Results of staged bilateral carotid endarterectomy

Increased incidence of cerebral clamping ischemia during early contralateral carotid endarterectomy

OBJECTIVES

The aim of our study was to assess the influence of previous contralateral carotid endarterectomy (CEA) and of the timing of the procedures on cerebral clamping ischemia during the second operation in patients undergoing staged bilateral CEA.

METHODS

We reviewed the 251 patients who presented with bilateral carotid stenosis of > or =70% at the time of the first admission and underwent staged bilateral CEA between January 2001 and December 2004. Surgery was performed under locoregional anesthesia. Cerebral perfusion was monitored with mental status and contralateral motor function evaluation in awake patients. Selective carotid shunting was performed for patients who manifested neurologic deficits. Univariate and multivariate analyses were performed for the variables of interest.

RESULTS

Twenty-two patients (8.8%) required carotid shunting during the first procedure and 28 (11.1%) during the second one. Nine of the latter also had shunts during the first CEA, whereas 19 tolerated cross-clamping during the first operation. Among the patients who underwent contralateral CEA < or =30 days, 23 of 146 required carotid shunting; between 31 and 60 days, 4 of 73; and after 61 days, 1 of 32 (P = .023; univariate analysis). The chi2 for trend was statistically significant (P = .009). Patients operated on the second side < or =30 days had a nearly fourfold risk of shunting during the second procedure compared with patients operated on > or =31 days. The highest risk was observed in patients with a shunt during the first operation who underwent the second CEA < or =30 days. Multivariate analysis also identified the time intervals between CEAs and the need of shunting during the first procedure as independent risk factors (P = .042 and P < .001).

CONCLUSIONS

These data show an increased incidence of cerebral clamping ischemia during contralateral endarterectomy performed < or =30 days; whereas after longer intervals between CEAs, the need for shunting is significantly reduced.

Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery

BACKGROUND AND PURPOSE

Reliable data on the risk of carotid endarterectomy (CEA) in relation to clinical indication and timing of surgery are necessary to target CEA more effectively, to inform patients, to adjust risks for case mix, and to understand the mechanisms of operative stroke.

METHODS

We performed a systematic review of all studies published from 1980 to 2000 inclusive that reported the risk of stroke and death resulting from CEA. Pooled estimates of risk by type of presenting ischemic event and time since the last event were obtained by Mantel-Haenszel meta-analysis.

RESULTS

Of 383 published studies, only 103 stratified risk by indication. Although the operative risk for symptomatic stenosis overall was higher than for asymptomatic stenosis (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.45 to 1.81; P<0.00001; 59 studies), risk in patients with ocular events only tended to be lower than for asymptomatic stenosis (OR, 0.75, 95% CI, 0.50 to 1.14; 15 studies). Operative risk was the same for stroke and cerebral transient ischemic attack (OR, 1.16; 95% CI, 0.99 to 1.35; P=0.08; 23 studies) but higher for cerebral transient ischemic attack than for ocular events only (OR, 2.31; 95% CI, 1.72 to 3.12; P<0.00001; 19 studies) and for CEA for restenosis than primary surgery (OR, 1.95; 95% CI, 1.21 to 3.16; P=0.018; 6 studies). Urgent CEA for evolving symptoms had a much higher risk (19.2%, 95% CI, 10.7 to 27.8) than CEA for stable symptoms (OR, 3.9; 95% CI, 2.7 to 5.7; P<0.001; 13 studies), but there was no difference between early (<3 to 6 weeks) and late (>3 to 6 weeks) CEA for stroke in stable patients (OR, 1.13; 95% CI, 0.79 to 1.62; P=0.62; 11 studies). All observations were highly consistent across studies.

CONCLUSIONS

Risk of stroke and death resulting from CEA is highly dependent on the clinical indication. Audits of risk should be stratified accordingly, and patients should be informed of the risk that relates to their presenting event.

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.

Carotid Endarterectomy Reoperations in a Regional Medical Center

Large, randomized prospective clinical trials have not addressed the safety of reoperation for recurrent carotid disease. Our purpose was to determine whether outcomes for carotid endarterectomy for recurrent disease were different from those for primary or contralateral carotid endarterectomy. We reviewed all carotid endarterectomies done in our regional medical center hospital from 1979 through 1997. We analyzed 1656 primary procedures, 377 contralateral carotid procedures, and 63 reoperations. Operation for recurrent disease was done in 3 per cent of those having primary operations. Patients in the three groups did not differ significantly with regard to age, race, or sex. Seventy per cent of patients were symptomatic with transient ischemic attacks, amaurosis, and reversible ischemic neurological deficit being most prominent. There were no deaths and three strokes in the reoperation group for a combined stroke and death rate of 4.8 per cent. This was not significantly different from that of 3.2 per cent for the stroke and death rate for the primary group and 3.5 per cent for the contralateral group. Carotid endarterectomy is a safe treatment for recurrent carotid artery disease.

Carotid endarterectomy in the community hospital in patients age 80 and older

OBJECTIVE

To determine whether the rates of death and complications of carotid endarterectomy (CE) were different in the octogenarian population than in patients younger than age 80.

SUMMARY BACKGROUND DATA

The utility of CE depends on the ability of the surgeon and hospital to attain low rates of death and complications, including all subgroups of the patient population. In the past 30 years, the number of people age 85 and older has increased 274%.

METHODS

Detailed chart review was carried out on all CE procedures done from 1979 through 1998. Descriptive demographic data, risk factors, surgical details, length of stay, deaths, and complications were recorded.

RESULTS

A total of 2,398 CEs were performed in 1,970 patients; 2,180 procedures were performed in 1,783 patients younger than 80, and 218 CEs were performed in 187 patients age 80 and older. Sixty-five percent of the octogenarians and 67% of patients younger than age 80 had neurologic symptoms. Among asymptomatic patients, 89% had stenosis of 75% or more. There were 62 strokes in the 2,180 procedures in the younger group, for a stroke rate of 2.8%, and 7 strokes in the 218 procedures in the older group, for a stroke rate of 3.2%. The death rates were 0.9% for the octogenarians and 1.4% for the younger group.

CONCLUSIONS

Carotid endarterectomy can be safely performed in a community hospital in patients age 80 and older. Outcomes in octogenarians were not significantly different than those of younger patients and were within the range required for CE to be considered beneficial in the prevention of stroke.

Comparative results of staged and simultaneous bilateral carotid endarterectomy: a clinical study and surgical treatment

OBJECTIVE

Bilateral carotid stenoses are actually managed by staged endarterectomy. The present study compares the results of the above surgical procedure with simultaneous bilateral carotid endarterectomy.

METHODS

Sixty-four carotid endarterectomies were carried out on two groups of thirty-two patients with bilateral carotid stenoses. Fifteen patients (group A) were subjected to staged and 17 patients (group B) who were subjected to simultaneous bilateral carotid endarterectomies.

RESULTS

The mortality rate was zero in both groups; no statistically significant difference was found concerning complications related to the heart, neurological deficit and postoperative hypertension.

CONCLUSIONS

Simultaneous carotid endarterectomy is a challenging and technically demanding operation but with limited indications in strictly selected patients. The development of methods of more effective monitoring and protection of the cerebral cells might broaden the indications of such a surgical tactic in the future. Staged carotid endarterectomy, however, remains the method of choice for the management of bilateral carotid occlusive disease.

Influence of the status of the contralateral carotid artery on the outcome of carotid surgery

From 1985 to 1995, 747 carotid arteries were operated on in 694 patients, who were under general anesthesia and continuous electroencephalogram (EEG) monitoring. These patients were divided into three groups according to contralateral carotid status. Group 1 consisted of 58 patients who had contralateral occlusion; group 2, 53 patients who had contralateral stenosis and bilateral staged surgery; and group 3, 583 patients who had nonstenotic contralateral internal carotid artery. All groups were similar with regard to age and sex ratio. There were more asymptomatic patients in group 3 than in group 1 (39.9% vs. 25.8%) (p < 0.05), and less preoperative strokes in group 2 than in the other groups (3.7% vs. 17.2% and 13. 6%, respectively) (p < 0.05). Among risk factors, smoking was less frequent in group 3 (59.5%) than in group 1 (82.7%) and group 2 (77%) (p < 0.01), and coronary artery disease was more frequent in group 2 (60%) than in group 1 (32.7%) and Group 3 (26.4%) (p < 0.01). EEG changes occurred more frequently in group 1 (25.8%) than in group 2 [5.6% (first stage) and 3.8% (second stage)] and in group 3 (4.9%) (p < 0.01). A shunt was used only when EEG changes did not disappear after pharmacologic increasing of central blood pressure, which occurred more frequently in group 1 (10.3%) than in group 2 (0%) and group 3 (0.3%) (p < 0.05). The combined morbidity/mortality rate was similar for groups 1 and 3 (1.7% and 1.5%, respectively), however, transient morbidity was more frequent in group 1 (6.9%) than in group 3 (1.5%) (p < 0.05). The combined morbidity/mortality rate was higher in group 2 than in group 3 (7.5% vs. 1.5%) (p < 0. 05), and all strokes in group 2 were seen during the second-stage operation. In conclusion, contralateral carotid artery occlusion had minimal influence over carotid surgery results. Selective use of a shunt based on EEG monitoring prevented ischemic strokes, with minimal neurologic morbidity. Contralateral carotid stenosis did not affect operative strategy for first stage, but we noted a higher incidence of strokes during the second procedure.

A statewide, hospital-based analysis of frequency and outcomes in carotid endarterectomy

BACKGROUND

For more than 40 years carotid endarterectomy (CE) has been used in the treatment of extracranial carotid disease for the prevention of stroke. Recent prospective clinical trials have confirmed the benefit of CE for both symptomatic and asymptomatic patients. Our purpose was to examine statewide trends in the numbers of CE over a 6-year time period and to evaluate outcomes.

METHODS

Using data from the North Carolina Medical Database Commission (NCMDC) all CE procedures from 1988 to 1993 were identified. Numbers of CE were compared with the population and hospital admissions. Variables of length of stay, hospital charges, discharge disposition, and occurrence of stroke and death were analyzed.

RESULTS

A total of 11,973 CE were performed in 6 years. Compared by admissions, population, and the proportion of elderly, the number of CE increased yearly. The stroke rate was 1.7% and the death rate 1.2% for an overall in-hospital stroke plus mortality rate of only 2.7%.

CONCLUSIONS

From a diverse group of hospitals and a large number of surgeons and patients, this hospital-based study documents the acceptance and safety of CE in the treatment of extracranial carotid disease.

Bilateral carotid endarterectomy during the same hospital admission

The efficacy of carotid endarterectomy for the prevention of strokes has been well demonstrated in recent multicenter randomized trials. However, patients presenting with bilateral significant disease pose a difficult problem to the vascular surgeon. Currently, bilateral carotid endarterectomies are staged at varying intervals between operations, with surgeon and patient weighing the risks of waiting for surgery versus the risks of having both procedures done within a shortened interval. There are few data and no consensus on the optimal time interval between these operations. In order to evaluate the timing of carotid endarterectomies in patients with severe bilateral disease, the authors reviewed their experience with patients who had bilateral procedures performed during one hospitalization. Over the past 5 years, they have performed 204 such carotid endarterectomies in 102 patients. Cervical block anesthesia was used in 99% (201/204) of these procedures. All patients either had symptomatic disease, > 60% stenosis or severe ulcerative plaque as defined by duplex scan and/or preoperative angiography. Symptomatic stenoses were the operative indications in 39% (80/204) of the patients; the remaining 61% (124/204) were symptom-free. The majority of patients (80%; 164/204) had their second procedure performed within 2 days of their first operation. There was no operative mortality and only one permanent neurologic defect in this group for a combined stroke mortality rate of 1%. Three patients (1.5%) had transient neurologic deficits postoperatively which completely resolved by discharge. These data show that bilateral carotid endarterectomies can be performed safely and effectively during one hospital admission with a short interprocedural interval and without an increase in mortality or morbidity.

A systematic review of the risks of stroke and death due to endarterectomy for symptomatic carotid stenosis

BACKGROUND AND PURPOSE

Carotid endarterectomy reduces the risk of carotid territory ischemic stroke ipsilateral to a recently symptomatic severe carotid stenosis. However, the benefit is limited by the risks of stroke and death associated with the operation. Although reported surgical risks vary enormously, there has been no systematic review of the published literature.

METHODS

We performed a systematic review of mortality and the risk of stroke and/or death due to endarterectomy for symptomatic carotid stenosis in studies published since 1980.

RESULTS

Fifty-one studies fulfilled our criteria. Overall mortality was 1.62% (95% confidence interval [CI], 1.3 to 1.9), and the risk of stroke and/or death was 5.64% (95% CI, 4.4 to 6.9). However, there was significant heterogeneity of risk of stroke and/or death (P < .001). The risk varied systematically with the methods and the authorship of the study. The risk of stroke and/or death was highest in studies in which patients were assessed by a neurologist after surgery (7.7%; 95% CI, 5.0 to 10.2) and lowest in studies with a single author affiliated with a department of surgery (2.3%; 95% CI, 1.8 to 2.7). After correcting for study methodology, there was no temporal trend in the risk of stroke and/or death between 1980 and 1995.

CONCLUSIONS

The reported risks of endarterectomy for symptomatic carotid stenosis show significantly greater variability than would be expected by chance. However, much of this variability can be accounted for by differences in methodology and authorship. The 5.6% overall risk of stroke and/or death is consistent with present guidelines.

A systematic comparison of the risks of stroke and death due to carotid endarterectomy for symptomatic and asymptomatic stenosis

BACKGROUND AND PURPOSE

There is some evidence that carotid endarterectomy reduces the risk of ipsilateral carotid territory ischemic stroke in patients with severe asymptomatic carotid stenosis. However, the benefit of endarterectomy is dependent on a low risk of stroke and/or death due to surgery. Whether the low operative risks reported in recent clinical trials and cited in recent guidelines are widely generalizable to clinical practice is unclear. Is endarterectomy for asymptomatic carotid stenosis really safer than surgery for recently symptomatic stenosis?

METHODS

We performed a systematic review comparing the risks of stroke and death due to carotid endarterectomy, performed by the same surgeons or in the same institutions, for symptomatic and asymptomatic stenosis in studies published since 1980.

RESULTS

Twenty-five studies fulfilled our criteria. Mortality within 30 days of endarterectomy was 1.31% for asymptomatic stenosis and 1.81% for symptomatic stenosis (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.49 to 0.99). The risks of fatal stroke were 0.47% and 0.91%, respectively (OR, 0.57; 95% CI, 0.34 to 0.98). The overall risk of stroke and/or death was 3.35% for asymptomatic and 5.18% for symptomatic stenosis (OR, 0.61; 95% CI, 0.51 to 0.74).

CONCLUSIONS

Mortality and the risk of stroke and/or death due to carotid endarterectomy are significantly lower for asymptomatic than symptomatic stenosis. These findings are consistent across virtually all studies and are likely to be widely generalizable.