A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery

OBJECTIVE

Current guidelines recommend that carotid endarterectomy (CEA) be performed as early as possible after the neurologic index event in patients with 50% to 99% carotid artery stenosis. However, recent registry data showed that patients treated ≤48 hours had a significantly increased perioperative risk. Therefore, the aim of this single-center study was to determine the effect of the time interval between the neurologic index event and CEA on the periprocedural complication rate at our institution.

METHODS

Prospectively collected data for 401 CEAs performed between 2004 and 2014 for symptomatic carotid stenosis were analyzed. Patients were divided into four groups according to the interval between the last neurologic event and surgery: group I, 0 to 2 days; group II, 3 to 7 days; group III, 8 to 14 days; and group IV, 15 to 180 days. The primary end point was the combined rate of in-hospital stroke or mortality. Data were analyzed by way of χ² tests and multivariable regression analysis.

RESULTS

The patients (68% men) had a median age of 70 years (interquartile range, 63-76 years). The index events included transient ischemic attack in 43.4%, amaurosis fugax in 25.4%, and an ipsilateral stroke in 31.2%. CEA was performed using the eversion technique in 61.1% of patients, and 50.1% were treated under locoregional anesthesia. The perioperative combined stroke and mortality rate was 2.5% (10 of 401), representing a perioperative mortality rate of 1.0% and stroke rate of 1.5%. Overall, myocardial infarction, cranial nerve injuries, and postoperative bleeding occurred in 0.7%, 2.2%, and 1.7%, respectively. We detected no significant differences for the combined stroke and mortality rate by time interval: 3% in group I, 3% in group II, 2% in group III, and 2% in group IV. Multivariable regression analysis showed no significant effect of the time interval on the primary end point.

CONCLUSIONS

The combined mortality and stroke rate was 2.5% and did not differ significantly between the four different time interval groups. CEA was safe in our cohort, even when performed as soon as possible after the index event.

Outcomes among valvular heart disease patients experiencing ischemic stroke or transient ischemic attack in Olmsted County, Minnesota

OBJECTIVE

To estimate the rates and predictors of survival and recurrence among residents of Olmsted County, Minnesota, who received an Initial diagnosis based on 2-dimensional color Doppler echocardiography of moderate or severe mitral or aortic stenosis or regurgitation and who experienced a first ischemic stroke, transient ischemic attack (TIA), or amaurosis fugax.

PATIENTS AND METHODS

At the Mayo Clinic in Rochester, Minn, we used the resources of the Rochester Epidemiology Project to identify Individuals who met the criteria for inclusion in the study and to verify exclusion criteria. The study included all residents of Olmsted County, Minnesota, who experienced a first Ischemic stroke, TIA, or amaurosis fugax within 30 days of or subsequent to receiving a first-time 2-dimensional color Doppler echocardlography-based diagnosis of moderate or severe mitral or aortic stenosis or regurgitation between January 1, 1985, and December 31, 1992. The Kaplan-Meier product-limit method was used to estimate the rates of subsequent stroke and death after the ischemic stroke, TIA, or amaurosis fugax. The Cox proportional hazards model was used to assess the effect of several potential risk factors on subsequent stroke occurrence and death.

RESULTS

For the 125 patients in the study, the Kaplan-Meier estimates of the risk of death and the risk of stroke at 2-year follow-up were 38.6% (95% confidence interval [CI], 29.9%-47.5%) and 18.5% (95% CI, 10.0%-27.0%), respectively. Compared with the general population, death rates were significantly Increased (standardized mortality ratio = 1.75; 95% CI, 1.38-2.19; P < .001) but rates of subsequent stroke occurrence were not (standardized morbidity ratio = 1.20; 95% CI, 0.75-1.84; P = .40). After adjustment for age, sex, and cardiac comorbidity, neither the type nor severity of valvular heart disease was an independent determinant of survival or subsequent stroke occurrence.

CONCLUSIONS

Patients with mitral or aortic valvular heart disease who experience Ischemic stroke, TIA, or amaurosis fugax have Increased rates of death, but not recurrent stroke, compared with expected rates. Other cardiovascular risk factors are more important determinants of survival In these patients than the type or echocardiographic severity of the valvular heart disease.

Axillary-to-carotid artery bypass grafting for symptomatic severe common carotid artery occlusive disease

PURPOSE

Revascularization of the internal or external carotid arteries is occasionally indicated for symptomatic atherosclerotic common carotid artery occlusion or long-segment high-grade stenosis beginning at its origin. I report the outcome of axillary artery-based bypass grafts to the distal common, internal, or external carotid arteries.

METHODS

Between 1981 and 1997, 29 axillary-to-carotid bypass grafting procedures were performed on 28 patients, 15 men and 13 women, with a mean age of 68 years. Indications were transient ischemia in nine patients, amaurosis fugax in four patients, completed stroke in six patients, and nonlateralizing global ischemia in nine patients. Twenty-three common carotid arteries were totally occluded, and six had long-segment stenosis of 90% or greater beginning at the origin. Saphenous vein grafts were used in 25 procedures, and synthetic grafts were used in four. Grafts were placed to 13 internal, eight distal common, and eight external carotid arteries.

RESULTS

There were no perioperative deaths; one stroke occurred (3.4%). No lymphatic or peripheral nerve complications occurred. In a 1- to 11-year follow-up period (mean, 4.5 years), there were no graft occlusions, one restenosis of 50% or greater, and two restenoses of 70% or greater. The 1-year stenosis-free rate for 50% or greater stenosis was 93%, and the 5- and 10-year rates were 87%. No late ipsilateral strokes occurred. The 5- and 10-year survival rates were 64% and 28%, respectively. Coronary artery disease was the major cause of late mortality.

CONCLUSION

Axillary-to-carotid bypass grafting for severe symptomatic common carotid occlusive disease is safe, well tolerated, durable, and effective in stroke prevention. There is a high late mortality rate because of coronary artery disease in patients with severe proximal common carotid occlusive disease.