Recurrent carotid stenosis: A consequence of local or systemic factors? The influence of unrepaired technical defects

Abstract

To determine the influence of unrepaired technical defects as well as systemic risk factors for atherogenesis on carotid artery healing after endarterectomy, we conducted a prospective study using intraoperative duplex scanning with spectral analysis to establish the initial status of the artery (N = 131 arteries), and then we studied these vessels at regular postoperative intervals with the same technique (N = 108 arteries, 265 studies). The vessels were divided into the operated and nonoperated segments of the common, internal, and external carotid arteries, and both intraoperative image and flow data were tabulated by artery segment. The technical factors that were analyzed included defect size, defect type, adjacent segment defects, number of defects, shunt use, vessel reopening, and peak, mean, and end-diastolic frequency and velocity. The systemic risk factors studied were sex, hypertension, diabetes, smoking, randomly drawn total serum cholesterol and triglyceride levels, and perioperative aspirin and dextran use. Data were analyzed by linear logistic regression analysis. Among the technical factors, only intraoperative defect size was significantly associated with risk of recurrent stenosis (p = 0.0175). Although any defect size adversely affected the condition of the vessel during follow-up, the magnitude of this effect was small for smaller defects (size category 1: less than or equal to 40% stenosis or flap length less than or equal to 25% of vessel diameter). The systemic factors that were associated with risk of recurrent stenosis were hypertension (p = 0.0002), smoking (p = 0.0016), and randomly drawn total serum cholesterol level (p = 0.0116). The fact that the operated segments consistently fared worse during follow-up than did the nonoperated segments (p = 0.0044) undoubtedly reflects the inevitable trauma of the endarterectomy, but also emphasizes the important contribution of systemic risk factors in recurrent carotid stenosis. Risk factor modification may be the most effective method of ensuring the durability of carotid endarterectomy.

Recurrent Carotid Stenosis

“…The combined mortality and neurological stroke morbidity of patients undergoing CEA was 1.5%. 18,19 The present study has demonstrated that the incidence of recurrent stenosis as measured with a Doppler cut point with 95% PPV was 12.7%. However, evaluation of patients within the immediate postoperative interval indicated that the incidence of postoperative stenosis was 4.1%.…”

Intra-Operative Assessment of Technical Defects after Carotid Endarterectomy: A Comparison between Angiography and Colour Duplex Scan

“…Reilly et al [12] found non-significant differences between the group with minor defects and those with normal duplex scan at 15 months follow-up.…”

Role of Residual Defects Following Carotid Endarterectomy in the Occurrence of Cerebrovascular Symptoms

“…Although the number of patients with carotid artery restenosis is relatively small to allow a significant statistical association to be made with the occurrence of neurologic events, nevertheless it is in accordance with the 0%-8% reported in the international literature. 3,[12][13][14][15][16][17][18][19][20][21] Investigators from The Asymptomatic Carotid Atherosclerosis Study reached opposite conclusions. 22 Although residual disease was found to occur in 4.1% to 6.5%, depending on the positive predictive value (PPV) confidence level desired (90% PPV or 95% PPV, respectively), no correlation was demonstrated between residual or recurrent carotid disease and incidence of late stroke.…”