Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the ad hoc Committee, American Heart Association

Auditing carotid endarterectomy: a regional experience

BACKGROUND

Proof from randomized controlled trials that carotid endarterectomy (CEA) is efficacious in stroke prevention has resulted in a large resurgence of its use in recent years. We wished to determine if patients in our region were being selected and treated with complication rates consistent with the randomized trials.

METHODS

We have completed four audits of CEAs performed in our region since 1994, each followed by feed-back of results to the participating surgeons. Operations for > 70% symptomatic stenosis were considered appropriate, those for 50%-69% symptomatic and > 60% asymptomatic stenosis were considered uncertain and all others, including those in medically or neurologically unstable patients, were designated inappropriate. In part 4, the referral source and nature of the patients was also determined.

RESULTS

Part 1 (April 1994-September 1995) found that of 291 CEAs performed 33% were appropriate, 48% were uncertain and 18% were inappropriate, and 40% of patients who underwent CEA were asymptomatic. In part 2 (September 1996-September 1997) appropriate indications significantly improved to 49% of 184 CEAs (P=0.005), uncertain indications remained nearly the same at 47%, inappropriate indications fell to 4% (P=.00002), and asymptomatic patients remained at 40%. The results of part 3 (October 1997-October 1998) remained nearly the same as part 2 (249 CEAs, 47% appropriate, 51% uncertain, 2% inappropriate, 45% asymptomatic). Part 4 (October 1999-October 2000) results were significantly better than part 3, appropriate indications increasing from 47% to 58% of 222 CEAs (P=0.02), and an elimination of inappropriate operations (P=0.03). Stroke and death complications declined over the study period from an overall rate of 5.2% in part 1 to 2.3% in part 4. In part 4 the majority of patients (69%) were referred to surgeons directly from general practitioners, including 58 (73%) of the 80 asymptomatic patients who underwent CEA.

INTERPRETATION

Regular auditing and feedback of results and information to surgeons has resulted in significant and continued improvements in the surgical performance of CEA in our region. Since the majority of patients are referred directly to surgeons by general practitioners, it is important that this group of physicians be familiar with current CEA guidelines.

Why do clinicians sometimes find it difficult to use the results of systematic reviews in routine clinical practice?

Reviews of systematic results have proved enormously useful in routine clinical practice. However, the uncritical application of the overall results of systematic reviews to clinical decisions about individual patients can sometimes do more harm than good. Clinical syndromes are often complex, with considerable pathological heterogeneity, and the likely balance of the risks and benefits of interventions can be difficult to judge on an individual patient basis. Active involvement of experienced clinicians is essential in the planning, reporting, and interpretation of reviews. Detailed consideration should be given to the possibility of diagnostic or pathological heterogeneity within the clinical trials included in the review or between the trial patients and patients seen in routine clinical practice. For treatments that have significant risk of harm or treatments that are particularly costly, meta-analysis of individual patient data with stratification by baseline risk is sometimes helpful in targeting treatment appropriately in routine clinical practice.

Cerebral protection with thiopentone during combined carotid endarterectomy and clipping of intracranial aneurysm

We report a case of carotid endarterectomy and clipping of an ipsilateral internal carotid artery aneurysm in a patient with complete contralateral carotid stenosis. The patient developed an ischaemic electroencephalographic (EEG) tracing on temporary carotid clamping and bypass shunt was contraindicated. We used thiopentone titrated to EEG burst suppression for pharmacological cerebral protection during the subsequent prolonged carotid clamp necessary for carotid endarterectomy. We review the use of thiopentone for this purpose, in particular the evidence for efficacy, mechanism of action and optimal dosage and timing of administration.

Multicenter evaluation of carotid artery stenting with a filter protection system

OBJECTIVES

The aim of this study was to evaluate the feasibility and safety of carotid artery stenting (CAS) with a filter protection system.

BACKGROUND

Neurologic events linked to the embolization of particulate matter to the cerebral circulation may complicate CAS. Strategies designed to capture embolic particles during carotid intervention are being evaluated for their efficacy in reducing the risk of these events.

METHODS

Between September 1999 and July 2001, a total of 162 patients (164 hemispheres) underwent CAS with filter protection (NeuroShield, MedNova Ltd., Galway, Ireland) according to prospective protocols evaluating the filter system at three institutions.

RESULTS

Angiographic success was achieved in 162 of the procedures (99%) and filter placement was successful in 154 (94%) procedures. Carotid access was unsuccessful in two cases (1%) and filter placement in eight cases (5%). Of the latter, five procedures were completed with no protection and three were completed using alternative protection devices. On an intention-to-treat basis, the overall combined 30-day rate of all-stroke and death was 2% (four events: two minor strokes and two deaths). This includes one minor stroke in a patient with failed filter placement and CAS completed without protection. There was one cardiac arrhythmic death and one death from hyperperfusion-related intracerebral hemorrhage. There were no major embolic strokes.

CONCLUSIONS

Carotid artery stenting with filter protection is technically feasible and safe. Early clinical outcomes appear to be favorable and need to be confirmed in a larger comparative study.

The safety of carotid endarterectomy in patients with preoperative renal dysfunction

Recent published data suggest that performing carotid endarterectomy (CEA) in patients with renal dysfunction is associated with a prohibitively high perioperative stroke and death rate. On the basis of our experience, we hypothesized that CEA is a safe procedure in patients with renal insufficiency. A retrospective review of one surgeon's CEA experience from 1988 to 1998 was performed. A total of 398 procedures performed on 370 patients were reviewed for patient demographics and adverse events in the 30-day perioperative period. Risk factors, indications for procedure, and degree of stenosis, as well as intraoperative use of shunts, patch angioplasty, drains, completion angiography, and EEG monitoring were compared. Patients were categorized by preoperative creatinine (Cr) levels as normal (Cr <or= 1.5) or abnormal (Cr > 1.5). All data were subjected to statistical analysis. Our results showed that CEA can be performed safely in patients with renal dysfunction with no increase in perioperative stroke or death rate. Performing CEA in patients with renal insufficiency does require preoperative cardiac evaluation and close cardiac monitoring, as there appears to be an increased rate of myocardial infarction in our series.

Stent placement for the treatment of occlusive atherosclerotic carotid artery disease in patients with concomitant coronary artery disease

OBJECT

The authors report their experience with carotid artery stent placement (CASP) in patients with concomitant carotid artery (CA) and coronary artery (CorA) diseases.

METHODS

In a review of 320 consecutive patients who underwent CASP, the authors identified 49 with severe CorA disease in addition to significant CA stenosis, who had undergone CASP before planned CorA bypass grafting (CorABG). The average age of these 49 patients was 68 years. In 39 patients (80%) the New York Heart Association functional classification grade was IV and in 10 the grade was III. In 26 patients 50% or greater stenosis of the left main CorA was found. Seventeen patients (35%) suffered from either significant hemodynamic contralateral CA stenosis (> 60% stenosis; eight patients) or contralateral CA occlusion (nine patients). Sixteen patients (33%) had symptomatic CA disease. No cerebrovascular events occurred during CorABG. Four patients (8%) died of cardiac arrest and one patient (2%) suffered a major stroke within 30 days after the CorABG procedure. No patient experienced clinically significant recurrent CA stenosis during the study period (average clinical follow-up period 27 months).

CONCLUSIONS

Carotid artery stent placement should be considered as an alternative for the management of concomitant CA and CorA diseases. These preliminary results support the feasibility and durability of CASP in the population studied.

Clinical and radiographic risk factors for operative stroke and death in the European carotid surgery trial

OBJECTIVES

carotid endarterectomy is associated with significant morbidity and mortality. A better understanding of the relationships between baseline characteristics and outcome may help to reduce the risks of surgery. In order to make accurate and unbiased estimates of surgical risk it is important to study cohorts of patients that were established prospectively, where independent physicians assessed outcome, and where the decision to analyse and report the results was not data-dependent. The surgical arm of the European Carotid Surgery Trial (ECST) is such a cohort.

METHODS

the 30-day outcome of carotid endarterectomy was analysed in ECST surgery patients in relation to their baseline clinical and angiographic characteristics. The severity of operative strokes was compared with that of strokes that occurred in the medical group.

RESULTS

1729 patients underwent trial surgery. There were 17 deaths (1.0%, 95% CI=0.6-1.6) and 105 non-fatal major strokes (6.1%, 95% CI=5.0-7.3) within 30 days of surgery. The risk of major stroke or death was 7.1% (95% CI=5.9-8.4). The risk of disabling or fatal stroke was 3.0% (95% CI=2.1-3.8). The ratio of disabling to non-disabling operative strokes was similar to that in the medical group. Several baseline characteristics predicted the operative risk of stroke and death in univariate analyses, but only four were independent risk factors in a multiple regression analysis: presentation with cerebral TIA vs ocular ischaemic events only (HR=2.99, 95% CI=1.33-6.69, p=0.008); female sex (HR=2.04, 95% CI=1.37--3.06, p=0.001); systolic hypertension (HR=1.01 per 10 mmHg, 95% CI=1.00-1.02, p=0.03) and peripheral vascular disease (HR=2.17, 95% CI=1.17-2.89, p=0.001).

CONCLUSIONS

the operative risk of stroke and death in the ECST was comparable with other prospective studies and trials in which patients were assessed postoperatively by both a physician and a surgeon. Case fatality and disability after operative stroke are similar to strokes that occur on medical treatment only. Several baseline patient characteristics predict surgical risk and it may be possible to use these characteristics to aid patient selection and surgical audit.

Clinicopathological significance of lipid peroxidation in carotid plaques

Several reports have suggested an association between lipid peroxidation and human carotid atherosclerosis, but few reports have demonstrated a link between lipid peroxidation and carotid plaques in humans. In this study, we investigated the relationship between clinical features, histopathological characteristics and lipid peroxidation in patients undergoing carotid endarterectomy (CEA). Forty-one carotid plaques were obtained. A portion of the most severe lesions was subjected to histopathologic examination, and the remainder of the plaques examined for lipid peroxidation. Thiobarbituric acid-reactive substances (TBARS) values were determined as a marker for lipid peroxidation. The lipid-rich core (LC) and macrophage infiltration (Mphi) component as a percentage of total plaque area were measured morphometrically. Based on the results, all plaques were classified into four groups. Group I (GI): LC <10%; Group IIa (GIIa): LC 10-30%, Mphi <5%; Group IIb (GIIb): LC 10-30%, Mphi < or = 5%, and Group III (GIII): LC < or =30%. The plaque TBARS values of GIII were significantly higher than those of GI, GIIa, and GIIb. The TBARS values of GIIb were one-and-a-half times higher than those of GIIa. Our results show that lipid peroxidation in carotid plaques is significantly associated with carotid atherosclerosis, especially plaque instability. These findings provide direct evidence of an association between lipid peroxidation and human atherosclerosis.

Risk modelling study for carotid endarterectomy

BACKGROUND

The aims of this study were to identify factors that influence the risk of stroke or death following carotid endarterectomy (CEA) and to develop a model to aid in comparative audit of vascular surgeons and units.

METHODS

A series of 839 CEAs performed by four vascular surgeons between 1992 and 1999 was analysed. Multiple logistic regression analysis was used to model the effect of 15 possible risk factors on the 30-day risk of stroke or death. Outcome was compared for four surgeons and two units after adjustment for the significant risk factors.

RESULTS

The overall 30-day stroke or death rate was 3.9 per cent (29 of 741). Heart disease, diabetes and stroke were significant risk factors. The 30-day predicted stroke or death rates increased with increasing risk scores. The observed 30-day stroke or death rate was 3.9 per cent for both vascular units and varied from 3.0 to 4.2 per cent for the four vascular surgeons. Differences in the outcomes between the surgeons and vascular units did not reach statistical significance after risk adjustment.

CONCLUSION

Diabetes, heart disease and stroke are significant risk factors for stroke or death following CEA. The risk score model identified patients at higher risk and aided in comparative audit.

[First Brazilian consensus for the management of the acute phase of cerebral vascular accidents]

The cerebrovascular diseases have a high incidence, and they cause an enormous social and economic burden. With the increasing knowledge of the pathophysiology of the ischemic insult, and the possibility of the thrombolysis in the acute phase, the management of the stroke patients is considered an emergency. This consensus is the result of a recent meeting to establish a better approach to these patients. This is the official guideline for the management of patients with acute stroke of the Brazilian Cerebrovascular Disease Society.

Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital

OBJECTIVES

The goal of this study was to determine whether carotid angioplasty and stenting (CAS) is equivalent to carotid endarterectomy (CEA) in patients with symptomatic carotid stenosis >70% by a randomized, controlled trial in a community hospital.

BACKGROUND

Carotid angioplasty and stenting has been suggested to be as effective as CEA for treatment of symptomatic carotid artery stenosis.

METHODS

A total of 104 patients presenting with cerebrovascular ischemia ipsilateral to carotid stenosis were selected randomly for CEA or carotid stenting and followed for two years.

RESULTS

Stenosis decreased to an average of 5% after CAS. The patency of the reconstructed artery remained satisfactory regardless of the technique as determined by sequential ultrasound. One death occurred in the CEA group (1/51); one transient ischemic attack occurred in the CAS group (1/53); no individual sustained a stroke. The perception of procedurally related pain/discomfort was similar. Hospital stay was similar, although the CAS group tended to be discharged earlier (mean = 1.8 days vs. 2.7 days). Complications associated with CAS prolonged hospitalization when compared with those sustaining a CEA-related complication (mean = 5.6 days vs. 3.8 days). Return to full activity was achieved within one week by 80% of the CAS group and 67% of the patients receiving CEA. Hospital charges were slightly higher for CAS.

CONCLUSIONS

Carotid stenting is equivalent to CEA in reducing carotid stenosis without increased risk for major complications of death/stroke. Because of shortened hospitalization and convalescence, CAS challenges CEA as the preferred treatment of symptomatic carotid stenosis if a reduction in costs can be achieved.

Influence of NASCET/ACAS trial eligibility on outcome after carotid endarterectomy

PURPOSE

Proponents of carotid angioplasty and stenting suggest that "high risk" patients, defined as patients excluded from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS), may have a significantly higher risk of stroke with carotid endarterectomy (CEA). However, this selected patient cohort has been poorly studied.

METHODS

A retrospective review of patients who underwent CEA during a 2-year period at a tertiary referral institution was performed. Each patient was evaluated and categorized, according to the exclusion criteria, by NASCET and ACAS standards. Statistical analysis using chi(2) and Fisher exact tests was performed.

RESULTS

There were 366 CEAs performed on 348 patients, including 32 (8.7%) for recurrent stenosis. A subgroup of 169 (46.2%) patients were trial ineligible. Focal ipsilateral symptoms were present in 148 (40.4%) of the patients. There were 9 (2.5%) strokes and 1 (0.3%) death, secondary to a major stroke, for an overall stroke and death rate of 2.5%. Trial-eligible patients had a stroke/death rate of 1.5% (3/197) while trial-ineligible patients had a 3.6% (6/169) stroke/death rate (P = .17).

CONCLUSION

Patients who were considered high risk for CEA as defined by trial ineligibility were common, comprising approximately half of our patients. Although trial-ineligible patients had a nonsignificant trend toward higher neurologic morbidity when compared with the eligible group, the risks were still comparable with NASCET/ACAS results. CEA was a safe procedure even in this "high risk" group. As such, ineligibility for a randomized carotid intervention trial should not be employed as a "de novo" indication for carotid stenting.

Momento ideal para a endarterectomia de carótida após um AVC recente

Vários estudos prospectivos de escolha aleatória confirmaram a eficácia da endarterectomia de carótida na prevenção de novos acidentes vasculares cerebrais (AVC) em pacientes sintomáticos com estenose grave na carótida. Entretanto, o timing da endarterectomia ainda é controverso. A cirurgia precoce pode estar associada à hemorragia intracerebral e à extensão do infarto inicial. A cirurgia tardia pode expor o paciente à recorrência do AVC e à oclusão da artéria carótida. Os estudos que avaliaram o intervalo de tempo para a endarterectomia são retrospectivos e não randomizados. Na ausência de um estudo prospectivo randomizado comparando endarterectomia precoce e tardia, uma abordagem para se interpretar os resultados das séries cirúrgicas é a comparação destes com a história natural do AVC isquêmico. Os autores descrevem os argumentos em favor da cirurgia precoce, a história natural do AVC isquêmico e os fatores de risco associados ao AVC no perioperatório da endarterectomia.

Postoperative morbidity of closely staged bilateral carotid endarterectomies: an intersurgical interval of 4 days or less

The purpose of this study was to determine if there is increased morbidity and mortality with bilateral carotid endarterectomies (CEAs) done with an intersurgical period of less than 4 days compared to historical groups of unilateral CEAs, or those with a greater intersurgical delay. From January 1991 to July 1998, 1390 carotid endarterectomies were performed, of which 154 (11.1%) were closely staged bilateral CEAs. Seventy-seven patients (51 male, 26 female; mean age 72.5 years) underwent bilateral CEAs within 4 days or less. Immediate and 30-day postoperative morbidity, including neurologic deficits, cranial nerve deficits, and mortality, were documented. Although controversial, there is no increased morbidity or mortality with bilateral CEAs done with an intersurgical delay of less than 4 days, when compared to the unilateral CEA historical groups.

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.

Efficacy of a proximal occlusion catheter with reversal of flow in the prevention of embolic events during carotid artery stenting: an experimental analysis

OBJECTIVE

The role of percutaneous angioplasty and stenting of carotid bifurcation lesions has been limited by its potential for producing embolic debris. We evaluated the efficacy of a proximal occlusion catheter (POC) in the prevention of embolic events during carotid artery stenting. In addition, pressure measurements relevant to the clinical application of this device were obtained from 10 patients undergoing carotid endarterectomy.

METHODS

The POC is a guiding catheter with an occlusion balloon attached on the outside of the catheter at its distal end. Occlusion of the common carotid artery (CCA) was achieved by inflating the balloon while access to carotid bifurcation lesions was obtained through the inner lumen. The POC was inserted in the CCA of 10 dogs via the femoral artery. The side port of the POC was connected to a sheath placed in the femoral vein, thereby creating an external arteriovenous shunt. Ten artificial radiopaque particles simulating embolic particles and contrast agent were introduced in the CCA and monitored fluoroscopically. As a control, the same procedure was performed with a standard guiding catheter without an occlusion balloon. In 10 patients undergoing carotid endarterectomy, the internal carotid artery (ICA) and external carotid artery stump pressures and the pressure in the internal jugular vein were measured.

RESULTS

Without the external arteriovenous shunt, in all animals there was prograde flow in the distal CCA despite CCA occlusion. This flow was derived from the thyroid artery. However, once the arteriovenous shunt was activated, reversal of flow in the distal CCA was achieved in each animal, and all the artificial particles were recovered from the side port of the POC. In the control group, each particle embolized to the brain (100%, P <.01). In the patients, the mean stump pressures in the ICA and external carotid artery and the jugular vein pressure were 51.8 +/- 14.2, 62.2 +/- 15.1, and 6.5 +/- 3.5 mm Hg, respectively. In each case, the jugular vein pressure was the lowest among the three.

CONCLUSIONS

Obtaining proximal CCA control by inflating the POC does not sufficiently prevent embolization. However, reversal of flow in the ICA can always be created with the external shunt, which effectively prevents embolization. Thus, POC may markedly lower procedural stroke rates during carotid artery stenting. The ability of POC to prevent embolization before crossing the lesion with a guidewire may be an important advantage over other distal protection devices.

Reconstructive surgery of the extracranial arteries

The first carotid endarterectomy (CEA) is usually accredited to Eastcott who reported in 1954 the successful incision of a diseased carotid bulb with end-to-end anastomosis of the internal carotid artery (ICA) to the common carotid artery (CCA). During the following years surgeons were quick to adopt and improve the intuitively attractive procedure. But by the early to mid 1980s several leading neurologists began to question the growing number of CEAs performed at that time. Six major CEA trials were then designed which are now completed or nearing completion. Most conclusive data are available from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) for symptomatic carotid disease, and from the Asymptomatic Carotid Atherosclerosis Study (ACAS) for asymptomatic carotid disease. The key result of these studies is that CEA is beneficial to high grade symptomatic and asymptomatic carotid stenosis. While the benefit in symptomatic disease is clear, it may be negligible in asymptomatic patients suffering from other medical conditions, the most important being coronary artery disease. Since the conclusions from the different studies vary significantly, guidelines and recommendations with regard to CEA have been issued by a number of interest groups, so-called consensus conferences. The best known guidelines are published by the American Heart Association (AHA). However, the practice of interest groups to issue guidelines is currently being criticized, the main reason being that interest groups have different ideas and all claim the right to issue guidelines. At present we recommend CEA for symptomatic high-grade stenosis in patients without significant coincident disease. With regard to asymptomatic stenosis we suggest surgery to otherwise healthy patients if the stenosis is very narrow or progressive. Preoperative evaluation has changed over the years. Currently we recommend duplex sonography in combination with intra- and extracranial magnetic resonance angiography (MRA). Concurrent coronary artery disease is a major consideration in the perioperative management, and the use of a specific algorithm is recommended. Surgery is performed under general anaesthesia with intraoperative monitoring such as electroencephalography (EEG) and transcranial Doppler (TCD). A temporary intraluminal shunt is used selectively if after cross-clamping the flow velocity in the middle cerebral artery (MCA) falls to below 30 to 40% of baseline. For years we employed routine barbiturate neuroprotection during cross-clamping. At the present time we use barbiturate selectively, if the flow velocity in the MCA falls to below 30 to 40% of baseline and if the use of a temporary intraluminal shunt is not possible due to difficult anatomic conditions. The reason to abandon systematic barbiturate protection was to accelerate recovery from anaesthesia. Our patients are monitored overnight on the ICU or a surveillance unit. Routine hospitalization after surgery is 5 to 7 days with a control duplex sonography being performed prior to discharge. A number of details with regard to surgical technique and perioperative management are a matter of discussion. Our surgical routine is described here step by step. Such management resulted in 6 major complications among the 402 cases with 4 of cardiopulmonary and 2 of cerebrovascular origin. For the future we can expect the development of percutaneous transluminal techniques competing with standard carotid endarterectomy. At the present time several comparative studies are under way. Irrespective of the technical approach to treat carotid stenosis, several other issues have to be clarified before long. One of the major unresolved items is the timing of treatment after completed stroke. In this regard prospective trials need to be performed. Although numerically not as important as carotid stenosis, vertebral artery (VA) and subclavian artery (SA) stenoses are more and more accepted as indication for surgical

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%.

Perioperative management of a patient requiring surgery for pituitary apoplexy and severe angina pectoris

We describe the management of a 71-yr-old man with pituitary apoplexy and severe angina pectoris who underwent treatment of an intra-cranial haemorrhage and open-heart surgery requiring anticoagulant therapy within a very short period. Subtotal removal of the pituitary tumour was undertaken under stable cardiovascular conditions. But ventricular fibrillation occurred after the neurosurgery in the intensive care unit. After the patient was defibrillated, intra-aortic balloon pumping was necessary to assist coronary artery blood flow. Twenty hours after neurosurgery, oozing from the surgical wound stopped and coronary artery bypass grafting with full heparinization was performed uneventfully.

Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy

PURPOSE

To identify surgeon characteristics associated with mortality or morbidity, following carotid endarterectomy (CEA).

METHODS

Data on all inpatient discharges from the 284 nonfederal Pennsylvania hospitals were obtained from the Pennsylvania Health Care Cost Containment Council for the period from 1994 to 1995. Physician data were obtained from the Physicians List of the American Medical Association, including name, gender, specialty, year of birth, board certified, and year of licensure. Cases were selected if any of six procedures codes were ICD-9-CM rubric 38.12, indicating CEA.

RESULTS

Among the 12,725 cases studied, in-hospital mortality was 0.7%, nonfatal morbidity was 3.0%, and the total bad outcome rate was 3.7%. Surgeons who performed 1 to 2 CEAs over 2 years had the highest mortality (2.0%) and total bad outcome (9.2%) rates. For surgeons performing three or more cases in 2 years, increased volume was not associated with better outcomes. A greater number of years since the surgeon was licensed was associated with greater mortality (p = 0.001), but not with morbidity or bad outcome rates. In regression analyses that adjusted for patient risk, both years since licensure and specialty predicted surgical mortality rate, but only volume predicted surgical bad outcome rate.

CONCLUSIONS

More years since licensure and very low patient volume are associated with worse patient outcomes following CEA.

Coronary and carotid operations under prospective standardized conditions: incidence and outcome

BACKGROUND

No randomized trial has yet evaluated the hypothetical benefit of carotid endarterectomy with coronary artery bypass grafting. This prospective review was undertaken to determine the differences between observed and predicted complication rates, as well as to define new predictors and assess costs in a standardized population.

METHODS

A prospective nonrandomized study was undertaken over a 4-year period involving all coronary artery bypass graftings done at one institution. Operative procedure was standardized. All patients underwent preoperative screening for carotid disease. If 80% or more stenosis was present, combined coronary artery bypass grafting and carotid endarterectomy was performed.

RESULTS

Of 2,071 patients, 1,987 had coronary artery bypass grafting only. In that group there were 34 strokes (1.7%) and 41 deaths (2.0%). Eighty-four patients underwent combined coronary artery bypass grafting/carotid endarterectomy and in that group there were four strokes (4.7%) and five deaths (5.9%). Independent risk factors for postoperative stroke were age (odds ratio 1.09; 95% confidence interval 1.04, 1.3), hypertension (odds ratio 2.67; 95% confidence interval 1.22, 5.23), extensively calcified aorta (odds ratio 2.82; 95% confidence interval 1.34, 5.97), and bypass time (odds ratio 1.01; 95% confidence interval 1.00, 1.02). Cost of a stroke was significant (p < 0.05) in both groups.

CONCLUSIONS

Patients with carotid disease fall into a higher risk group than patients without it. This increased risk is not because of carotid disease alone. Patients without significant carotid disease, who suffered a perioperative stroke, fell into an even higher risk category. Furthermore, carotid endarterectomy was not a significant risk factor by either the univariate or the multivariate analysis.

Global experience in cervical carotid artery stent placement

The purpose of this article is to review and update the current status of carotid artery stent placement in the world. Surveys to major interventional centers in Europe, North and South America, and Asia were initially completed in June 1997. Subsequent information from these 24 centers in addition to 12 new centers has been obtained to update the information. The survey asked the various questions regarding the patients enrolled, procedure techniques, and results of carotid stenting, including complications and restenosis. The total number of endovascular carotid stent procedures that have been performed worldwide to date included 5,210 procedures involving 4,757 patients. There was a technical success of 98.4% with 5,129 carotid arteries treated. Complications that occurred during the carotid stent placement or within a 30-day period following placement were recorded. Overall, there were 134 transient ischemic attacks (TIAs) for a rate of 2.82%. Based on the total patient population, there were 129 minor strokes with a rate of occurrence of 2.72%. The total number of major strokes was 71 for a rate of 1.49%. There were 41 deaths within a 30-day postprocedure period resulting in a mortality rate of 0.86%. The combined minor and major strokes and procedure-related death rate was 5.07%. Restenosis rates of carotid stenting have been 1.99% and 3.46% at 6 and 12 months, respectively. The rate of neurologic events after stent placement has been 1.42% at 6-12-month follow-up. Endovascular stent treatment of carotid artery atherosclerotic disease is growing as an alternative for vascular surgery, especially for patients that are high risk for standard carotid endarterectomy. The periprocedure risks for major and minor strokes and death are generally acceptable at this early stage of development and have not changed significantly since the first survey results. Cathet. Cardiovasc. Intervent. 50:160-167, 2000.

Carotid Artery Occlusive Disease

Stroke is the third most common cause of death and the leading cause of disability in the United States. Management of identifiable risk factors and careful selection of patients for operative intervention constitute the current approach to reducing the morbidity and mortality associated with stroke. A carefully performed carotid endarterectomy (CEA), which has a low periprocedural complication rate, is the only form of mechanical cerebral revascularization for which definitive evidence of clinical effectiveness has been reported. Recently, retrospective case reports and case series have demonstrated the feasibility of carotid angioplasty and stenting as a possible alternative to CEA. In the tradition of the two previous National Institutes of Health (NIH)-sponsored trials--the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS)--the National Institutes of Health has sponsored a clinical trial (CREST: Carotid Revascularization-Endarterectomy vs Stent Trial) that is currently under way to determine the efficacy and risks of carotid angioplasty and stenting compared with CEA.

Gender and carotid endarterectomy: does it matter?

OBJECTIVE

Multiple large series have retrospectively identified female gender as a risk factor for perioperative stroke and death after carotid endarterectomy (CEA).

METHODS

Data for all patients who underwent CEA at a single institution from January 1990 to December 1998 were entered into a computerized vascular registry and form the basis of this report.

RESULTS

A total of 1298 CEA procedures were performed, of which 520 (40%) were in women and 778 (60%) in men. The mean age was 69.8 +/- 8.7 years for men and 71.2 +/- 8.5 years for women (P <.001). Cardiac risk factors significantly varied among the two groups, with women more likely to have diabetes (42% vs 36%) and hypertension (77% vs 66%), whereas tobacco history was higher among men (85% vs 71%) (P <.05 for all). Female patients were more likely to be asymptomatic at presentation (men, 44% vs women, 51%; P =.022). Postoperative myocardial infarction occurred in eight patients (0.6%) with no differences between men (0.4%) and women (1.0%) (P = not significant). For all adverse postoperative cardiac events (myocardial infarction, congestive heart failure, or arrhythmia), the incidence was 1.9% (25 patients), again with no differences between men (1.5%) and women (2. 5%) (P = not significant). There were 25 postoperative neurologic events (19 strokes, six transient ischemic attacks) among the entire cohort (1.9%), of which 16 were in men (2.1%) and nine in women (1. 6%; P = not significant). The overall postoperative stroke rate was 1.5% (13 [1.7%] of 778 men; 6 [1.2%;] of 520 women; P = not significant). Total operative mortality was 0.3% (3 [0.4%] of 778 men; 1 [0.2%] of 778 women; P = not significant). Late recurrent stenosis requiring operation developed in 14 patients (1.1%) during follow-up (6 [0.8%] of 778 men; 8 [1.5%] of 520 women; P =.19).

CONCLUSIONS

Although there is significant variability in cardiac risk factors and presentation, female gender is not a risk factor for stroke, death, or cardiac morbidity after CEA. Women are not at higher risk for reoperation for recurrent stenosis.

Carotid stenting in patients older than 65 years with inoperable carotid artery disease: a single-center experience

Carotid angioplasty and stenting to treat extracranial carotid stenosis is an alternative (as yet not widely accepted) to high-risk surgery, but its safety and efficacy are little known, especially in elderly patients. We reviewed our 3-year experience of treating 100 elderly patients (> 65 years old) considered to be inoperable (76 men, 24 women, mean age 76+/-10 years, mean follow-up 18+/-9.2 months) and present two case histories. Most (85%) were symptomatic (transient ischemic attacks in 60, stroke in 25); 80 had concomitant coronary artery disease (severe in 30 [defined by > 70% stenosis in two or more epicardial coronary arteries or the left main coronary artery]) and 25 had severe left ventricular dysfunction (ejection fraction < or =20%). The procedure was technically successful in all patients; there was one major stroke and no patient died. Postprocedure, 15% had minor complications: reversible neurological deficit (5%), pulmonary edema (3%), prolonged hypotension (3%), vascular access complications (3%), and neck hematoma (1%). Over 90% of patients were discharged home within 24 hr.

Hemispheric stroke following cardiac surgery: a case-control estimate of the risk resulting from ipsilateral asymptomatic carotid artery stenosis

A case-control study was undertaken to determine if asymptomatic carotid artery stenosis (ACS) is independently associated with ipsilateral hemispheric stroke following cardiac surgery (CS). All CS patients (3069) who were at two hospitals between 1989 and 1994 were reviewed. Cases (31) selected for this study were those with hemispheric stroke within 30 days following CS. Controls (69) were taken from those without hemispheric stroke. Case-control analysis demonstrated that ACS of 50-90% and of 80-90% increased the risk of ipsilateral stroke 5.2-fold (95% confidence interval [CI] = 1.5-16.3, p = 0.01) and 24.3-fold (CI = 2.6-114.9, p = 0.002), respectively. Other variables with significant odds ratios (OR) were age > or =65 years (OR = 4.0, CI = 1.3-10.5, p = 0.01), peripheral vascular disease (OR = 3.4, CI = 1.3-8.8, p = 0.02), hypertension (OR = 3.0, CI = 1.2-7.0, p = 0.02), and female gender (OR = 3.0, CI = 1.2-7.1, p = 0.04). A second conservative analysis for missing data demonstrated a significant association for ACS of 80-90% alone (OR = 13.1, CI = 1.5-60.9, p = 0.01). This association remained significant after multivariate adjustment with propensity score stratification. ACS (80-90%) appears to be independently associated with ipsilateral hemispheric stroke following CS when evaluated against the present study variables. This finding supports the need for a properly conducted prospective natural history study, including an evaluation of aortic arch atherosclerosis, to determine the clinical relevance of this observation.

Patient satisfaction after carotid endarterectomy using a selective policy of local anesthesia

BACKGROUND

Patient satisfaction after carotid endarterectomy has not been specifically studied or reported. Results of carotid endarterectomy using either local or general anesthesia have been widely reported, and outcomes are not significantly different for either technique. Patient satisfaction data were obtained in order to determine whether patients preferred one method of anesthesia over another. Data regarding outcome may be added to the surgical literature as benchmark data when comparing operative carotid endarterectomy to newer techniques.

METHODS

During a 30-month period, 186 consecutive carotid endarterectomies were performed on 169 patients by a single surgeon with assistance from senior surgical residents. All patients were offered local anesthesia using a cervical block technique with intraoperative supplementation. Patients for whom local anesthesia was inappropriate or who declined were operated on using general endotracheal anesthesia. Results of operation were tabulated including indication for operation, method of anesthesia, intraoperative and postoperative complications, and mortality, and completion of a patient satisfaction survey form either on postoperative visit or by telephone questionnaire.

RESULTS

Of 169 patients who underwent carotid endarterectomy, 151 (89%) completed the satisfaction survey form. One hundred fourteen (62%) had local anesthesia and 71 patients (38%) had general anesthesia. There was 1 stroke (0.5%) and 1 death (0.5%) in the series. Perioperative complications including temporary cranial nerve injury, neck hematoma, myocardial infarction, and restenosis were noted and not significantly different in either the general anesthesia or local anesthesia group. Patient satisfaction data including intraoperative discomfort, postoperative pain, attentiveness of the operating room staff, and length of stay were all tabulated. There was no statistically significant difference in satisfaction between the general anesthesia group and the local anesthesia group (chi-square and Fisher's exact test). Additionally, satisfaction with the procedure was extremely high.

CONCLUSIONS

Patient outcome and perception of pain and recovery were not statistically significantly different in patients undergoing carotid endarterectomy using local anesthesia compared with general anesthesia. Overall patient satisfaction was extremely high. Patients should be offered carotid endarterectomy using an anesthesia technique with which the surgeon and patients are both comfortable, having confidence that the outcome is not related to anesthesia technique and that patients will be highly satisfied.

Carotid angioplasty and stenting: new horizons

Advances in technology have made it possible for lesions that affect the carotid artery, both extra-and intracranially, to be treated by endovascular means. Depending upon the type and location of the pathology, as well as the existing comorbidities in any given patient, angioplasty and stenting may be considered an alternative to traditional methods of revascularization. In fact, in some instances, endovascular therapy may be the procedure of choice. For patients whose lesions can be treated either surgically or endovascularly, future randomized trials will help define the role of each type of procedure.

Computer-assisted ultrasonographic analysis of carotid plaques in relation to cerebrovascular symptoms, cerebral infarction, and histology

The objective of this study was to determine the relationship between plaque echogenicity as measured by computer and the incidence of cerebrovascular symptoms and cerebral infarction. The correlation between carotid plaque echogenicity and plaque histology was also evaluated. In this prospective nonrandomized study, 38 consecutive patients with 54 atherosclerotic carotid plaques producing 50-99% stenosis were reviewed. The ultrasonic images of the plaques were digitized and transferred to a computer. A histogram for each plaque representing its composition was obtained. The median of the gray scale (GSM) of each histogram was used as measure of plaque echogenicity. All patients had a computed tomography (CT) brain scan performed to determine the presence of cerebral infarction. Twenty-eight plaques were examined histologically to determine the deposition of calcium, hemorrhage, cholesterol, and amorphous granular material. It is possible to identify carotid plaques at high risk for development of cerebrovascular symptoms and cerebral infarction by the computerized measurement of plaque echogenicity. This method may be used to improve the criteria of patients selection for carotid endarterectomy.

Vinpocetine for acute ischaemic stroke

BACKGROUND

Vasoactive and neuroprotective drugs are used to treat stroke in some countries.

OBJECTIVES

The objective of this review was to assess the effect of vinpocetine in acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched: August 1999) and Medline. We contacted researchers in the field and drug companies.

SELECTION CRITERIA

Unconfounded randomised trials of vinpocetine compared with placebo, or any other reference treatment, in people with acute stroke. Trials were included if treatment started no later than 14 days after stroke onset.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria. One reviewer extracted the data that was then checked by the second reviewer. Trial quality was assessed.

MAIN RESULTS

One trial involving 40 patients was included. Data for 33 patients were reported. No deaths occurred in the trial and no significant difference in dependency was shown between the treatment and placebo groups. No adverse effects were reported.

REVIEWER'S CONCLUSIONS

There is not enough evidence to evaluate the effect of vinpocetine on survival or dependency of patients with acute stroke.

Evaluation of carotid endarterectomy with sequential MR perfusion imaging: a preliminary 12-month follow up

AIM

The clinical benefit of carotid endarterectomy is partially determined by peri-operative mortality and morbidity. Post-operative abnormalities in cerebral perfusion may be a risk factor for cerebral haemorrhage, and may be estimated from Bolus Arrival Time (BAT) as demonstrated by MR perfusion imaging. We aimed to use MR perfusion imaging to determine the temporal extent of these changes.

MATERIALS AND METHODS

A single slice gradient recalled echo sequence was employed in five patients who underwent carotid endarterectomy. Sequential studies were undertaken pre-operatively, 3-5 days post carotid endarterectomy, and additionally at 3, 6 and 12 months.

RESULTS

Asymmetric BATs were demonstrated in 3/5 patients, changes occurring as late as 6 to 12 months after carotid endarterectomy. These changes were not associated with either clinical or conventional MR morphological complications.

CONCLUSIONS

MR perfusion imaging is able to demonstrate changes in BAT characteristics for up to 12 months after carotid endarterectomy. The clinical significance and underlying cause of these changes, including any association with post carotid endarterectomy hyperaemia, remains unknown.

Efficacy of a filter device in the prevention of embolic events during carotid angioplasty and stenting: An ex vivo analysis

OBJECTIVE

Although percutaneous angioplasty and stenting (PTAS) of carotid bifurcation lesions is feasible and appropriate for surgically inaccessible lesions, its general role and comparative value remain unclarified. Moreover, the acceptance of carotid PTAS has been limited by its potential for producing embolic debris. This study used an ex vivo model to evaluate the efficacy of a novel filter device to entrap emboli during PTAS of human carotid plaques.

METHODS

Eight carotid bifurcation plaques were obtained from patients who underwent carotid endarterectomy for high-grade atherosclerotic stenosis (>90%). The mean age of the patients was 63 years, and six patients were symptomatic. Each plaque was encased with polytetrafluoroethylene material to simulate adventitia and was connected to a perfusion circuit, which provided continuous flow through the plaque. The filter device consisted of an expandable polymeric membrane with multiple micro pores that was attached to the distal end of a 0.014-in wire with a shapeable tip. This filter was encased in a delivery catheter. With fluoroscopic guidance, the filter wire was passed through the stenosis and the delivery catheter was then retracted to open the filter to capture particles released into the distal internal carotid artery. PTAS with a self-expandable stent then was carried out over the filter wire. The particles released during the initial filter passage, those captured in the filter, and those that flowed through or around the filter (missed) were collected and analyzed with light microscopy.

RESULTS

Filter deployment, PTAS, and filter retrieval were achieved successfully with each lesion. Because the filter has a low crossing profile, it passed through the stenoses smoothly and only produced occasional small particles. PTAS improved the angiographic stenosis from 96.2% +/- 3.7% to 1.3% +/- 1.6%. The mean number and the maximum size of the particles that were released during initial filter passage, missed, and captured by the filter device were 3.1 and 500 microm, 2.8 and 360 microm, 20.1 and 1100 microm, respectively. Most of the particles and those of large size were released during PTAS. The filter captured 88% of these particles.

CONCLUSION

These study results show that this filter device, at least in this model, did not add complexity to the interventional procedure itself. Furthermore, the filter may markedly decrease embolic events during carotid PTAS and expand the indications for this procedure.

Carotid Angioplasty

Although no consensus yet exists on the ideal patient characteristics, materials, and indications for carotid angioplasty, it is clear that this procedure which is increasing in popularity will continue to do so. Until such time as the procedure is routinely approved (there are still barriers to insurance coverage for these procedures in the United States), we are highly selective in our application of carotid angioplasty. So far our experience is limited to approximately 40 patients with no major complications and no strokes. However, patient characteristics, operator experience, and patient selection play large roles in the outcomes of these procedures.

The current status of carotid angioplasty and stenting wilt be discussed as well as the potential complications and their treatment.

Risk neutralization in cardiac operations: detection and treatment of associated carotid disease

BACKGROUND

A screening and treatment protocol was implemented to extend the benefit of prophylactic carotid endarterectomy to patients who had open heart operations.

METHODS

Patients aged 65 or older or who at any age had left main coronary disease, transient ischemic attack, or stroke were eligible for preoperative carotid duplex screening. Carotid endarterectomies and open heart operations were planned as a staged (n = 59) or combined procedure (n = 55) for angiographically confirmed carotid stenosis of at least 80%.

RESULTS

Duplex scans were obtained in 1,719 of 7,035 open heart surgical patients over 8 years. The overall stroke rate was 1.5% (108 of 7,035). Seven of these were strokes of carotid origin (0.1%). There were 129 patients with at least 80% stenosis. One hundred fourteen had carotid endarterectomy preceding open heart operation, and none had carotid artery stroke. Twelve patients with at least 80% carotid stenosis by duplex scan had open heart operations without prophylactic carotid endarterectomies. There were four carotid strokes in these 12 patients (p = 0.0001; odds ratio, 20.2). Stroke risk remained significantly elevated (16.8%, p = 0.005) in the 50% to 79% group. The changes associated with the reduced risk afforded by this screening and treatment strategy amounted to $346 for each patient in the study.

CONCLUSIONS

The risk of carotid stroke at the time of cardiac operation can be defined by duplex screening. Prophylactic carotid endarterectomy neutralizes the risk in those with at least 80% stenosis. Consideration for lowering the threshold for assessment and treatment of carotid stenoses appears warranted. The economic investment is recouped by the savings in system resources that would have been depleted through care for carotid stroke and its sequelae.

Carotid bifurcation CT angiography: assessment of interactive volume rendering

PURPOSE

The purpose of this study was to compare the accuracy of CT angiography (CTA) for the assessment of carotid bifurcation stenosis, using interactive volume rendering (VR), maximum intensity projection (MIP), and 2D transverse CT technique (t-CT).

METHOD

Nineteen consecutive patients were prospectively studied with CTA and selective digital subtraction angiography (DSA). There were 13 men and 6 women from 51 to 84 years old (mean 70 years). Results of DSA were compared with those of interactive VR, MIP, and conventional t-CT results, using North American Symptomatic Carotid Endarterectomy Trial criteria for stenosis grading.

RESULTS

There were a total of 38 carotid bifurcations studied, with 9 mild, 10 moderate, and 15 severe stenoses and 4 occlusions. Overall agreement with DSA for VR was achieved in 76%. Eighty percent of the severe stenoses were correctly predicted by VR. The overall agreement between t-CT and DSA was 89%. MIP images, when analyzed independently, showed an overall agreement with angiography of only 71%. VR was not significantly different from MIP (p = 0.60). The difference between VR and t-CT had borderline significance (p = 0.09). MIP had significantly poorer agreement with angiography than t-CT (p = 0.02).

CONCLUSION

CTA has a high degree of accuracy for the assessment of carotid artery disease compared with catheter angiography. Interactive VR increases the accuracy of diagnosing carotid stenosis and decreases the number of unsatisfactory studies as compared with MIP. Further advances in computation speeds and improvements in software may dramatically alter the future use of VR for the communication of results to clinicians; however, careful analysis of transverse sections is essential to accurate CT interpretation.

Risk factors for post-carotid endarterectomy hematoma formation

PURPOSE

To identify risk factors for post-carotid endarterectomy (CEA) hematoma formation and establish the incidence of this complication at The Ottawa Hospital - Civic Campus (TOH-CC).

METHODS

A chart review of all patients who underwent CEA at TOH-CC from January 1, 1996 to December 31, 1997 was completed. Identified cases of post-CEA wound hematoma were entered into a case-control study using age and sex-matched controls from within the cohort. These matched pairs were assessed for 31 potential risk factors including demographic details, co-existing medical conditions, preoperative medications, intraoperative management, and postoperative parameters. Risk factors associated with post-CEA hematoma with P<0.05 were entered into a backward step-wise logistic regression model for multivariate analysis.

RESULTS

Charts from 249 patients were reviewed and 29 cases of post-carotid endarterectomy hematoma were identified (12% incidence). Six of the initial 31 potential risk factors emerged as univariate predictors of post-CEA hematoma formation (P<0.05): general anesthesia, carotid shunt placement, intraoperative hypotension, non-reversal of heparin, neurosurgery service, and preoperative aspirin use. Following logistic regression only non-reversal of heparin, intraoperative hypotension, and carotid shunt placement were identified as multivariate predictors of post-CEA hematoma formation. More time was spent in critical care settings (ICU/PACU) (P<0.01) and there was increased perioperative mortality (P = 0.04) within the hematoma group.

CONCLUSIONS

Post-CEA hematoma formation is associated with increased morbidity and mortality. Non-reversal of heparin, intraoperative hypotension, and carotid shunt placement are multi-variate predictors of post-CEA hematoma formation.

Renal insufficiency and altered postoperative risk in carotid endarterectomy

PURPOSE

Higher complication rates have been reported in patients with renal insufficiency (RI) undergoing peripheral vascular surgery. Little attention has been paid specifically to carotid endarterectomy (CEA) in patients with RI where the risk/benefit considerations are very sensitive to small increases in postoperative complications.

METHODS

One thousand one consecutive CEAs performed since 1990 were reviewed from our vascular registry, and 73 CEAs on patients with RI were identified. For comparison, two groups were established: group I (n = 928), normal renal function (creatinine level, <1.5 mg/dL); and group II (n = 73), RI (creatinine level, >/=1.5 mg/dL).

RESULTS

Differences in the nonfatal stroke rates and combined stroke and death rates were statistically significant (P <.02) between the groups: group I (1. 08% and 1.18%) and group II (5.56% and 6.94%) respectively. Both groups were similar in regard to operative indications. In addition with the comparison of group I to group II, there was a statistically significant increase in hematoma rate, 1.61% versus 12. 5% ( P <.001), total cardiac morbidity, 1.72% versus 6.94% (P =.003), and total complications, 6.24% versus 36.1% (P =.001). Multivariate analysis demonstrated pre-existing RI to be the only significant predictor for perioperative stroke and hematoma.

CONCLUSION

Patients with preoperative RI are at a higher, but not prohibitive, risk for stroke and death after CEA than patients with normal renal function. They are also at risk for hematoma formation, cardiac morbidity, and overall complications. Care in selection of these patients for CEA must be emphasized.