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

Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients

Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I² test. I²>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I²=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I²=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I²=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I²=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I²=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I²=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I²=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I²=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I²=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I²=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I²=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I²=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.

The impact of contralateral carotid artery stenosis on outcomes after carotid endarterectomy

OBJECTIVE

Patients with contralateral carotid occlusion (CCO) have been excluded from randomized clinical trials because of a deemed high risk for adverse neurologic outcomes with carotid endarterectomy (CEA). Evidence for this rationale is limited and conflicting. Therefore, we aimed to compare outcomes after CEA between patients with and without CCO and varying degrees of contralateral carotid stenosis (CCS).

METHODS

We identified patients undergoing CEA from 2003 to 2015 in the Vascular Study Group of New England (VSGNE) registry. Patients were stratified by preoperative symptom status and presence of CCO. Multivariable analysis was used to account for differences in demographics and comorbidities. Our primary outcome was 30-day stroke/death risk.

RESULTS

Of 15,487 patients we identified who underwent CEA, 10,377 (67%) were asymptomatic. CCO was present in 914 patients, of whom 681 (75%) were asymptomatic. Overall, the 30-day stroke/death was 2.0% for symptomatic patients (CCO: 2.6%) and 1.1% for asymptomatic patients (CCO: 2.3%). After adjustment, including symptom status, CCO was associated with higher 30-day stroke/death (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.3; P = .001), any in-hospital stroke (OR, 2.8; 95% CI, 1.7-4.6; P < .001), in-hospital ipsilateral stroke (OR, 2.2; 95% CI, 1.2-4.0; P = .02), in-hospital contralateral stroke (OR, 5.1; 95% CI, 2.2-11.4; P < .001), and prolonged length of stay (OR, 1.6; 95% CI, 1.3-1.9; P < .001). CCS of 80% to 99% was only associated with a prolonged length of stay (OR, 1.3; 95% CI, 1.1-1.6; P = .01), not with in-hospital stroke. Neither CCO nor CCS was associated with 30-day mortality.

CONCLUSIONS

Although CCO increases the risk of 30-day stroke/death, in-hospital strokes, and prolonged length of stay after CEA, the 30-day stroke/death rates in symptomatic and asymptomatic patients with CCO remain within the recommended thresholds set by the 14 societies' guideline document. Thus, CCO should not qualify as a high-risk criterion for CEA. Moreover, there is no evidence that patients with CCO have lower stroke/death rates after carotid artery stenting than after CEA. We believe that CEA remains a valid and safe option for patients with CCO and that CCO should not be applied as a criterion to promote carotid artery stenting per se.

Contralateral occlusion increases the risk of neurological complications associated with carotid endarterectomy

Objective. To report on the incidence and factors associated with the development of perioperative neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO) and to compare results between those patients and the whole group of patients submitted to CEA at our vascular division from 1997 to 2012. Methods. Our nonrandomized prospective experience including 1639 patients consecutively submitted to CEA was retrospectively reviewed. 136 patients presented a CO contralateral to the treated carotid stenosis. Outcomes considered for analysis were perioperative neurological death rates, major and minor stroke rates, and a combined endpoint of all neurological complications. Results. CO patients more frequently were male, smokers, younger, and symptomatic (P < 0.001), presented with a preoperative brain infarct and associated peripheral arterial disease (P < 0.0001), and presented with higher perioperative major stroke rate than patients without CO (4.4% versus 1.2%, resp., P = 0.009). Factors associated with the highest neurological risk in CO patients were age >74 years and preoperative brain infarct (P = 0.03). The combination of the abovementioned factors significantly increased complication rates in CO patients submitted to CEA. Conclusions. In our experience CO patients were at high risk for postoperative neurological complications particularly when presenting association of advanced age and preoperative brain infarction.

Contralateral carotid occlusion in endovascular and surgical carotid revascularization: a single centre experience with literature review and meta-analysis

OBJECTIVE/BACKGROUND

The influence of contralateral carotid occlusion (CCO) on the outcome of carotid endarterectomy (CEA) and stenting (CAS) is debated. This study aims to evaluate CEA and CAS results in patients with CCO.

METHODS

All carotid revascularizations from 2005 to 2011 were analyzed, focusing on the role of CCO on 30-day cerebral events and death (CED). A meta-analysis was performed to evaluate the results of the literature by random effect.

RESULTS

Of the 1,218 carotid revascularizations performed in our institution, 706 (57.9%) were CEA and 512 (42.1%) were CAS. CED occurred in 3.6% of the CEAs and 8.2% of the CASs (p = .001). CCO was present in 37 (5.2%) CEAs and 38 (7.4%) CASs. In CEA, CCO patients had a higher CED compared with the non-CCO patients (16.2% vs. 2.9%, p = .001), as confirmed by multiple regression analysis (OR [odds ratio]: 5.1[1.7-14.5]). In CAS, CED was not significantly different in the CCO and non-CCO patients (2.6% vs. 8.7%, p = 0.23). The comparative analysis of the CCO patients showed a higher CED in CEA compared with that in CAS (16.2% vs. 2.6%, p = 0.04). Meta-analysis of 33 papers (27 on CEA and 6 on CAS) revealed that CCO was associated with a higher CED in CEA, but not in CAS (OR: 1.82 [1.57-2.11]; OR: 1.22 [0.60-2.49], respectively).

CONCLUSION

CCO can be considered as a risk factor for CED in CEA, but not in CAS. CAS appears to be associated with lower CED than CEA in CCO patients.

Impact of practice patterns in shunt use during carotid endarterectomy with contralateral carotid occlusion

PURPOSE

This study investigated the association between surgeon practice pattern in shunt placement and 30-day stroke/death in patients undergoing carotid endarterectomy (CEA) with contralateral carotid occlusion (CCO).

METHODS

Among 6379 CEAs performed in the Vascular Study Group of New England (VSGNE) between 2002 and 2009, we identified 353 patients who underwent CEA with CCO and compared the 30-day stroke/death rate with 5279 patients who underwent primary, isolated CEA with a patent contralateral carotid artery. Within patients with CCO, we examined the 30-day stroke/death rate across the reason for shunt placement and two distinct surgeon practice patterns in shunt placement: surgeons who selectively used a shunt (≤95% of CEAs) or routinely used a shunt (>95% of CEAs). We used observed/expected (O/E) ratios to provide risk-adjusted comparisons across groups.

RESULTS

Of 353 patients with CCO, 118 (33%) underwent CEA without a shunt, 173 (49%) underwent CEA using a shunt placed routinely, and 62 (18%) had a shunt placed for a neurologic indication. Rates of 30-day stroke/death across categories of reason for shunt use were no shunt, 3.4%; routine shunt, 4.0%; and shunt for indication, 4.8% (P = .891). The risk of 30-day stroke/death was higher for surgeons who selectively placed shunts (5.6%) in all their CEAs and lower for surgeons who routinely placed shunts (1.5%, P = .05). The risk of 30-day stroke/death was >1 in patients undergoing selective shunting (O/E ratio, 1.4; 95% confidence interval [CI], 1.1-1.7) and <1 for surgeons who placed shunts routinely (O/E ratio, 0.4; 95% CI, 0.2-0.9). Stroke/death rates were lowest when individual surgeons' intraoperative decisions reflected their usual pattern of practice: 1.5% stroke/death rate when "routine" surgeons placed a shunt, 3.4% when "selective" surgeons did not place a shunt, and 7.6% stroke/death rate for "selective" surgeons who placed a shunt (P = .05 for trend).

CONCLUSIONS

The risk of 30-day stroke/death is higher in CEA in patients with CCO than with a patent contralateral carotid artery. Surgeons who place shunts selectively during CEA have higher rates of stroke/death in patients with CCO. This suggests that shunt use for CCO during CEA is associated with fewer complications, but only if the surgeon uses a shunt as part of his or her routine practice in CEA. Surgeons should preoperatively consider their own practice pattern in shunt use when faced with a patient who may require shunt placement.

Contralateral internal carotid artery occlusion impairs early but not 30-day stroke rate following carotid endarterectomy

Neurological complications and mortality within 30 days following carotid endarterectomy (CEA) alone or with concomitant cardiac surgery/cardiopulmonary bypass (CPB) were assessed in patients with or without contralateral occlusion of the internal carotid artery (CO-ICA).Of 335 patients undergoing CEA, 173 underwent concomitant cardiac surgery with CPB. Group A consisted of 260 patients without CO-ICA and group B of 75 patients with CO-ICA. The neurological complications (peripheral nerve damage, transient ischemic attack [TIA], prolonged reversible ischemic neurological deficit [PRIND], and stroke) and the Rankin index within 24 hours and 30 days postoperatively were compared. Strokes within 24 hours were significantly increased (P = .006) in group B (11%) compared with A (3.1%); TIA and PRIND did not differ (P = .33). The overall neurological complications and in particular for peripheral neurological damage, TIA/PRIND, and stroke did not differ within the 30-day-period postsurgery. A significantly higher stroke rate within 24 hours postsurgery occurred in patients with CO-ICA.

Risk of stroke for carotid endarterectomy patients with contralateral carotid occlusion

The role of a contralateral carotid occlusion in the appearance of neurological complications after carotid endarterectomy (CEA) operations is a matter of some debate. In the North American Symptomatic Carotid Endarterectomy Trial, the risk of perioperative stroke was found to be higher in patients with a contralateral carotid occlusion. In a literature survey in 2004, however, a significantly increased risk of perioperative stroke was found in only one out of 17 studies on contralateral carotid occlusion patients. We therefore examined the frequency of stroke in patients with contralateral carotid occlusion at our own institution and performed a meta-analysis based on 19 representative studies, including the data from our own institution. Out of 1,960 CEAs at the authors' institute, a significantly higher frequency of 5.6% compared to 2.1% (p = 0.012) for perioperative stroke risk was seen in patients with contralateral carotid occlusion compared to those without. The meta-analysis, based on 19 studies, also showed in 13,438 CEA operations a significantly higher perioperative stroke rate of 3.7% compared to 2.4% (p = 0.002) in the presence of a contralateral carotid occlusion. Nevertheless, due to the extremely poor outcomes of medically treated symptomatic patients, a surgical or endovascular procedure should be sought for these patients. Since the superiority of angioplasty/stent procedures has not yet been verified compared to surgical procedures in these patients, special indication for an endovascular procedure should also be taken into consideration.

Carotid Endarterectomy in Patients with Contralateral Carotid Artery Occlusion

The aim of this study was to evaluate the 30-day outcome of carotid endarterectomy in patients with contralateral carotid artery occlusion and compare it to that in patients with patent contralateral carotid artery. We compared 2,959 carotid endarterectomies performed in patients with patent contralateral internal carotid artery to 373 carotid endarterectomies performed in patients with occlusion of the contralateral carotid artery in the same institute between 1988 and 2004. Patient demographics, surgical and anesthesiological strategy, perioperative neurological and cardiac events, and deaths were compared. The patients were grouped and analyzed according to the presence or absence of symptoms and to their gender. No significant difference was shown in perioperative cardiological and neurological events and deaths in patients with contralateral carotid occlusion versus patients without contralateral carotid occlusion. Females had significant more neurological events than males, in both the asymptomatic (P < 0.001) and symptomatic (P = 0.02) groups. Concomitant occlusion of the contralateral carotid artery was not associated with increased risk of perioperative cardiological or neurological adverse events. However, female gender was associated with higher risk for adverse neurological events.

Asymptomatic Carotid Artery Stenosis: Past, Present and Future

BACKGROUND

The role of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis (aCAS) remains a matter of debate. It seems that not only the degree of stenosis, but also other factors have to be taken in account to improve patient selection and increase the benefit of CEA for aCAS.

METHODS AND RESULTS

The literature pertaining aCAS was reviewed in order to describe the natural history, risk of stroke and benefit of CEA for patients with aCAS in regard to several factors.

CONCLUSION

The benefit of CEA for aCAS is low. Current factors influencing the indication for CEA are severity of stenosis, age, contralateral disease, stenosis progression to >80%, gender, concomitant operations and life expectancy. To improve patient selection investigations will concentrate on plaque characteristics and instability and cerebral hemodynamics and metabolism.

Carotid endarterectomy in cervical block anesthesia in patients with occluded contralateral internal carotid artery

Introduction: The goal of modern carotid surgery is relief of symptoms, stroke prevention, improvement in quality of life, prevention of vascular dementia, and prolongation of lifetime. OBJECTIVE: The objective of this paper was to compare the outcome of carotid endarterectomy in cervical block vs. general anesthesia in patients with occluded contralateral internal carotid artery (ICA). METHOD: One hundred patients (76 male, 24 female, mean age 60.81 years) with occluded contralateral ICA were operated from 1997-2000. Neurological symptomatology, deficiency and stroke incidence were preoperatively analyzed in two groups. Duplex-scanning, angiograms and CT-scan confirmed the diagnosis. Risk factors analysis included hypertension, diabetes, lipid metabolism disorders, smoking and history of CAD, CABG and PAOD. Morbidity and mortality were used to compare the outcome of surgery in two groups. RESULTS There was no difference of age, gender and symptomatology between the groups. Paresis, TIA and dysphasia were most frequent. 70%-90% of ICA stenosis was seen in the majority of patients. Hypertension and smoking were dominant risk factors in these two groups. Eversion carotid end arterectomy was the most frequent technique used. In three cases out of nine that were operated under cervical block, the neurological symptoms developed just after clamping, so the intra-luminal shunt was placed. Postoperative morbidity was 12% and mortality was 8%. Conclusion: There was no difference of preoperative parameters, surgical technique and outcome in these two groups. Without other intraoperative monitoring, cervical block anesthesia might be an option in patients with the occlusion of the contralateral ICA. However, prospective studies involving more patients are needed.

Carotid endarterectomy with contralateral carotid artery occlusion: is this a higher risk subgroup?

OBJECTIVE

to evaluate early and mid-term term results of carotid endarterectomy (CEA) in patient with and without contralateral carotid occlusion.

METHODS

between 1996 and 1999, 1324 CEAs were performed. In 82 patients contralateral carotid artery occlusion was present (group I); 1242 patients had patent contralateral carotid (group II). All patients were operated under general anaesthesia, and selective shunting was based on somatosensory evoked potentials (SEPs). Ultrasonographic follow-up was performed at 1, 6 and 12 months and then once a year. Early results and follow-up data were analysed retrospectively.

RESULTS

in group I there was a significantly higher incidence of SEPs reduction and shunt insertion; however, there were no differences in terms of perioperative complications. The cumulative stroke and death rate at 30 days in group 1 and group 2 were 2.4% vs 1.4% (p=n.s.), respectively. At a mean follow-up of 15 months there were no differences between the two groups in terms of cumulative symptom-free survival.

CONCLUSIONS

the presence of contralateral carotid occlusion caused an increased use of shunt, but not in early complications rates.

Carotid endarterectomy in patients with contralateral internal carotid artery occlusion without intraoperative shunting

BACKGROUND

Controversy about the optimal method of performing a carotid endarterectomy (CEA) exists despite its widespread application and support from various randomized clinical trials. Many surgeons selectively or routinely use electroencephalography (EEG) monitoring as well as shunting when performing this operation.

METHODS

We conducted this retrospective study to assess the maximum carotid clamp time without shunting or EEG monitoring during a CEA without the development of neurological deficits in an already compromised cerebral circulation.

RESULTS

Fifteen consecutive patients who underwent CEAs between 1988 and 1999 met our criteria of angiographically documented ipsilateral internal carotid artery (ICA) stenosis with contralateral ICA occlusion. The patient presentations included asymptomatic (14%), transient ischemic attack (TIA) (50%), and stroke (36%). All patients were operated under general anesthesia without shunting and only 4 patients underwent EEG monitoring. On angiography, all 15 patients had ipsilateral ICA stenosis (70-99%) and contralateral occlusion. In 54% of patients, the vertebral arteries (VAs) were both patent, while in 46% of patients only 1 VA was patent. Eighty-five percent of patients had at least 1 patent anterior communicating (Pcomm) artery, while 15% had nonvisualized Pcomm arteries bilaterally. Of the 15 patients, 14 had a patent anterior communicating artery. The mean clamp time of the CCA was 18.5 minutes (range 14-30 minutes). None of the 15 patients had new neurological changes immediately postoperatively or during the 6 weeks of follow-up.

CONCLUSION

We propose that shunting may not be necessary during CEA for high-grade stenosis with contralateral ICA occlusion, presumably because of adequate distal small vessel collaterals.

Effect of contralateral occlusion on long-term efficacy of endarterectomy in the asymptomatic carotid atherosclerosis study (ACAS). ACAS Investigators

BACKGROUND AND PURPOSE

The Asymptomatic Carotid Atherosclerosis Study (ACAS) established the effectiveness of prophylactic carotid endarterectomy, for patients in good health who had stenosis >/=60%, if conducted by surgeons with a surgical morbidity and mortality of <3%. This secondary analysis was performed to determine whether the presence of contralateral cervical carotid occlusion alters the efficacy of asymptomatic ipsilateral carotid endarterectomy.

METHODS

One hundred sixty-three participants who had a baseline contralateral occlusion documented by Doppler ultrasound (77 medical, 86 surgical) were compared with 1485 participants with a patent contralateral carotid artery (748 medical, 737 surgical) for the risk of a combined end point of perioperative (30-day) death or stroke or long-term (5-year) ipsilateral stroke.

RESULTS

For those without contralateral occlusion, surgery was associated with a 6.7% absolute reduction in the 5-year risk (95% CI, 2.1% to 11.4%), while for those with a contralateral occlusion, surgery was associated with a 2.0% absolute increase in risk (95% CI, -9.3% to 5.2%), which was a statistically significant difference in the effect of surgery (P:=0.047). This difference is primarily attributable to low long-term risk for medically managed patients with contralateral occlusion.

CONCLUSIONS

While this post hoc analysis should be interpreted with caution, the findings suggest that endarterectomy in asymptomatic subjects with contralateral occlusion provides no long-term benefit (and may be harmful) in preventing stroke and death. These findings were a result of the benign course of medically treated subjects.

Carotid endarterectomy in an awake patient with contralateral carotid occlusion: influence of selective shunting

The objectives of this study were to determine whether the presence of a contralateral carotid occlusion increases risk and whether the perioperative results are influenced by a systematic or selective policy of shunting during carotid endarterectomy (CEA) in an awake patient. In a retrospective study we compared patients with and without contralateral carotid occlusion (group I, n = 198 - group II, n = 1068) who required CEA. In 77 patients of group I, a shunt was systematically adopted (subgroup A); in the other 121 patients (subgroup B) and in all patients of group II a selective shunting policy was adopted. The risk for the patients with contralateral carotid occlusion was not significantly higher than that for patients without occlusion. Results were not influenced by systematic/selective shunting policy, and the incidence of signs of cerebral ischemia was higher in patients with contralateral carotid occlusion.