Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators

BACKGROUND: Previous studies have shown that carotid endarterectomy in patients with symptomatic severe carotid stenosis (defined as stenosis of 70 to 99 percent of the luminal diameter) is beneficial up to two years after the procedure. In this clinical trial, we assessed the benefit of carotid endarterectomy in patients with symptomatic moderate stenosis, defined as stenosis of less than 70 percent. We also studied the durability of the benefit of endarterectomy in patients with severe stenosis over eight years of follow-up. METHODS: Patients who had moderate carotid stenosis and transient ischemic attacks or nondisabling strokes on the same side as the stenosis (ipsilateral) within 180 days before study entry were stratified according to the degree of stenosis (50 to 69 percent or <50 percent) and randomly assigned either to undergo carotid endarterectomy (1108 patients) or to receive medical care alone (1118 patients). The average follow-up was five years, and complete data on outcome events were available for 99.7 percent of the patients. The primary outcome event was any fatal or nonfatal stroke ipsilateral to the stenosis for which the patient underwent randomization. RESULTS: Among patients with stenosis of 50 to 69 percent, the five-year rate of any ipsilateral stroke (failure rate) was 15.7 percent among patients treated surgically and 22.2 percent among those treated medically (P=0.045); to prevent one ipsilateral stroke during the five-year period, 15 patients would have to be treated with carotid endarterectomy. Among patients with less than 50 percent stenosis, the failure rate was not significantly lower in the group treated with endarterectomy (14.9 percent) than in the medically treated group (18.7 percent, P=0.16). Among the patients with severe stenosis who underwent endarterectomy, the 30-day rate of death or disabling ipsilateral stroke persisting at 90 days was 2.1 percent; this rate increased to only 6.7 percent at 8 years. Benefit was greatest among men, patients with recent stroke as the qualifying event, and patients with hemispheric symptoms. CONCLUSIONS: Endarterectomy in patients with symptomatic moderate carotid stenosis of 50 to 69 percent yielded only a moderate reduction in the risk of stroke. Decisions about treatment for patients in this category must take into account recognized risk factors, and exceptional surgical skill is obligatory if carotid endarterectomy is to be performed. Patients with stenosis of less than 50 percent did not benefit from surgery. Patients with severe stenosis (> or =70 percent) had a durable benefit from endarterectomy at eight years of follow-up.     

Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis

OBJECTIVE: To assess the value of carotid endarterectomy for prevention of stroke in patients with asymptomatic carotid stenosis. DESIGN: Systematic review and meta-analysis of randomised controlled trials in patients with asymptomatic carotid stenosis in which subjects were allocated to carotid endarterectomy or to medical treatment alone. SUBJECTS: Five trials enrolled 2440 patients with stenosis >/ 50%. MAIN OUTCOME MEASURES: Stroke ipsilateral to the stenosis, all strokes, and perioperative complications (stroke or death). RESULTS: In patients who underwent carotid endarterectomy (n=1215) there was a significant reduction in the odds of ipsilateral stroke plus perioperative stroke or death (odds ratio 0.62; 95% confidence interval 0.44 to 0.86), corresponding to a 2% absolute risk reduction over about 3.1 years. The prevalence of stroke in any location was also reduced (0.68; 0.51 to 0.9) in patients undergoing carotid endarterectomy. During the immediate postoperative period there was an increased prevalence of stroke or death among such patients (4.51; 2.36 to 8.64). CONCLUSION: Carotid endarterectomy in patients with asymptomatic carotid stenosis unequivocally reduces the incidence of ipsilateral stroke, though the absolute benefit is relatively small. Given the modest benefit of surgery for unselected patients with asymptomatic carotid artery stenosis carotid endarterectomy cannot be routinely recommended for these patients pending reliable identification of high risk subgroups, and medical management is a sensible alternative for most patients.     

Indications for carotid endarterectomy in patients with symptoms: when, where?

Carotid endarterectomy (CEA) is one of the most commonly used surgical methods in the treatment of cerebral stroke with both therapeutic and also prophylactic implications. CEA has been used in surgical practice for 40 years. At the beginning it was very popular and was widely used. Later, the opposite extreme was reached, and its therapeutic efficacy was denied unjustifiably. However, at the beginning of the ninetieth three large controlled studies were completed (North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial and Veterans Administrations Symptomatic Trial) and the results of these trials were the basis for establishing the solid criteria for the surgical procedure in some groups of symptomatic patients with stenosis of the internal carotid artery. Thus, CEA was in again. In accordance with the attitudes of the American Association Ad Hoc Committee (1995), evidenced indications for CEA in patients with symptomatic stenosis of the internal carotid artery (in the group with surgical risk less than 6%) include (a) single or recurrent episodes of TIA in the last 6 months, "crescendo" TIA combined with carotid stenosis > 70% with or without plaque ulceration, with or without antiplatelet therapy, and (b) mild stroke in last 6 months with carotid stenosis > 70% with or without plaque ulceration, with or without antiplatelet therapy. The authors report their experience and results of a six-month pilot study of 301 patients, of whom 248 were operated on for symptomatic carotid stenosis with low combined perioperative morbidity and mortality (0.6%). Also, indications for surgical reconstruction of carotid and coronary arteries in patients with marked signs of atherosclerosis in both arterial systems are discussed.     

Uptake and intracellular activity of moxifloxacin in human neutrophils and tissue-cultured epithelial cells

BACKGROUND AND PURPOSE: In light of previously reported concerns regarding carotid endarterectomy (CEA) use in our city, our goal was to determine the influence of a prospective audit and educational campaign on the performance of CEA with respect to surgical appropriateness and complication frequency. METHODS: Results of our previous audit of 291 CEAs, along with CEA practice guidelines and notification of prospective surveillance, were supplied to surgeons performing CEA in our city. After this, 184 consecutive patients undergoing CEA from September 1996 to August 1997 were followed prospectively. On the basis of blinded standardized remeasurements of angiographic carotid stenoses, CEA was classified as appropriate for patients with symptomatic carotid stenoses >/=70%, uncertain for those with symptomatic stenoses <70% or asymptomatic stenoses >/=60%, and inappropriate for patients with asymptomatic carotid stenoses <60% or preoperative neurological or medical instability. RESULTS: Forty percent of patients were asymptomatic. Compared with our prior audit, the rate of appropriate CEAs improved from 33% previously to 49% of cases in the present study (P=0.0005), uncertain indications did not change significantly (49% versus 47%; P=0.61), and inappropriate indications dropped from 18% to 4% (P=0. 00002). Perioperative stroke or death occurred in 6.4% of symptomatic patients but developed in only 2.7% of asymptomatic patients, which was improved from the 5.1% rate previously found. CONCLUSIONS: In our city, the use of a surgical audit identified areas of concern regarding CEA, and subsequent education and ongoing surveillance significantly improved the use and performance of this procedure.     

Effect of salinity on the swimming velocity of the water flea Daphnia magna

BACKGROUND: Cost-effective carotid endarterectomy implies a good outcome; low morbidity, a short hospital stay and selective use of non-invasive preoperative diagnostic tests done alone. METHODS: A solo surgeon's clinical experience with two hundred and eighteen consecutive operations, over seven years, at two Community Hospitals in Northern Virginia. RESULTS: There were three perioperative strokes, of which one resulted in death, for a mortality rate of 0.45%, and a stroke rate of 1.4%. The majority of the operations in the past two years were done on the basis of Duplex ultrasonography and magnetic resonance angiography, but without invasive angiography. General anesthesia, routine use of shunt and use of autogenous vein patch in almost every case was employed. Patients were selectively observed in the Intensive Care Unit postoperatively. Forty eight percent of the series and 75% of the most recent 121 patients operated on in 1995 and 1996 were discharged on the first postoperative day without any need for re-admission to the hospital. CONCLUSIONS: Carotid endarterectomy can be performed with a short hospital stay and an extremely low morbidity and mortality. Carotid endarterectomy is a highly effective surgical procedure both from the medical and economy stand-points.     

The impact of advanced age on the results of carotid endarterectomy: an outcome analysis

BACKGROUND: This study examined whether advanced age adversely influences the outcome of carotid endarterectomy. STUDY DESIGN: The records of 173 patients who underwent 187 carotid endarterectomies performed by the author from January 1990 through December 1995 were retrospectively reviewed. Group 1 included 58 patients, ranging in age from 75 to 92 years (mean, 79.4 years), who underwent 63 procedures, and group 2 included 115 patients, ranging in age from 41 to 74 years (mean, 66.3 years), who underwent 124 procedures. The operation was performed for symptomatic disease in 67 percent of the cases in each group. The operated lesion was more than 80 percent stenotic in 85 percent of the group 1 and 79 percent of the group 2 cases. RESULTS: No significant differences were found in the operative mortality (1.6 percent compared with 1.6 percent), incidence of perioperative stroke (4.8 percent compared with 1.6 percent), or rate of major cardiac complications (7.9 percent compared with 7.3 percent) between groups 1 and 2. No significant difference was found in the mean postoperative length of hospital stay between the group 1 and group 2 patients (4.13 +/- 2.58 days compared with 3.68 +/- 1.40 days). However, during the last 2 years of the study, the mean postoperative length of stay among the group 2 patients (3.06 +/- 1.44 days) was significantly shorter than among the group 1 patients (4.15 +/- 1.45 days) (p < .05). CONCLUSIONS: Advanced age does not adversely affect the results of carotid endarterectomy. However, the very elderly may be expected to experience a longer postoperative length of stay because of associated comorbid conditions.     

Tribute to 50 years and a look forward

OBJECTIVES: Carotid angiography is associated with a 2% risk of stroke and, since the advent of colour-duplex ultrasound, its role in the assessment of patients with carotid disease has been the subject of debate. The aim of this study was to evaluate a policy of adopting routine duplex supplemented by selective angiography on operative outcome over a 5-year period. METHODS: A prospective audit of the results of carotid endarterectomy without routine angiography from January 1992 to December 1996. Angiography was performed only if the ultrasonography was concerned about the distal or proximal extent of disease or to assess subocclusion. RESULTS: During the study period, 494 carotid endarterectomies were performed but only 35 patients underwent carotid angiography. The indications for angiography were subocclusion/string sign in 22 patients, to assess the limits of proximal or distal disease in 12 and abnormal anatomy in one. During the 5-year study period the overall perioperative death and/or stroke rate was 4.2%. By 1997, the perioperative stroke rate had fallen to 1.3%. In no case in this series was the operation abandoned due to unexpected findings. CONCLUSION: Although concerns exist about the precise duplex criteria for diagnosing a severe stenosis, this study has shown that a policy of selective angiography does not compromise patient safety or operability and avoids the unnecessary mortality, morbidity and costs associated with routine angiography.     

US national survey of physician practices for the secondary and tertiary prevention of ischemic stroke. Design, service availability, and common practices

BACKGROUND AND PURPOSE: Stroke is largely a preventable disease. However, there are little data available concerning the use of stroke prevention diagnostic and treatment modalities by practicing physicians. These data are critical for the rational allocation of resources and targeting of educational efforts. The purposes of this national survey were to gather information about physicians' stroke prevention practice patterns and their attitudes and beliefs regarding secondary and tertiary stroke prevention strategies. METHODS: We conducted a national survey of stroke prevention practices among a stratified random sample of 2000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and the use of diagnostic and preventive strategies for patients at elevated risk of stroke. RESULTS: Sixty-seven percent (n = 1006) of eligible physicians completed the survey. Diagnostic studies considered readily available by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography was perceived as being readily available by 68% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logistic regression analyses showed that the availability of services varied with physician specialty (noninternist primary care, internal medicine, neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or large metropolitan areas), and for carotid endarterectomy, region of the country (South, Central, Northeast, and West). The odds of carotid endarterectomy being reported as readily available were approximately 2.5 to 3.5 times greater for physicians practicing in the central, northeastern, and western regions compared with those practicing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulation with international normalized ratios, and 78% reported monitoring anticoagulated patients at least once a month. Fewer than 20% of physicians reported knowing the perioperative carotid endarterectomy complication rates at the hospital where they perform the operation themselves or refer patients to have the procedure done. CONCLUSIONS: Although all routine and most specialized services for secondary and tertiary stroke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for monitoring warfarin therapy has not yet become universal. Physician knowledge of carotid endarterectomy complication rates is generally lacking. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the way in which services are provided.     

Carotid endarterectomy with shortened hospital stay

OBJECTIVE: To review the outcome of a consecutive series of patients undergoing carotid endarterectomy with a focus on length of stay. DESIGN: Retrospective case review. SETTING: Six hundred-bed community hospital. PATIENTS: During a 40-month period, we performed 266 carotid endarterectomies. Ages of patients ranged from 49 to 91 years (mean, 71.2 years). Seventy-two percent were hypertensive, 55% were smokers, 24% were diabetic, and 22% had symptomatic heart disease. Indications for operation included asymptomatic stenosis in 48% of patients, transient ischemia attack in 23%, stroke in 24%, and nonhemispheric symptoms in 5%. OUTCOME MEASURES: Perioperative complications and conditions precluding early hospital discharge were noted. In patients discharged within 48 hours of operation, problems requiring readmission within 30 days were recorded. RESULTS: Five patients (1.9%) experienced perioperative strokes, of which three were permanent and two temporary. There was one perioperative death. Hospital stays ranged from 1 to 9 days (mean 1.7 days). Sixty-three percent of the patients were discharged within 24 hours and 88% within 48 hours of operation. Patients staying in the hospital more than 48 hours were significantly older (P = .008). Other factors did not correlate with length of stay. Readmission was required in five patients. CONCLUSIONS: Patients having an uneventful course following carotid endarterectomy may be safely discharged within 48 hours of operation. Complications occurring after this time are infrequent and often unpredictable. It is unlikely that lengthening patient stay would decrease or eliminate these complications.     

Symptomatic recurrent carotid stenosis and aneurysmal degeneration after endarterectomy

BACKGROUND: Aneurysmal degeneration of a carotid reconstruction was not recognized until the patient, who was known to have recurrent carotid artery stenosis, had a thromboembolic stroke. This sequelae of carotid endarterectomy is a serious complication, associated with a high morbidity and mortality rate. This review was conducted to establish the risk of transient ischemic attack and stroke for patients found to have recurrent carotid stenosis associated with aneurysmal degeneration of the carotid artery after endarterectomy. METHODS: A case is reported, and 100 literature references of aneurysmal degeneration of the carotid artery after endarterectomy were reviewed. RESULTS: False aneurysm from anastomotic disruption was the most common presentation identified in the cases reviewed. Nineteen of the patients had a significant neurologic event; however, three (50%) of six patients with aneurysm and recurrent carotid artery stenosis had a transient ischemic attack or stroke. CONCLUSIONS: The incidence of neurologic symptoms is markedly increased when recurrent carotid artery stenosis is associated with carotid aneurysm. During postoperative surveillance after endarterectomy, the identification of recurrent carotid artery stenosis requires evaluation for aneurysmal degeneration of the carotid artery with duplex scanning. These patients are at significant risk for transient ischemic attack and stroke. This rare complication merits operative repair.     

Indications, outcomes, and provider volumes for carotid endarterectomy

CONTEXT: While trials have demonstrated that carotid endarterectomy is superior to best medical therapy, most recently among asymptomatic patients, uses and outcomes of the procedure in more representative settings have not been established. OBJECTIVES: To profile the use and outcomes of carotid endarterectomy in a representative sample of Ohio's Medicare beneficiaries and to examine the relationships between provider-specific procedural volumes and patient outcomes. DESIGN: Retrospective cohort using Medicare Provider Analysis and Review files supplemented by detailed reviews of medical records on a random sample of patients. SETTING: Ohio hospitals performing carotid endarterectomy. PATIENTS: A random sample of 678 charts of the 4120 non-health maintenance organization Medicare beneficiaries who underwent carotid endarterectomy between July 1, 1993, and June 30, 1994. MAIN OUTCOME MEASURES: Nonfatal stroke or death within 30 days of surgery. RESULTS: The reviewed patients were similar to all eligible patients in sociodemographic characteristics and 30-day mortality rates. Among the 678 patients, indications for surgery were asymptomatic carotid stenosis in 167 (24.6%), transient ischemic attack in 294 (43.4%), completed stroke in 62 (9.1%), and nonspecific symptoms in 155 (22.9%). Thirty-two patients (4.7%) died or suffered nonfatal strokes by 30 days postoperatively. In univariate analyses, rates varied by hospital volume (P=.004) but not surgeons' volume (P=.47), although power to detect this difference was limited. Patients at higher- and lower-volume hospitals had similar indications and distributions of comorbidities. In analyses controlling for indications, comorbid conditions, and surgeon's volume, being operated on in a higher-volume hospital conferred a 71% reduction in risk for 30-day stroke or death (odds ratio, 0.29; 95% confidence interval, 0.12-0.69; P=.006). CONCLUSIONS: Almost half (47.5%) of the carotid endarterectomies among Ohio's Medicare population are performed on persons who are asymptomatic or who have nonspecific symptoms. These results highlight the importance of identifying patients and providers having the most favorable outcome profiles. The higher rate of adverse outcomes observed in lower-volume hospitals deserves further investigation, as it does not appear to be due to differences in patient selection.     

The relationship between zinc, copper and lipid metabolic indicators in adults

With the completion of the major carotid endarterectomy trials the indications for this procedure can be defined. The procedure, if done by experienced teams, has been shown to improve the chance of stroke free survival in symptomatic and asymptomatic patients with a high-grade stenosis of the internal carotid artery. In asymptomatic patients the risk reduction gained by prophylactic carotid endarterectomy may be small in relation to the risk of coincident factors particularly coronary artery disease. The benefit gained by carotid endarterectomy depends closely on the risk of the procedure itself, and a single little flaw during the management can annulate the benefit of the operation in asymptomatic patients. There are still considerable controversies with regard to peri-operative management and surgical technique, e.g., the necessity of routine pre-operative arteriography has recently been questioned. Quality control programmes become a requirement with the publication of performance standards for carotid endarterectomy. According to a consensus of the American Heart Association, the surgical morbidity/mortality must be less than 6% for symptomatic carotid lesions and less than 3% for asymptomatic lesions. The present review discusses the steps of the pre-operative work-up, the procedure itself and the post-operative management with the aim to identify accepted safety standards as well as areas of uncertainty.     

Role of transcranial Doppler and stump pressure during carotid endarterectomy

BACKGROUND AND PURPOSE: The aim of our study was to clarify the pathophysiology of perioperative cerebral complications during carotid endarterectomy in our series. METHODS: By means of transcranial Doppler ultrasonography and stump pressure measurement, we monitored 112 patients who underwent carotid endarterectomy under general anesthesia for symptomatic or asymptomatic severe carotid stenosis. RESULTS: Of 18 patients who underwent carotid endarterectomy with intra-arterial shunt, 2 (11.1%) developed an ischemic stroke. Of the other 94 patients, one suffered a nucleocapsular hemorrhage and 5 had cerebral ischemic complications. In these 5 patients, the duration of clamping was significantly longer (mean +/- SD, 16.4 +/- 1.1 versus 12.7 +/- 2.6 minutes; P = .0019), and the decrease of middle cerebral artery mean velocity on clamping was significantly greater (mean +/- SD, 56.4 +/- 4.9% versus 28.8 +/- 20.2%; P = .0031), while stump pressure was not significantly different. Microembolic signals were recorded in 70 patients (62.5%) and were not associated with cerebral ischemic complications. The 7 patients who developed cerebral ischemic complications had a significantly higher percentage of stenosis in the contralateral internal carotid artery (mean +/- SD, 82.0 +/- 17.8% versus 29.3 +/- 36.4%; P = .0018). CONCLUSIONS: The results of our study suggest that the major complications of carotid endarterectomy may be due to hemodynamic factors. Stump pressure alone is not a reliable indicator of hemodynamic changes that predict cerebral ischemia. Particulate microembolism may cause more subtle changes in cerebral parenchyma, but further studies are needed to clarify this point.     

Assessing the predictive validity of the RAND/UCLA appropriateness method criteria for performing carotid endarterectomy

We assessed the predictive validity of an expert panel's ratings of the appropriateness of carotid endarterectomy by comparing ratings to the results of subsequent randomized clinical trials. We found the trials confirmed the ratings for 44 indications (covering almost 30% of operations performed in 1981) and refuted the ratings for none.     

Determinants of outcome after carotid endarterectomy

BACKGROUND: The efficacy of carotid endarterectomy for selected patients has been evaluated with randomized controlled clinical trials. The generalizability of these studies to average surgical practice remains an important public health concern. OBJECTIVE: The objective of the study was to determine the predictors of outcome after carotid endarterectomy on a regional basis. Patients and Methods: The study was designed as a retrospective cohort study and included all consecutive patients presented for carotid endarterectomy at the 8 University of Toronto-affiliated hospitals in the period from January 1, 1994, to December 31, 1996. The main outcome measure was 30-day postoperative stroke or death rate. RESULTS: During the study interval, 1280 primary carotid endarterectomies were performed. The overall combined stroke and death rate was 6.3% for all patients who underwent endarterectomy (4.0% for patients who were asymptomatic). The significant predictors of poor outcome were the following: presenting symptoms (odds ratio, 1.74; 95% confidence interval [CI], 0.96, 3.12), low surgeon volume (<6 cases per year; odds ratio, 3.98; 95% CI, 1.65, 9.58), and left-sided surgery (odds ratio, 1.72; 95% CI, 1.07, 2.76). CONCLUSION: These data suggest that adoption of the recommendations of the symptomatic carotid endarterectomy trials is appropriate. However, endarterectomy for asymptomatic lesions remains of uncertain benefit on a regional basis and must be individualized to the experience of the specific surgeon. The surgeon volume/outcome relationship that is identified in this study suggests a need for a minimum volume threshold for this procedure.     

Carotid endarterectomy without a shunt for symptomatic lesions associated with contralateral severe stenosis or occlusion

PURPOSE: The purpose of this study was to assess the adequacy of thiopental protection against ischemic cerebral damage in patients undergoing carotid endarterectomy for symptomatic stenosis greater than 70% in association with contralateral stenosis greater than 70% or contralateral occlusion. METHODS: All patients (n=259) with severe bilateral carotid disease who underwent carotid endarterectomy for symptomatic stenosis greater than 70% were extracted from the database of an ongoing prospective carotid surgery study. Large-dose thiopental sodium without shunting was used for cerebral protection during endarterectomy. Asymmetric electroencephalogram changes during the operation, carotid occlusion time, stroke onset, and neuropathologic outcomes were analyzed. RESULTS: Three contralateral strokes occurred in the series, producing a cerebral morbidity/mortality rate of 1.2% (major 0.4%, minor 0.8%). Transient morbidity was 1.9% made of two reversible ischemic neurologic deficits and three transient ischemic attacks. New asymmetric electroencephalography changes were seen in 49 (19% patients, one of whom had transient deficit. Average occlusion time was 35 minutes. All strokes occurred within 24 hours of the procedure. Patients with previous stroke and and systemic hypertension seemed at greatest risk, and the contralateral hemisphere was the area at greatest risk. All transient deficits were ipsilateral and related to technical complications rather failed protection. CONCLUSIONS: Thiopental cerebral protection eliminates strokes caused by complications of shunting, prevents ischemic stroke during carotid occlusion for periods up to 67 minutes (average 35 minutes), allows meticulous management of the operative site, may modify or minimize clinical neurologic deficit, and in our experience has rendered intraluminal shunting obsolete.     

Carotid endarterectomy

Although controversies still exist, recently reported trials have confirmed the efficacy of carotid endarterectomy and more clearly elucidated the appropriate indications for surgical therapy. The efforts to optimize outcomes for patients with carotid artery disease have expanded to the asymptomatic patient, the patient suffering from stroke, and the patient with coexistent cardiac symptoms.     

Early results of combined carotid endarterectomy and coronary artery bypass grafting in patients with severe coronary and carotid artery disease

The management of patients with carotid artery disease who require coronary artery bypass grafting (CABG) remains controversial. Several published series from the USA (including one with prospective randomization) advocate a combined approach of carotid endarterectomy (CEA) followed immediately by coronary artery bypass surgery. However, experience of combined carotid endarterectomy and coronary bypass grafting has not been previously reported by a centre from the United Kingdom. Between 1986 and 1991 we performed this combined procedure on 18 patients who required myocardial revascularization and had co-existing severe (> 70%) carotid stenosis. Sixteen patients (89%) had angina and 11 patients (61%) had symptomatic carotid artery disease. The perioperative mortality was 5.5% and the ipsilateral perioperative stroke rate was 5.5%. These early results are encouraging and suggest that further evaluation of combined carotid endarterectomy and coronary artery bypass surgery is warranted.     

Full sternotomy through a minimally invasive incision: a cardiac surgeon''s true comfort zone

The increasing risk of perioperative stroke after coronary artery bypass grafting can in part be attributed to the increased incidence of carotid stenosis with increasing patient age. The efficacy of carotid endarterectomy has been demonstrated for both symptomatic and asymptomatic patients. Combined operations yield acceptable mortality and stroke risks, provide good freedom from late events, and cost less than staged operations.     

Asymptomatic severe carotid stenosis: immediate surgery or watchful waiting? A decision analysis

OBJECTIVE: To analyze, for patients with asymptomatic severe carotid stenosis, the risks and benefits of two strategies: (1) immediate prophylactic carotid endarterectomy (CEA), and (2) medical management followed by CEA only after a transient ischemic attack (TIA) or a minor stroke has occurred. DESIGN: A Markov-based decision analysis model that simulates and counts the possible clinical outcomes (deaths, TIAs, and major strokes) of the two strategies. Data were drawn from the current literature. SUBJECTS: A hypothetical cohort of asymptomatic patients with severe (> 75% diameter reduction) carotid stenosis identified by noninvasive diagnostic tests. MAIN RESULTS: Given the immediate surgery-related risks, patients with a stroke incidence without preceding TIA of 3% per year will benefit from prophylactic CEA only if they survive more than 4 years after the procedure, whereas those with a higher stroke incidence (5% per year) will benefit from prophylactic CEA after just 2 years. However, the gain yielded by prophylactic CEA remains small. As age- or cardiovascular-related mortality increases, the maximum tolerated combined surgical mortality and morbidity rate below which prophylactic CEA yields an improved 5-year stroke- and surgery-related-event-free survival decreases--from 5% for patients aged 55 years to 2% for patients aged 85 years with a stroke incidence of 3% per year, and from 8.5% for patients aged 55 years to 4% for patients aged 85 years with a stroke incidence of 5% per year. On the other hand, for risk-intolerant patients who value the 2-year stroke- and surgery-related-event-free survival more than life in the distant future, the combined surgical morbidity and mortality rate below which prophylactic CEA remains the preferred strategy is below 3% at any age. CONCLUSION: Risk-intolerant patients should not undergo prophylactic CEA. On the other hand, for risk-tolerant patients willing to accept an immediate and dangerous procedure to decrease the future risk of death or chronic disability due to stroke, assessment of both perioperative risk and the risk of premature death from coexistent coronary artery disease should guide individual therapeutic decision-making.