Recurrent Carotid Stenosis

Das, Mrinalendu; Hertzer, Norman; Ratliff, Norman B.; O׳Hara, Patrick J.; Beven, Edwin G.

doi:10.1097/00000658-198507000-00004

Cited by 158 publications

(6 citation statements)

References 10 publications

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“…Others have reported on outcome after redo-CEA in single center cohorts without a control group. 24–30 While most of these studies reported ‘acceptable’ perioperative stroke/death rates (0 – 4.6%, all patients), several groups have reported increased risk for local complications such as nerve injury (4.6% – 21%) and wound hematoma (4.2%) 7,8,20,30,31 . We did not identify an increased risk for CNI compared to primary CEA, nor did we note an increased risk for other local complications with redo-surgery in a much larger population.…”

Section: Discussionmentioning

confidence: 99%

Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy

Fokkema¹,

Borst

Nolan

et al. 2014

Journal of Vascular Surgery

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Introduction Outcomes for patients undergoing intervention for restenosis after prior ipsilateral carotid endarterectomy (CEA) in the era of carotid stenting (CAS) are unclear. We compared perioperative results and durability of CAS versus CEA in patients with symptomatic or asymptomatic restenosis after prior CEA and investigated the risk of re-intervention compared to primary procedures. Methods Patients undergoing CAS and CEA for restenosis between January 2003 and March 2012 were identified within the Vascular Study Group of New England (VSGNE) database.Endpoints included any stroke, death or myocardial infarction (MI) within 30 days, cranial nerve injury at discharge and restenosis ≥70% at 1-year follow-up. Multivariable logistic regression was done to identify whether prior ipsilateral CEA was an independent predictor for adverse outcome. Results Out of 9305 CEA procedures, 212 patients (2.3%) underwent redo-CEA (36% symptomatic). Of 663 CAS procedures, 220 patients (33%) underwent CAS after prior ipsilateral CEA (31% symptomatic). Demographics of patients undergoing redo-CEA were comparable to patients undergoing CAS after prior CEA. Stroke/death/MI rates were statistically similar between redo-CEA vs CAS after prior CEA in both asymptomatic (4.4% vs 3.3%, P=0.8) and symptomatic patients (6.6% vs 5.8%, P=1.0). No significant difference in restenosis ≥70% was identified between redo-CEA and CAS after prior CEA (5.2% vs. 3.0%, P = 0.5). Redo-CEA vs primary CEA had increased stroke/death/MI rate in both symptomatic (6.6% vs 2.3%, P=0.05) and asymptomatic patients 4.4% vs 1.7%, P=0.03). Prior ipsilateral CEA was an independent predictor for stroke/death/MI among all patients undergoing CEA (OR 2.1, 95% CI 1.3 – 3.5). No difference in cranial nerve injury was identified between redo-CEA and primary CEA (5.2% vs 4.7%, P=0.8). Conclusions In the VSGNE, CEA and CAS showed statistically equivalent outcomes in asymptomatic and symptomatic patients treated for restenosis after prior ipsilateral CEA.However, regardless of symptom status, the risk of re-intervention was increased compared to patients undergoing primary CEA.

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Section: Discussionmentioning

confidence: 99%

Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy

Fokkema¹,

Borst

Nolan

et al. 2014

Journal of Vascular Surgery

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“…Moreover, given the much higher risk of perioperative complications reported for repeat CE [34, 35, 36]it would be difficult to justify using routine surveillance to identify asymptomatic patients with disease progression to be considered for this type of intervention. furthermore, if we assume that the standard protocol for routine surveillance should be 2–3 ultrasounds in the 1st year and yearly thereafter as previously suggested by some [4, 6, 37], and that about 91,000 CE procedures [38]are performed annually, then, assuming a cost of $157 (US dollars based on medicare reimbursement [39], a conservative estimate of overall cost would be $57.1 million for the first 2 years of routine surveillance after CE in a country like the United States.…”

Section: Discussionmentioning

confidence: 99%

Significance of Carotid Restenosis following Endarterectomy

Ganesan¹,

Côté²,

Mackey³

1998

Cerebrovasc Dis

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Background and Purpose: The clinical significance of restenosis after carotid endarterectomy as detected by duplex ultrasound has not been clearly established. To address this problem, we retrospectively evaluated the experience at two university-affiliated hospitals. Methods: All charts of patients with carotid endarterectomies between June 1987 and April 1995 were reviewed. Inclusion required neurological assessment and postoperative duplex ultrasound. Exclusion was based on a known source of cardioembolic disease, or recent (<6 months) myocardial infarction. Primary clinical endpoints were ipsilateral transient ischemic attack (TIA) or ischemic stroke. Contributing vascular risk factors were also identified. The effect of restenosis on event-free survival was analyzed using life tables and Gehan-Wilcoxon rank sum tet. Logistic regression was used to identify independent risk factors for restenosis and vascular events. Results: One hundred and eighty-seven patients were identified who underwent a total of 207 endarterectomies. Mean follow-up was 30.4 ± 20.9 months during which a total of 64 vascular events, including 42 TIAs, 18 strokes, and 4 vascular deaths occurred. Of these 21 TIAs and 8 strokes were ipsilateral to the side of endarterectomy. Event rates were compared for patients with ipsilateral high- (≥50%) and low-grade (<50%) restenosis. These two groups were comparable in terms of baseline risk factors. There was no significant difference in vascular event rates (for either ipsilateral events or events in any vascular territory) between the group with high- and low-grade restenosis. Nor was any such difference in event rates shown for patients who showed ipsilateral progression of carotid disease on serial ultrasound. However, patients operated for symptomatic carotid disease had a significantly higher risk of neurological events (p = 0.035). Logistic regression failed to disclose any other risk factors that were independently predictive of either restenosis or vascular events during follow-up. Conclusion: This study does not show a difference in vascular event rates for higher grades of carotid restenosis after carotid endarterectomy. Routine surveillance with carotid ultrasound does not appear to identify patients at higher risk for postoperative cerebrovascular events.

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“…Because others have previously reported that prior radiation therapy and redo CEA can be predictive conditions for CNI, we forced them into our prediction model. 15,16,21 However, no impact on CNI was identified among these variables: prior radiation therapy, OR 0.9, 95% CI 0.3–2.5, p = .8; and redo CEA, OR 1.0, 95% CI 0.5–2.1, p = .9.…”

Section: Resultsmentioning

confidence: 93%

“…21,25 In the current era of carotid stenting, it is likely that those with the most hostile necks are no longer selected for redo CEA. 28 …”

Section: Discussionmentioning

confidence: 99%

Clinical Relevance of Cranial Nerve Injury following Carotid Endarterectomy

Fokkema

Borst

Nolan

et al. 2014

European Journal of Vascular and Endovascular Surgery

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Objectives The benefit of carotid endarterectomy (CEA) may be diminished by cranial nerve injury (CNI). Using a quality improvement registry, we aimed to identify the nerves affected, duration of symptoms (transient vs. persistent), and clinical predictors of CNI. Methods We identified all patients undergoing CEA in the Vascular Study Group of New England (VSGNE) between 2003 and 2011. Surgeon-observed CNI rate was determined at discharge (postoperative CNI) and at follow-up to determine persistent CNI (CNIs that persisted at routine follow-up visit). Hierarchical multivariable model controlling for surgeon and hospital was used to assess independent predictors for postoperative CNI. Results A total of 6,878 patients (33.8% symptomatic) were included for analyses. CNI rate at discharge was 5.6% (n = 382). Sixty patients (0.7%) had more than one nerve affected. The hypoglossal nerve was most frequently involved (n = 185, 2.7%), followed by the facial (n = 128, 1.9%), the vagus (n = 49, 0.7%), and the glossopharyngeal (n = 33, 0.5%) nerve. The vast majority of these CNIs were transient; only 47 patients (0.7%) had a persistent CNI at their follow-up visit (median 10.0 months, range 0.3–15.6 months). Patients with perioperative stroke (0.9%, n = 64) had significantly higher risk of CNI (n = 15, CNI risk 23.4%, p < .01). Predictors for CNI were urgent procedures (OR 1.6, 95% CI 1.2–2.1, p < .01), immediate re-exploration after closure under the same anesthetic (OR 2.0, 95% CI 1.3–3.0, p < .01), and return to the operating room for a neurologic event or bleeding (OR 2.3, 95% CI 1.4–3.8, p < .01), but not redo CEA (OR 1.0, 95% CI 0.5–1.9, p = .90) or prior cervical radiation (OR 0.9, 95% CI 0.3–2.5, p = .80). Conclusions As patients are currently selected in the VSGNE, persistent CNI after CEA is rare. While conditions of urgency and (sub)acute reintervention carried increased risk for postoperative CNI, a history of prior ipsilateral CEA or cervical radiation was not associated with increased CNI rate.

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Recurrent Carotid Stenosis

Cited by 158 publications

References 10 publications

Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy

Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy

Significance of Carotid Restenosis following Endarterectomy

Clinical Relevance of Cranial Nerve Injury following Carotid Endarterectomy

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