Risks Associated With Primary and Redo Carotid Endarterectomy in the Endovascular Era

Abstract

IMPORTANCE Clinical experience suggests worse outcomes for redo carotid endarterectomy (CEA) relative to primary CEA. Objective quantification of the excess risk attributable to redo CEA in this era of proliferating endovascular therapy remains to be determined. OBJECTIVE To evaluate the risks of redo CEA relative to primary CEA. DESIGN, SETTING, AND PARTICIPANTSThis study was a retrospective analysis of a prospective cohort of patients maintained by the Society for Vascular Surgery in the Vascular Quality Initiative between January 1, 2003, and April 30, 2016. The setting was consecutive patients from academic and community hospitals across the United States. Participants were patients who underwent primary CEA or redo CEA for symptomatic or asymptomatic carotid stenosis.EXPOSURES Primary CEA and redo CEA.MAIN OUTCOMES AND MEASURES Stroke, death, myocardial infarction, stroke or death, and stroke, death, or myocardial infarction at 30 days and 1 year. RESULTS There were 64 118 CEAs recorded, including 62 749 primary CEAs (97.9%) (median age, 71 years; 39.5% female) and 1369 redo CEAs (2.1%) (median age, 71 years; 42.2% female). Comparing primary CEA vs redo CEA, the incidence of 30-day stroke was 0.7% vs 1.9% (P < .001) for asymptomatic patients and 1.5% vs 1.4% (P = .77) for symptomatic patients for an overall 0.9% vs 1.8% (P = .002). Incidences were 0.8% vs 1.3% (P = .09) for perioperative myocardial infarction, 0.6% vs 1.4% (P = .003) for death, and 1.5% vs 2.6% (P = .001) for stroke or death. Risk-adjusted 30-day stroke (odds ratio [OR], 2.82; 95% CI, 1.69-4.71; P < .001), death (OR, 2.15; 95% CI, 1.21-3.79; P = .009), and stroke or death (OR, 2.06; 95% CI, 1.32-3.23; P = .002) were higher for redo CEA compared with primary CEA among asymptomatic patients but were similar among symptomatic patients for stroke (OR, 0.79; 95% CI, 0.33-1.95; P = .62), death (OR, 1.32; 95% CI, 0.53-3.26; P = .55), and stroke or death (OR, 0.85; 95% CI, 0.39-1.82; P = .68). Stroke or death at 1 year among asymptomatic patients was higher for redo CEA (hazard ratio [HR], 1.36; 95% CI, 1.08-1.69; P = .009) but was similar among symptomatic patients (HR, 0.94; 95% CI, 0.67-1.31; P = .71). CONCLUSIONS AND RELEVANCEThe outcomes of redo CEA and primary CEA fall within the professional guidelines for carotid revascularization. However, redo CEA is associated with a 2.8 times increase in the risk of stroke and a 2.2 times increase in the risk of death compared with primary CEA among asymptomatic patients. There is no significant difference in outcomes among symptomatic patients. These redo CEA and primary CEA results should inform patient and clinician expectations at the point of care.

Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy

“…This data goes in line with the proportion of asymptomatic patients undergoing carotid revascularization for carotid artery stenosis in the United States. [42][43][44] However, given the results obtained from this study and several previous studies, 25 there is a raised concern about performing redo-CEA in asymptomatic patients, especially with moderate restenosis, because the postoperative course of the procedure is not benign, arousing a conservative approach of watchful waiting by some physicians. However, O'Donnell et al 45 showed that nonoperative management in patients with high-grade (>75%) recurrent stenosis was associated with 7.5% stroke rate compared with 2.1% among patients managed operatively.…”

The outcome of radiocephalic after brachiocephalic and redo arteriovenous fistula

“…Although this issue has been emphasized in carotid surgery, further studies are needed to prove this because the behavior of the vessels and complications may differ in different vascular sites/procedures. 22 The meticulous excessive dissection needed in the redo-AVF group may explain the longer operative time in this group. Our operative time in the remaining groups was comparative to what Kumar et al 23 reported in their series.…”

“…Although this issue has been emphasized in carotid surgery, further studies are needed to prove this because the behavior of the vessels and complications may differ in different vascular sites/procedures. 22 …”

Outcomes in Asymptomatic Redo Carotid Endartectomy

“…Outcomes in Asymptomatic Redo Carotid Endartectomy A Word of Caution Rishi A. Roy, MD; Gilbert R. Upchurch Jr, MD Arhuidese et al 1 compare primary carotid endartectomy (CEA) and redo CEA using the Society for Vascular Surgery Vascular Quality Initiative database. 1 This large study compares 64 118 primary CEAs with 1369 redo CEAs, with the primary outcomes of stroke, death, myocardial infarction, stroke/ death, and stroke/death/ myocardial infarction at 30 days and at 1-year follow-up. The higher incidence of stroke, death, stroke/death, and stroke/death/ myocardial infarction in the asymptomatic redo CEA group compared with the primary CEA group but not in the symptomatic patients is the primary finding in this study.…”

“…Arhuidese et al compare primary carotid endartectomy (CEA) and redo CEA using the Society for Vascular Surgery Vascular Quality Initiative database . This large study compares 64 118 primary CEAs with 1369 redo CEAs, with the primary outcomes of stroke, death, myocardial infarction, stroke/death, and stroke/death/myocardial infarction at 30 days and at 1-year follow-up.…”