Outcome after carotid endarterectomy for asymptomatic carotid stenosis

Objective: To compare the long-term outcome in patients with asymptomatic carotid stenosis (ACS) among those treated with carotid endarterectomy (CE) or medical therapy.

Background: Until randomized trials are completed, treatment of ACS will depend on identification of subgroups likely to benefit from CE.

Methods: A retrospective cohort study was done on 215 patients with ACS: 107 underwent CE, and 108 were treated medically (MED). A neurologist reviewed medical records and performed a telephone interview to detect outcome (stroke and death). Mean follow-up was 3.8 years; only 4% were lost to follow-up.

Results: Among CE patients, there was a 4.7% risk of postoperative ipsilateral stroke within 30 days. Four of five postoperative strokes occurred among patients with prior contralateral symptoms. There was no significant difference between CE and MED in the cumulative lifetable 5-year risk of ipsilateral stroke, any stroke, or survival free of any stroke. Among diabetics, however, there were no ipsilateral strokes at 5 years after CE compared to 20% in MED (p = 0.03). Excluding postoperative complications, the 5-year risk of ipsilateral stroke was reduced among CE patients who “ever smoked” (CE 1%, MED 8%, p = 0.03) and the 5-year risk of any stroke was reduced among CE patients who had no prior myocardial infarction (CE 6%, MED 16%, p=0.02). Among those with prior contralateral carotid territory symptoms, the 5-year risk of any stroke was worse in the MED patients (CE 5% MED 32%, p=0.004). Among CE patients, a Cox proportional hazards model determined that the independent predictors of worse long-term outcome were: a history of myocardial infarction; admission systolic blood pressure greater than 160 mm Hg; and age greater than 65.

Conclusion: The approach to patients with ACS will await completion of large, randomized clinical trials, now in progress. Even if these studies are negative, there may remain specific subgroups of patients who show clear benefit from carotid endarterectomy.     

Long-term results after carotid endarterectomy for carotid artery stenosis with contralateral occlusion

Patients with one internal carotid artery occlusion and a contralateral stenosis run a significantly higher risk of stroke. We performed endarterectomy of the stenotic carotid in 44 such patients and followed them for mean 54 months (range 1–172 months). Early mortality was 2%. Life-table analysis shows that the incidence of a new stroke was 0.6% per year, the survival rate was 78% after three years, and 70% after five years. We conclude that carotid endarterectomy can be safely performed in patients with contralateral internal carotid artery occlusion and can significantly improve the long-term prognosis of these patients.     

Cerebral hemodynamics in symptomatic and asymptomatic patients with severe unilateral carotid stenosis before and after carotid endarterectomy.

BACKGROUND: Data concerning hemodynamic status prior to and after carotid endarterectomy (CEA) in symptomatic and asymptomatic patients is insufficient. Transcranial Doppler (TCD) provides information regarding compensatory collateral flow as well as mechanisms of cerebral autoregulation in patients with carotid stenosis. PATIENTS AND METHODS: Forty eight symptomatic and 81 asymptomatic patients with unilateral severe carotid stenosis were examined by TCD before and in early postoperative period after CEA. RESULTS: Cigarette smoking was the only risk factor significantly more frequent in symptomatic patients. Preoperative anterior cerebral artery (ACA) and middle cerebral artery (MCA) asymmetry, basilar artery velocity and number of ophthalmic arteries with reversed flow, were not significantly different between the two groups. Pulsatility index, cerebrovascular reactivity and flow acceleration on the side of stenosis were significantly lower in symptomatic patients. After surgery there was a significant improvement of all TCD parameters in symptomatic as well as asymptomatic patients. CONCLUSIONS: The exhausted ability of cerebral autoregulation is an important factor differentiating between symptomatic and asymptomatic patients with severe carotid stenosis. Successful surgery provides good recovery of cerebral hemodynamics in both symptomatic and asymptomatic patients.     

Association of sex with perioperative mortality and morbidity after carotid endarterectomy for asymptomatic carotid stenosis

OBJECTIVE: To examine whether perioperative morbidity and mortality after carotid endarterectomy depend on the sex and the presence of symptoms on presentation. DESIGN: Retrospective review of quality assurance database prospectively collected. SETTING: A university teaching hospital. PARTICIPANTS: One thousand two hundred eighty-seven patients who had 1,503 carotid endarterectomies from 1990 to 1999 from a quality assurance database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The cases were divided into 4 groups by sex and symptoms on presentation: male-symptomatic (MS), male-asymptomatic (MA), female-symptomatic (FS), and female-asymptomatic (FA). The 4 groups were compared for preoperative demographic and comorbidity profiles, carotid plaque characteristics, and outcome. Outcome measures included in-hospital stroke, myocardial infarction (MI), congestive heart failure (CHF), and death. There were 496 cases in the MS group, 407 in the MA group, 315 in the FS group, and 285 in the FA group. Women were less likely to have a history of coronary artery disease, prior MI, or smoking, and their carotid plaques were less likely to be ulcerated or contain intraplaque hemorrhage. Even when controlling for the comorbidities and plaque characteristics, the incidence of each of the complications examined was low and not significantly different between the sexes in both the symptomatic and asymptomatic groups. The rate of stroke or death was 3.0% (MS) versus 1.9% (FS) (p = NS) and 1.2% (MA) versus 1.8% (FA) (p = NS). CONCLUSION: There is no significant sex difference in perioperative cardiac or cerebrovascular complications. Women with symptomatic or asymptomatic carotid stenosis can have acceptably low complication rates from carotid endarterectomy and may benefit from the surgery as much as men.     

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.     

Homocysteine and early re-stenosis after carotid eversion endarterectomy.

BACKGROUND: Homocysteine (Hcy) appears to be involved in the development of intimal hyperplasia and arterial thrombosis. The purpose of this study was to evaluate the association of plasma Hcy with early re-stenosis following carotid eversion endarterectomy. PATIENTS AND METHODS: Of 398 consecutive patients, 363 were included in this study. 62% of patients had symptomatic internal carotid artery (ICA) stenosis. Patients had preoperative assessment of Hcy and other well established atherosclerosis risk factors. Intraoperatively, completion angiography was performed in 2 planes. Patients had clinical, Hcy and duplex follow up at 1, 3, 18 and 36 months postoperatively. RESULTS: Complete follow up data were available for 312 patients. Five patients suffered from strokes and 2 patients died during the peri-operative period (combined stroke and death rate of 2%). Mean follow up was 26+/-5 months (range 17 to 36 months). Seventeen and six patients (5.5%) developed a 50-69% and >70% re-stenosis, respectively. Serum creatinine was significantly higher in patients with early re-stenosis, occlusion or stroke after CEA (P=0.043). High grade re-stenosis, occlusion and stroke ipsilateral to the operated side (17 patients) was associated with HbA1C and creatinine (P=0.043 and 0.046, respectively) but not Hcy. CONCLUSION: While Hcy is a recognized independent risk factor for atherothrombosis, our study suggests that there is no association of Hcy with early re-stenosis after eversion endarterectomy.     

A therapeutic window for carotid endarterectomy in patients with asymptomatic carotid stenosis

The natural history of asymptomatic carotid stenosis was prospectively and systematically studied in 500 patients by clinical observation and carotid Doppler ultrasonography. In the 40% of carotid arteries (398) with an initial stenosis of over 35%, there were apparently two separate populations, with a cutoff point of 85% stenosis. There were 79 ischemic cerebral events (54 transient ischemic attacks and 25 strokes) among the 500 patients during 60 months of follow-up, predominantly in the severe-stenosis (more than 75%) group, with few events occurring in the near-or total-occlusion (95% to 100% stenosis) group; the highest incidence was in patients whose arteries had 75% to 90% stenosis. These observations indicate a critical degree of carotid stenosis at which stroke risk becomes maximal, declining as the artery becomes occluded. These findings suggest that there may be a "window" for carotid endarterectomy in patients with asymptomatic carotid stenosis, when the stroke risk may be high enough (5.5%/year) to warrant surgery.     

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目的探讨外翻式颈动脉内膜切除术在预防脑缺血性“中风”的临床应用价值方法总结1999～2003年42例接受这一手术的病人的临床资料，分析其动脉阻断时间及术后并发症的发生情况结果手术均获成功，颈动脉平均阻断时间为16min，明显低于常规术式，术后并发症较少，结论外翻式颈动脉内膜切除术具有阻断时间短，再狭窄率低等优点，但对操作者的熟练程度及病人局部的情况具备较高要求。     

Stepwise revascularization by carotid endarterectomy after balloon angioplasty for symptomatic severe carotid artery stenosis

The authors report a novel stepwise carotid revascularization method to prevent perioperative complication. A 68-year-old man presented with left hemiparesis and dysarthria caused by severe stenosis of the right cervical internal carotid artery. According to the preoperative cerebral blood flow evaluation and plaque characterization, the patient was at risk for postoperative hyperperfusion and ischemic complications after carotid artery stenting. Initially, the patient underwent percutaneous angioplasty using an undersized balloon. Fifteen days later, the patient underwent a carotid endarterectomy. The surgical specimen obtained during the carotid endarterectomy showed the presence of typical vulnerable plaque. Of note was the complete preservation of the thin fibrous cap. The postoperative single-photon emission tomography images showed no signs of hyperperfusion, and the patient developed no neurological symptoms after each of the procedures.     

Carotid endarterectomy for severe asymptomatic carotid stenosis: a perioperative experience at a community hospital

The purpose of this study was to evaluate the safety and feasibility of carotid endarterectomy (CEA) for severe asymptomatic carotid stenosis in a community setting with direct surgical resident participation. The medical records of all patients who had undergone CEA for severe asymptomatic carotid stenosis between 1989 and 1997 were retrospectively reviewed to ascertain perioperative morbidity and mortality. One hundred forty-seven CEAs were performed on 131 patients over the 8-year interval. Perioperative stroke and death rate was 0 per cent. However, one patient had a postoperative transient ischemic attack, and one patient had vocal cord dysfunction due to vagus nerve injury (1.3%). Three other patients had perioperative complications not directly related to CEA (2.1%). Therefore the total perioperative complication rate of (3.4%) compares favorably with results reported by several large tertiary referral centers. CEA for severe asymptomatic carotid stenosis can be safely performed in a community hospital setting with direct surgical resident participation.     

Carotid endarterectomy for asymptomatic carotid stenosis is safe in octogenarians

ObjectiveCarotid endarterectomy (CEA) is the gold standard to prevent a recurrent stroke in symptomatic patients with carotid stenosis. However, in the modern era, the benefit of CEA in asymptomatic octogenarian patients has come into question. This study investigates real-world outcomes of CEA in asymptomatic octogenarians.MethodsPatients who underwent CEA for asymptomatic carotid stenosis were identified in the American College of Surgeons National Surgical Quality Improvement Program CEA-targeted database from 2012 to 2017. They were stratified into two groups: octogenarians (≥80 years old) and younger patients (<80 years old). The 30-day outcomes evaluated included mortality and major morbidities such as stroke, cardiac events, pulmonary, and renal dysfunction. Multivariable logistic regression was used for data analysis.ResultsWe identified 13,846 patients with asymptomatic carotid stenosis who underwent an elective CEA including 2509 octogenarians and 11,337 younger patients. Octogenarians were more likely to be female and less likely to be diabetic or smokers compared with younger patients. There was no difference in preoperative use of statins or antiplatelet therapy. Examination of 30-day outcomes revealed that octogenarians had slightly higher mortality (1.2% vs 0.5%; odds ratio, 2.1; 95% confidence interval, 1.3-3.4; P < .01), and a higher risk of return to the operating room (3.3% vs 2.3%; odds ratio, 1.4; 95% confidence interval, 1.1-1.9; P = .01). However, there was no difference between octogenarians and younger patients in adverse cardiac events or pulmonary, renal, or wound complications. Twenty-five octogenarian and 138 younger patients suffered from periprocedural stroke at a similar rate (1.0% vs 1.2%; P = .54). Stroke/death occurred for 51 of 2509 patients (2.0%) in the older group and 184 of 11,337 patients (1.6%) in the younger group, a difference that was not significant (P = .15).ConclusionsThe 30-day outcomes of CEA in octogenarians are comparable with those in younger patients. Although the octogenarians had slightly higher mortality than younger patients, the absolute risk of mortality was still low at 1.2%. Therefore, CEA is safe in asymptomatic carotid stenosis in octogenarians. Overall life expectancy and preoperative functional status, rather than age, should be the major determinants in the decision to operate.     

Immediate and long-term results of carotid endarterectomy for asymptomatic high-grade stenosis

We examined the operative risks and long-term results of carotid endarterectomy for asymptomatic patients in terms of stroke, death, and recurrent stenosis. The results of a nonrandomized study with a follow-up of 1 to 104 months (mean 46 months) is reported. A tertiary referral center served as the setting for this report. One hundred consecutive patients with severe but asymptomatic carotid artery stenosis out of a total of 514 patients undergoing carotid endarterectomy were entered into this study. The severity of carotid disease was determined by duplex scanning and confirmed arteriographically. No patients were lost to follow-up after surgery. Eighty-nine operations (77%) were done under cervical block anesthesia and all arteries were closed with saphenous vein patches. Life-table analysis showed that the stroke-free rate at 5 years was 96.3% with an ipsilateral stroke-free rate of 98.2%. The 5-year overall survival rate was 78.2% with a stroke-free survival rate of 75%. Carotid endarterectomy can be performed safely for asymptomatic patients believed to be at risk for stroke. The potential for early death due to myocardial disease, late stroke, and recurrent stenosis do not justify advising patients against undergoing prophylactic carotid endarterectomy for asymptomatic high-grade stenosis.     

Selective shunting with eversion carotid endarterectomy

PURPOSE: The consensus is that eversion carotid endarterectomy (CEA) is a safe, effective, and durable surgical technique. Concern remains, however, regarding insertion of a shunt during the procedure. We studied the advisability of shunting with eversion CEA by comparing patients who underwent eversion CEA with and without shunting. METHODS: Over 9 years, 624 primary eversion CEAs were performed in 580 selected patients to treat symptomatic (n = 398, 63.8%) and asymptomatic (n = 226, 36.2%) carotid lesions. All eversion CEAs were performed by the same surgeon (E.B.), with the patient under deep general anesthesia, with continuous electroencephalographic (EEG) monitoring for selective shunting, based exclusively on EEG changes consistent with cerebral ischemia. A Pruitt-Inahara shunt was used in 43 eversion CEAs (6.9%). All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at 1, 6, and 12 months and once a year thereafter. Mean follow-up was 52 months (range, 3-91 months). The main end points were perioperative (30-day) stroke and death, and recurrent stenosis. RESULTS: No perioperative death occurred in this series. Overall, ischemic perioperative stroke occurred in 4 of 624 patients (0.6%). Two strokes were minor and two were major. Only one (major) stroke occurred in the group with shunt insertion (1 of 43, 2.3%; P = not significant); the everted internal carotid artery was patent. Long-term follow-up was performed in all living patients. There was no late recurrent stenosis (>50%), and one late asymptomatic occlusive event occurred in the group without shunt insertion. CONCLUSIONS: Shunt insertion can be safely performed during eversion CEA. Perioperative mortality and morbidity after eversion CEA are not statistically modified with shunting.     

Clinical application of eversion carotid endarterectomy

The results of 250 eversion carotid endarterectomies (ECEAs) in 227 consecutive patients in 1 institution were evaluated. The outcomes of 250 consecutive ECEAs at North Shore University Hospital by a single surgeon, between January 1998 and August 2001, were recorded prospectively. In the single series of 250 ECEAs the 30-day operative mortality was 0.4% and the perioperative stroke rate was 0.8%. During a mean follow-up of 23 months, the recurrent stenosis rate was 0.8%. A reduction in stroke and mortality rates is often observed with ECEA.     

Long-term restenosis rate of eversion endarterectomy on the internal carotid artery.

OBJECTIVES: The eversion endarterectomy of the internal carotid artery was introduced in Hungary in 1991. The aim of this study was to define the long-term restenosis rate of this procedure. PATIENTS AND METHODS: Between 1991 and 1993, 171 operations, on 151 patients, were performed by single surgeon: with long-term follow up of 109 patients, which included annual physical and ultrasound examinations. Restenosis rate and plaque morphology were defined. Survival and patency rate were analysed by life-tables. RESULTS: The combined perioperative stroke morbidity and mortality rate was 0.8%. The 5-year patient survival rate was 85%, the recurrent stenosis free rate was 88% at 5 years. Only 9% of the patients had carotid restenosis of more than 70% during this period. Ultrasound plaque morphology showed calcification in one case. Two patients had re-operations, with plaque histology showed myointimal hyperplasia in each case. CONCLUSIONS: Our results for restenosis are compare favourably with the 2-34% restenosis rate reported in the literature. Ultrasound and histological findings suggest that atherosclerosis does not play a significant role in the development of restenosis after the eversion carotid endarterectomy.