contralateral to carotid endarterectomy (CEA), except for a small series including a subset of patients from two randomized trials, the Asymptomatic Carotid Atherosclerosis Study and the North American Symptomatic Carotid Endarterectomy Trial. This study analyzes the natural history of patients with carotid artery occlusion contralateral to CEA, specifically assessing long-term neurologic events occurring in the hemisphere associated with the occluded carotid artery. METHODS: Of the 599 CEAs in 544 patients that were included in two previously updated prospective studies, 63 patients had contralateral internal carotid artery occlusion, and their perioperative and long-term outcomes were evaluated. A Kaplan-Meier analysis was used to estimate the rate of freedom from late stroke occurring in the hemisphere ipsilateral to the occluded carotid artery. The stroke-free survival rate was also noted. RESULTS: Mean follow-up was 58 months (range, 1 to 147 months). One perioperative stroke (1.6%) occurred, which was not in the cerebral hemisphere ipsilateral to the occluded carotid artery. Two late strokes (3.2%) and nine transient ischemic attacks (TIAs) (14.3%) occurred involving the hemisphere of the occluded carotid artery. There were also three late TIAs (4.8%) and no late strokes involving the hemisphere supplied by the operative site. There were a total of 14 late deaths. Fifteen patients had late > or =50% restenosis of the operative side. Six of these had neurologic events (TIA/stroke) involving the hemisphere of the occluded carotid artery, in contrast to five of 48 patients with no restenosis who had neurologic symptoms (P < .001). Freedom from late strokes in the hemisphere ipsilateral to the occluded carotid artery at 1, 3, 5, and 10 years was 98%, 96%, 96%, and 96%, respectively. The stroke-free survival rates at 1, 3, 5, and 10 years were 90%, 87%, 80%, and 59%, respectively. CONCLUSIONS: The natural history of carotid artery occlusion contralateral to CEA is relatively benign. This may suggest a protective effect of carotid endarterectomy on the cerebral hemisphere ipsilateral to the carotid occlusion from late strokes.     

Reasons why data from the Nationwide Inpatient Sample can be misleading for carotid endarterectomy and carotid stenting

The Nationwide Inpatient Sample (NIS) is often used for population-based research comparing the safety of carotid artery stenting (CAS) to that of carotid endarterectomy (CEA) in the United States. At least two findings from the NIS dataset seem questionable, however. First, several NIS studies indicate that >90% of CEAs and CAS procedures are currently being performed for asymptomatic carotid stenosis, which considerably exceeds the prevalence of asymptomatic patients reported elsewhere. Second, these studies also suggest that periprocedural stroke rates for CEA and CAS are collectively lower at hundreds of community hospitals contributing data to the NIS than they were in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), even though the participating surgeons and interventionalists in CREST were vetted on the basis of their previous experience and results. In addition, some unexpectedly low stroke to death ratios are present in NIS studies, implying that not all iatrogenic strokes have been entered into the NIS dataset. These issues might be related to inadequate documentation of preprocedural symptoms and periprocedural strokes in the medical records, leading to subsequent coding errors in the hospital discharge abstracts from which NIS data are extracted. The clinical limitations of the NIS and other administrative datasets have been pointed out in the past, but they appear to be particularly relevant to carotid interventions and must be recognized.     

Karotisendarteriektomie vs. Karotisstent

Carotid stenosis is responsible for 15–20% of ischemic strokes in the adult population. Carotid endarterectomy is a procedure that has been shown to be superior to medical treatment in the prevention of stroke in patients with symptomatic carotid stenosis >70% stenosis according to NASCET criteria. Now randomised studies and meta-analysis reported short term safety and intermediate term efficacy of carotid endarterectomy vs. carotid artery stenting. The periprocedural risk of stroke was shown to be lower for carotid endarterectomy. In the intermediate term follow up, both treatments are comparable in stroke and death prevention. Restonis of carotid artery is significantly higher in the carotid stenting group. Patients age influences the number of primary outcome events in the carotid stenting group.     

Protected carotid stenting in high-surgical-risk patients: the ARCHeR results

BACKGROUND: Carotid endarterectomy is the standard of care for most patients with severe extracranial carotid bifurcation disease. However, its safety and efficacy in patients with significant surgical risk are unclear. The ARCHeR (ACCULINK for Revascularization of Carotids in High-Risk patients) trial was performed to determine whether carotid artery stenting with embolic protection is a safe and effective alternative to endarterectomy in high-surgical-risk patients. METHODS: The ARCHeR trial is a series of three sequential, multicenter, nonrandomized, prospective studies. Forty-eight sites enrolled 581 high-surgical-risk patients between May 2000 and September 2003. Patients with severe carotid artery stenosis (angiographically defined, symptomatic > or =50%, or asymptomatic > or =80%) had an ACCULINK nitinol stent implanted. The ACCUNET filter embolic protection system was added to the procedure in the final 2 studies (422 patients). The primary efficacy end point was a composite of periprocedural (< or =30 days) death, stroke, and myocardial infarction, plus ipsilateral stroke between days 31 and 365. RESULTS: The 30-day rate of death/stroke/myocardial infarction was 8.3% (95% confidence interval [CI], 6.2%-10.8%), and that of stroke/death was 6.9% (95% CI, 5.0%-9.3%). Most (23/32) strokes were minor, of which more than half (12/23) returned to baseline National Institutes of Health Stroke Scale scores within 30 days. The 30-day major/fatal stroke rate was 1.5% (95% CI, 0.7%-2.9%). No hemorrhagic strokes were observed in the study. Ipsilateral cerebrovascular accident occurred in 1.3% between 30 days and 1 year, thus giving a primary composite end point of 30-day death/stroke/myocardial infarction plus ipsilateral stroke at 1 year of 9.6% (95% CI, 7.2%-12.0%), which is below the 14.4% historical control comparator. Target lesion revascularization at 12 months and 2 years was 2.2% and 2.9%, respectively. CONCLUSIONS: The ARCHeR results demonstrate that extracranial carotid artery stenting with embolic filter protection is not inferior to historical results of endarterectomy and suggest that carotid artery stenting is a safe, durable, and effective alternative in high-surgical-risk patients.     

Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels

BACKGROUND: Carotid endarterectomy (CEA) is the standard of care for patients with high-grade carotid artery stenosis who are acceptable surgical candidates. Focal occlusive lesions of the origin of aortic arch vessels can be effectively and safely treated with balloon angioplasty and primary stenting. The purpose of this study was to retrospectively review results of carotid endarterectomy for high-grade carotid bifurcation stenosis combined with intraoperative retrograde transluminal angioplasty and primary stenting of a hemodynamically significant stenosis at the origin of a proximal ipsilateral aortic arch vessel. METHODS: Between October 1994 and August 1998, 592 patients underwent CEA. Six patients were found to have hemodynamically significant tandem lesions affecting one of the aortic arch vessels and the ipsilateral ICA for an overall incidence of 1%. Age ranged from 63 to 78 years (mean 74.7). Four of 6 (67%) patients had asymptomatic lesions, and 2 of 6 (33%) had symptoms of cerebral ischemia. Five patients had tandem lesions affecting the proximal left common carotid artery and the left ICA. One patient had a tandem lesion affecting the innominate artery and the right ICA. Carotid duplex imaging and arch and cerebral arteriography was performed in all six patients. Arteriography confirmed high-grade stenoses in both the ICA and ipsilateral proximal aortic arch vessel. The range of stenoses in the ICA was 70 to 95% (mean 80.8%) measured arteriographically. The range of stenoses at the origin of the aortic arch vessels was 75-90% (mean 79.2%). All six patients underwent combined retrograde transluminal balloon angioplasty and primary stenting of the ipsilateral CCA or innominate artery with temporary occlusion of the ICA for cerebral protection. The endovascular procedure was then followed with standard surgical endarterectomy using an inline shunt. RESULTS: All six procedures were successfully completed. There were no periprocedural strokes or other morbidities. Follow-up ranged from 6 to 43 months (mean 23.6) and showed no evidence of recurrent stenosis by carotid duplex imaging. No TIAs or strokes related to the surgically corrected lesions were noted during the follow-up period. One patient suffered a right hemispheric stroke secondary to a high-grade right carotid stenosis which occurred two months after her procedure surgically correcting tandem lesions on the opposite side. CONCLUSIONS: Carotid endarterectomy with balloon angioplasty and primary stenting of an ipsilateral hemodynamically significant aortic arch trunk vessel stenosis can be safely and successfully accomplished and avoids the need for an intra/extrathoracic bypass procedure.     

Outcomes of carotid endarterectomy: how does the Australian state of New South Wales compare with international benchmarks?

OBJECTIVES: The objective of this study was to determine the outcomes of carotid endarterectomy (CEA) in New South Wales, Australia. METHODS: This state-wide prospective audit of all public and private hospitals during a 6-month period had main outcome measures of 30-day mortality, 30-day fatal stroke, 30-day nonfatal stroke, and 30-day combined stroke and mortality. RESULTS: Fifty-three of 54 eligible surgeons participated (response rate, 98%). The audit obtained inpatient data for 689 internal CEA procedures performed on 666 patients. Of 666 first or only procedures, 462 (69.4%) were performed on patients who were symptomatic and 204 (30.6%) on patients who were asymptomatic. After adjustment for cluster by surgeon, we determined a state-wide 30-day death rate of 1.2% (95% CI, 0.3% to 2.1%), a 30-day fatal or nonfatal stroke rate of 3.0% (95% CI, 1.6% to 4.4%; ipsilateral stroke, 2.6%), a 30-day nonfatal stroke rate of 2.3% (95% CI, 1.1% to 3.4%; ipsilateral stroke, 2.0%), and a 30-day combined stroke and death rate of 3.5% (95% CI, 2.1% to 4.9%). A significant linear relationship was found between patient preoperative hypertensive status and the combined 30-day stroke and death rate (trend odds ratio, 3.5; 95% CI, 1.6 to 7.7). No association was seen between any main outcome measures and hospital volume (<10 CEAs versus > or = 10 CEAs). Four patients underwent surgery outside guideline recommendations (CEA performed for either < or = 30% stenosis or occluded carotid artery). CONCLUSION: This first comprehensive state-wide audit confirms that Australian surgeons achieve 30-day outcomes comparable with international benchmarks.     

Carotid endarterectomy in octogenarians: comparison with patient characteristics and outcomes in younger patients

OBJECTIVES: Carotid endarterectomy has been shown to be of clear benefit to selected patients. However, recent trials of carotid endarterectomy versus best medical therapy have excluded octogenarians, and some authors have suggested that carotid endarterectomy would have an unfavorable cost-benefit relationship in octogenarians. We compared patients and results for carotid endarterectomy in octogenarians and younger patients. METHODS: We reviewed the results for 582 primary carotid endarterectomies (90 in octogenarians and 492 in younger patients) performed in 528 patients between February 1, 1985, and January 31, 1998 (all data were collected prospectively for the most recent 301 carotid endarterectomies). Conventional surgical technique was used with general anesthesia, selective shunting, and selective patching. Main outcome measures were perioperative and late ipsilateral stroke and death. RESULTS: The two groups were similar with respect to indications for carotid endarterectomy and patient characteristics, except that octogenarians were more likely to have histories of congestive heart failure or hypertension and less likely to have histories of smoking or chronic lung disease. Carotid endarterectomy was performed for asymptomatic disease in 27% of the octogenarians and 33% of the younger patients (P =.31). Stenosis was >/=80% in 90% of the octogenarians and 78% of the younger patients (P =.014). Perioperative strokes, all of which were ipsilateral, occurred in one octogenarian (1.1%) and eight younger patients (1.6%, P = 1.00). No octogenarians and two younger patients died within 30 days of surgery (P = 1.00). Length of stay and direct costs associated with carotid endarterectomy were similar for octogenarians and younger patients. Late strokes occurred in two octogenarians (one ipsilateral) and four younger patients (two ipsilateral). Life table estimates of freedom from ipsilateral stroke at 2 years were 98% and 97% for octogenarians and younger patients, respectively (log-rank P =.69), and life table estimates of patient survival at 4 years were 81% and 89% for octogenarians and younger patients, respectively (P =.11). Octogenarians represented an increasing fraction of the carotid endarterectomies performed during the study period. CONCLUSIONS: Octogenarians selected for carotid endarterectomy were similar to younger patients with respect to indications for carotid endarterectomy and comorbidities. Early mortality, early and late neurologic outcome, complications, and resource utilization were similar for the two groups, and more than 75% of octogenarians survived 4 years after undergoing carotid endarterectomy. Cost-benefit analyses for carotid endarterectomy, which are highly sensitive to expected patient survival, might not be pertinent to individual patient situations. Intellectually intact octogenarians without unusually severe comorbidities are good candidates for and should be offered the benefits of carotid endarterectomy.     

Carotid endarterectomy in patients with contralateral carotid occlusion

Total occlusion of the contralateral internal carotid artery has often been considered to be a predictor of adverse neurologic outcomes following carotid endarterectomy of an ipsilateral carotid stenosis. Results from both the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study have suggested this to be true. However, each of these trials had relatively few patients with contralateral occlusion in the surgical arms of the studies. In contrast to these studies, there are multiple surgical series in the literature demonstrating excellent results of carotid endarterectomy in patients with contralateral total occlusion. Recently, advocates of carotid angioplasty and stenting have suggested that this technique may be preferable in patients with a contralateral occlusion because of the perceived poor outcomes with surgery. As carotid angioplasty and stenting becomes more popular, it is becoming even more crucial to better define those patients who are truly at increased risk following carotid endarterectomy; ultimately, this will help clinicians decide which patients may derive the most benefits from endovascular therapies. With these issues in mind, the purpose of this review is to examine results of carotid endarterectomy in patients with total occlusion of the contralateral carotid artery.     

Current management of extracranial carotid artery disease

Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year; 80% are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter, randomized, controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis and compare these data to a critical analysis of the recent results of CAS.     

Early endarterectomy for severe carotid artery stenosis after a nondisabling stroke: Results from the North American Symptomatic Carotid Endarterectomy Trial

Purpose: The timing of carotid endarterectomy (CE) after a recent nondisabling stroke remains controversial. Delaying surgery in such cases may needlessly place patients at risk for a recurrent stroke that may be major and disabling. This study examines the prognostic implications of performing early endarterectomy compared with delayed endarterectomy in patients from the North American Symptomatic Carotid Endarterectomy Trial.Method: This retrospective, subgroup analysis involved 100 surgical patients with severe (70% to 99%) angiographically defined carotid artery stenosis, who were diagnosed with a nondisabling hemispheric stroke at entry into the trial. Forty-two CEs were performed within 30 days (early group, ranging 3 to 30 days), and 58 were performed beyond 30 days (delayed group, range 33 to 117 days) after stroke. The risk of subsequent stroke after CE was compared between the two groups.Results: Baseline clinical characteristics were comparable in both the early and delayed groups. In the delayed group more lesions were identified ipsilateral to the symptomatic side on the preoperative computed tomography scans. The postoperative (30 days after endarterectomy) stroke rate was 4.8% in the early group and 5.2% in the delayed group, yielding a relative rate of 0.92 (95% confidence interval, 0.16 to 5.27; p = 1.00). No deaths occurred after operation in either group. At the end of 18 months, the rates of any stroke or death were 11.9% and 10.3% for the early and delayed groups, respectively, resulting in a relative rate of 1.15 (95% confidence interval, 0.38 to 3.52; p = 1.00). No association was found between an abnormal preoperative computed tomography scan result and the subsequent risk of stroke when early operation was used.Conclusion: Early CE for severe carotid artery stenosis after a nondisabling ischemic stroke can be performed with rates of morbidity and mortality comparable to those who receive delayed endarterectomy. Delaying the procedure by 30 days for patients with symptomatic high-grade stenosis exposes them to a risk of a recurrent stroke, which may be avoidable by earlier surgery. (J VASC SURG 1994;20:288-95.)     

Perioperative strokes after 1001 consecutive carotid endarterectomy procedures without an electroencephalogram: incidence, mechanism, and recovery

HYPOTHESIS: That alternative methods of cerebral protection, especially routine shunting of all patients undergoing general anesthesia or shunting on the basis of neurologic assessment with the patient awake under cervical plexus block, result in outcomes of carotid endarterectomy comparable with those reported using electroencephalographic monitoring. DESIGN: Retrospective review of cases from a vascular registry established in 1990. SETTING: Tertiary care center. PATIENTS: Consecutive sample of 1001 patients who underwent carotid endarterectomy. INTERVENTIONS: Carotid endarterectomy procedures were performed without electroencephalographic monitoring, using general anesthesia with routine shunting or using regional anesthesia. MAIN OUTCOME MEASURES: Overall stroke and mortality rates and cause and consequence of the postoperative strokes. RESULTS: There were 14 nonfatal strokes (1.4%) and 2 deaths (0.2%), for a combined stroke and death rate of 1.6%. Nine (64%) of the 14 strokes appeared to result from a technical error during the endarterectomy. Mild deficits were noted after 7 strokes (50%), with the remainder resulting in deficits that required inpatient rehabilitation. Twelve patients with strokes (86%) eventually returned home without need for assistance. CONCLUSIONS: Most postoperative strokes in this series were due to technical errors. Overall, even in patients with strokes initially requiring inpatient rehabilitation, there was good recovery of function. Low stroke and mortality rates can be achieved in carotid endarterectomy without the use of electroencephalographic monitoring.