The practice of carotid endarterectomy in a large metropolitan area

All carotid endarterectomies performed in the greater Cincinnati metropolitan area during 1980 were reviewed. For the 431 procedures performed in 16 hospitals, the operative stroke rate was 8.6% (37 of 431), and the operative mortality rate was 2.8% (12 of 431). The combined morbidity and mortality was 9.5% (41 of 431). Fifty percent of the procedures were done for asymptomatic carotid disease (216 of 431) and 50% were done for symptomatic carotid disease (215 of 431). The stroke rate was 5.6% for the asymptomatic patients and 11.6% for the symptomatic patients (difference significant, p less than 0.05). Neurosurgeons and vascular surgeons had similar surgical morbidity. All of the operative strokes involved the hemisphere ipsilateral to the endarterectomy. Fifty-seven percent of the operative strokes (21 of 37) occurred after a neurologically intact interval lasting hours to days. Four occurred following combined endarterectomy-coronary bypass surgery, and one was an intracerebral hemorrhage. The other late strokes (17) occurred without evidence for cardiac embolus or hemorrhage, consistent with a thrombogenic-embologenic operative site, and raising the question of need for adjunctive perioperative medical therapy.     

Early outcome of carotid angioplasty and stenting versus carotid endarterectomy in a single academic center

BACKGROUND: Evidence is accumulating that carotid angioplasty and stenting (CAS) might become an alternative to carotid endarterectomy (CEA) for the treatment of high-grade carotid artery disease (CAD). Evaluating the efficacy of this novel technique in single institutions in addition to performing further large trials can help to guide optimal patient management in everyday practice. METHODS: In this study we compared the early outcome of 100 prospectively followed patients who underwent CAS with a retrospectively reviewed group of 142 patients that underwent CEA over the same time period. Only patients who had received pre- and postsurgical evaluations by a neurologist were included. According to the criteria set forth by the large trials the occurrence of minor or major strokes, myocardial infarction and death within 30 days was analysed. RESULTS: Both groups had similar age and sex distributions, as well as cerebrovascular risk factors. In the group of CAS patients 63 (63%) and in the group of CEA patients 92 (65%) had a symptomatic carotid stenosis, respectively. For symptomatic patients the overall complication rate (any stroke or death) was 6.5% (3 minor and 3 major strokes) in the surgical and 8% (2 minor strokes, 2 major strokes, and 1 death) in the non-surgical group (n.s.). For asymptomatic patients there was one minor stroke (2%) in the surgical and no stroke or death in the non-surgical group. As a frequent non-neurological complication the post-procedural course was complicated by groin hematoma requiring surgery in 3 CAS patients, and neck hematoma requiring additional surgery in 3 CEA patients. CONCLUSIONS: Within our academic institution we found comparable complication rates for CAS and CEA in patients with symptomatic or asymptomatic high-grade CAD. Although these early results are promising and support the notion that CAS may become an alternative treatment option for CAD in everyday practice, the long-term efficacy of CAS has to be evaluated critically by means of further prospective studies.     

Carotid endarterectomy. Clinical results in a community-based teaching hospital

Since 1971, 688 consecutive carotid endarterectomies were performed in 612 patients in a community-based teaching hospital by 16 surgeons; 82% of the procedures were performed in patients who had suffered a transient ischemic attack, amaurosis fugax, or a previous stroke. Seven patients (1%) died, five of perioperative stroke and two of myocardial infarction. Thirty-one patients suffered a perioperative stroke (4.5% of the 688 endarterectomies); 20 patients (2.9% of 688) were left with moderate to severe neurologic deficits. The combined mortality/major neurologic deficit morbidity rate (number of patients divided by number of endarterectomies) is 3.2%. Both operative mortality and morbidity have progressively declined in successive 5-year periods, with no deaths and a 2.7% stroke rate in 148 endarterectomies performed after 1984. Our results indicate that carotid endarterectomy as practiced in a community-based teaching hospital can be performed without excessive risk.     

Selection process for surgeons in the Asymptomatic Carotid Atherosclerosis Study.

BACKGROUND AND PURPOSE: The Asymptomatic Carotid Atherosclerosis Study is a prospective, multicenter, randomized clinical trial of carotid endarterectomy for the treatment of asymptomatic hemodynamically significant stenosis. This report describes the selection process for participating surgeons in the trial. METHODS: The Surgical Management Committee established guidelines for minimal annual experience and maximum neurological morbidity and mortality for surgeons to qualify to participate in the study. For approval, a surgeon must perform at least 12 carotid endarterectomies per year. Based on a review of the surgeon's last 50 consecutive endarterectomies, the combined neurological morbidity and mortality rate must be no greater than 5% for all indications and no greater than 3% for endarterectomies performed on asymptomatic patients. RESULTS: One hundred sixty-four surgeons from 48 centers applied for approval: 117 were approved, 17 were rejected, and 30 were not reviewed. The 117 approved surgeons submitted a total of 5,641 endarterectomies with a combined mortality and neurological morbidity rate of 2.3% for the variety of indications for operation. CONCLUSIONS: This overall experience with carotid endarterectomy is one of the largest series reported to date. The data from approved surgeons are well within the range of acceptable neurological morbidity and mortality rates recommended by the Stroke Council of the American Heart Association, which attests to the overall quality of the surgeons participating in the study.     

Prognosis of asymptomatic carotid occlusion

Ninety-four asymptomatic patients with internal carotid artery occlusion were followed for a mean of 44 months, 16% suffered strokes and 11.7% reported transient ischemic attacks (TIA). The annual stroke and TIA rates were 4.4% and 3.2%, respectively, the annual mortality was 11.3%. In 27 asymptomatic patients progression of extracranial arterial disease to occlusion was observed: 7.4% of these patients suffered from stroke and 18.5% reported TIA's during that period. Thus the annual stroke rate was lower (1.9%) but the TIA rate higher (4.7%) than post-occlusive rates. These data reflect an increase risk in patients with progressive high-degree carotid stenosis which continues after occlusion. This may favour carotid endarterectomy for selected patients in the pre-occlusive state because medical treatment has not been shown to prevent progression of stenosis to occlusion.     

Real-world replication of randomized controlled trial results for carotid endarterectomy

BACKGROUND: The efficacy of carotid endarterectomy (CE) has been shown in randomized clinical trials (RCTs), but doubts remain about whether the results can be replicated in routine clinical practice, especially in asymptomatic patients for whom the absolute risk reduction shown in the trials is small. In particular, a low rate of short-term adverse events is required for the long-term benefits of CE to accrue over time. OBJECTIVE: To determine whether the incidence of short-term adverse events after CE met the standards established by the major RCTs and those recommended by major clinical practice guidelines. Design, Setting, and Patients We used clinically detailed data derived from a comprehensive medical record review to measure the short-term adverse outcomes of CE, focusing on in-hospital death and stroke, in 3283 cases in western Canada in 2000 and 2001, and compared the results with those from the RCTs. RESULTS: For symptomatic patients, the in-hospital ischemic stroke or death rate was 3.9%; for asymptomatic patients, the rate was 2.6%. Extrapolating our in-hospital results to the 30-day post-CE results of the RCTs gave stroke or death rates of 4.9% for cases involving symptomatic patients and 4.1% for cases involving asymptomatic patients. These results are comparable to or better than those of the major RCTs for symptomatic patients but slightly worse for asymptomatic patients. About 45% of hospitals had adverse event rates higher than those recommended by authoritative clinical practice guidelines. CONCLUSIONS: This large population-based study shows that the RCT results for CE can be achieved in the real world. However, the finding that some hospitals exceeded the maximum suggested rates of adverse events highlights the need for continuous outcome monitoring and associated quality improvement efforts to ensure that all providers and institutions involved achieve desired outcomes.     

Comparative Analysis of Carotid Artery Stenting and Carotid Endarterectomy in Clinical Practice

The objective of the study was to describe immediate and long-term results of carotid endarterectomy (CEA) versus carotid stenting (CAS) with embolic protection in patients with severe carotid artery stenosis in clinical practice. Materials and Methods: This is a retrospective cohort study, conducted between 2009 and 2017.During the analyzed period, 2132 operations (2006 patients) were performed: 1215 (57%) CEA and 917 (43%) CAS. 278 patients (13.8% of 2006) were not contactable during the follow-up period (>30 days) leaving 1791 cases (1728 patients) for inclusion in the analysis. Propensity score matching was used to compare the treatment results of groups (561 cases were matched out of 1791). The results of 615 CEA (316 eversion, 299 “classic” with patch) and 615 CAS (using a variety of carotid stents) were compared. Results: In the asymptomatic subgroup (n = 455), the 30-day rate of stroke was not significantly different between the CEA group and the CAS group (1.5% versus 2.4%, P = .48). The 5-year rate of stroke was not significantly higher for CAS than for CEA (4.6% versus 3.3%, P = .3). In the symptomatic subgroup (n = 160), the 30-day rate of stroke was significantly higher in the CAS group than in the CEA group (7.5% versus 2.5%, P = .04). The 5-year rate of stroke was 13% for CAS and 8.7% for CEA (P = .2). Conclusions: In the symptomatic subgroup, the 30-day rate of stroke was significantly higher in the CAS group than in the CEA group, therefore the use of CAS for symptomatic patients in routine practice should be limited. Our study demonstrates that the rates of stroke and survival after CEA and CAS in patients aged 80 years or younger with asymptomatic or symptomatic severe carotid stenosis did not differ significantly over a period of 5 years.     

Carotid endarterectomy without shunt: the role of cerebral metabolic protection

BACKGROUND: The optimal method to protect the brain from hemodynamic ischemia during carotid endarterectomy (CEA) remains controversial. This study reports our experience with induced arterial hypertension and selective etomidate cerebral protection in a cohort of patients who underwent CEA without shunting and continuous electroencephalography (EEG) monitoring. METHODS: We reviewed retrospectively 102 consecutive CEAs performed in 102 patients with routine EEG monitoring and general anesthesia between March 1998 and October 2002. There were 65 (66%) symptomatic and 37 (34%) asymptomatic individuals. A protocol of induced arterial hypertension against EEG ischemic changes during carotid artery cross clamping was followed. Only patients with EEG changes refractory to induced hypertension went into etomidate-induced burst suppression. RESULTS: EEG changes were classified as mild, moderate and severe. Twenty patients (19.6%) developed asymmetric EEG changes, of which the great majority were mild and moderate (75%, p< 0.05). Seven patients with moderate (n=3) and severe (n=4) EEG changes needed etomidate cerebral protection. There were no mortalities and only one stroke (0.98%) is reported in the series. The morbidity rate was 6.8% and included transient cranial nerve palsies (n=5) and wound hematoma (n=1). CONCLUSIONS: Carotid endarterectomy can be safely performed with EEG monitoring and selective induced arterial hypertension and etomidate cerebral protection. Our results suggest that this method may be a good alternative for shunting and its inherent risks.     

Microembolic signals and intraoperative stroke in carotid endarterectomy

Objectives – Microembolic signals (high-intensity transient signals, HITS) detected by means of transcranial Doppler sonography (TCD) may be relevant for intraoperative strokes in carotid endarterectomy (CEA). Material and methods – An intraoperative HITS detection study was performed on 77 patients (63 men, 14 women, mean age±SD, 64±8 years) with a total of 81 CEAs. Using the Scandinavian Stroke Scale the patients were clinically examined by a neurologist preoperatively and postoperatively within 6 h. A deterioration of the Scandinavian Stroke Scale was considered an intraoperative stroke if persisting longer than 24 h. Cranial computed tomography (CT scan) was performed preoperatively and 3 to 5 days postoperatively. By means of TCD total HITS count and mean blood velocity changes, for shunting, were recorded sufficiently in the middle cerebral artery in 79 CEAs. Results – HITS were significantly more frequent in symptomatic [ n =53; HITS: median, 15 (range 1–159)] than in asymptomatic stenoses [ n =26; HITS: 6.5 (0–41); P < 0.001]. An intraoperative stroke in the hemisphere ipsilateral to the operation occurred in eight of the 81 CEAs. On postoperative CT scans, five of the eight strokes showed new corresponding territorial infarctions. In the three strokes without new CT lesions, the mean blood velocity changes after clamping indicated normal cerebral perfusion. Total HITS count was significantly higher in procedures with intraoperative strokes [ n =8; HITS: 33 (11–159)] than in the uncomplicated [ n =71; HITS: 10 (0–62); P =0.002]. No stroke occurred in 37 CEAs with 10 or less HITS, but eight in 42 CEAs with 11 or more HITS [ P =0.006; relative risk 1.23 (95% confidence interval: 1.06 to 1.43)]. Conclusion – Microembolism seems clinically relevant in carotid endarterectomy. Asymptomatic patients may run a lower risk of intraoperative embolization.     

Results from 88 consecutive prophylactic carotid endarterectomies in cerebral infarction and transitory ischemic attacks

Thirty-two patients with transitory ischemic attacks (TIA), 55 with cerebral infarction (minor stroke) and one with a disturbing bruise underwent carotid endarterectomy during a 4 year period. Within the first 2 weeks postoperatively, 10 patients (11 %) had developed new neurological symptoms from the operated side. Two patients died postoperatively due to major stroke and 2 patients developed persistent neurological deficits, yielding a total operative mortality and permanent morbidity rate of 4.5 %. In the other 6 patients, the neurological signs and symptoms disappeared completely within one month.
During a follow-up for an average of 21 months, the only symptoms from the operated side were TIA in 3 patients, while 3 patients developed TIA and 5 infarctions from other vascular territories.     

Systematic comparison of the early outcome of angioplasty and endarterectomy for symptomatic carotid artery disease

BACKGROUND AND PURPOSE: Endoluminal treatment is being increasingly used for carotid artery disease. The aim of this study was to compare the stroke and death risk within 30 days of endovascular treatment or endarterectomy for symptomatic carotid artery disease. METHODS: systematic comparison of the 30-day outcome of angioplasty with or without stenting and endarterectomy for symptomatic carotid artery disease reported in single-center studies, published since 1990, was performed. RESULTS: Thirty-three studies (13 angioplasty and 20 carotid endarterectomy) were included in this analysis. Carotid stents were deployed in 44% of angioplasty patients. Mortality within 30 days of angioplasty was 0.8% compared with 1.2% after endarterectomy (OR 0.68, 95% CI 0.43 to 1.05; P=0.6). The stroke rate was 7.1% for angioplasty and 3.3% for endarterectomy (OR 2.22, CI 1.62 to 3.04; P<0.001), while the risk of fatal or disabling stroke was 3.2% and 1.6%, respectively (OR 2.09, CI 1.3 to 3.33; P<0.01). The risk of stroke or death was 7.8% for angioplasty and 4% for endarterectomy (OR 2.02, CI 1.49 to 2.75; P<0.001), while disabling stroke or death was 3.9% after angioplasty and 2.2% after endarterectomy (OR 1.86, CI 1.22 to 2.84; P<0.01). CONCLUSIONS: In the treatment of symptomatic carotid artery disease, the risk of stroke is significantly greater with angioplasty than carotid endarterectomy. At present, carotid angioplasty is not recommended for the majority of patients with symptomatic carotid artery disease.     

Carotid endarterectomy in high risk patients

We elected to compare the clinical outcomes of carotid endarterectomy (CEA) patients who were thought to be at increased risk for peri-operative complications because of advanced age (> 79 years), medical comorbidities and contralateral internal carotid artery occlusion to patients without these risk factors. A prospective series of 875 CEAs done using regional anesthesia were analyzed. All patients were operated upon under the direction of one neurosurgeon (REH). Clinical outcomes measures evaluated were any stroke, death or myocardial infarction within 30 days of operation. All patients were followed to a clinical endpoint and/or six weeks post-operatively. The incidence of adverse clinical outcomes in the suspected high risk patients was compared to the incidence in the entire series using contingency table analysis (Chi-square and Fisher's exact test). Twenty strokes (2.3%), four myocardial infarctions (0.5%) and three deaths (0.3%) occurred within 30 days of CEA. None of the suspected risk factors was associated with a significantly (p < 0.05) increased risk of peri-operative morbidity or mortality. CEA using regional anesthesia can be performed in patients with advanced age, diabetes mellitus, atherosclerotic coronary vascular disease and contralateral ICA occlusion with acceptably low peri-operative morbidity.     

Complications following carotid angioplasty and carotid stenting in patients with symptomatic carotid artery disease

BACKGROUND: We review a single centre's experience of the endovascular treatment of carotid artery disease, present the 30-day and 1-year complication rates and assess whether changes in technique are associated with a change in clinical outcome. METHODS: Patients who underwent carotid angioplasty with or without stenting for symptomatic > or = 70% carotid artery stenosis secondary to atherosclerosis were included. 333 procedures were performed, i.e. angioplasty alone (86), stent without cerebral protection (150) and stent with cerebral protection (97). RESULTS: At 30 days, the total major disabling stroke and all death rate was 3.0%. For angioplasty alone, this was 2.3%, for stent without cerebral protection 4.0% and for stent with cerebral protection 2.1%. If non-stroke-related deaths were excluded, it was 2.3, 3.3 and 0%, respectively. After 30 days, the 1-year ipsilateral stroke rate was 0.8%. CONCLUSIONS: Carotid artery stenting, in particular with a cerebral protection device, is a safe alternative to carotid endarterectomy for the treatment of symptomatic high-grade carotid artery disease.     

MMP-9 and/or TIMP as predictors of ischaemic stroke in patients with symptomatic and asymptomatic atherosclerotic stenosis of carotid artery treated by stenting or endarterectomy – A review

We still lack an optimal tool to predict ischaemic stroke in patients with symptomatic and asymptomatic carotid stenosis (CS). It has already been shown that patients at increased risk of ischaemic stroke can be identified based on the elevated plasma levels of metalloproteinases (MMPs) and reduced activity tissue inhibitor of metalloproteinase (TIMP). There are few studies presenting the role of MMP-9 and TIMP in ischaemic stroke both in patients with symptomatic and asymptomatic CS treated with stenting or endarterectomy, however we have not found any published review summarizing the role of abovementioned markers. MEDLINE was accessed via Pub Med, and searched for published studies that analyzed MMP-9 and TIMP levels in patients with asymptomatic and symptomatic internal carotid stenosis and/or examined these parameters as potential risk markers for ischaemic stroke. A total of 13 articles documenting the outcomes of patients with symptomatic or asymptomatic carotid stenosis treated by carotid stenting or endarterectomy, were analyzed. Statistically significant differences in the levels of MMP-9 and/or TIMP in patients with symptomatic and asymptomatic CS have been reported. Also the concentrations of MMP-9 and TIMP in CS patients subjected to stenting or endarterectomy were higher than in baseline group. Moreover higher levels of MMP-9 and decreased TIMP was reported to be associated with the risk of restenosis. This systematic review shows that available evidence regarding the dynamics of MMP-9 and TIMP levels may be a predictor of cerebrovascular events in both symptomatic and asymptomatic carotid stenosis in patients treated with stenting or endarterectomy.     

Asymptomatic embolization predicts stroke and TIA risk in patients with carotid artery stenosis.

BACKGROUND AND PURPOSE: Improved methods of identifying patients at high risk of thromboembolism would allow improved targeting of therapy. One such situation is carotid artery stenosis. This is associated with an increased risk of stroke, which can be reduced by carotid endarterectomy. However, the risk-benefit ratio is low in patients with tight asymptomatic stenosis and moderate symptomatic stenosis. Most stroke in patients with carotid stenosis is believed to be embolic. Therefore, the detection of asymptomatic cerebral emboli using Doppler ultrasound may allow identification of a high-risk group. METHODS: Transcranial Doppler ultrasound was used to record for 1 hour the ipsilateral middle cerebral artery in 111 patients with >60% carotid artery stenosis (69 symptomatic, 42 asymptomatic). The Doppler audio signal was recorded onto digital audio tape for later analysis for embolic signals (ES) by an individual blinded to clinical details. In 67 subjects the relationship between ES and angiographically determined plaque ulceration was investigated. All subjects were followed up prospectively, and the relationship between ES and risk of future ipsilateral carotid artery territory ischemic events (TIA and stroke) was determined. RESULTS: ES were detected in 41(36.9%) subjects. In symptomatic patients there was a significant inverse relationship between the number of ES per hour and time elapsed since last symptoms (Spearman's rho=-0.2558, P=0.034). ES were more common in subjects with plaque ulceration, with a relative risk of 4. 94 (95% CI, 1.23 to 19.84; P=0.025) after controlling for both symptomatic status and degree of stenosis. The presence of ES at entry was predictive of TIA and stroke risk during follow up in both symptomatic (P=0.02) and asymptomatic patients (P=0.007). Considering all 111 patients, the presence of asymptomatic embolization was predictive of a further ischemic event, with an adjusted OR of 8.10 (95% CI, 1.58 to 41.57; P=0.01) after controlling for other cardiovascular risk factors, degree of stenosis, symptomatic status, and aspirin or warfarin use. CONCLUSIONS: Asymptomatic embolization in patients with carotid artery stenosis correlates with known markers of increased stroke risk and is an independent predictor of future stroke risk in patients with both symptomatic and asymptomatic carotid stenosis. It may allow identification of a high-risk group of patients who will particularly benefit from carotid endarterectomy. A large multicenter study is now required to confirm these findings.     

Dependence of the risk of brain infarct on the degree of severity of occlusive internal carotid artery lesions

This retrospective study was performed in order to evaluate the relationship between the risk of brain infarction and the severity of 274 internal carotid artery (ICA) stenoses in 218 patients. Clinical, vascular and brain-morphological findings were compared. Of 106 occluded ICAs, 59% had induced a completed stroke with visible hemispheric infarction in 77%, most of them of the territorial type (35%). 32% of 85 high-grade stenoses had led to completed strokes, with territorial, low-flow and microangiopathic patterns of infarction occurring equally frequent. CT was normal in two-thirds of 83 low-grade ICA-stenoses, whereas 14% showed microangiopathic brain lesions. We conclude that (1) asymptomatic ICA stenoses should not be operated on, as long as they are not of very high degree and (2) even symptomatic ICA stenoses should not undergo endarterectomy, if the patient's stroke was due to lacunar infarctions of typical site and size.     

Carotid endarterectomy: is it still a gold standard?

Extracranial internal carotid artery stenosis accounts for 15-20% of ischemic strokes. Carotid endarterectomy has high efficacy in stroke prevention in selected patients with symptomatic (age <80 years) and asymptomatic carotid stenosis (age <75 years). Randomized clinical trials demonstrated that carotid endarterectomy reduces the stroke risk, compared to medical therapy alone, for patients with 70-99% symptomatic stenosis with 16% absolute risk reduction at 5 years. The benefit for patients with 50-69% symptomatic stenosis is lower i.e. absolute risk reduction 4.6% at 5 years. Endarterectomy is not indicated for symptomatic patients with <50% stenosis. There is no need for time-delay for surgery in patients after transient ischemic attack or minor stroke. Patients with more extensive strokes or hemorrhage should undergo surgery after 4-6 weeks following initial symptoms. Carotid endarterectomy for asymptomatic stenosis reduces the risk of ipsilateral stroke, and any stroke, by approximately 30% over 3 years. However, the absolute risk reduction is small over the first few years and decision should be based on individual institutional experience. In all situations, the best medical therapy should accompany surgery. In the recent years, appearance of angioplasty, stenting, and distal protection procedures provides competitive alternatives to classical endarterectomy. However, long-term benefits of carotid angioplasty should be confirmed by bigger, randomized, comparative clinical trials.     

Carotid endarterectomy: a review

BACKGROUND: Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEA results. INVESTIGATION: Brain imaging with CT or MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRA or CT angiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment. INDICATIONS: Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50-69% symptomatic stenosis, and those with asymptomatic stenosis > or = 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions. TECHNIQUES: Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. "Eversion" endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis. CAROTID ANGIOPLASTY AND STENTING: Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA. AUDITING: It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.     

Treatment of Carotid Artery Disease: Endarterectomy or Angioplasty?

The management of carotid stenosis has enjoyed renewed interest in the neurological community in recent years due to the advent of endovascular approaches. In concert, progress in medical treatment of these patients has rekindled the debate regarding the best management of carotid stenosis overall, both for symptomatic and asymptomatic disease. For symptomatic carotid stenosis, the major decision required is choosing the type of intervention best suited for individual patients: carotid endarterectomy versus carotid artery stenting. For patients with asymptomatic carotid stenosis, intensive medical management has evolved significantly over the past decade to decrease the risk of ischemic stroke to match surgical intervention under most circumstances. This review will examine the supporting evidence for each intervention, and discuss the recent advances in medical and endovascular therapy that provide the data for a new era in clinical decision making.     

Operative versus nonoperative management of asymptomatic high-grade internal carotid artery stenosis: improved results with endarterectomy

In a 4-year period, 129 asymptomatic high-grade (80-99%) internal carotid artery stenoses were identified in 115 patients. Because we previously demonstrated a strong relation between degree of carotid stenosis and subsequent development of ipsilateral related events (stroke, transient ischemic attack, and carotid occlusion), we changed our previous policy and began to offer carotid endarterectomy to good surgical risk patients referred to us with asymptomatic high-grade carotid stenosis. A total of 56 carotid endarterectomies were performed while 73 lesions were followed nonoperatively. Operated and nonoperated groups were similar with regard to age, prevalence of hypertension, cardiac disease, diabetes, and aspirin use. Life table analysis to 24 months revealed a higher rate of stroke (19 vs. 4%, p = 0.08), transient focal neurologic deficits (28 vs. 5%, p = 0.008), and carotid occlusion (29 vs. 0%, p = 0.003) in the nonoperated group. Eight of the 9 strokes in the nonoperated group occurred within 9 months of diagnosis of the high-grade lesion; none were preceded by a transient ischemic attack. There was 1 perioperative stroke (1.8%) but no in-hospital operative deaths and no difference in the late death rates of the two groups. This suggests that the preservation of neurologic status in patients with asymptomatic high-grade internal carotid artery stenosis can be improved by carotid endarterectomy.