The North American Symptomatic Carotid Endarterectomy Trial

Abstract

Background and Purpose-This study reports the surgical results in those patients who underwent carotid endarterectomy in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Methods-The rates of perioperative stroke and death at 30 days and the final assessment of stroke severity at 90 days were calculated. Regression modeling was used to identify variables that increased or decreased perioperative risk. Nonoutcome surgical complications were summarized. The durability of carotid endarterectomy was examined. Results-In 1415 patients there were 92 perioperative outcome events, for an overall rate of 6.5%. At 30 days the results were as follows: death, 1.1%; disabling stroke, 1.8%; and nondisabling stroke, 3.7%. At 90 days, because of improvement in the neurological status of patients judged to have been disabled at 30 days, the results were as follows: death, 1.1%; disabling stroke, 0.9%; and nondisabling stroke, 4.5%. Thirty events occurred intraoperatively; 62 were delayed. Most strokes resulted from thromboembolism. Five baseline variables were predictive of increased surgical risk: hemispheric versus retinal transient ischemic attack as the qualifying event, left-sided procedure, contralateral carotid occlusion, ipsilateral ischemic lesion on CT scan, and irregular or ulcerated ipsilateral plaque. History of coronary artery disease with prior cardiac procedure was associated with reduced risk. The risk of perioperative wound complications was 9.3%, and that of cranial nerve injuries was 8.6%; most were of mild severity. At 8 years, the risk of disabling ipsilateral stroke was 5.7%, and that of any ipsilateral stroke was 17.1%. Conclusions-The overall rate of perioperative stroke and death was 6.5%, but the rate of permanently disabling stroke and death was only 2.0%. Other surgical complications were rarely clinically important. Carotid endarterectomy is a durable procedure. (Stroke. 1999;30:1751-1758.)

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary

“…173 Risk is related mainly to the patient's preoperative clinical status. Symptomatic patients have a higher risk than asymptomatic patients (OR 1.62; p<0.0001), as do those with hemispheric versus retinal symptoms (OR 2.31; p<0.001), urgent versus nonurgent operation (OR 4.9; p<0.001), and reoperation versus primary surgery (OR 1.95; p<0.018).…”

Variability in Carotid Endarterectomy at a Single Medical Center: An Outcome and Cost Analysis

“…[3][4][5] Traditionally, the surgeon performing the procedure has been free to select his or her preference for a particular technique. Systematic analysis has shown excellent results for the procedure with a great variety of methods including primary closure with or without shuntplaced endarterectomy and patch endarterectomy with or without shunt placement.…”

“…Systematic analysis has shown excellent results for the procedure with a great variety of methods including primary closure with or without shuntplaced endarterectomy and patch endarterectomy with or without shunt placement. [3][4][5] The overall results that specifically compare one technique to another, however, remain less clear. [6][7][8][9] The argument for the practicality of shunt placement stems from the potential reduction of perioperative stroke risk through the minimization of the loss of cerebral blood flow during clamping.…”

“…[3][4][5] CEA and arterial reconstruction can be performed in a variety of ways including standard endarterectomy with primary closure, standard endarterectomy with patch closure, shunt-placed endarterectomy with primary closure, and shunt-placed endarterectomy with patch closure. Currently, there is wide variability in technique of this operation and limited statistical evidence regarding the risks and benefits of one particular method versus another.…”

Radiology Quality Measure Compliance Reporting: an Automated Approach

“…Using a Javascript step in a Mirth channel, a Boolean variable is set to true if the string NASCET was present, inferring compliance with CMS's carotid stenosis quality measure and referring to the measurement technique utilized in the North American Symptomatic Carotid Endarterectomy Trial [5]. We performed periodic hand audits to verify that the presence of the NASCET substring was a reasonable surrogate for actual compliance.…”