Temporal Trends in Eversion Carotid Endarterectomy for Carotid Atherosclerosis: Single-Center Experience with 5,034 Patients

Abstract

The aim of this article is to review our experience in surgical treatment of carotid atherosclerosis using eversion carotid endarterectomy (ECEA) in 5,034 patients, with particular attention to temporal changes in patients' characteristics, diagnostic approach, surgical technique, medical therapy, and outcome in the early (group A, 1991-1997) versus late (group B 1998-2004) period of ECEA. From January 1991 to December 2004, 5,034 primary ECEAs were performed for high-grade carotid stenosis. Patients treated for restenosis after previous carotid surgery were excluded from the analysis. Group A consisted of 1,714 patients who underwent surgery between 1991 and 1997, and group B consisted of 3,320 patients who underwent surgery between 1998 and 2004. Follow-up included routine clinical evaluation and noninvasive surveillance, with duplex scanning at 1 month after surgery, after 6 months, and annually afterward. Only 3% of patients in group A and 0.6% in group B were asymptomatic, with 23% and 47% of them having preoperative stroke, respectively. In group A, angiography was used for the final diagnosis in 78% of patients. In group B, duplex scanning was performed in 82% of patients and angiography in only 18% (p < .001). Clamping time was shorter in the latter group (12.4 +/- 3.1 vs 14.5 +/- 4.1 min, p < .01). Introperative shunting and regional anesthesia were rarely performed in both groups (1.4% vs. 0.4%, p < .01, and 2% vs 0.3%, p < .001). Total and neurologic morbidity was significantly higher in group A than in group B (6.41% +/- 0.47% vs 4.81% +/- 0.53%, p < .001, and 2.14% +/- 0.31% vs 1.23% +/- 0.29%, p < .001, respectively). Total mortality was also higher in group A than in group B (1.92% +/- 0.24% vs 1.36% +/- 0.50%, p < .05), but although there was a trend toward lower neurologic mortality, it did not reach statistical significance (1.04% +/- 0.5% vs 0.57% +/- 0.25%, p = .074). There was a lower rate of nonsignificant restenosis (< 50%) in group B (2% vs 5%, p < .01), but the incidence of restenosis > or = 50% was identical between the groups (5.5% for both). Our data show that ECEA is a reliable surgical technique for the treatment of atherosclerotic carotid disease. Temporal trends in our patients demonstrated a decline in periopertive mortality and morbidity, despite a higher incidence of preoperative stroke.

Techniques in carotid artery surgery

“…This makes the suturing easier and more comfortable for the surgeon. With the confidence of a shorter clamp time, the need for a shunt may be dramatically reduced, as evidenced by the extremely low usage reported by Radak et al 69 and Darling and colleagues. 24 Many surgeons have reported clamp times close to 10 minutes.…”

“…Radak and associates 69 reported clamp times averaging 12.4 minutes in the latter part of their series of more than 5000 patients, and 14.5 minutes in the first group. The same authors reported significantly shorter clamp times with eversion than with conventional CE (13.5 and 19.9 minutes, respectively) in their earlier prospective study.…”

“…24 Many surgeons have reported clamp times close to 10 minutes. 50,69 This may be especially advantageous given the complexities and potential complications associated with shunt placement, including air embolism, arterial dissection, and thromboembolism are possible.…”

Are the carotid kinking and coiling underestimated entities?

“…If there are atherosclerotic changes associated with CAs in the same procedure eversion carotide endarterectomy can be done 21,31,35 . Similarly, Radak et al 37 reported low total mortality rate after endarterectomy procedures of carotid artery 37 . Similarly, Radak et al 37 reported low total mortality rate after endarterectomy procedures of carotid artery 37 .…”

Carotid endarterectomy should be performed early after a cerebral ischemic event in order to be most effective

“…Carotid endarterectomy reduces the risk of subsequent stroke in patients with symptomatic stenosis [6][7][8][9][10][11] but there is one neglected fact: the risk of stroke is highest in the first weeks following initial symptoms, which meens that long waiting could be dangerous [12][13][14] .…”