Carotid lesions--to operate or not to operate?

Abstract

Ischemic cerebrovascular disease, a major public health problem, is accompanied, and possibly caused in a large percentage of cases, by extracranial arterial lesions. A rapidly expanding body of surgical litera ture records the success of procedures designed to re pair these lesions along with a decline in recent years in surgical mortality for such procedures. If an area of carotid abnormality is a constant threat to adequate cerebral blood flow, why not remove it? There is no fully documented analysis of replies to this important question, but the present view addresses five areas of study that may result in a postponement or rejection of the decision to operate. These areas are not mutually exclusive; rather, they are variables that interact and should be considered in conjunction. Availability of Nonsurgical Prophylactic TreatmentThere is little evidence that surgical or medical treat ment produces major reversals in deficits of cerebral function already caused by cerebral infarction. Treat ment is primarily directed toward prevention of future ischemic episodes. At the present time two medical treatments are available: anticoagulants and platelet aggregation inhibiting agents. No justice can be done here to the massive body of literature on prophylactic results with these agents; however, discussion of the surgical decision would be incomplete without a brief comment on the current status of medical treatment.Despite decades of study, the place of anticoagu lants in ischemic cerebrovascular disease remains un certain. Although several studies have reported the success of these agents in preventing further ischemic attacks, there are only four well-designed prospective controlled studies. One major problem, as in most studies of treatment of this condition, has been that of properly defining controls. All patients with transient ischemic attacks are not alike. The large number of variables that should be considered in stratifying pa tients has been thoughtfully discussed by Brust, 1 but no study has done this stratification completely. Uncer tainty persists as to the actual prognosis in various types of TIA patients. In one recent follow-up study of 314 patients with TIAs, there was an amazingly low 6 In summary, anticoagulation remains a viable alternative, particularly on a short-term basis, but there is still uncertainty about its role vis-a-vis surgery and the treatments discussed below. One recent random ized study of anticoagulants and platelet aggregation inhibitors in TIA patients found only 3.3% of antico agulated patients to have sustained cerebral infarction during a two-year follow-up. 7

Vascular Surgery in Senescence Carotid Endarterectomy in Patients over 70 Years

“…'4 If the spontaneous course of symptomatic carotid artery disease is assumed to deteriorate with age in proportion to the &dquo;normal&dquo; increase in incidence of cerebral infarction with age, a spontaneous stroke rate of about 10% can be expected . 4,11,11 If this is the case, a randomized study requiring an accrual of 2 x 174 patients over a period of five years would be needed to demonstrate the supposed beneficial effect of prophylactic carotid endarterectomy in old age. '6 Poul Vasehus Madsen, M.D.…”

“…''2 Although an increased active attitude toward surgical treatment of occlusive vascular disease in old age has proved successful in general, information on advanced age as a risk factor in carotid surgery is scarce and long-term results are lacking. [3][4][5] The aim of this study was to evaluate the perioperative and long-term results of carotid endarterectomy in patients over seventy years of age.…”

Perioperative stroke Part I: General surgery, carotid artery disease, and carotid endarterectomy

“…Surgery on patients whose symptoms do not fit the diseased carotid artery is not likely to be beneficial. 163 The immediate and late surgical results depend largely on the preoperative neurological presentation. The more severe the neurological deficits from the previous stroke, and the more neurologically unstable the patient, the less favourable the outcome.…”

Carotid endarterectomy: how does it work? A clinical and angiographic evaluation.

“…Over the past few decades, carotid endarterectomy has evolved as the treatment of choice for selected patients with atherosclerotic disease involving the carotid bifurcation. 1 " 3 The available data do not support a role for this operative procedure in asymptomatic patients or in patients with severe neurological deficit or with serious accompanying diseases. Several studies, however, indicate that in patients with transient ischemic attacks or mild to moderate neurological deficit due to carotid stenosis, the survival rate can be improved by carotid endarterectomy when surgery is performed by an experienced surgeon and when the combination of angiography and surgery creates a combined mortality and morbidity rate not exceeding 5%.…”