Surgical outcome of carotid artery disease: analysis of 367 carotid endarterectomies

Carotid endarterectomy is a method of prophylaxis. A total of 367 carotid endarterectomies in 335 patients were performed during the period of 1989-1997: 222 (66.3%) were symptomatic and 113 (33.7%) asymptomatic patients. In all, 262 (78.2%) had unilateral, 41 (12.2%) contralateral occlusion and 32 (9.6%) bilateral artery disease. All were operated on under general anesthesia without using shunt or patch. Of the patients with bilateral occlusive disease, 17 underwent simultaneous and 15 staged endarterectomy. The mortality rate of the first 30 postoperative days was 1.19% and the mortality/stroke rate 2.38%. Transient neurogenic dysfunction occurred in 3.68%, myocardial ischemia in 0.89%, and postoperative hypertension in 16.7%. Endarterectomy of symptomatic and asymptomatic patients with unilateral localisation, contralateral occlusion or bilateral occlusive disease remains a highly acceptable prophylactic method. The future will show whether other endovascular procedures affect the broad application of carotid endarterectomy.     

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.     

Incidental asymptomatic carotid bruits in patients scheduled for peripheral vascular reconstruction: results of cerebral and coronary angiography

From 1978 to 1982 routine preoperative coronary angiography was performed in a series of 1000 patients under consideration for elective peripheral vascular reconstruction, including 295 who were selected primarily because of recognized extracranial cerebrovascular disease. Incidental asymptomatic carotid bruits were discovered in 144 (20%) of the remaining 705 patients who primarily were scheduled for such procedures as aortic replacement, lower extremity revascularization, or visceral artery bypass, and 139 of these 144 patients underwent cerebral angiography as well as cardiac catheterization. Carotid stenosis exceeding 50% of lumen diameter was documented by biplanar angiography in 39 (58%) of 67 patients with unilateral bruits and in 54 (75%) of 72 patients with bilateral bruits (p = 0.0471), and greater than 75% stenosis was present in 42% and 46% of these subsets, respectively. Cardiac catheterization revealed severe, surgically correctable coronary artery disease (CAD) in 29% of patients with incidental carotid bruits and in 24% of those without bruits, as well as in 32% of patients who had documented carotid stenosis and in 22% of those who did not. Although these differences were not statistically valid, the incidence of severe, correctable CAD was significantly higher among patients suspected to have CAD by standard clinical criteria (33% to 38%) than among those who were not (13%), irrespective of whether carotid bruits were present (p = 0.0021) or absent (p = 3.48 X 10(-9). Prophylactic carotid endarterectomy was performed in 54 patients (bilateral in nine), with one death (1.6%) and one postoperative stroke. In addition, 153 patients underwent elective myocardial revascularization in an attempt to reduce subsequent surgical risk and enhance late survival, with an early mortality rate of 5.2%. Only three strokes (0.4%) occurred after a total of 714 other peripheral vascular procedures in this series, and the overall operative mortality rate was 2.7%. While this study does not resolve the controversy concerning the management of incidental asymptomatic carotid bruits in patients scheduled for other operations, it provides new perspective regarding synchronous carotid and coronary disease and confirms the low risk for subsequent stroke and death after appropriate carotid and coronary reconstruction.     

Combined myocardial and cerebral revascularization. A ten year experience

We report on the results of combined carotid endarterectomy and coronary artery bypass grafting in 82 patients. Vascular pathology was severe in these cases: 94% of patients had extensive multivessel coronary artery disease, 29% had unstable angina, 30% had severe left main stem stenosis and all patients had hemodynamically significant stenosis of at least one carotid artery, 13% had an additional occlusion of the contralateral internal or common carotid artery and 26% had severe bilateral carotid artery stenosis. The carotid lesion was asymptomatic in 64% of cases, 24% of the patients experienced previous transient cerebral ischemia and 12% of the patients had a history of completed stroke. Hospital mortality was 7.3%. Neurological deficit occurred in 7.3% but functional impairment was not permanent. Late results have been obtained for 76 survivors at a mean postoperative interval of 29 months. Five year life table survival rate was 86%. Follow-up showed that 3 patients (4%) have died and that 3 patients (4%) experienced a late neurologic event (one TIA; two strokes) but none of these events involved the cerebral cortex on the side of the carotid endarterectomy. The cumulative 5 year stroke free survival rate is 91%. We conclude that combined carotid endarterectomy and coronary artery bypass grafting can be done with an acceptable mortality rate in these critically ill patients and that the postoperative incidence of neurological events is low.     

Die operative Rekonstruktion der hochgradigen Karotisstenose: ein sicheres Verfahren? Ergebnisse aus 2.162 Eingriffen

Carotid surgery is still controversial. Some large randomized trials have demonstrated the benefit of surgery in correlation to conservative treatment alone, but these positive results depend on how specific the diagnosis is and a low complication rate. This study presents the results of 2162 patients (male n = 1596 (74%), female n = 566 (26%), mean age 65 +/- 9 years), who underwent carotid surgery between 1990 and 1999. Forth-three percent of these patients had no ipsilateral neurological symptoms with high-grade carotid artery stenosis (Stage I). Thirty-eight percent appeared with prior ipsilateral TIA or PRIND--symptomatology (Stage II) and 19% suffered from stroke with persisting deficits (Stage IV). The operative technique of choice was thromboendarterectomy of the carotid bifurcation with vein-patch closure in 1967 patients (91%). In 1324 patients segmental resection of the internal carotid artery was performed. Carotid endarterectomies and other reconstructions for coronary artery disease including abdominal aortic aneurysm were combined during the same operation in 11% of the patients. The rate of postoperative ipsilateral neurological events was 4.1%. On the ontralateral side neurological symptoms appeared among 0.8%, and 0.4% of the patients had bilateral symptoms. Twenty patients (0.9%) died as a result of postoperative stroke. In relation to preoperative staging of the cerebrovascular occlusive disease in stage I, postoperative neurological symptoms appeared in 2.8% (mortality 0.6%), stage II in 5.7% (mortality 1.0%) and stage IV in 7.8% (mortality 1.2%) of the patients. These results confirm the importance of carotid reconstruction as a measure in the prevention of cerebral infarction in patients with asymptomatic or symptomatic high-grade carotid artery stenosis. The complication rate was lower than the data reported in the literature and the results were clearly better than under conservative treatment alone. In our opinion, the indication for carotid artery reconstruction should be made by a team of vascular surgeons, neurologists and neuroradiologists taking all patient-specific factors into consideration. Only by optimal patient selection and minimal complication rates will a significant benefit for the patient be achieved.     

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.     

Indikationen zur Therapie von Stenosen der A. carotis

The annual stroke risk for patients with asymptomatic stenoses of the carotid artery is around 1% in case of <70% stenosis (NASCET criteria) and 2-5% in patients with >70% stenosis. The risk of recurrent ischemic events for patients with symptomatic stenoses is much higher, around 15% during the first year. For more than 10 years, the efficacy of carotid surgery has been proven, and there is growing evidence to support surgery in case of asymptomatic stenosis. Patients with severe stenoses, male or elderly patients, and those with bilateral stenoses benefit more from surgery. Carotid artery stenting has not proven its safety or efficacy. Despite this lack of evidence, the method is used in many centers as an alternative to surgery. Especially symptomatic carotid artery stenosis should be used mainly in the setting of a randomized trial such as SPACE.     

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.     

Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature.

OBJECTIVES: to determine the role of carotid artery disease in the pathophysiology of stroke after coronary artery bypass (CABG). DESIGN: systematic review of the literature. RESULTS: the risk of stroke after CABG was 2% and remained unchanged between 1970-2000. Two-thirds occurred after day 1 and 23% died. 91% of screened CABG patients had no significant carotid disease and had a <2% risk of peri-operative stroke. Stroke risk increased to 3% in predominantly asymptomatic patients with a unilateral 50-99% stenosis, 5% in those with bilateral 50-99% stenoses and 7-11% in patients with carotid occlusion. Significant predictive factors for post-CABG stroke included; (i) carotid bruit (OR 3.6, 95% CI 2.8-4.6), (ii) prior stroke/TIA (OR 3.6, 95% CI 2.7-4.9) and (iii) severe carotid stenosis/occlusion (OR 4.3, 95% CI 3.2-5.7). However, the systematic review indicated that 50% of stroke sufferers did not have significant carotid disease and 60% of territorial infarctions on CT scan/autopsy could not be attributed to carotid disease alone. CONCLUSIONS: carotid disease is an important aetiological factor in the pathophysiology of post-CABG stroke. However, even assuming that prophylactic carotid endarterectomy carried no additional risk, it could only ever prevent about 40-50% of procedural strokes.     

Carotid endarterectomy before and after publication of randomized controlled trials

BACKGROUND: In 1991, the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) demonstrated that carotid endarterectomy (CEA), in addition to best medical therapy, significantly reduces ipsilateral stroke in patients with high-grade (70 per cent or more) carotid artery stenosis compared with best medical therapy alone. In 1995, the Asymptomatic Carotid Atherosclerosis Study demonstrated that CEA was of benefit in asymptomatic patients with stenosis greater than 60 per cent. The aim of this paper was to examine how the practice and outcome of CEA have changed since publication of these data. METHODS: A prospectively gathered computerized database comprising 634 consecutive CEAs was studied. Two time intervals were analysed: 1975-1991 inclusive (17 years) and 1 January 1992 to 1 May 1998 (6 years 4 months). RESULTS: Since 1991, there has been a fourfold increase in the number of CEAs performed annually for symptomatic disease. CEA is now performed almost exclusively for high-grade (more than 70 per cent) stenosis. There has been a significant reduction in the total peri-operative neurological event rate (12.5 versus 5.9 per cent, P < 0.05), and the 30-day combined major stroke (Rankin grade 3-5) and mortality rate has fallen to 2.0 per cent. The number of patients who have CEA for asymptomatic disease remains small with 16 of 30 being randomized within the Asymptomatic Carotid Surgery Trial. CONCLUSION: Publication of ECST and NASCET data has been associated with a major increase in the number of CEAs performed for symptomatic disease in this unit. Despite a greater proportion of high-risk patients, the results have improved progressively.     

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

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

Management of patients with concomitant coronary and carotid vascular disease

Stroke is a major complication of coronary artery bypass graft (CABG) surgery. Carotid stenosis is an important cause of stroke in certain CABG patients. Randomized trials have revealed that carotid endarterectomy (CEA) is clearly indicated in non-CABG patients with symptomatic severe carotid stenosis. CEA is also indicated in patients with symptomatic moderate stenosis and asymptomatic severe stenosis if the predicted incidence of perioperative morbidity and mortality is low. Therapeutic options for patients with concomitant coronary and carotid disease include CABG alone, CABG plus CEA, and CABG plus carotid stenting. In this article we discuss each of these management techniques in detail, and make recommendations regarding the preferred approach in specific patient populations.     

PREVALENCE OF SIGNIFICANT CAROTID STENOSIS IN CHINESE PATIENTS WITH PERIPHERAL AND CORONARY ARTERY DISEASE

Background : The prevalence of extracranial carotid stenosis in the Chinese population is not known. This study aims to investigate and compare carotid disease in several groups of high-risk patients. Method : Routine screening carotid duplex scans were performed on high-risk Chinese patients without cerebrovascular symptoms. These consisted of 249 patients with peripheral vascular disease, 207 patients with coronary artery disease, and 45 patients with abdominal aortic aneurysm. In addition, 220 patients with cerebrovascular symptoms and 58 patients with carotid bruits were scanned. A group of 108 healthy individuals was included as a control. The data of all 887 subjects were analysed. Results : Carotid stenosis of 70% or greater was detected in 37.7% of patients in the cerebrovascular disease group and 24.5% of patients with peripheral arterial disease; it was higher than in patients with coronary artery disease (11.1%), asymptomatic carotid bruit (10.3%) and aortic aneurysms (8.9%; P < 0.001). No significant disease was found in the controls. Patients with cerebrovascular disease have more severe degrees of carotid stenosis and significantly more total occlusions. Smoking, age and male sex were the main risk factors for high-grade (≥ 70%) carotid stenosis. Conclusion : The prevalence of extracranial carotid stenosis in Chinese patients is not low. Patients with peripheral arterial disease have the highest risk of significant carotid stenosis: routine carotid duplex screening in these patients is recommended.     

腔内治疗颅外颈动脉闭塞性疾病的近期疗效

目的回顾性分析颈动脉成形加支架植入术（CAS）治疗颅外颈动脉闭塞性疾病（ECOD）的近期疗效。方法48条颈动脉接受了CAS。手术进路经股动脉穿刺完成。术后随访分2阶段：≤30d和〉30d。分析病死率和主要的并发症发生率。结果本组男性占91.7％;女性占8．3％,平均年龄（70．6±5.9）岁。术前无脑缺血症状占37．5％,有症状占62．5％。颈动脉内径平均狭窄程度（71．2±14．8）％。术前仅合并1种高危因素的为43．8％;2种或2种以上的47．9％。33．3％的患者对侧颈内动脉内径狭窄≥50％或完全闭塞。CAS的成功率为100％。术后无死亡及明显脑卒中发生。4．2％的患者发生了一过性脑缺血,18．8％的患者发生了颈动脉窦压迫综合征。30d后的随访中,有4．2％的患者出现了〉50％支架内再狭窄;无支架变形发生。结论CAS可用于治疗ECOD,特别对于那些合并有颈动脉内膜切除术高危因素的患者,具有安全、术后致残率和病死率低的优点。     

Hypothermic circulatory arrest for cerebral protection during combined carotid and cardiac surgery in patients with bilateral carotid artery disease.

OBJECTIVE: The authors evaluated the protective effect of hypothermic circulatory arrest for patients with bilateral carotid artery disease who underwent cardiac surgical procedures. SUMMARY BACKGROUND DATA: Severe bilateral carotid artery disease coexisting with cardiac disease that requires surgical treatment is associated with a substantial incidence of stroke after operations that require cardiopulmonary bypass. The optimal method of management of patients with these coexisting conditions is not established clearly. Because hypothermia has a protective effect on neural and myocardial tissue during cardiac operations, a protocol employing profound hypothermia and a period of circulatory arrest was evaluated in a group of patients who underwent combined carotid and cardiac surgery who were considered to be at increased risk for the development of stroke. METHODS: Fifty patients with bilateral carotid artery disease, including 24 patients with high-grade unilateral stenosis and contralateral occlusion and 6 patients with 80% to 99% bilateral stenosis, underwent combined carotid endarterectomy and cardiac surgery (coronary artery bypass grafting in all 50 patients and additional procedures in 8 patients). Profound systemic hypothermia (15 C) was instituted, and the carotid endarterectomy was performed during a period of circulatory arrest that averaged 30 minutes. The cardiac procedure was performed during the periods of cooling and rewarming. RESULTS: The 30-day mortality rate was 6% (3 patients). There were no early postoperative strokes or reversible ischemic neurologic deficits. There have been seven late deaths in the postoperative period, which extends to 54 months. None of these deaths were caused by stroke. There has been one late stroke, which occurred in the distribution of the unoperated carotid artery. CONCLUSIONS: This technique provides adequate protection of the brain and myocardium during combined carotid and cardiac surgical procedures and appears to reduce the frequency of stroke in the high-risk subgroup of patients with bilateral carotid artery disease.     

Carotid endarterectomy was performed with lower stroke and death rates than carotid artery stenting in the United States in 2003 and 2004

OBJECTIVE: Although carotid endarterectomy (CEA) is the gold standard for the treatment of carotid artery stenosis, the recent United States Food and Drug Administration approval of carotid artery stenting (CAS) may have led to its widespread use outside of clinical trials and registries. This study compared in-hospital postoperative stroke and mortality rates after CAS and CEA at the national level. METHODS: The Nationwide Inpatient Sample (NIS) was queried to identify all patient-discharges that occurred for revascularization of carotid artery stenosis. The International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for CEA (38.12), CAS (00.63), and insertion of noncoronary stents (39.50, 39.90) were used in conjunction with the diagnostic codes for carotid artery stenosis, with (433.11) and without (433.10) stroke. Primary outcome measures included in-hospital postoperative stroke and death rates. Multivariate logistic regressions were performed to evaluate independent predictors of postoperative stroke and mortality. Adjustment was made for age, sex, medical comorbidities, admission diagnosis, procedure type, year, and hospital type. RESULTS: During the calendar years 2003 and 2004, an estimated 259,080 carotid revascularization procedures were performed in the United States. CAS had a higher rate of in-hospital postoperative stroke (2.1% vs 0.88%, P < .0001) and higher postoperative mortality (1.3% vs 0.39%) than CEA. For asymptomatic patients (92%), the postoperative stroke rate was significantly higher for CAS than CEA (1.8% vs 0.86%, P < .0001), but the mortality rate was similar (0.44% vs 0.36%, P = .36). For symptomatic patients (8%), the rates for postoperative stroke (4.2% vs 1.1%, P < .0001) and mortality (7.5% vs 1.0%, P < .0001) were significantly higher after CAS. By multivariate regression, CAS was independently predictive of postoperative stroke (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.91 to 3.25). CAS was also associated with in-hospital postoperative mortality for asymptomatic (OR, 2.37; 95% CI, 1.46 to 3.84) and symptomatic (OR, 2.64; 95% CI, 1.89 to 3.69) patients. CONCLUSIONS: As determined from a large representative national sample including the years 2003 and 2004, the in-hospital stroke rate after CAS for asymptomatic patients was twofold higher than after CEA. For symptomatic patients, the respective in-hospital stroke and mortality rates were fourfold and sevenfold higher. These unexpected results indicate that further randomized controlled trials with homogenous symptomatic and asymptomatic patient groups should be performed.     

Postoperative stroke in cardiac and peripheral vascular disease.

The postoperative stroke rate in 330 patients requiring coronary artery (170) or peripheral vascular (160) surgery was compared with the presence of carotid bruits and the results of noninvasive screening (Doppler imaging and spectral analysis of flow) to determine prevalence and significance of carotid lesions) and their relationship to perioperative stroke. Carotid lesions were suspected because of bruits in 70 patients with peripheral vascular disease (PVD) and in 28 patients with coronary artery disease (CAD). Noninvasive tests showed high grade stenosis or occlusion in 62 patients with PVD and in 14 with CAD. Forty-four patients with PVD and 101 patients with CAD had normal Doppler studies. The rest in both groups had plaquing without major stenosis. Noninvasive tests uncovered severe, occult lesions in only 13 patients (9 PVD, 4 CAD). Postoperative neurologic complications occurred in 16 patients (13 strokes: 5 PVD, 8 CAD and 3 TIAs: 2 PVD, 1 CAD). Thirteen neurologic complications occurred in patients having nonstenotic plaques or normal carotids without bruits. Only three of the strokes and 1 TIA occurred in patients with bruits and detectable carotid stenosis. Few of the postoperative strokes or TIAs were focal (2 PVD, 1 CAD), and the rest were nonfocal. None of the postoperative strokes or TIAs were associated with postoperative carotid occlusion. Physical examination is not an accurate method of determining severity of carotid disease. Severe carotid stenosis is more common in PVD patients than in CAD patients, but there is no significant difference in postoperative stroke rate. No direct relationship has been found between a bruit, severity of disease, and incidence of perioperative stroke.     

Carotid endarterectomy to correct asymptomatic carotid stenosis: ten years later

The ideal management of the patient with an asymptomatic stenosis of the extracranial internal carotid artery remains controversial. The purpose of this article was to evaluate the effects of prophylactic carotid endarterectomy (CE) done to treat asymptomatic carotid stenosis (greater than 50% diameter reduction by angiography) 10 years later. In 1976, 42 prophylactic CEs were performed. There were no postoperative deaths or strokes. During 10-year follow-up two strokes occurred in the operated hemisphere; one stroke was fatal and was due to an intracranial hemorrhage, whereas the other stroke was thromboembolic in origin. Two other patients suffered strokes in the contralateral hemisphere and seven patients had transient ischemic attacks in the contralateral hemisphere, which necessitated CE. The survival rate at the end of the study period by life-table analysis was 57% (mean 8.7 years). Sixteen late deaths occurred, with coronary artery-related disease the most common cause of death. This review with actual 10-year follow-up demonstrated that prophylactic CE may be performed with minimal risk, that late stroke in the operated hemisphere was negligible, and that long-term survival was similar to that of a comparable age-matched population, possibly because late deaths attributed to stroke were reduced. On the basis of long-term follow-up, CE to treat asymptomatic high-grade carotid stenoses appears to be indicated in appropriate patients.     

Simultaneous carotid and coronary artery surgery in asymptomatic carotid artery stenosis--report of three cases

Some patients with coronary artery disease are diagnosed as having additional carotid artery disease. This subset of patients has been identified as a high-risk group for cardiac and cerebral complications following surgical intervention. Three patients who underwent combined CEA/CABG for coexistent asymptomatic carotid occlusive disease are reported. Case 1: A 69-year-old female who suffered chest pain on exertion. Her coronary angiogram showed severe stenosis of three vessels. Her carotid angiogram showed 98% stenosis of the right internal carotid artery and poor collateral circulation. The severe stenosis of her carotid artery was considered as a risk factor for perioperative cerebral stroke. Intraoperatively, CEA preceded the CABG. Postoperative course was uneventful. Case 2: A 64-year-old male. Intermittent claudication was his initial symptom. His coronary angiogram showed stenosis in three vessels and carotid angiogram showed 75% stenosis in the right carotid artery. Simultaneous CABG and CEA was performed. His postoperative course was uneventful. Case 3: A 62-year-old male whose ECG indicated ischemic heart disease, although he had no symptoms. His coronary angiogram showed stenosis in three vessels, and 80% stenosis of his right carotid artery was observed by carotid angiogram. He underwent simultaneous surgery, and had an uneventful postoperative course. It has been reported that 1.5-8.7% of CABG patients have severe carotid artery stenosis, and perioperative cerebral stroke occurs in 0.9-16%. Simultaneous surgery was successful in our three patients who had asymptomatic carotid artery stenosis. Using this surgical approach for critical coexistent disease may minimize the incidence of perioperative cerebrovascular complications in patients undergoing CABG.     

Current management of extracranial carotid artery disease

Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year; 80% are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter, randomized, controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis and compare these data to a critical analysis of the recent results of CAS.