Is routine duplex examination after carotid endarterectomy justified?

Routine follow-up of patients after carotid endarterectomy with duplex scanning is commonly practiced, yet the clinical significance of identifying those with asymptomatic restenosis is unclear. To address this issue we reviewed 120 consecutive patients who underwent 143 carotid endarterectomies from August 1983 to December 1988. One hundred one patients (118 operations) were available for clinical follow-up, and the overall incidence of recurrent symptoms was 6% (6/101). Sixty-three of these patients (78 carotid endarterectomies) had postoperative duplex examination. Two had evidence of residual disease from the time of surgery and were not included in further analysis. Significant recurrent stenosis (greater than 50% diameter reduction) developed in 14 of the remaining 76 arteries (18.2%). Twelve of 14 stenoses remained asymptomatic during follow-up from 18 to 72 months (mean 47.0 months) and did not undergo reoperation. Recurrent ipsilateral hemispheric symptoms developed in two patients with restenosis (14.3%). Four of the 62 arteries without significant recurrent stenosis developed ipsilateral symptoms (6.5%), but none required reoperation during follow-up from 1 to 71 months (mean 31.6 months). Life-table analysis showed no increased risk of transient ischemic attack, stroke, or death in patients with restenosis. This study supports regular clinical follow-up after carotid endarterectomy with emphasis on patient education in the recognition of symptoms. Although duplex scanning may be useful to follow known contralateral asymptomatic disease or evaluate those with recurrent symptoms, its routine use to identify patients with asymptomatic restenosis after carotid endarterectomy may be unnecessary.     

Frequency of postoperative carotid duplex surveillance and type of closure: results from a randomized trial

BACKGROUND/PURPOSE: In several nonrandomized studies investigators have reported on the value of postoperative carotid duplex surveillance (PCDS) with mixed results; however the type of closure was not analyzed in these studies. In this study we analyze the frequency and timing of postoperative carotid duplex ultrasound scanning according to the type of closure from a randomized carotid endarterectomy (CEA) trial comparing primary closure (PC) versus patching. PATIENT POPULATION AND METHODS: We randomized 399 CEAs into 135 PCs, 134 polytetrafluoroethylene (PTFE) patch closures, and 130 vein patch closures (VPCs) with a mean follow-up of 47 months. PCDS was done at 1, 6, and 12 months and every year thereafter (a mean of 4.0 studies per artery). Kaplan-Meier analysis was used to estimate the rate of > or = 80% restenosis over time and the time frame of progression from < 50%, to 50%-79% and > or = 80% stenosis. RESULTS: Restenoses of > or =80% developed in 24 (21%) arteries with PC and nine (4%) with patching. Kaplan-Meier estimate of freedom of > or = 80% restenosis at 1, 2, 3, 4, and 5 years was 92%, 83%, 80%, 76%, and 68% for PC, respectively, and 100%, 99%, 98%, 98%, and 91% for patching, respectively, (P <.01). Of 56 arteries with 20% to 50% restenosis, two of 28 patch closures and 10 of 28 PCs progressed to 50% to < 80% restenosis (P =.02); none of the patch closures and six of 28 PCs progressed to > or =80% (P =.03). In PCs, the median time to progression from <50% to 50%-79%, < 50% to > or =80%, and 50%-79% to > or = 80% was 42, 46, and 7 months, respectively. Of the 24 arteries with > or =80% restenosis in PC, 10 were symptomatic. Thus, assuming th symptomatic restenosis would have undergone duplex scan examinations regardless, there were 14 asymptomatic arteries (12%) that could have been detected only with PCDS (estimated cost, $139, 200), and those patients would have been candidates for redo CEA. Of the 9 arteries (3 PTFE closures and 6 VPCs) with > or =80% restenosis with patch closures, 6 asymptomatic (4 VPCs and 2 PTFE closures) arteries (3%) could have been detected with PCDS. In patients with normal duplex scan findings at the first 6 months, only four (2%) of 222 patched arteries (two asymptomatic) developed > or = 80% restenosis versus five (38%) of 13 in patients with abnormal duplex scan examination findings (P<.001). CONCLUSIONS: PCDS is beneficial in patients with PC, but is less beneficial in patients with patch closure. PCDS examinations at 6 months and at 1- to 2-year intervals for several years after PC are adequate. For patients with patching, a 6-month postoperative duplex scan examination with normal results is adequate.     

The use of patch angioplasty to alter the incidence of carotid restenosis following thromboendarterectomy

Eighty-nine consecutive patients were followed for twelve to twenty-four months after carotid thromboendarterectomy. Forty-seven underwent operations using a standard carotid closure; a second group of forty-two patients had a saphenous vein patch graft applied in closure. The patients were evaluated with carotid duplex scans at regular intervals to evaluate the incidence of early restenosis. Patients with positive duplex scans underwent arterial angiography or digital subtraction angiography. Operative mortality was zero. Twelve late deaths occurred; eleven due to cardiac disease. In the unpatched group, 19.1% of the patients developed significant restenosis (a luminal narrowing of greater than 50%) with only a 2.4% incidence occurring in the patched group, a statistically significant difference (p less that 0.05). There was a higher incidence of symptomatic restenosis in the unpatched group, though the results were not considered significant. Venous patch rupture was seen in three patients who have not been included in the study group. All of these had venous patches harvested from a distal greater saphenous vein site at the ankle. The authors recommend venous patch closure with a thicker patch taken from the proximal saphenous vein at the groin to reduce the incidence of early restenosis and to avoid venous patch rupture. Regular non-invasive evaluation is recommended to detect restenosis with careful clinical follow-up to evaluate neurologic complications.     

Comparison of saphenous vein patch, polytetrafluoroethylene patch, and direct arteriotomy closure after carotid endarterectomy. Part I. Perioperative results

To evaluate the perioperative outcomes and the immediate increases in size after patch closure, 140 carotid endarterectomies were randomized into one of three groups: direct no-patch closure, saphenous vein patch closure, and polytetrafluoroethylene patch closure. Seven patients (4.4%) experienced signs of cerebral ischemia in the immediate postoperative period. In three cases this was transient and reversible. In the other four reexploration was undertaken and carotid thrombosis was corrected by thrombectomy. The condition of one of these patients deteriorated to a permanent stroke, whereas the other patients made a complete recovery. Neurologic complications were more frequent in the no-patch group, but the differences between the groups were not significant. The incidence of perioperative internal carotid stenosis, aneurysmal dilatation, and other morphologic abnormalities was assessed in 131 intravenous digital subtraction angiograms taken before the patient was discharged from the hospital. Eight (17.0%) of the endarterectomies in the no-patch group were narrowed by 30% to 50% diameter stenosis, whereas none of the patched arteries had more than 30% stenosis. In contrast, dilatation of the common or internal carotid artery to more than twice the measured diameter was absent in non-patched arteries but was present in seven (17.0%) saphenous patch closures and four (9.23%) polytetrafluoroethylene patch closures. We conclude that patch closure after carotid endarterectomy is less likely to cause stenosis in the perioperative period. Poly-tetrafluoroethylene patches resist dilatation better than do saphenous vein patches and are less likely to become aneurysmal.     

Selective patching in carotid endarterectomy: is patching always necessary?

BACKGROUND: The value of carotid patching in carotid endarterectomy in achieving low perioperative morbidity and long-term freedom from restenosis is controversial. We hypothesized that if large internal carotid arteries were closed primarily and smaller arteries selectively patched, there would be no difference in early or long-term results between the two groups. METHODS: A retrospective analysis of 133 carotid endarterectomies performed by one surgeon in a community teaching hospital was performed to evaluate a selective approach to patching vs primary closure. Primary closure was performed if the arteriotomy could be closed without tension over a Javid shunt. Seventy-seven arteries underwent primary closure and 56 underwent patching (Vein-14, PTFE-17, Dacron-25). Postoperative (>6 month) duplex scans were available on 46/77 (60%) patients undergoing primary closure, and 33/56 (59%) of patients with patch repair. RESULTS: There were 2 perioperative neurologic deficits, both in the patch group. Restenosis of equal or greater than 50% at 11 months occurred in 5/46 (10.8%) of patients with primary closure and 2/34 patients (5.9%) with patch closure (p=ns). No patient in either group had a late neurologic event or required a redo operation. CONCLUSIONS: Selective primary closure is not associated with increased risk of perioperative neurologic events or statistically significant evidence of late postoperative stenosis if primary closure is performed in large internal carotid arteries.     

Natural history of nonoperated,significant carotid stenosis

One-hundred sixty-seven patients with 190 carotid arteries (109 asymptomatic) demonstrating 50-99% stenosis by arteriography (80), duplex scanning, or other noninvasive techniques were followed from 1-84 months (mean 24.2) for evidence of brain infarct, transient ischemic attacks, or vertebrobasilar symptoms. Thirty-nine arteries (20.5%) were symptomatic at last follow-up, including 13 (6.8%) producing ipsilateral strokes. Twenty-eight sides underwent carotid endarterectomy, 16 for symptomatic lesions at a mean interval of 14.5 months after the initial diagnostic study, with no neurologic deficit. Twenty-seven patients (16.2%) died, eight from stroke (30%), and 12 from cardiac causes (44%). In initially symptomatic sides, the incidence of any subsequent neurologic event (28.7%) or stroke/transient ischemic attack (25%) was significantly greater than in asymptomatic arteries (14.6% and 12%, respectively) (p less than .05). Carotid arteries with greater than 80% stenosis by arteriography and duplex scanning had a 46% incidence of further symptoms and 41.6% stroke/transient ischemic attack rate compared to 19.6% and 15%, respectively, in arteries with less than 80% stenosis (p less than .01). Cumulative life table analysis at 12, 24 and 36 months showed greater than 80% stenosed arteries to have stroke/transient ischemic attack free rates of 69%, 50.5%, and 21.6% compared to 91%, 83.7%, and 76% for arteries with less than 80% stenosis (p less than .05). At a mean follow-up of over two years, nonoperated carotid stenosis (greater than 50%) carries a 20.5% risk of neurologic symptoms and a 6.8% risk of stroke, 61.5% of strokes being fatal. Symptomatic carotid stenosis had a significantly greater incidence of ensuing neurologic events than asymptomatic arteries.(ABSTRACT TRUNCATED AT 250 WORDS)     

Benefits of carotid patching: a randomized study

Advocates of carotid artery patching claim a reduced incidence of recurrent stenosis after endarterectomy. A prospective study was undertaken to determine its value with random selection between primary closure and saphenous vein patching. A consecutive series of 129 carotid endarterectomies was evaluated by duplex scanning at 3, 6, and 12 months after operation. Intravenous digital subtraction angiography (DSA) was performed in the first postoperative days for control of the surgical technique and after 1 year to serve as a reference for the duplex scanning. Sixty-two patients were selected to have primary closure and 67 were chosen for the patching technique. Both groups were identical with regard to risk factors (mean age 63 years, 74% were men, 57% had hypertension, 41% had coronary disease, 37% had peripheral arterial disease, and 9% had diabetes mellitus), side of operation (55% left), symptoms (18% were asymptomatic), and postoperative DSA (81% were normal, 17% had residual lesions, and 2% had occlusions). A complete 1-year follow-up was obtained in 105 cases (81%); duplex scanning showed recurrent stenosis of more than 50% in 12 cases (11%). This was significantly higher after primary closure (10 of 48 patients = 21%) compared with patch closure (2 of 57 = 3.5%; p = 0.006) and also in women (6 of 25 = 24%) compared with men (6 of 80 = 7.5%; p = 0.03). Recurrent stenosis was present in 6 of 11 women with primary closure (55%), 4 of 37 men with primary closure (11%), 2 of 43 men with patching (5%), and none of 14 women with patch closure (0%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Carotid artery revascularization through a radiated field

OBJECTIVE: Extracranial carotid stenosis is a complication of external head and neck irradiation. The safety and durability of carotid artery revascularization through a radiated field has been debated. We describe the immediate and long-term results in a series of 27 consecutive patients who received treatment over 12 years. METHODS: From May 1990 to May 2002, 27 consecutive patients underwent 30 primary carotid artery revascularization procedures. All patients had received previous radiation therapy within a mean interval of 10 years (range, 1-26 years), with average radiation dose of 62 Gy (range, 50-70 Gy). Moderate to severe scarring of the skin or radiation fibrosis was present in three fourths of patients. Thirteen patients (48%) had undergone radical neck dissection, and 2 patients had a permanent tracheotomy. The indications for carotid surgery included high-grade (>70%) symptomatic stenosis in 18 patients (60%) and high-grade asymptomatic stenosis in 12 patients (40%). General anesthesia with systematic shunting was used in 18 patients (60%), and regional anesthesia with selective shunting was used in 12 patients (40%). Operations included standard carotid endarterectomy (n = 20), with patch angioplasty (n = 12) or direct closure (n = 8); carotid interposition bypass grafting (n = 7); and subclavian to carotid bypass grafting (n = 3). Primary closure of the surgical wound was performed in all procedures without any special muscular or skin flaps. All patients were followed up for a mean of 40 months (range, 3-99 months). RESULTS: There was one (3.3%) perioperative death, from massive intracerebral hemorrhage; and 1 patient had a transient ischemic attack. In-hospital complications included neck hematoma in 2 patients, which required surgical drainage in 1 patient. There was neither delayed wound healing nor infection. Twelve patients died during follow-up, of causes not related to treatment. None of the surviving patients had further stroke, and all remained asymptomatic. Follow-up duplex scans showed asymptomatic recurrent stenosis greater than 60% in 3 patients, 2 of whom with stenosis greater than 80% underwent repeat operation. Risk for recurrent stenosis greater than 60% at 18 months was 16.6%. Recurrent stenosis occurred in 2 of these patients after saphenous vein bypass, and in 1 patient after endarterectomy with vein patch angioplasty. CONCLUSION: The clinical results and sustained freedom from symptoms and stroke over 40-month follow-up suggests that carotid revascularization through a radiated field is a safe and durable procedure in patients at high surgical risk, despite a marked incidence of recurrent stenosis.     

Endovascular intervention for stenosis following carotid stent-supported angioplasty--a case report

This report is on a patient with symptomatic late restenosis after carotid stent-supported angioplasty (CSSA). Initially, the patient underwent carotid endarterectomy (CEA) with primary closure in response to an index transient ischemic attack 13 months before CSSA. He returned with angiographic evidence of recurrent carotid artery stenosis. A balloon-expandable stent was deployed with technical success. Follow-up angiography 1 year later showed an asymptomatic, noncritical in-stent restenosis (50%). Three years after the initial stent placement, the patient presented with ischemic symptoms and a carotid duplex confirming critical restenosis. The patient was successfully treated by deployment of a stent within a stent and showed significant hemodynamic improvement. This is a case report of late progressive restenosis, which raises concerns about long-term patency of CSSA in patients with aggressive postendarterectomy recurrence.     

Safety and long-term benefit of carotid endarterectomy in the asymptomatic patient

In order to determine the safety and long-term salutary effects of carotid endarterectomy in the asymptomatic patient, we retrospectively reviewed all asymptomatic patients who underwent carotid endarterectomy from 1980 through 1986. There were 60 carotid endarterectomies performed in 54 patients, 53 men and one woman. The mean age was 64 years. Arteriography revealed a high grade stenosis of 70% or greater in 46 carotid arteries (77%), ulceration in five (8%), and both in nine (15%). Risk factors included coronary artery disease in 60% of patients, smoking in 87%, hypertension in 67%, and diabetes in 22%. Perioperative morbidity included three cranial nerve injuries, one myocardial infarction and one contralateral stroke. There were no deaths. Mean follow-up was 47 months with only two patients being lost to follow-up. During follow-up three patients suffered ipsilateral transient ischemic attacks without recurrent carotid stenosis and one patient had a transient ischemic attack secondary to contralateral carotid occlusion. There was one ipsilateral stroke occurring two years after operation secondary to restenosis that required reoperation and four late contralateral strokes. Ten patients died in the follow-up period. Causes of death were stroke (1), cardiac (4), malignancy (2), pulmonary (2), and unknown (1). All surviving patients were evaluated by duplex scan at a mean interval following surgery of 47 months. Restenosis of endarterectomized arteries was seen at the following rates: less than 50% in 41 (87%); 50–75% in four (8.5%); 80% in one (2%); and 90% in one (2%). Life table analysis revealed a 98% ipsilateral stroke-free rate at five and eight years. In summary, (1) carotid endarterectomy in the asymptomatic patient can be done with low morbidity and virtually no mortality. (2) Late stroke occurs rarely in the hemisphere ipsilateral to the operated carotid artery. (3) Objective follow-up by duplex scanning shows only a 4% incidence of significant restenosis. (4) The low restenosis rate correlates with the low long-term stroke rate.Presented at the Annual Meeting of the Peripheral Vascular Surgery Society, New York, New York, June 17, 1989.     

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.     

Carotid patch angioplasty: immediate and long-term results

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.     

Carotid Artery Patch Angioplasty: Impact and Outcome

Our study objective was to determine if patch angioplasty after carotid endarterectomy decreases the incidence of post-reconstruction technical defects and recurrent stenosis. This was a retrospective review of a prospectively maintained database from February 1980 to February 2000. Main outcome measures included incidence of intraoperative technical defects, residual disease within 3 months of endarterectomy, and early/late carotid restenosis >50%. During the study period, 71% (1053) of patients had primary closure and 29% (435) had patch closure. Immediate post-reconstruction intraoperative imaging with angiography or duplex ultrasound was accomplished in all cases. Technical defects prompted the reopening of 136 (13%) carotid arteries closed primarily but only 9 (2%) of those that were patched (p <0.0001). There were no instances of residual disease in either group. Overall rate of recurrent stenosis was 2%, 3%, and 3.5% at 5, 10, and 15 years, respectively by life-table analysis. Early and late restenosis was significantly reduced by patch angioplasty (p = 0.024 and 0.006, respectively). This study demonstrates that carotid artery patch angioplasty significantly reduces the incidence of detectable technical defects and the early/late recurrent stenosis rate.     

The Role of Patch Angioplasty in Prevention of Early Recurrent Carotid Stenosis

The aim of this study was to determine the effect of primary closure versus patch angioplasty on the incidence of early recurrent stenosis after carotid endarterectomy in the hands of a single surgeon, and to analyze the risk factors associated with early recurrent stenosis after carotid endarterectomy. A retrospective review was performed of 178 consecutive patients who underwent 200 carotid endarterectomies-100 done consecutively with primary closure and 100 done consecutively with patch angioplasty. Of these patients, 126 qualified for analysis by having had at least 18 months of follow-up by serial duplex scanning. Of this group, the first 65 patients underwent 75 routine primary closures, while the last 61 underwent 67 routine patch angioplasties. All patients underwent a completion angiogram at the end of the case. Recurrent stenosis was defined as luminal diameter narrowing >60% on duplex scan. A multifactorial analysis was performed to analyze the effect of age, sex, tobacco use, diabetes, hypertension, peripheral vascular disease, coronary artery disease, and contralateral stenosis on recurrent stenosis. The results of this study showed that in a single surgeon's experience with carotid endarterectomy, varying only the method of closure between primary closure versus patch angioplasty, there is no statistically significant difference in the rate of early restenosis. No difference was noted in the perioperative morbidity and mortality between groups.     

Restenosis after CEA: pathogenesis and treatment

This study examined the incidence and mechanism of restenosis after carotid endarterectomy (CEA) in Japanese patients. To determine the optimal management for carotid restenosis, we retrospectively compared re-CEA with stent placement. One hundred and twenty-six patients who had received 135 CEA with primary suture were studied with angiography or duplex ultra-sonography as a follow-up study to detect restenosis (> 50% diameter reduction). Data was collected regarding demographics of the patients suffering restenosis, including age, sex, other risk factors. Recurrent carotid stenosis (more than 50% stenosis) developed in 9 CEA sites (6.7%) during a mean follow-up interval of 11.0 months (4.7-46.7 months). Recurrent carotid stenosis occurred to a significantly higher degree in women (p = 0.015). There was no significant difference in other risk factors. All patients who developed carotid restenosis were asymptomatic. Re-do CEA and carotid stenting were used to treat restenosis in 3 and 5 patients, respectively. No operative procedure was performed in the remaining one patient with milder restenosis (55%). The 30-day stroke morbidity-mortality rate was 33.3% in CEA and 0% in stent placement. In only one of 4 early restenosis patients, there was a bright lesion in diffusion weighted MR images after stent placement. To treat restenosis after CEA, stent placement is indicated because of a lower risk of distal emboli and there being no need to dissect the previous wound. To prevent restenosis, through plaque removal is necessary and patch closure may be needed especially in females.     

Duplex scanning of normal or minimally diseased carotid arteries: correlation with arteriography and clinical outcome

This study evaluated the role of duplex scanning in the management of patients with normal or minimally diseases carotid arteries. Carotid duplex scans were interpreted according to previously established criteria and considered normal when pulsed Doppler spectral waveforms showed laminar flow or only minor flow disturbances. Normal flow patterns were noted by duplex scanning in 100 carotid bifurcations of 72 patients who also underwent carotid arteriography. Neurologic symptoms (amaurosis fugax, transient ischemic attack, or stroke) were present in relation to 23 arteries and absent in relation to 77 arteries. On the 23 symptomatic sides arteriography was interpreted as normal in eight, 1% to 15% stenosis in 14, and 16% to 40% stenosis in one. For the 77 asymptomatic sides, arteriography showed normal vessels in 15, 1% to 15% stenosis in 43, and 16% to 40% stenosis in 19. One symptomatic patient was treated by carotid endarterectomy for an irregular 1% to 15% stenosis. None of the asymptomatic lesions were in the range of 80% to 99% stenosis, which would justify endarterectomy for asymptomatic disease. Clinical follow-up for a mean interval of 28 months on 20 of the 22 symptomatic patients not undergoing surgery revealed no strokes and transient recurrent symptoms in two patients. Assuming that the single operation in this study was indicated, duplex scanning correctly identified lesions not requiring carotid endarterectomy in 96% (22/23) of the symptomatic patients. A normal duplex scan also predicted a benign clinical outcome without operation. Duplex scanning can reliably exclude surgically treatable carotid bifurcation lesions in asymptomatic patients, and endarterectomy is rarely indicated in symptomatic patients with normal duplex scan results. This study supports a nonoperative therapeutic approach for most patients with neurologic symptoms and a normal carotid duplex scan on the appropriate side.     

Restenosis after carotid endarterectomy performed with routine intraoperative duplex ultrasonography and arterial patch closure: a contemporary series

The restenosis rates of 5% to 15% have been reported after carotid endarterectomy (CEA). We undertook this investigation to determine whether the routine practice of carotid artery patch closure and intraoperative completion duplex ultrasonography would result in lower rates of carotid restenosis after CEA. All consecutive carotid endarterectomies performed between 2000 and 2004 at a single institution were reviewed retrospectively. Patients underwent CEA using a longitudinal arteriotomy, followed by routine patching and intraoperative completion duplex ultrasonography. Only patients with at least one postoperative duplex scan performed at a minimum of 180 days after CEA were included. During the 5-year study period, 407 consecutive carotid endarterectomies were performed, with a combined 30-day stroke and mortality rate of 2.5%; 217 patients (53%) had one or more duplex ultrasound examinations performed at least 180 days after CEA. The mean follow-up duration was 692 days. Of the patients who underwent intraoperative intervention based on the results of the completion duplex study, none experienced restenosis, stroke, or death. CEA that is performed with routine patching and intraoperative duplex completion ultrasonography is a safe, durable operation with restenosis rates below those commonly reported.     

Eversion carotid endarterectomy: a technical alternative that may obviate patch closure in women

PURPOSE: Recurrent carotid stenosis following standard longitudinal carotid endarterectomy (s- CEA), with and without patch angioplasty, effects the durability of the procedure and can lead to reintervention. The purpose of this study is to evaluate the incidence of restenosis following eversion carotid endarterectomy (e-CEA) in women. METHODS: The records of all patients undergoing elective carotid endarterectomy (CEA) for symptomatic and asymptomatic high-grade carotid stenosis over a 5-year period from July 1994 to June 1999 were reviewed. Eversion endarterectomy was performed preferentially under regional anesthesia in awake patients. Postoperatively, patients were routinely evaluated by duplex scans at 3 months, 6 months, 12 months, and yearly thereafter. Hemodynamically significant restenosis (>70%) via duplex scans was confirmed by standard or magnetic resonance angiography. Student's t-test and Chi square analysis were used to assess statistical significance and assumed for P<0.05. RESULTS: Over this 5-year period, 3429 eversion carotid endarterectomies were done for symptomatic (female: 375, male: 573) and asymptomatic (female: 1091, male: 1390) high grade carotid stenosis. In the postoperative period 18 (0.9%) male and 12 (0.8%) female patients developed a permanent stroke (P = NS). Operative mortality was 0.6% (n = 12) in males and 0.5% (n = 8) in females (P = NS). Cranial nerve injuries, wound infections, and neck hematoma occurred in 7 (0.4%), 2 (0.1%), and 26 (1.3%) male and in 3 (0.2%), 3 (0.2%), and 15 (1.0%) female patients, respectively. Recurrent carotid stenosis greater than 70% via duplex scan (PSV >125 cm/s and EDV >100 cm/s) developed in 12 (1.0%) males and 15 (1.5%) females (P = NS). CONCLUSION: The eversion technique for CEA requires both the transection and anastomosis of the internal carotid artery at the carotid bulb, and appears to result in a low incidence of restenosis in women. This is a straightforward technique and obviates the need for primary closure of distal smaller caliber internal carotid artery that can lead to narrowing, and the use of patch closure that has its attendant risks.     

Poor durability of carotid angioplasty and stenting for treatment of recurrent artery stenosis after carotid endarterectomy: an institutional experience

PURPOSE: Recurrent stenosis after carotid endarterectomy (CEA) is often regarded as an optimal application of carotid artery angioplasty and stenting (CAS). The extended durability of CAS for recurrent carotid artery stenosis after CEA is unknown. We present the intermediate-term surveillance results for all eight CAS procedures performed over a 28-month period at a single tertiary referral center. METHODS: Patients had recurrent carotid stenosis after CEA, whether symptomatic or asymptomatic, of 80% to 99% stenosis on preprocedural carotid duplex scan examination. Uncovered, self-expanding metal stents, in conjunction with angioplasty, were used in all patients. Baseline and scheduled interval follow-up duplex ultrasound scan was used to assess intrastent restenosis. Further angiography was reserved for those patients obtaining additional intervention. RESULTS: One transient ischemic attack was observed 1 day after the procedure, and no cerebral infarcts occurred. All patients had angiographic resolution of the stenosis and postprocedural duplex scan studies without residual stenosis. Subsequent interval surveillance duplex scan examinations revealed significant (60%-79%) to critical (80%-99%) recurrent stenosis in six (75%) of eight patients, two of whom went on to further interventions. Of those with intrastent restenosis, four (75%) progressed to critical (80%-99%) stenosis. Mean follow-up was 20.2 months (range, 12-37 months). The two lesions that have not yet shown restenosis are those with the shortest follow-up interval, each at 12 months. CONCLUSIONS: In contrast to the optimistic claims in other series, this limited series suggests that angioplasty with stenting for recurrent carotid artery occlusive disease after CEA, although relatively safe in the short term, has significant limitations in terms of durability of results.     

Early recurrent carotid artery stenosis

IntroductionEarly recurrent carotid artery stenosis, defined as stenosis occurring within 2 years of carotid endarterectomy, occurs in 4% to 36% of patients. Management of asymptomatic early recurrent stenosis is controversial because of different outcomes in multiple natural history studies. Optimal follow-up post–carotid endarterectomy has not been defined. The purpose of this study was to determine the natural history of early recurrent stenosis and to define the optimal duplex surveillance strategy during follow-up.MethodsPatients who underwent carotid endarterectomy between January 1995 and June 1998 at a single tertiary-care institution were reviewed retrospectively. Data were collected regarding degree of stenosis, closure technique, neurologic morbidity, mortality, and the intervals between postoperative duplex studies. These results were compared with accepted rates in the literature. Life-table analysis was done on restenosis-free survival. Discrete variables were tested for significance by chi-square analysis and Fisher’s exact test. A p value less than or equal to 0.05 was considered significant.ResultsTwo hundred thirty-one carotid endarterectomies in 226 patients were evaluated. A total of 57 (24.6%) of 231 carotid endarterectomies had recurrent stenosis. These 57 sites were in 56 patients. Fifty-four (23.4%) of 231 sites had a stenosis of 16% to 59%. All of these lesions were asymptomatic and found within 1 year of carotid endarterectomy on duplex imaging. The 3 (1.3%) remaining sites had a restenosis of greater than 60%. Early recurrent stenosis occurred more frequently in women (women 28/80 [35%] vs. men 28/146 [19.2%]). High-grade stenosis occurred more often with primary (1/5 [20%]) than with patch (2/226 [0.8%]) closure and in patients less than 65 years of age.