Clinical impact of sex on carotid revascularization

BackgroundThe impact of sex in the management of carotid disease is unclear in the current literature. Therefore, we evaluated the effect of sex on perioperative outcomes following carotid endarterectomy (CEA) and carotid artery stenting (CAS).MethodsWe included patients who underwent CEA or CAS between 2012 and 2017 in the Vascular Quality Initiative database. Our primary outcome was perioperative stroke/death. Secondary outcomes were in-hospital stroke, 30-day mortality, and in-hospital MI. We compared perioperative outcomes between female and male patients, stratified by treatment modality and symptom status, and used multivariable regression to account for differences in baseline characteristics.ResultsA total of 83,436 patients underwent either a CEA (71,383) or CAS (12,053). Asymptomatic and symptomatic CEA females were less likely to be on a preoperative antiplatelet agent, when compared to males. Females overall, were less likely to be on a preoperative statin and more likely to have chronic obstructive pulmonary disease. Within the CAS cohort, females were more likely to have a previous ipsilateral CEA. There were no differences between males and females in major adverse events following CEA for asymptomatic disease. Following CEA for symptomatic disease, there was no difference in stroke/death rate or in-hospital stroke. However, females experienced a higher 30-mortality after adjustment (univariate: 1.0% vs 0.7%, P = .04; adjusted: odds ratio [OR], 1.4:1.02-1.94). Following CAS for asymptomatic disease, females experienced a higher rate of perioperative stroke/death (2.9% vs 1.9% P = .02; OR, 1.5: 1.05-2.03) and in-hospital stroke (2.1% vs 1.2% P = .01; OR, 1.8: 1.20-2.60). There were no differences in outcomes for symptomatic females vs males undergoing CAS.ConclusionsFemales with carotid disease less frequently receive optimal medical treatment with antiplatelet agents and statins. This is an important target area for quality improvement issue in both females and males. Furthermore, among symptomatic CEA patients the female sex is associated with higher mortality and among asymptomatic CAS patients, females experience higher rates of stroke/death. These findings suggest that careful patient selection is necessary in the treatment of female patients. Quality improvement projects should be created to further investigate and eliminate the disparities of optimal medical management between the sexes.     

Gender as a primary predictor of outcome after carotid endarterectomy

OBJECTIVE: Post hoc analysis results of the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study suggest that carotid endarterectomy (CEA) may not be as efficacious in women as it is in men. This study was undertaken for the evaluation of whether there is a difference between men and women in early postoperative outcome after CEA and whether such a difference is consistent across other predictors. METHODS: We conducted a retrospective review of all CEAs entered into our departmental registry between January 1, 1989, and November 30, 2000. A total of 3422 CEAs was performed in 3077 consecutive patients. The ratio of men to women was 2:1, and the ratio of patients who were asymptomatic to patients who were symptomatic was 2.3:1. The following in-hospital outcome data were analyzed: transient ischemic attack (TIA), stroke, mortality, combined TIA or stroke, and combined stroke or mortality. Univariate and multivariate analysis results of selected risk factors for an adverse perioperative event were assessed with generalized estimating equation analysis with backwards selection. The following risk factors were considered: gender, preoperative neurologic status, urgency of operation, type of arteriotomy repair, reoperative CEA for recurrent stenosis, history of cardiopulmonary disease, previous coronary artery intervention, simultaneous CEA and coronary bypass grafting surgery, renal failure, and diabetes. RESULTS: Univariate analysis results of gender differences revealed that women were at higher risk for a postoperative TIA or stroke (3.3% for women versus 2.1% for men; odds ratio [OR], 1.6; confidence interval [CI], 1.04 to 2.5; P =.03) and for postoperative stroke or mortality (3.1% for women versus 2.1% for men; OR, 1.6; CI, 1.04 to 2.5; P =.03). Multivariate analysis results showed that female gender was an independent predictor for a postoperative TIA or stroke (OR, 1.7; CI, 1.1 to 2.6; P =.03). Further analysis disclosed that women who were asymptomatic were at greater risk than were men for postoperative stroke or mortality (OR, 2.3; CI, 1.3 to 3.9; P =.003). Conversely, there was no gender association for postoperative stroke or mortality in the consideration of only patients who were symptomatic (OR, 1.0; CI, 0.45 to 2.1; P =.95). The interaction between women and preoperative symptoms approached significance (P =.07) with respect to postoperative stroke and mortality rate, which suggests that the gender effect could be influenced by the clinical presentation. CONCLUSION: The combined TIA or stroke and stroke or mortality rates are higher in women as compared with men in the postoperative period, but these risks remain acceptable when CEA is performed for appropriate indications. The interaction between symptoms and gender suggests that, in patients who are asymptomatic, women are more likely than are men to have early complications. However, there is no gender difference in patients who are symptomatic. Therefore, despite a low postoperative complication rate, CEA is appropriate in both women who are asymptomatic and women who are symptomatic only if the postoperative TIA, stroke, and mortality rates are appreciably lower than in the natural history of medical management of these patients.     

Comparison of outcomes in women and men following carotid interventions in the Washington state's Vascular Interventional Surgical Care and Outcomes Assessment Program

Background

The benefit for carotid endarterectomy (CEA) to prevent a potential stroke has been shown to be less beneficial for women compared with men and the risk of carotid stenting (CAS) is higher in women than men. We hypothesized that a community-based Washington state registry data would also reveal increased morbidity and mortality for women undergoing carotid interventions.

Optimal contemporary management of symptomatic and asymptomatic carotid artery stenosis

This commentary addresses the issue of optimal contemporary management of symptomatic and asymptomatic carotid artery stenosis. Based on current data, carotid endarterectomy (CEA) should be performed in the majority of patients with symptomatic carotid artery stenosis. Carotid artery stenting (CAS) should be reserved for a minority of these symptomatic patients, in whom CEA is contraindicated. In asymptomatic patients, all should be placed on best medical treatment (BMT). With the use of one or more of the proposed stroke risk stratification models or some as yet undetermined method, the identification of those asymptomatic individuals may be possible in whom stroke risk is higher than usual with BMT. This asymptomatic subgroup, which may be small and is yet to be determined with certainty, could be offered an invasive carotid procedure (either CAS or CEA).     

Selection of treatment for patients with carotid artery disease: medication, carotid endarterectomy, or carotid artery stenting

Patients presenting with atherosclerosis of the extracranial carotid arteries may be offered carotid endarterectomy (CEA), carotid artery stenting (CAS), or medical therapy to reduce their risk of stroke. In many cases, the choice between treatment modalities remains controversial. An algorithm based on patients' neurologic symptoms, comorbidities, limiting factors for CAS and CEA, and personal preferences was developed to determine the optimal treatment in each case. This algorithm was then employed to determine therapy in 308 consecutive patients presenting to a single institution during one calendar year. Ninety-five (30.8%) patients presented with an asymptomatic carotid stenosis of more than 80% and 213 (69.2%) with a symptomatic stenosis of more than 50%. According to our algorithm, 59 (62.1%) of the 95 asymptomatic patients received CAS, 20 (21.1%) received CEA, and 16 (16.8%) received medical therapy. All symptomatic patients underwent intervention; 153 (71.8%) were treated with CAS and 60 (28.2%) with CEA. Combined 30-day stroke and death rates after CAS were 1.7% in asymptomatic patients and 2.6% in symptomatic patients. After CEA, these rates were 0% and 3.3%, respectively. Careful selection of treatment modality according to predetermined criteria can result in improved outcomes.     

Alert for increased long-term follow-up after carotid artery stenting: results of a prospective, randomized, single-center trial of carotid artery stenting vs carotid endarterectomy

BACKGROUND: Carotid endarterectomy (CEA) has been shown to be effective in stroke prevention for patients with symptomatic or asymptomatic carotid artery stenosis. Although several prospective randomized trials indicate that carotid artery stenting (CAS) is an alternative but not superior treatment modality, there is still a significant lack of long-term data comparing CAS with CEA. This study presents long-term results of a prospective, randomized, single-center trial. METHODS: Between August 1999 and April 2002, 87 patients with a symptomatic high-grade internal carotid artery stenosis (>70%) were randomized to CAS or CEA. After a median observation time of 66 +/- 14.2 months (CAS) and 64 +/- 12.1 months (CEA), 42 patients in each group were re-evaluated retrospectively by clinical examination and documentation of neurologic events. Duplex ultrasound imaging was performed in 61 patients (32 CAS, 29 CEA), and patients with restenosis >70% were re-evaluated by angiography. RESULTS: During the observation period, 23 patients (25.2%) died (10 CAS, 13 CEA), and three were lost to follow up. The incidence of strokes was higher after CAS, with four strokes in 42 CAS patients vs none in 42 CEA patients. One transient ischemic attack occurred in each group. A significantly higher rate of restenosis >70% (6 of 32 vs 0 of 29) occurred after CAS compared with CEA. Five of 32 CAS patients (15.6%) presented with high-grade (>70%) restenosis as an indication for secondary intervention or surgical stent removal, and three presented with neurologic symptoms. No CEA patients required reintervention (P < .05 vs CAS). A medium-grade (<70%) restenosis was detected in eight of 32 CAS patients (25%) and in one of 29 CEA patients (3.4%). In five of 32 CAS (15.6%) and three of 29 CEA patients (10.3%), a high-grade stenosis of the contralateral carotid artery was observed and treated during the observation period. CONCLUSION: The long-term results of this prospective, randomized, single-center study revealed a high incidence of relevant restenosis and neurologic symptoms after CAS. CEA seems to be superior to CAS concerning the development of restenosis and significant prevention of stroke. However, the long-term results of the ongoing multicenter trials have to be awaited for a final conclusion.     

Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: an analysis of 758 procedures

PURPOSE: Surgical treatment of hemodynamically significant carotid artery stenoses has been well documented, especially in the asymptomatic patient. However, in those patients presenting with hemodynamically significant asymptomatic carotid artery disease who are to undergo cardiac surgery, optimal treatment remains controversial. In this study, we analyze our experience with patients who underwent synchronous carotid endarterectomy (CEA) and coronary artery bypass graft procedures (CABG) for hemodynamically significant (>70%) asymptomatic carotid artery stenosis and coronary artery disease (CAD). METHODS: Demographics and outcomes of all patients undergoing synchronous CEA/CABG for asymptomatic carotid stenosis between April 1980 and January 2005 were reviewed from our vascular registry and patient charts. We included patients who underwent standard patching of their carotid artery and those undergoing eversion CEA. All neurologic events within the first 30 days that persisted >24 hours were considered a stroke. For purposes of comparison, we also reviewed outcomes for patients undergoing synchronous CEA/CABG for symptomatic carotid stenosis. RESULTS: Asymptomatic carotid artery stenosis (>70%) was the indication in 702 patients (276 women and 426 men) undergoing 758 CEAs. In the asymptomatic group, 22 patients, of which 21 succumbed to cardiac dysfunction, and one died from a hemorrhagic stroke. The overall mortality rate was 3.1%. Seven permanent nonfatal neurologic deficits occurred in this series (1 woman, 6 men). The combined stroke mortality was 4.3%. This compares to a 30-day stroke mortality of 6.1% in 132 symptomatic combined CEA/CABG patients. The difference in stroke mortality in women compared with men was not significant. CONCLUSION: In this experience, patients presenting with hemodynamically significant (>70%) asymptomatic carotid artery stenosis can undergo synchronous CEA/CABG with low morbidity and mortality.     

A personal experience with coronary artery bypass grafting, carotid patching, and other factors influencing the outcome of carotid endarterectomy

OBJECTIVE: This study was conducted to investigate the influence of coronary artery bypass grafting (CABG), carotid patching, and other factors on the outcome of all carotid endarterectomies (CEAs) performed by a single surgeon at a tertiary referral center. METHODS: The series includes 2262 CEAs (335 bilateral) in 1521 men and 741 women (33%) with median ages of 66 and 68 years, respectively. Surgical indications were asymptomatic stenosis for 1503 procedures (66%), retinal ischemia or cerebral transient ischemic attacks each for 271 (12%), and prior stroke for 217 (9.6%). CEA was done as an isolated operation in 1959 patients and was performed in conjunction with simultaneous CABG in 303 (13%). Primary arteriotomy closure was used for 783 CEAs (35%), vein patching for 1232 (54%), and synthetic patching for 247 (11%). Outcome event rates were assessed by logistic regression analysis, proportional hazards models, and Kaplan-Meier estimations. RESULTS: Postoperative mortality (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.7 to 7.5; P = .001), stroke (OR, 3.2; 95% CI, 1.6 to 6.4; P = .001), and combined stroke and mortality rates (OR, 3.4; 95% CI, 2.0 to 5.8; P < .001) were significantly higher for simultaneous CEA/CABG than for isolated CEA. Ipsilateral postoperative stroke rates were similar (2.6% vs 1.7%, P = .41) in both settings. Vein patching had a lower risk for ipsilateral stroke (OR, 0.42; 95% CI, 0.21 to 0.86; P = .015) than primary closure, but was not significantly different from synthetic patching (P = .10). The documented incidence of postoperative carotid thrombosis was 1.5% with primary closure, 0.6% with vein patching, and 2.0% with synthetic patching (P = .088). Overall Kaplan-Meier survival was 92% at 1 year, 71% at 5 years, 41% at 10 years, and 20% at 15 years, but long-term mortality rates were higher after simultaneous CEA/CABG (hazard ratio, 1.3; 95% CI, 1.1 to 1.5; P = .002) than after CEA alone. Late strokes or retinal infarctions have been reported after 97 (5.0%) of the 1923 operations for which follow-up was available, 51 (2.3%) of which were ipsilateral to CEA. The incidence of > or = 60% recurrent stenosis was independently influenced by carotid patching (OR, 0.61; 95% CI, 0.40 to 0.92; P = .019) but not by the choice of patch material (P = .11). CONCLUSIONS: These results substantiate the common observation that patients who require simultaneous CEA/CABG have a higher risk for adverse outcomes than patients who undergo isolated CEA. Carotid patching provided significant benefit with respect to the risks for ipsilateral postoperative stroke and > or = 60% recurrent stenosis.     

In-hospital outcomes alone underestimate rates of 30-day major adverse events after carotid artery stenting

ObjectiveOutcome studies using databases collecting only hospital discharge data underestimate morbidity and mortality because of failure to capture postdischarge events. The proportion of postdischarge major adverse events is well characterized in patients undergoing carotid endarterectomy (CEA) but has yet to be characterized after carotid artery stenting (CAS).MethodsWe retrospectively reviewed all patients undergoing CAS from 2011 to 2017 using the American College of Surgeons National Surgical Quality Improvement Program procedure targeted database to evaluate rates of 30-day major adverse events, stratified by in-hospital and postdischarge occurrences. The primary outcome was 30-day stroke/death. Multivariable analysis using purposeful selection was used to identify independent factors associated with in-hospital, postdischarge, and 30-day stroke/death events.ResultsOf the 899 patients undergoing CAS, reporting of in-hospital outcomes alone would yield a stroke/death rate of 2.7%, substantially underestimating the 30-day stroke/death rate of 4.0%. In fact, 35% of stroke/deaths, 27% of strokes, 73% of deaths, 35% of cardiac events, and 35% of stroke/death/cardiac events occurred after discharge. More postdischarge stroke/death events occurred after treatment of symptomatic compared with asymptomatic patients (47% vs 27%; P < .001). During this same study period, the 30-day stroke/death rate after CEA was 2.6%, with similar proportions of postdischarge strokes (28% vs 27%; P = .51) compared with CAS but lower proportions of postdischarge deaths (55% vs 73%; P < .001). After CAS, patients experiencing postdischarge stroke/death events had a shorter postoperative length of stay compared with patients with in-hospital stroke/death (1 [1-2] vs 5 [3-10] days; P < .001). Chronic obstructive pulmonary disease was independently associated with postdischarge stroke/death (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.2-16; P = .02) after CAS. Nonwhite ethnicity was independently associated with overall 30-day stroke/death (OR, 3.4; 95% CI, 1.4-7.9; P < .01), whereas statin use was associated with not having stroke/death within 30 days (OR, 0.5; 95% CI, 0.2-1.0; P = .049).ConclusionsMore than one-quarter of perioperative strokes occur following discharge after both CAS and CEA. A higher proportion of postdischarge deaths occur after CAS in symptomatic patients, which may reflect treatment of a population of higher risk patients. Further investigation is needed to elucidate the cause of postdischarge stroke to develop methods to reduce these complications.     

Intraoperative neurological changes in 1665 regional anaesthetic carotid endarterectomies predicts postoperative stroke

BACKGROUND: To maximize the benefit of carotid endarterectomy (CEA) in stroke prevention its complication rate must be minimized. The purpose of this study was to report the outcomes of a large series of CEA carried out under regional anaesthesia with selective shunting, with particular emphasis on identifying predictors for perioperative stroke and mortality. METHODS: Between 1987 and 2003 the data for 1665 consecutive regional anaesthetic CEA carried out in 1495 patients were collected prospectively; awake neurological testing facilitated selective shunting. Preoperative data, intraoperative events and postoperative in-hospital complications were recorded and analysed. RESULTS: There were 38 non-fatal strokes (2.3%) and 10 deaths (0.6%), giving a combined stroke and mortality rate of 2.9%. Only patients who needed shunting were found to have significantly higher rate of postoperative stroke and mortality (7.0 vs 1.9%, P < 0.001). Patient characteristics, comorbidities, indication for operation (P = 0.34) and the degree of stenosis of the contralateral carotid artery (P = 0.65) were not found to be predictive of perioperative stroke or mortality, although the latter two were found to be predictive of the need for shunting (P < 0.001 and P = 0.002). CONCLUSION: Regional anaesthetic CEA is a safe and effective technique with excellent morbidity and mortality rates. The technique can be undertaken safely regardless of the indication for endarterectomy or the status of the contralateral carotid artery. Patients who developed intraoperative neurological changes requiring shunting are identified as high risk for perioperative stroke or mortality and should therefore be carefully monitored postoperatively.     

颅外段颈动脉狭窄的治疗策略

目的：探讨颅外段颈动脉粥样硬化性狭窄的治疗方法。方法回顾性分析上海中山医院血管外科2012年1～6月51例颅外段颈动脉粥样硬化性狭窄患者的临床资料,16例行颈动脉内膜剥脱术（carotid endarterectomy,CEA）,35例行颈动脉支架置入术（ carotid artery stenting ,CAS）。结果51例手术均获成功,1例CAS术后即刻脑卒中,1例CEA术后第3天短暂性脑缺血发作（transient ischemic attack,TIA）,1例CAS术后颈动脉窦压迫。全组术后随访9～15个月,平均13．6月,复查颈动脉B超,无严重再狭窄。结论根据颅外段颈动脉粥样硬化性狭窄患者的相关医学资料,对于有下列情况之一的患者我们倾向于行CEA：①6个月内1次或多次TIA,且颈动脉狭窄度≥70％;②6个月内1次或多次轻度非致残性卒中发作,症状或体征持续超过24小时且颈动脉狭窄度≥70％;③对于经颈部血管CTA和颈动脉全脑血管造影发现的颈动脉狭窄段≥2 cm。对于有下列情况之一的患者我们倾向于行CAS：①无症状性颈动脉狭窄度≥70％;②有症状性狭窄度范围50％～69％;③无症状性颈动脉狭窄度＜70％,但血管造影或其他检查提示狭窄病变处于不稳定状态。     

Stroke after coronary artery bypass grafting in patients with cerebrovascular disease

BACKGROUND: Stroke has been associated with a significantly increased mortality from coronary artery bypass grafting (CABG). To determine the predictors of stroke in patients undergoing CABG, we collected data on 472 consecutive patients. METHODS: From March 1991 to March 1999, all patients undergoing CABG at our institution underwent routine duplex scanning of the extracranial carotid and vertebral arteries. Seven patients with symptomatic carotid stenosis were treated by carotid endarterectomy (CEA) before CABG. RESULTS: There was a 10-fold increase in mortality (12.5%) associated with postoperative stroke. Many variables were analyzed by a multivariate technique and the severity of extracranial carotid artery stenosis was determined to be the only independent predictor of postoperative stroke (p < 0.01). None of the patients with carotid artery occlusion and none of the patients who underwent CEA before CABG experienced a stroke. CONCLUSIONS: To reduce the stroke rate, the indications for prophylactic CEA may be extended for asymptomatic patients with carotid artery stenosis greater than 75%.     

颈动脉内膜剥脱术和颈动脉支架的前瞻性随机对照研究

目的 评价颈动脉内膜剥脱术和颈动脉支架治疗颈动脉狭窄的近期和中期临床效果.方法 前瞻性单中心随机对照研究,自2004年5月至2006年12月,将同意入组的40例有症状(狭窄程度>50%)和无症状(狭窄程度>70%)颈动脉狭窄患者随机分为两组,即颈动脉内膜剥脱术组(CEA)和颈动脉支架组(CAS).一期观察终点是术后30 d内出现严重脑梗死或死亡;二期观察终点是各种手术并发症、急性脑缺血发作、偏瘫、急性心肌梗死和术后18个月内的脑卒中、死亡和再狭窄等,同时回顾性分析两组总的住院费用.结果 CEA和CAS两组患者术前一般资料、临床症状、伴随疾病等因素均无差异.CEA组20例23支颈动脉手术(3例分别行双侧CEA),术中应用转流管9条(39.1%),颈动脉补片12条(52.2%);CAS组20例23支颈动脉支架(3例行双侧CAS),应用脑保护装置21个(91.3%).CEA和CAS两组术后30 d内神经系统并发症(4.3%对8.7%,P=0.46)、急性心肌梗死(4.3%对0,P=0.31)和伤口血肿(8.7%对0,P=0.14)等差异均无统计学意义,至术后18个月无短暂性脑缺血发作和再狭窄病例.CEA和CAS两组平均住院费用分别为(16 450.95±6188.76)和(70 130.15±11 999.02)元人民币,差异有统计学意义(P<0.01).结论 CEA和CAS术后30 d和术后18个月的并发症、病死率和临床疗效无明显差异,但CAS的住院花费明显高于CEA.     

Concomitant severe carotid and coronary artery diseases: a separate management or concomitant approach

Objective: To systematically compare outcomes between patients with asymptomatic carotid artery diseases (>80% stenosis) that had undergone staged carotid endarterectomy (CEA) before coronary artery bypass grafting (CABG) vs simultaneous CEA and CABG. Methods: A comprehensive electronic search of MEDLINE, Scopus, EMBASE, and Ovid from their inception up till August 2018 was performed to identify all studies comparing staged CEA followed by CABG to simultaneous CEA and CABG. Primary outcome measure was postoperative stroke, and secondary measures were myocardial infarction (MI) and 30‐day mortality rates. Results: A total of 67 953 patients were analyzed from 11 articles. There was higher rate of previous stroke in the staged cohort (2.64% vs 2.32%; odds ratio [OR], 0.81; 95% confidence interval [CI; 0.66, 0.99]; P = .040). There was no difference in previous MI (P = .57) or unstable angina (P = .08) among both cohorts. Postoperatively, there were higher stroke rates (3.64% vs 2.83%; OR, 0.72; 95% CI [0.62‐0.89]; P < .0001), operative mortality (4.32% vs 3.58%; OR, 0.90; 95% CI [0.83‐0.98]; P = .02), and 30‐day mortality (4.40% vs 3.58%; OR, 0.86; 95% CI [0.78‐0.96]; P = .006) in the simultaneous cohort. However, length of stay was significantly shorter in the simultaneous cohort (11.9 days vs 12.6 days; weighted mean difference 3.14 [0.77‐5.51]; P = .009). There were no significant differences in 1‐year mortality (P = .33), MI rates (P = .08), and rates of transient neurological deficits (P = .06). Conclusion: The results from this study favors staged CEA with CABG with lower incidence of postoperative stroke, operative, and 30‐day mortality. A larger study, ideally a randomized controlled trial, is required to address the superiority of each technique.     

Silent stroke and cognitive decline in asymptomatic carotid stenosis revascularization

The aim of this study was to assess the relationship between serum levels of S100β and neuron-specific enolase (NSE), postoperative diffusion-weighted magnetic resonance imaging (DW-MRI) and Mini-Mental State Examination (MMSE) score in asymptomatic patients affected by ≥ 70% carotid stenosis submitted to carotid endarterectomy (CEA) or carotid artery stenting (CAS), and to compare MMSE scores and DW-MRI findings at follow-up evaluations. Between April 2008 and April 2009, 60 patients were submitted to carotid intervention. All patients underwent DW-MRI and MMSE preoperatively, at 24 hours postoperatively, at 6 months and at 12 months. Neurobiomarkers were assessed for each patient at six time-points. Thirty-two patients were submitted to CEA and 28 to CAS. No mortality was observed. One CAS patient presented with an ischemic stroke. In six CAS patients and one CEA patient, new subclinical ischemic lesions were detected at postoperative DW-MRI (21.4% versus 3%, P = 0.03). In CAS patients, new DW-MRI lesions were significantly associated with MMSE score decline (P = 0.001). At 12 months, patients presenting with new postoperative ischemic lesions showed lower MMSE scores (P = 0.08). CAS patients showed increasing neurobiomarker levels compared with CEA patients (P = 0.02). In conclusion, microembolization effects may persist over time, so it should be avoided whenever possible. Carotid revascularization procedures should be evaluated and compared not only with respect to death/stroke but also to microembolism rates.     

Carotid endarterectomy in octogenarians: Does increased age indicate “high risk?”

OBJECTIVE: Carotid endarterectomy (CEA) is proven to be the most effective treatment for symptomatic carotid artery stenosis of 50% or greater and asymptomatic carotid stenosis of 60% or greater. Although the prevalence of carotid artery disease increases with age, most prospective and randomized trials have excluded patients older than 80 years, implying that they are either at higher procedural risk or have decreased life expectancy. Since advanced age (>/=80 years) has been viewed as a "high-risk" indicator for CEA, age >/=80 years has been used as an indication for alternative treatment. The study was conducted to determine if age >/=80 years is related to increased morbidity, mortality, and length of stay in patients undergoing CEA. METHODS: In the 12-year period from 1993 to 2004, 2217 CEAs were performed in 1961 patients. Three hundred sixty procedures were performed in 334 patients >/=80 years. Demographics, presentation, risk factors, operative outcome, and survival were analyzed. Contemporary literature was reviewed and the results summarized. RESULTS: In patients aged >/=80 years, compared with their younger cohort, there was no difference in stroke (1.1% vs 0.8%, P = .333) but there was a higher operative mortality (1.9% vs 0.8%, P = .053). The combined stroke/death rate was higher in octogenarians (3.1% vs 1.5%, P = .041). This difference was due to the greater stroke/death rate in symptomatic octogenarians vs asymptomatic octogenarians (6.0% vs 0.9%, P = .007). The average postoperative length of stay was 3.2 +/- 4.8 days for octogenarians compared with 2.4 +/- 3.5 days for their younger counterparts ( P < .001). Thirty-seven percent of the octogenarians were discharged on the first postoperative day vs 51% ( P < .001), whereas 13% remained hospitalized beyond 5 days vs 8% ( P = .003). Although Kaplan-Meier survival curves show a higher mortality in octogenarians, survival after CEA approaches that of the overall population. A summary of the contemporary literature of CEA in 2204 patients >/=80 shows an operative stroke rate of 2.23% and death rate of 1.28%, with a combined stroke/death rate of 3.51%. CONCLUSION: CEA is a safe and effective procedure in the octogenarian. The combined stroke/death rate is increased in patients aged >/=80, indicating increased risk, predominantly in symptomatic patients. Although CEA risk in octogenarians is higher compared with a younger cohort, outcomes remain within acceptable national guidelines and within outcome measures known to confer benefit compared with best medical care. Therefore, the term "high risk" should not be arbitrarily applied to patients reaching the 80-year threshold. This is confirmed by the contemporary literature.     

Carotid endarterectomy versus carotid stenting: an updated review of randomized trials and subgroup analyses

Atherosclerotic disease of the carotid arteries is responsible for a significant portion of ischemic strokes. Carotid endarterectomy (CEA) is currently the accepted standard of treatment for patients with severe symptomatic carotid stenosis. In the past few years, however, carotid angioplasty and stenting (CAS) has emerged as a potential alternative endovascular treatment strategy for this disorder. In fact, spurred by the positive results of single center studies and small, pivotal randomized trials, some even consider CAS as the treatment modality of choice, especially in presumably surgical high-risk patients. Yet, randomized trials directly comparing CAS with CEA are sparse and have produced conflicting results. The aim of this article is to review the current trial data on this issue and to define the role of these techniques for the management of two important subgroups of patients. An updated meta-analysis of seven randomized trials comparing CEA with CAS demonstrates that CAS is associated with a significantly increased risk of any stroke or death within 30 days (OR. 1.41, 95% CI 1.07-1.87, p < 0.05). Focusing on patients with a symptomatic carotid stenosis, there was also a significant difference in the odds of treatment-related stroke and death between CAS and CEA (OR, 1.41 ; CI 1.05 to 1.88, p < 0.05). Data on all disabling strokes and deaths within 30 days was available from five trials. The odds of disabling stroke or death at 30 days were similar in the endovascular and surgical group (OR, 1.33, 95% CI 0.89 to 1.98). Overall, these data do not justify a blind enthusiasm for CAS and a widespread use of this procedure for the treatment of carotid artery stenosis. On the other hand, a closer inspection of the current literature on elderly patients and those with a contralateral carotid occlusion clearly indicates that CAS and CEA already now have a complementary role. While elderly patients should preferentially be treated with CEA, CAS appears to be the treatment of choice in patients with a symptomatic carotid artery stenosis and a contralateral carotid occlusion in experienced centers.     

Durability of carotid endarterectomy for treatment of symptomatic and asymptomatic stenoses

PURPOSE: Although many studies have well established that carotid endarterectomy (CEA) is beneficial in selected patients with severe carotid disease, only a few large studies have focused on the durability of the surgical procedure. Carotid artery angioplasty and stenting (CAS) has recently been proposed as a potential alternative to CEA. We analyzed the incidence of late occlusion and recurrent stenosis after CEA. METHODS: Over 13 years 1000 patients underwent 1150 CEA procedures to treat symptomatic and asymptomatic high-grade carotid stenosis. CEA procedures involving either traditional CEA with patching (n = 302) or eversion CEA (n = 848) were all performed by the same surgeon, with patients under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at 1, 6, and 12 months, and yearly thereafter. New neurologic events, late occlusions, and recurrent stenoses 50% or greater were recorded. Complete follow-up (mean, 6.2 years; range, 6-156 months) was obtained in 95% of patients (949 of 1000), for an overall average of 95% of procedures (1092 of 1150). Survival analysis was performed with the Kaplan-Meier life table method. RESULTS: Perioperative (30-day) mortality rate was 0.3% (3 of 1000), and stroke rate was 0.9% (11 of 1150), with a combined mortality and stroke rate of 1.2%. The incidence of late occlusion and recurrent stenosis 70% or greater was 0.6% and 0.5%, respectively, with a combined occlusion and restenosis rate of 1.1%. Kaplan-Meier analysis showed that the rate of freedom from occlusion, restenosis 70% or greater, and combined occlusion and restenosis 70% or greater at 12 years was 99,4%, 99.5%, and 98.8%, respectively. Occlusion and restenosis developed asymptomatically. CONCLUSIONS: CEA is a low-risk procedure for treating severe symptomatic and asymptomatic carotid disease, with excellent long-term durability. Proponents of CAS should bear this in mind before considering CAS as a routine alternative to CEA.     

Treatment of asymptomatic carotid artery disease: similar early outcomes after carotid stenting for high-risk patients and endarterectomy for standard-risk patients

BACKGROUND: The role of carotid angioplasty and stenting (CAS) in the treatment of asymptomatic patients with carotid disease remains controversial. The purpose of this report is to compare outcomes in asymptomatic patients treated with CAS and carotid endarterectomy (CEA). This was the initial experience performing CAS for most of the surgeons. For comparison, we also report our outcomes in standard-risk patients treated concurrently with CEA during the same period of time. METHODS: A retrospective, nonrandomized review of asymptomatic patients undergoing CEA or CAS at Washington University Medical Center in St. Louis was done. Patients with >70% asymptomatic carotid stenosis treated between September 2003 and April 2005 were identified. CEA was the first therapeutic consideration in all patients. CAS was reserved for high-risk patients. Thirty-day outcomes of stroke or death were recorded. During this time interval, 248 patients were treated including with 93 CAS and with 145 CEA. Symptomatic or clinically detected adverse outcomes such as myocardial infarction (MI), arrhythmia, renal failure, or pulmonary complications were noted but were not the primary end points of this review. This study addresses only the periprocedural outcomes of CEA and CAS in asymptomatic patients. No data >30-day follow-up are included. RESULTS: During this period, 93 CAS and 145 CEA procedures were done in asymptomatic patients. Patient characteristics in both groups were similar. Carotid protection devices were used in 91.4% of CAS patients. The results in the CAS group showed one death (1.1%) and one stroke (1.1%). In the CEA group, three strokes occurred (2.1%, P = 0.9999), one associated with death (0.7%, P = 0.9999). The CAS group had 1.34 +/- 0.83 risk factors vs 0.39 +/- 0.58 in the CEA group (P < .0001). Median CAS and CEA length of stay was 1 day. CONCLUSIONS: CAS for asymptomatic carotid stenosis demonstrated equivalent outcomes compared with CEA, despite CAS being reserved for use in a disadvantaged subset of high-risk patients owing to anatomic risk factors or medical comorbidities. These results suggest CAS should be considered a reasonable treatment option in the high-risk but asymptomatic patient. Enthusiasm for CAS should be tempered by the recognition that long-term outcomes in CAS-treated asymptomatic patients remain unknown.     

Comparison of angioplasty and stenting with cerebral protection versus endarterectomy for treatment of internal carotid artery stenosis in elderly patients

PURPOSE: Carotid angioplasty and stenting (CAS) is being evaluated as an alternative to carotid endarterectomy (CEA) for treatment of severe carotid artery stenosis. Because CAS does not require general anesthesia and is less traumatic, it might be especially advantageous in older patients, but data comparing these 2 treatment methods in older patients are scarce. METHODS: The periprocedural complication rates in 53 patients aged 75 years or older who had undergone protected CAS between June 2001 and April 2004 were compared with those in a group of 110 patients aged 75 years or older who had undergone CEA between January 1997 and December 2001, before widespread introduction of CAS procedures at our institution. All patients were evaluated by a neurologist both before and after surgery. According to the criteria set forth by the large trials the occurrence of minor, major, or fatal stroke, and myocardial infarction within 30 days was determined. RESULTS: The demographic characteristics and indications for an intervention were similar in both treatment groups. Thirty patients (57%) in the CAS group had symptomatic carotid stenosis, compared with 69 patients (63%) in the CEA group. In neither group was there any fatal stroke or myocardial infarction. The 30-day stroke rate was significantly higher in the CAS group (4 minor, 2 major strokes; 11.3%) than in the CEA group (no minor, 2 major strokes; 1.8%; P < .05). Although the 30-day major stroke rate between CAS and CEA groups was comparable (3.8% vs 1.8%; P = 0.6), this effect was mainly attributable to a significantly higher rate of minor stroke in the CAS group (7.5% vs 0%; P < .05). CONCLUSION: Despite the use of cerebral protection devices the neurologic complication rate in patients aged 75 years and older associated with CAS was significantly higher than with CEA performed by highly skilled surgeons at our academic institution. Although this finding is mainly based on a significantly higher rate of minor stroke in the CAS group, the common practice of preferentially submitting older patients to CAS is questionable, and should be abandoned until the results of further randomized trials are available.