High-risk carotid endarterectomy: Fact or fiction

Gasparis, Antonios P.; Ricotta, L; Cuadra, Salvador A.; Char, Daniel; Purtill, William; Bemmelen, Paul S. van; Hines, George L.; Giron, Fabio; Ricotta, John J.

doi:10.1067/mva.2003.56

Cited by 115 publications

(97 citation statements)

References 32 publications

(28 reference statements)

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“…Kragsterman et al (16) confirmed this association in a Swedish cohort (risk ratio 1.41, P = 0.02), whereas Rothwell et al (28) demonstrated, in a meta-analysis of available literature, that age greater than 75 years confers a 36% increase in the risk of stroke or death owing to CEA. Although the concept of a high-risk CEA population remains controversial (6,21,26), our findings raise the possibility that post-CEA stroke and neurocognitive decline share related risk factors and etiologies.…”

Section: Discussionmentioning

confidence: 85%

Predictors of Neurocognitive Decline after Carotid Endarterectomy

et al. 2006

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OBJECTIVE-Although the incidence of stroke after carotid endarterectomy (CEA) is low (1-3%), approximately 25% of patients experience subtle declines in postoperative neuropsychometric function. No studies have investigated the risk factors for this neurocognitive change. We sought to identify predictors of postoperative neurocognitive dysfunction.METHODS-We enrolled 186 CEA patients, with both symptomatic and asymptomatic stenosis, to undergo a battery of neuropsychometric tests preoperatively and on postoperative Days 1 and 30. Neurocognitive dysfunction was defined as a two standard deviation decline in performance compared with a similarly aged control group of lumbar laminectomy patients. Univariate logistic regression was performed for age, sex, obesity, smoking, symptomatology, diabetes mellitus, hypertension, hypercholesterolemia, use of statin medication, previous myocardial infarction, previous CEA, operative side, duration of surgery, duration of carotid cross-clamp, and weightadjusted doses of midazolam and fentanyl. Variables achieving univariate P < 0.10 were included in a multivariate analysis. Data is presented as (odds ratio, 95% confidence interval, P-value). CONCLUSIONS-Advanced age and diabetes predispose to neurocognitive dysfunction after CEA. These results are consistent with risk factors for neurocognitive dysfunction after coronary bypass and major stroke after CEA, supporting an underlying ischemic pathophysiology. Further work is necessary to determine the role these neurocognitive deficits may play in appropriately selecting patients for CEA. KeywordsCarotid endarterectomy; Cerebral ischemia; Neuropsychological tests; Risk factorsCarotid endarterectomy (CEA) reduces the risk of future stroke in patients with high-grade stenosis (5,10,15,25). However, approximately 25% of CEA patients experience declines in postoperative neurocognitive function that are detected by a battery of neuropsychometric tests (NPMTs) (12,13). Although the mechanism of post-CEA neurocognitive decline is poorly understood, it is thought to be ischemic in nature, and may be owing to hypoperfusion during carotid artery cross-clamping or the dislodgement of microemboli during vessel dissection and plaque removal.To date, no studies have thoroughly investigated the risk factors for these neurocognitive changes after CEA. With nearly 100,000 CEAs performed annually (5,25), many for borderline indications with small absolute benefit (11,35), understanding the variables that predispose to subtle changes in cerebral function is crucial in appropriate patient selection. We sought to identify factors that predict postoperative neurocognitive dysfunction. PATIENTS AND METHODS Study PopulationOne hundred and eighty six consecutive patients undergoing elective CEA for both symptomatic and asymptomatic carotid artery stenosis were prospectively enrolled in this institutional review board-approved study. All CEA patients had 60% or greater stenosis of the operative carotid artery. After obtaining written informed conse...

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Section: Discussionmentioning

confidence: 85%

Predictors of Neurocognitive Decline after Carotid Endarterectomy

et al. 2006

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“…They have demonstrated surgical results that are much different from what is observed in other reference services, as well as from the results of general experience with patients at Medicare (Table 5). [11][12][13]56,60,63 By acting like that, the studies SAPPHIRE and SPACE showed very similar results, certainly due to reasons explained above. 11,13 The EVA-3S study, funded by the French Department of Health and performed in university centers, showed extremely favorable results regarding endarterectomy (3.9% in the CEA group and 9.6% in the CAS group), the reason why the ethics committee determined its suspension, since the evidence had already been confirmed.…”

Section: Limitations Of the Endovascular Techniquementioning

confidence: 78%

“…In anatomic risk, they included 66 patients with contralateral occlusion, 29 cases of reoperations, three patients with previous radiotherapy and 53 with distal lesion. 60 Those authors possibly published the best study to demonstrate the mystification created with the widespread use of the "high risk" classification. They were careful enough to offer the 560 low-risk patients the same cares provided to the group of 228 high-risk patient, namely patch in 86 and 84% of cases, internal shunt in 93 and 97% of cases and general anesthesia in 98% of cases.…”

Section: High-risk Patients For Carotid Endarterectomymentioning

confidence: 99%

“…22 Other authors published studies about the definition and conduct in high-risk patients. [60][61][62] Gasparis et al 60 defined high risk in two groups: physiological risk and anatomic risk. In the former, they included 80 patients older than 80 years, 11 with AMI over the past 6 months, 16 with heart failure, chronic pulmonary occlusive disease and 13 with serum creatinine levels above 3 mg/dL.…”

Section: High-risk Patients For Carotid Endarterectomymentioning

confidence: 99%

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Análise crítica das indicações e resultados do tratamento cirúrgico da doença carotídea

Bonamigo

Lucas

2007

J. vasc. bras.

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O tratamento da doença carotídea tem ganhado enfoque nos últimos anos, principalmente com o advento da técnica endovascular, que defende o emprego da angioplastia e stent de carótida (CAS), principalmente em pacientes considerados de "alto risco" para a endarterectomia carotídea (ECA). Através da revisão bibliográfica, analisamos os resultados do tratamento da lesão carotídea em ambas as técnicas, realizando comentários embasados na experiência pessoal e nos dados da literatura, sobretudo nos pacientes de alto risco. Até o presente momento, não há evidência e justificativa para o emprego da CAS em larga escala nos pacientes com doença carotídea, inclusive nas situações de alto risco, tais como nos octogenários. No entanto, acreditamos que a CAS possa ser um coadjuvante no tratamento de pequeno número de pacientes com lesão carotídea (até 4% dos casos), como na presença de pescoço hostil, radioterapia prévia e alguns casos de estenose carotídea alta. Quando realizada com os cuidados técnicos necessários, a ECA ainda continua a melhor opção terapêutica aos doentes com lesão carotídea.

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“…5,6 However, larger studies such as an analysis of 13 622 CEA operations in the National Surgical Quality Improvement Program have found higher periprocedure complication rates in patients with SAPPHIRE high-risk features (3.0% mortality in high risk versus 1.7% without high risk, P<0.001).…”

Section: Discussionmentioning

confidence: 99%

Variability in Carotid Endarterectomy Practice Patterns Within a Metropolitan Area

Kansara

Miller

Damani

et al. 2012

Stroke

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Background and Purpose-Previous clinical studies have suggested that patients with carotid stenosis with high surgical risk features may fare better with carotid artery stenting or aggressive medical therapy. The extent to which carotid endarterectomy is still being performed in this group of patients is unclear. Methods-A retrospective audit was performed among 4 hospitals over a 2-year period. The proportion of high surgical risk patients was compared and the in-hospital stroke, myocardial infarction, and death rates were compared among conventional and high surgical risk patients. Results-Three hundred thirty-five carotid endarterectomy operations were performed (63% asymptomatic) with 37.9% being high surgical risk subjects. The stroke, myocardial infarction, and death rate was 4.6% in conventional risk subjects and 10.2% in high surgical risk patients (P<0.05). The only hospital with multidisciplinary carotid conferences had the lowest proportion of carotid endarterectomy operations in asymptomatic patients. Conclusions-A substantial proportion of carotid endarterectomy operations are performed in patients with high surgical risk features. These patients experienced a 2-fold increase in major in-hospital complications, raising doubts about whether they benefit from carotid surgery.

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High-risk carotid endarterectomy: Fact or fiction

Cited by 115 publications

References 32 publications

Predictors of Neurocognitive Decline after Carotid Endarterectomy

Predictors of Neurocognitive Decline after Carotid Endarterectomy

Análise crítica das indicações e resultados do tratamento cirúrgico da doença carotídea

Variability in Carotid Endarterectomy Practice Patterns Within a Metropolitan Area

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