Impact of cerebral ischemic lesions on the outcome of carotid endarterectomy (original) (raw)
Related papers
Journal of Vascular Surgery, 2016
Background: The influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients. Methods: All patients with symptomatic carotid artery stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 2005 and 2014 were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography. The volume was quantified in mm 3 and correlated with 30-day rates of stroke and stroke/death by c 2 , multivariate analysis, Pearson correlation, and receiver operating characteristic curves. Results: A total of 489 symptomatic patients were treated by CEA (327 [67%]) or CAS (162 [33%]), 186 (38%) #2 weeks and 303 (62%) >2 weeks from symptom onset. CEA and CAS patients had statistically similar rates of stroke (3.3% vs 5.5%; P ¼ .27) and stroke/death (3.8% vs 5.9%; P ¼ .22). CILs were identified in 251 patients (53%) and were associated with similar stroke and stroke/death rate compared with patients without CIL (12 [4.8%] vs 8 [3.5%], P ¼ .46; and 14 [5.6%] vs 8 [3.5%]; P ¼ .26, respectively). The median CIL volume was 1000 mm 3 (interquartile range [IQR], 7000 mm 3). Patients with postoperative stroke and stroke/death had a significantly higher preoperative CIL volume of 5100 mm 3 (IQR, 31,000 mm 3) vs 1000 mm 3 (IQR, 7000 mm 3 ; P ¼ .01) and 4500 mm 3 (IQR, 17,450 mm 3) vs 1000 mm 3 (IQR, 7000 mm 3 ; P ¼ .03), respectively. The receiver operating characteristic curve analysis showed a volume of 4000 mm 3 was predictive of postoperative stroke with 75% sensitivity and 63% specificity. A CIL volume 4000mm3wasanindependentriskfactorforpostoperativestroke,withastrokerateof9.34000 mm 3 was an independent risk factor for postoperative stroke, with a stroke rate of 9.3% (n ¼ 9) vs 1.9% (n ¼ 3) for a CIL volume of <4000 mm 3 (odds ratio, 4.6; 95% confidence interval, 1.1-19.1; P ¼ .03). Conclusions: CIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume of 4000mm3wasanindependentriskfactorforpostoperativestroke,withastrokerateof9.34000 mm 3 could be considered a significant predictor for postoperative stroke after carotid revascularization.
Journal of Vascular Surgery, 1999
Objective: The purpose of this study was to summarize the existing literature on the efficacy of carotid endarterectomy in patients with ipsilateral symptomatic carotid stenosis. Methods: Database searching, relevance assessment, methodologic quality assessments, and data extraction were all performed in duplicate with prespecified criteria. Results: Twenty-three publications were identified from the North American Symptomatic Carotid Endarterectomy Trial, the European Carotid Surgery Trial, and the Veterans Affairs Cooperative Studies Program. Stenosis was reported as measured in the North American Symptomatic Carotid Endarterectomy Trial. In patients with >70% stenosis, carotid endarterectomy was associated with a pooled relative risk reduction of 48% (95% confidence interval [CI], 27% to 73%) and an absolute risk reduction of 6.7% (95% CI, 3.2% to 10%) for the outcome of death or major disability from stroke. This translates into a number needed to treat of 15 (95% CI, 10 to 31). For patients with 50% to 69% stenosis, the benefit of surgery was less and the confidence intervals were wider. A relative risk reduction of 27% (95% CI, 5% to 44%), an absolute risk reduction of 4.7% (95% CI, 0.8% to 8.7%), and a number needed to treat of 21 (95% CI, 11 to 125) were observed in this group. The patients with the lowest degrees of stenosis (<50%) were harmed by the intervention (number needed to harm, 45). Increasing degree of stenosis, increasing age, male sex, the presence of other medical risk factors, and the presence of hemispheric rather than retinal antecedent events were factors that increased the benefits from surgery. Conclusion: Carotid endarterectomy reduced death or major disability from stroke in patients with >50% symptomatic stenosis. To maximize the benefits of surgery, careful preoperative risk assessment and the maintenance of low rates of major perioperative complications are mandatory. (J Vasc Surg 1999;30:606-17.)
Journal of Neural Transmission, 2011
Patients with a significant carotid stenosis are at an increased risk of suffering from a potentially fatal or disabling stroke. The current management strategies available to a patient with an asymptomatic carotid stenosis are either medical therapy alone, or in combination with either carotid endarterectomy, or carotid angioplasty and stenting. Medical therapy alone can reduce the incidence of stroke in general, but whether there is any reduction in stroke attributable to a significant carotid stenosis is less clear. Carotid endarterectomy, on the other hand, has been shown to reduce the incidence of ipsilateral ischaemic stroke in both symptomatic and asymptomatic patients, with the benefits extending into the long-term. Carotid angioplasty and stenting is a newer technique with the benefit of being minimally invasive. The results of trials comparing the technique to endarterectomy have had conflicting results, and the results of large multi-centre trials are awaited. Currently the safest strategy for a patient with a significant asymptomatic carotid stenosis consists of optimal medical therapy with carotid endarterectomy for those less than 75 years of age, who are suitable for surgery.
World Journal of Surgery, 2015
Background and purpose The risk of perioperative stroke and the benefits of carotid endarterectomy (CEA) remain uncertain in the case of an ipsilateral intracranial stenosis. The aim of this observational study was to analyze the early and late outcomes of CEA in patients with a carotid tandem lesion (CTL), defined as a severe stenosis at the bifurcation with any concomitant lesion C50 % involving the intracranial portion of the ipsilateral internal carotid artery or the main trunk of the anterior or middle cerebral artery. Methods From 2000 to 2009, 1143 patients underwent CEA for symptomatic or asymptomatic extracranial carotid stenosis according to the NASCET and ACAS recommendations, respectively. CTLs were diagnosed in 219 patients (19.2 %) by extracranial and transcranial color-coded Doppler sonography combined with noninvasive brain imaging studies. The primary endpoints of the study were perioperative (30-day) stroke and death, and any ipsilateral ischemic adverse events during the follow-up, which ranged from 0.1 to 10 years (mean 4.9 ± 3.3 years). The rates of the primary endpoints were compared between patients with (group I) and without CTL (group II). Results Overall, 219 CEAs were performed in group I and 924 in group II. Nearly two in three of the carotid lesions (777 of 1143, 68 %) were symptomatic at presentation (62.1 % in group I vs 69.4 % in group II; p = 0.03), with a 23.8 % rate of stroke (21.9 % in group I vs 24.2 % in group II; p = 0.85). There were 2 (0.9 %) perioperative ipsilateral strokes in group I and 5 (0.5 %) in group II (p = 0.62), and no deaths. The 5-year ipsilateral stroke-free, any stroke-free, and overall survival rates did not differ significantly between patients with and without CTL. Conclusions This study has shown that patients with and without CTL who underwent CEA had a similar occurrence of perioperative adverse events (probably due to the extremely low incidence of perioperative complications) and comparable late outcomes, suggesting that the presence of CTL does not justify refusing CEA for patients who could benefit from it.
Carotid endarterectomy for symptomatic low-grade carotid stenosis
Journal of Vascular Surgery, 2013
Objective: Although the management of carotid disease is well established for symptomatic lesions $70%, the surgical treatment for a symptomatic #50% stenosis is not supported by data from randomized trials. Factors other than lumen narrowing, such as plaque instability, seem to be involved in cerebral and retinal ischemic events. This study analyzes the early-term and long-term outcomes of carotid endarterectomy (CEA) performed in patients with low-grade (#50% on North American Symptomatic Carotid Endarterectomy Trial criteria) symptomatic carotid stenosis. Methods: The study involves 57 consecutive patients undergoing CEA for symptomatic low-grade carotid disease at our institution over 5 years, and 21 (36.8%) had experienced more than one ischemic event. Overall, 48 (84.2%) had a minor stroke, and nine (15.8%) had an episode of retinal ischemia. Diagnosis was made by a vascular neurologist based on an ultrasound examination combined with noninvasive imaging studies, after ruling out other possible causes of embolization. Before CEA, all patients were receiving antiplatelet treatment, and 87% were taking statins. All patients underwent eversion CEA under general deep anesthesia, with selective shunting. All carotid plaques were examined histologically. Long-term follow-up (median, 28 months; mean, 32 6 5 months; range, 3-56 months) was obtained for 55 patients. Results: No 30-day strokes or deaths occurred, and no patients had recurrent neurologic events related to the revascularized hemisphere during the follow-up. No late carotid occlusions were detected, but one asymptomatic moderate restenosis was documented. There were seven late deaths (12.7%), none of which were stroke-related. Survival rates were 98% at 1 year and 90% at 3 years. All removed carotid plaques showed different features of ulceration or rupture, with underlying hemorrhage associated with a thrombus. Conclusions: This study shows that CEA is a safe, effective, and durable treatment for patients with symptomatic lowgrade carotid stenosis associated with unstable plaque. Patients had excellent protection against further ischemic events and survived long enough to justify the initial surgical risk. Plaque instability seems to play a major part in the onset of ischemic events, regardless the entity of lumen narrowing. (J Vasc Surg 2013;-:1-7.)