Perioperative outcomes after reoperative carotid endarterectomy are worse than expected

Abstract

Reoperative carotid surgery is associated with a longer operative time and higher risk for perioperative stroke compared with index CEA. This information informs the risk-benefit analysis for reoperation.

Carotid Disease

“…Most common complications of CEA include myocardial infarction, perioperative stroke, postoperative bleeding, and the potential consequences of cervical hematoma, nerve injury, surgical site infection, and carotid restenosis. However, the rates of complications after carotid endarterectomy is low [25][26][27][28][29][30][31][32][33].…”

“…In randomized trials, myocardial infarction has occurred at a slightly higher rate for carotid endarterectomy than carotid artery stenting [25,26,[28][29][30][31]; with a reported incidence between 0 and 2%, pooled absolute risk of perioperative (30-day) myocardial infarction was 0.87%. The risk factors for myocardial infarction included older age, coronary heart disease, peripheral artery disease, and carotid restenosis.…”

“…Perioperative stroke is the second most common cause of death in carotid endarterectomy [25,26,28,32,33,35,36] with a rate of less than 3% for symptomatic patients and less than 5% for the symptomatic patients depending on the indication of the CEA and the experience of the surgeon. But also there are some factors that can contribute to postoperative stroke [28,[37][38][39][40][41][42] like plaque emboli, platelet aggregates, improper flushing, poor cerebral protection, and relative hypotension.…”

“…If perioperative stroke is suspected, ultrasound is a good option; but if it shows good flow throughout the carotid artery with no thrombosis or intimal flaps, a head computed tomography (CT) scan should be obtained to rule out intracranial bleeding [38,[43][44][45]. If there is access to a hybrid operating room, another approach to obtain may be head CT first, and, if no bleeding is identified, intraoperative arteriography to identify any correctable lesions is performed [28].…”

“…Clinically the patient will have neck swelling and drainage from incision in acute events; in delayed infections, a draining sinus tract or pulsatile neck mass could be indicative of a carotid pseudoaneurysm. If infection persists, a patch excision is indicated with early carotid ligation, reconstruction with autogenous vein, or bypass; nowadays the use of negative pressure systems is a good option to perform a better treatment of these infections, resulting in better outcomes and reducing complications of a new exploratory surgery in these patients [3,13,19,[25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41].…”