In-stent recurrent stenosis after carotid artery stenting: life table analysis and clinical relevance

OBJECTIVES: Carotid artery stenting has been proposed as an alternative to carotid endarterectomy in cerebral revascularization. Although early results from several centers have been encouraging, concerns remain regarding long-term durability of carotid artery stenting. We report the incidence, characteristics, and management of in-stent recurrent stenosis after long-term follow-up of carotid artery stenting. METHODS: Carotid artery stenting (n = 122) was performed in 118 patients between September 1996 and March 2003. Indications included recurrent stenosis after previous carotid endarterectomy (66%), primary lesions in patients at high-risk (29%), and previous ipsilateral cervical radiation therapy (5%). Fifty-five percent of patients had asymptomatic stenosis; 45% had symptomatic lesions. Each patient was followed up with serial duplex ultrasound scanning. Selective angiography and repeat intervention were performed when duplex ultrasound scans demonstrated 80% or greater in-stent recurrent stenosis. Data were prospectively recorded, and were statistically analyzed with the Kaplan-Meier method and log-rank test. RESULTS: Carotid artery stenting was performed successfully in all cases, with the WallStent or Acculink carotid stent. Thirty-day stroke and death rate was 3.3%, attributable to retinal infarction (n = 1), hemispheric stroke (n = 1), and death (n = 2). Over follow-up of 1 to 74 months (mean, 18.8 months), 22 patients had in-stent recurrent stenosis (40%-59%, n = 11; 60%-79%, n = 6; > or =80%, n = 5), which occurred within 18 months of carotid artery stenting in 13 patients (60%). None of the patients with in-stent recurrent stenosis exhibited neurologic symptoms. Life table analysis and Kaplan-Meier curves predicted cumulative in-stent recurrent stenosis 80% or greater in 6.4% of patients at 60 months. Three of five in-stent recurrent stenoses occurred within 15 months of carotid artery stenting, and one each occurred at 20 and 47 months, respectively. Repeat angioplasty was performed once in 3 patients and three times in 1 patient, and repeat stenting in 1 patient, without complications. One of these patients demonstrated asymptomatic internal carotid artery occlusion 1 year after repeat intervention. CONCLUSIONS: Carotid artery stenting can be performed with a low incidence of periprocedural complications. The cumulative incidence of clinically significant in-stent recurrent stenosis (> or =80%) over 5 years is low (6.4%). In-stent restenosis was not associated with neurologic symptoms in the 5 patients noted in this cohort. Most instances of in-stent recurrent stenosis occur early after carotid artery stenting, and can be managed successfully with endovascular techniques.     

Carotid angioplasty and stenting for postendarterectomy stenosis: long-term follow-up

BACKGROUND: Carotid angioplasty and stenting (CAS) for recurrent stenosis after carotid endarterectomy (CEA) has been proposed as an alternative to redo CEA. Although early results are encouraging, the extended durability remains unknown. We present the long-term surveillance results of CAS for post-CEA restenosis. METHODS: Between 1998 and 2004, 57 CAS procedures were performed in 55 patients (36 men) with a mean age of 70 years. The mean interval between CEA and CAS was 83 months (range, 6 to 245). Nine patients (16%) were symptomatic. RESULTS: CAS was performed successfully in all patients. No deaths or strokes occurred. A periprocedural transient ischemic attack (TIA) occurred in two patients. During a mean follow-up of 36 months (range, 12 to 72 months), two patients exhibited ipsilateral cerebral symptoms (1 TIA, 1 minor stroke). In 11 patients (19%), in-stent restenosis (> or =50%) was detected post-CAS at month 3 (n = 3), 12 (n = 3), 24 (n = 2), 36 (n = 1), 48 (n = 1), and 60 (n = 1). The cumulative rates of in-stent restenosis-free survival at 1, 2, 3, and 4 years were 93%, 85%, 82%, and 76%, respectively. Redo procedures were performed in six patients, three each received repeat angioplasty and repeat CEA with stent removal. The cumulative rates of freedom from reintervention at 1, 2, 3, and 4 years were 96%, 94%, 90%, and 84%, respectively. CONCLUSION: Carotid angioplasty and stenting for recurrent stenosis after CEA can be performed with a low incidence of periprocedural complications with durable protection from stroke. The rate of in-stent recurrent stenosis is high, however, and does not only occur early after CAS but is an ongoing process.     

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.     

Long-term follow-up and clinical outcome of carotid restenosis

The efficacy of carotid endarterectomy is dependent on the inherent ability of the operation to prevent stroke as well as the incidence of restenosis and associated symptoms. To examine the long-term effects of restenosis, 301 patients having carotid endarterectomy were followed by serial duplex scanning for an average of 4 years. Carotid restenosis, defined as 50% or greater diameter reduction by duplex scanning, occurred after 78 of the endarterectomies; regression of recurrent stenosis occurred in 20 arteries. By life-table analysis the cumulative incidence of restenosis at 7 years was 31%, and the cumulative incidence of regression was 10%. Thus the prevalence of recurrent stenosis at 7 years was 21%. Restenosis developed in women more frequently than men (p = 0.01). Transient ischemic attack occurred in 12% of patients with restenosis, and stroke occurred in 3%; however, the cumulative incidence of stroke or transient ischemic attack was not statistically different in those patients with and without restenosis. Similarly, cumulative survival at 7 years was no different. Carotid restenosis usually occurs early in the postoperative period and tends to regress or remain stable during long-term follow-up. A conservative approach to treatment appears justified, since transient ischemic attacks and stroke were rarely associated with restenosis.     

Surgery for radiation-induced symptomatic carotid atherosclerosis

Carotid atherosclerosis occurring secondary to cervical irradiation is known to produce stroke. Transient neurologic symptoms have necessitated surgical intervention to prevent stroke despite concern over technical problems, wound healing, operative risks, and uncertain therapeutic outcome. With this report, 26 surgical procedures in 20 patients are now documented in the literature (12 men--60%; eight women--40%). Mean age of these patients (56 years) was 10 years younger than carotid surgery patients with no prior radiation history. No relationship was noted between elevated serum cholesterol and the subsequent development of radiation-induced carotid atherosclerosis. Surgical procedures performed included carotid endarterectomy in 17 cases (65%) and arterial bypass in nine (35%). The combination of radiation therapy and previous neck surgery, including prior radical neck dissection, did not adversely influence operability. Surgical outcome was uniformly good with only one stroke (4%) documented in the perioperative period. Longer follow-up on our six cases (mean two years) disclosed neither new clinical symptoms nor the development of hemodynamically significant restenosis.     

Early morbidity and fatality following carotid disobliteration

At the University Hospital of Cologne-Lindenthal 260 patients underwent carotid endarterectomy during a period of 10 years. 9 patients died, representing an operative mortality rate of 2.9%. 80% of our patients with an acute stroke died. We see no indication for surgery in acute stroke. Postoperatively, 20 patients had a neurologic deficit, transient deficits occurred in 3,6% (11 patients) permanent deficits in 3% (9 patients). Carotid endarterectomy may be complicated by cranial nerve damage. The importance of these injuries is evident if bilateral carotid endarterectomy is being considered.     

Prospective randomized trial of ACUSEAL (Gore-Tex) vs Finesse (Hemashield) patching during carotid endarterectomy: long-term outcome

BACKGROUND: Several studies have reported that carotid endarterectomy with patch angioplasty is superior to primary closure. Conventional polytetrafluoroethylene (Gore-Tex, W. L. Gore & Associates, Flagstaff, Ariz) patching has been shown to have results similar to autogenous saphenous vein patching; however, it requires a longer hemostasis time. This study examined the long-term clinical outcome and incidence of restenosis after carotid endarterectomy using the new ACUSEAL (Gore-Tex) patching vs Hemashield Finesse (Boston Scientific Corp, Natick, Mass) patching. METHODS: The study randomized 200 patients (1:1) undergoing carotid endarterectomy to 100 with ACUSEAL patching and 100 with Hemashield-Finesse patching. All patients underwent immediate and 1-month postoperative duplex ultrasound studies, which were repeated at 6-month intervals. Kaplan-Meier analysis was used to estimate the freedom from stroke, stroke-free survival, and the risk of restenosis for both groups. RESULTS: The demographic and clinical characteristics, the mean operative diameter of the internal carotid artery, and the length of the arteriotomy were similar in both groups. The mean hemostasis time was 5.1 for the ACUSEAL patching vs 3.7 minutes for Finesse patching (P = .01); however, the mean operative times were similar for both groups (P = .61). The incidence of ipsilateral stroke was 2% for ACUSEAL patching (both early perioperative strokes) vs 3% for Finesse patching (2 early and 1 late stroke) at a mean follow-up of 21 months. The respective cumulative stroke-free rates at 1, 2, and 3 years were 98%, 98%, and 98% for ACUSEAL patching vs 97%, 97%, and 97% for Finesse patching (P = .7). The respective cumulative stroke-free survival rates at 1, 2, and 3 years were 97%, 92%, and 88% for ACUSEAL patching vs 96%, 96%, and 91% for Finesse patching (P = .6). The respective freedom from > or =70% carotid restenosis at 1, 2, and 3 years was 98%, 96%, and 89% for ACUSEAL patching vs 92%, 85%, and 79% for Finesse patching (P = .04). CONCLUSIONS: Carotid endarterectomy with ACUSEAL patching and Finesse patching had similar stroke-free rates and stroke-free survival rates. The mean hemostasis time for the ACUSEAL patch was 1.4 minutes longer than that for the Finesse patch; however, the Finesse patch had higher restenosis rates than the ACUSEAL patch.     

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.     

Durability of surgery for restenosis after carotid endarterectomy

BACKGROUND: The role of carotid surgery for the management of restenosis after carotid endarterectomy (CEA) is challenged by carotid artery stenting (CAS). We reviewed redo CEA in a consecutive series of patients to determine the safety, durability, and long-term benefit associated with repeat surgical treatment for restenosis. METHODS: A consecutive series of 73 redo procedures in 72 patients (57% men) with a mean age 66 years (range, 49-81 years) was analyzed. The mean interval between prior CEA and redo CEA was 53 months (range, 8-192 months). Operative indications included symptomatic restenosis in 28 patients (38%). A patch angioplasty was performed in 62 patients (85%). The main outcome measures included perioperative and late stroke and death, and the development of secondary restenosis. RESULTS: There were no perioperative deaths or strokes. During a mean follow-up of 52 months (range, 12-144 months), the Kaplan-Meier cumulative survival was 85% at 5 years. At 5 years, the cumulative rate of freedom from all strokes was 98%, and the freedom from ipsilateral stroke was 100%. After secondary procedures, re-recurrent stenosis > or =50% occurred in 10 patients (13.7%). The cumulative freedom from re-restenosis (> or =50%) was 85% at 5 years. Five patients (7%) received tertiary carotid reconstructions. CONCLUSION: Repeat CEA for recurrent stenosis can be performed safely with excellent long-term protection from stroke. These data provide a standard against which the results of CAS can be compared.     

Eversion endarterectomy--out?

Carotid eversion endarterectomy has become a well established alternative to conventional carotid endarterectomy. Similar perioperative morbidity and mortality results have been documented in several large clinical series. Our experience with carotid reconstructive surgery consists of 12,596 operations between 8/84 and 12/97, some 60% of which were performed using the eversion technique. Transient or permanent neurologic deficit was observed in 2.0%; 0.8% died after the procedure. Eversion endarterectomy should only be performed under suitable anatomic conditions. It is a challenging technique which requires advanced surgical skills and sound clinical judgement. The long-term rate of restenosis seems to be influenced favourably after eversion endarterectomy.     

Restenosis after eversion vs patch closure carotid endarterectomy

OBJECTIVES: Recurrent stenosis after carotid endarterectomy (CEA), previously reported to occur in 1%/year after operation, is the finite limitation of CEA. Eversion endarterectomy has a perceived lower incidence of recurrent stenosis, although data to support this contention are conflicting. The goal of the present study was to compare the late anatomic results of patch closure (PC) vs eversion CEA. METHODS: Between January 1, 1995 and June 30, 2005, 950 CEA were performed by the senior author with adoption of eversion (EV) as the primary technique as of January 1, 2001. With minimum of 1-year follow-up by study inclusion criteria, complete follow-up data (including a duplex scan) was available for 155 PC and 135 EV patients. Incidence of moderate (50% to 70%) and severe (>70%) restenosis was examined at < or =2 months and >1 year after operation. Study end-points included late stroke, survival, and freedom from restenosis (moderate and severe) and were assessed by actuarial methods. RESULTS: There were no differences in relevant demographic/clinical parameters, indication for surgery (69% overall asymptomatic) or early perioperative stroke/death (1.1% overall; P = .25) between PC and EV. After correction for different mean follow-up intervals (PC = 5.5 years vs EV = 3.5 years) by actuarial methods, there was no significant difference in late moderate (P = .91) or severe (P = .54) recurrent stenosis between PC and EV. In the group of patients with at least 1-year follow-up, 11/290 (3.8%) patients (4/135 EV, 7/155 PC; P = .39) required reintervention on their operated carotid artery at a cumulative follow-up interval of 4.5 years. Three strokes (3/290; 1.1%) occurred during late follow-up, all in the PC group, with only one related to the operated carotid artery. Late survival was similar between EV and PC, (P = .86). Female gender (odds ratio [OR] 3.72[1.02-13.5], P = .046) was associated with severe restenosis irrespective of surgical technique. Univariate analysis also showed that female gender (OR 7.6[CI: 0.88-66.7], P = .042) was associated with late stroke. CONCLUSION: These findings indicate that restenosis rates are similar between eversion and patch CEA and likely represent biological remodeling phenomenon rather than technical variations of operations. While EV offers distinct advantages in certain anatomic circumstances, adoption of EV with the hope of decreasing restenosis is not warranted.     

Results of carotid endarterectomy in patients 75 years of age and older.

From April 1980 to September 1989, 69 patients over 75 years of age (mean 78 years, range 75 to 86) underwent 81 carotid endarterectomies. Twenty three percent were asymptomatic, 56.5% had symptoms appropriate to lesion location and 20.5% had a non hemispheric syndrome. Nine patients required an associated procedure (combined cardiac surgery 6 pts; vascular surgery 3 pts). Perioperative mortality was 3.7%. The combined early lethal and non lethal stroke rate was 6.1%. Actuarial survival, at 10 years, was 58.4% +/- 10, and the incidence of freedom from stroke at 10 years was 86.2% +/- 5. Despite the fact that the hospital mortality of patients over 75 years undergoing carotid endarterectomy is more than three times that of patients operated on under 75 years of age (1.2%), the combined stroke and neurologic mortality rate is similar to that of patients under 75 years (5.3%). Carotid surgery in patients over 75 years of age does not increase life expectancy but does improve the quality of survival which depends mainly on cardiac events.     

Risk factors for restenosis after carotid artery angioplasty and stenting

OBJECTIVES: With carotid artery stenting (CAS) becoming an ever-increasing procedure, we sought to determine risk factors for in-stent restenosis after CAS. METHODS: Consecutive patients undergoing CAS between January 2002 and October 2004 at a tertiary care hospital were retrospectively reviewed. Patient, filter, and stent selection were left to the discretion of the attending surgeon. High-risk patients were defined by significant comorbidities or a hostile neck (prior surgery or radiation, or both), and risk factor analysis was performed. In-stent restenosis was defined as >60%, and selective angiography was performed on patients with an in-stent restenosis >80% by duplex ultrasound imaging. RESULTS: Reviewed were 101 patients (55 men, 46 women) who underwent 109 CAS procedures. Comorbidities were typical for patients with atherosclerosis. In addition, 38% (n = 41) of procedures were performed in patients who had prior neck surgery, of which 29% (n = 32) had previous ipsilateral carotid endarterectomy. Seventeen patients (16%) had a history of neck cancer, and all had prior neck radiation. Median follow-up was 5 months (range, 0 to 30 months). Neurologic complications included three transient ischemic attacks (2.8%) and one nondisabling stroke (0.9%). There were two myocardial infarctions (1.9%) and no periprocedural deaths (30 days), for a combined stroke, myocardial infarction, and death rate of 2.9%. Asymptomatic in-stent restenosis developed in 12 carotids (11%), five of which required endovascular intervention, with a mean of 6 months to restenosis. Univariate Cox proportional hazard regression models were used to determine risk factors for the development of restenosis. Prior stroke, transient ischemic attack, amaurosis fugax, and prior neck cancer were all significant risk factors. When these significant risk factors from univariate analysis were put into multivariate analysis, however, the only marginally significant risk factor was prior neck cancer (P = .06). Kaplan-Meier analysis revealed a cumulative freedom from in-stent restenosis at 24 months of 88% +/- 6% in patients without neck cancer compared with 27% +/- 17% (P = .02) in patients with neck cancer. CONCLUSIONS: CAS has been shown to be safe and effective in high-risk patients, with minimal adverse events.     

The incidence of carotid in-stent stenosis is underestimated ≥50% or ≥80% and its clinical implications

BackgroundThe incidence of carotid in-stent stenosis has been reported to vary between 1% and 30%. Most published studies have short follow-up, which may lead to underestimation of the incidence of in-stent stenosis. This study analyzed the incidence of ≥50% and ≥80% in-stent stenosis using validated duplex ultrasound criteria and its clinical implications.MethodsThis is a retrospective analysis of prospectively collected data of 450 carotid artery stenting (CAS) procedures (February 6, 2001-December 19, 2016). All patients had postoperative carotid duplex ultrasound examination, which was repeated at 1 month, 6 months, and every 6 to 12 months thereafter. A Kaplan-Meier analysis was used to estimate rates of freedom from ≥50% in-stent stenosis (internal carotid artery peak systolic velocity of ≥224 cm/s) and ≥80% in-stent stenosis (internal carotid artery peak systolic velocity of ≥325 cm/s), freedom from reintervention, and survival.ResultsThe mean age was 68.3 years, with a mean follow-up of 40.3 months. A total of 201 patients (45% [201/450]) had CAS for symptomatic disease. Primary CAS was done in 291 patients (65%); in the remaining 35%, CAS was done for postcarotid endarterectomy (CEA) stenosis. A total of 101 patients (23%) had ≥50% late carotid in-stent stenosis, and of these, 33 (7.4%) had ≥80% in-stent stenosis. Nineteen patients (4.3%) developed late transient ischemic attack and three (0.7%) late stroke. Twenty-three (5.2%) patients had late reintervention. Rates of freedom from ≥50% in-stent stenosis in the whole series were 85%, 79%, 75%, 72%, and 70% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. The rates of freedom from ≥50% in-stent stenosis for primary CAS and CAS for post-CEA stenosis were not statistically significant (P = .540). The rates of freedom from ≥80% in-stent stenosis for the whole series were 96%, 95%, 93%, 90%, and 89% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. The rates of freedom from ≥80% in-stent stenosis for primary CAS and CAS for post-CEA stenosis were also not statistically significant (P = .516). Rates of freedom from reintervention were 98%, 96%, 93%, 93%, and 91% at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, and there were no significant differences between primary CAS and CAS for post-CEA stenosis (P = .939). The overall late survival rates were 99%, 97%, 96%, 94%, and 91% at 1 year, 2 years, 3 years, 4 years, and 5 years.ConclusionsThe incidence of ≥50% in-stent stenosis is relatively high; however, the rates of ≥80% stenosis and late neurologic events are low. Longer follow-up of patients with ≥50% carotid in-stent stenosis may yield higher incidence of ≥80% stenosis.     

Stenosis following carotid endarterectomy. Its implication in management of asymptomatic carotid stenosis

Carotid endarterectomy is established in the treatment of atherosclerosis of the carotid bifurcation, but the incidence of restenosis and the role of endarterectomy in the management of asymptomatic carotid stenosis are variable. During a four-year period, we performed 80 endarterectomies of the internal carotid artery in 73 patients. Patients were prospectively studied by means of Doppler ultrasonography in combination with real-time spectral analysis to determine the incidence of restenosis postoperatively. A concomitant study of 116 patients with 79 asymptomatic carotid stenoses was undertaken. We found a 12.5% incidence of stenosis following carotid endarterectomy and a 3% risk of transient neurologic deficit in the patients with asymptomatic carotid stenoses.     

CAROTID ENDARTERECTOMY FOR ASYMPTOMATIC CAROTID ARTERY STENOSIS: PATIENTS WITH SEVERE BILATERAL DISEASE A HIGH RISK SUBGROUP

Carotid endarterectomy if advised for asymptomatic disease must be associated with a low peri-operative morbidity and mortality and satisfactory long-term results. Over a 12 year period between 1978–1989 181 carotid endarterectomies were performed on 163 patients with asymptomatic carotid artery stenosis. There were 112 males and 51 females with a mean age of 64.9 years. All patients had a high-grade lesion (> 70% stenosis). The combined operative mortality and stroke rate was 2.8%. On long-term follow up six patients suffered a stroke. Only one patient however sustained a stroke in the same territory as the previously operated carotid artery. Four years following surgery 78% of patients were alive. Carotid restenosis or occlusion occurred in 8.3% of the remaining patients, all of whom were asymptomatic. All the immediate postoperative strokes occurred in patients with severe bilateral carotid artery disease. These patients with severe bilateral disease appear to constitute a high risk sub-group for peri-operative stroke. The role of ‘normal pressure-hyperperfusion breakthrough’ syndrome as the presumed aetiology of two of the postoperative cerebral haemorrhages is discussed.     

Efficacy of surgical and therapeutic methods of repeated carotid ischemic stroke prophylaxis

Comparative efficacy of surgical and therapeutic methods of repeated ischemic stroke prophylaxis at the patients with clinical symptoms of acute brain ischemia and carotid stenosis less 70% was analyzed. Three-year period of follow-up demonstrated that at the patients who have undergone carotid endarterectomy the repeated ischemic events were seen only at 4 (3.9%), and in the group of therapeutic prophylaxis--at 57 (52.7%). Carotid endarterectomy permits to reduce relative risk of repeated ischemic stroke from 0.77 in therapeutic prophylaxis to 0.07 in surgical treatment. Antiaggregant therapy after surgery is mandatory. Prolonged administration of Clopidogrel permits to reduce restenosis and thrombotic complication rate.     

Refining the indications for carotid endarterectomy in patients with symptomatic carotid stenosis: A systematic review.

OBJECTIVE: The purpose of this study was to summarize the existing literature on the efficacy of carotid endarterectomy in patients with ipsilateral symptomatic carotid stenosis. METHODS: Database searching, relevance assessment, methodologic quality assessments, and data extraction were all performed in duplicate with prespecified criteria. RESULTS: Twenty-three publications were identified from the North American Symptomatic Carotid Endarterectomy Trial, the European Carotid Surgery Trial, and the Veterans Affairs Cooperative Studies Program. Stenosis was reported as measured in the North American Symptomatic Carotid Endarterectomy Trial. In patients with >70% stenosis, carotid endarterectomy was associated with a pooled relative risk reduction of 48% (95% confidence interval [CI], 27% to 73%) and an absolute risk reduction of 6.7% (95% CI, 3.2% to 10%) for the outcome of death or major disability from stroke. This translates into a number needed to treat of 15 (95% CI, 10 to 31). For patients with 50% to 69% stenosis, the benefit of surgery was less and the confidence intervals were wider. A relative risk reduction of 27% (95% CI, 5% to 44%), an absolute risk reduction of 4.7% (95% CI, 0.8% to 8.7%), and a number needed to treat of 21 (95% CI, 11 to 125) were observed in this group. The patients with the lowest degrees of stenosis (<50%) were harmed by the intervention (number needed to harm, 45). Increasing degree of stenosis, increasing age, male sex, the presence of other medical risk factors, and the presence of hemispheric rather than retinal antecedent events were factors that increased the benefits from surgery. CONCLUSION: Carotid endarterectomy reduced death or major disability from stroke in patients with >50% symptomatic stenosis. To maximize the benefits of surgery, careful preoperative risk assessment and the maintenance of low rates of major perioperative complications are mandatory.     

Carotid artery stenting with distal protection using the carotid wallstent and filterwire neuroprotection: single-center experience of 380 cases with midterm outcomes

Emerging data have supported the clinical efficacy of carotid artery stenting (CAS) in stroke prevention in high-risk surgical patients. This study was performed to evaluate the midterm clinical outcome of CAS using the Carotid Wallstent and FilterWire distal protection (both Boston Scientific, Natick, MA) at an academic institution. Risk factors for in-stent restenosis (ISR) were also analyzed. Clinical variables and treatment outcome of high-risk patients who underwent Carotid Wallstent placement with FilterWire EX/EZ neuroprotection were analyzed during a recent 54-month period. Three hundred eighty CAS procedures were performed in 354 patients. Technical success was achieved in 372 cases (98%), and symptomatic lesions existed in 85 (24%) patients. No patient experienced periprocedural mortality or neuroprotective device-related complication. The 30-day stroke and death rate was 2.7%, and the overall complication rate was 6.9%. The overall major or fatal stroke rates in symptomatic and asymptomatic patients were 4.6% and 1.3%, respectively (not significant). The overall stroke and death rates between the symptomatic and asymptomatic groups were 5.8% and 2.4%, respectively (not significant). The median follow-up period was 29 months (range 1-53 months). With Kaplan-Meier analysis, the rates of freedom from 60% or greater ISR after CAS procedures at 12, 24, 36, and 48 months were 97%, 94%, 92%, and 90%, respectively. The rates of freedom from all fatal and nonfatal strokes at 12, 24, 36, and 48 months were 97%, 91%, 89%, and 85%, respectively. Multivariable analysis of significant univariate predictors identified that postendarterectomy stenosis (odds ratio [OR] 3.98, p = .02) and multiple stent placement (OR 3.68, p = .03) were independent predictors of ISR. Our study yielded favorable short-term and midterm clinical results using Carotid Wallstent with FilterWire neuroprotection. Late follow-up results showed low rates of fatal and nonfatal stroke and favorable ISR rates compared with other carotid stent trials. Postendarterectomy and multiple stent placement were associated with subsequent ISR.     

Clinical and operative predictors of outcomes of carotid endarterectomy

OBJECTIVE: The net benefit for patients undergoing carotid endarterectomy is critically dependent on the risk of perioperative stroke and death. Information about risk factors can aid appropriate selection of patients and inform efforts to reduce complication rates. This study identifies the clinical, radiographic, surgical, and anesthesia variables that are independent predictors of deaths and stroke following carotid endarterectomy. METHODS: A retrospective cohort study of patients undergoing carotid endarterectomy in 1997 and 1998 by 64 surgeons in 6 hospitals was performed (N = 1972). Detailed information on clinical, radiographic, surgical, anesthesia, and medical management variables and deaths or strokes within 30 days of surgery were abstracted from inpatient and outpatient records. Multivariate logistic regression models identified independent clinical characteristics and operative techniques associated with risk-adjusted rates of combined death and nonfatal stroke as well as all strokes. RESULTS: Death or stroke occurred in 2.28% of patients without carotid symptoms, 2.93% of those with carotid transient ischemic attacks, and 7.11% of those with strokes (P < .0001). Three clinical factors increased the risk-adjusted odds of complications: stroke as the indication for surgery (odds ratio [OR], 2.84; 95% confidence interval [CI] = 1.55-5.20), presence of active coronary artery disease (OR, 3.58; 95% CI = 1.53-8.36), and contralateral carotid stenosis > or =50% (OR, 2.32; 95% CI = 1.33-4.02). Two surgical techniques reduced the risk-adjusted odds of death or stroke: use of local anesthesia (OR, 0.30; 95% CI = 0.16-0.58) and patch closure (OR, 0.43; 95% CI = 0.24-0.76). CONCLUSIONS: Information about these risk factors may help physicians weigh the risks and benefits of carotid endarterectomy in individual patients. Two operative techniques (use of local anesthesia and patch closure) may lower the risk of death or stroke.