Carotid endarterectomy. Clinical results in a community-based teaching hospital.

Abstract

Since 1971, 6$8 consecutive carotid endarterectojnies were performed in 612 patients in a commun.ity-based teaching hospital by 16 surgeons; 82% of the procedures were performed in patients who had suffered a transient ischemic attack, amaurosis fugax, or a previous stroke. Seven patients (1%) died, five of perioperative stroke and two of myocardial infarction. Thirty-one patients suffered a perioperative stroke (4.5% of the 688 endarterectomies); 20 patients (2.9% of 688) were left with moderate to severe neurologic deficits. The combined mortality/major neurologic deficit morbidity rate (number of patients -s-number of endarterectomies) is 3.2%. Both operative mortality and morbidity have progressively declined in successive 5-year periods, with no deaths and a 2.7% stroke rate in 148 endarterectomies performed after 1984. Our results indicate that carotid endarterectomy as practiced in a community-based teaching hospital can be performed without excessive risk. (Stroke 1988; 19:1323-1327) D eath and disability related to stroke remain one of the most important public health problems in the United States today. Even though the stroke rate is declining by approximately 6% annually, more than 150,000 Americans die each year of stroke. Many of the estimated 2 million people disabled by stroke are in their economically productive years. The total cost to the nation was estimated at 12.8 billion dollars in 1987. ' The role of carotid endarterectomy in the prevention of stroke has come under increasing scrutiny. It is estimated that more than 100,000 carotid endarterectomies are performed annually in the United States, at a cost in excess of 1.2 billion dollars. 2Many surgeons have achieved excellent results with low morbidity and mortality rates, and many centers also report excellent results. However, the overall results of surgery may be substantially worse than those reported in the best series. Communitybased studies appear to indicate that morbidity and mortality rates, although declining, are still excessive for some groups of patients.3 Because of allegations of high morbidity and mortality rates, all institutions in which carotid endarterectomy is performed have been challenged to review their results. Subjects and MethodsWe reviewed the results of 688 consecutive carotid endarterectomies performed at Baystate Medical Center from 1971 to the present. Virtually all patients were operated on under general anesthesia; shunting was routinely used, as was heparin anticoagulation. Primary closure of the arteriotomy was most commonly employed, although patch closures with autogenous vein or synthetic materials were occasionally used. Endarterectomy was performed under local or regional anesthesia extremely rarely, and other types of monitoring such as intraoperative electroencephalography or cerebral blood flow measurements were not used. Completion angiography was rarely used, and intraoperative ultrasonic, imaging was not employed. ResultsThere were 688 carotid endarterectomies performed in 612 patients; 76 p...

A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy

“…Of these, 7 papers reported risks in older patients but did not compare their results to younger patients in the same centre(s) and were therefore excluded. Among the 62 remaining eligible papers [35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97], there were no differences in the associations between either age or sex and overall 30-day stroke rate, death rate or combined stroke and death rate between studies reporting the associations as their primary aim and those which reported them as a subanalysis along with other risk factors (fig. 1, 2) and so data from both types of study are combined in the analyses below.…”

Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients

“…3,14 Therefore, many practitioners have long been reluctant to undertake early CEA because of the fears of increased operative risk and of transforming a pre-existing ischemic stroke into a fatal hemorrhagic one. However, recent advances in sensitive neuroimaging techniques, the organization of the admission wards into acute stroke units, and close cooperation among neurologists, vascular surgeons, and neuroradiologists have facilitated the identification and selection of neurologically unstable patients who may benefit from early carotid surgery.…”

“…Seven eligible patients received thrombolytic therapy Յ3 hours of stroke onset. The median NIHSS score was 9 (range, 5-15) in these 7 patients and was 6 (range, [2][3][4][5][6][7][8][9][10][11][12] in the remaining 20 patients; resulting in a median NIHSS score of 8 (range, 2-15) in the 27 patients overall. All patients received duplex ultrasound imaging at admission and showed evidence of complete ICA occlusion in 11 patients.…”

“…Most authors defined SIE as a fluctuating or progressive neurologic deficit. 2 Some small institutional studies have reported very high operative risks in such patients, 3 whereas other studies have suggested that the risk is similar to that for stable symptoms. 4 A recent systematic review of 12 series with 135 patients reporting early CEA for SIE showed that the pooled absolute risks of stroke and death were 20.2 (95% confidence interval [CI], 12.0-28.4), much higher than that of an elective procedure.…”

Urgent Carotid Endarterectomy for Patients with Unstable Symptoms: Systematic Review and Meta-Analysis of Outcomes

“…[26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] For 353 patients who underwent CEA following cTIA, the mean stroke rate was 6% (n 5 20) and the death rate was 3.2% (n 5 12), giving a Table 2). [26][27][28]30,33,34,36,37,39,[42][43][44][45][46][47][48][49][50][51][52][53][54][55] The results of the four studies (n 5 68) that combined patients with cTIA and unstable stroke yielded a perioperative combined rate of 34.1% (see Table 3). …”