The risks and benefits of carotid endarterectomy in patients with near occlusion of the carotid artery

Abstract

Some believe that carotid endarterectomy (CEA) for carotid near occlusion is a necessary emergency procedure while others call it dangerous. We used the North American Symptomatic Carotid Endarterectomy Trial (NASCET) data to perform an observational study to examine the safety and benefit of CEA for carotid near occlusion. We divided the data of 659 patients into stenosis groups: 70 to 79%, 80 to 89%, 90 to 94%, and near occlusion. The 106 carotid-near-occlusion patients were subdivided into those with a string-like lumen (n = 29) and those without a string-like lumen (n = 77). Of the 48 patients with near occlusion treated with CEA, 3 (6.3%) had perioperative strokes, similar to the 70-94% stenosis group. Only 1 of 58 patients (1.7%) with near occlusion treated medically had a stroke in the first month, suggesting that CEA is not needed on an emergency basis in this circumstance. For medically treated patients, the 1-year risk of stroke increases with escalating degrees of carotid stenosis, where the risk is 35.1% for patients with 90-94% stenosis. For patients with near occlusion, the 1-year stroke risk diminishes to 11.1%, which approximates the risk for patients with 70-89% stenosis. A comparison of treatment differences indicates that surgery reduces the risk of stroke at 1 year by approximately one-half (p < 0.001), regardless of the degree of stenosis or the subcategory of carotid near occlusion (p = 0.89). Our data suggest that CEA is beneficial for near occlusion and not more dangerous than in patients with 70-94% stenosis, provided that the procedure is performed by an experienced surgeon with a low complication rate.

Internal carotid artery stenosis: comparison of duplex scan and magnetic resonance angiography with digital subtraction angiography

“…This level of difference was chosen because it is outside the range of measurement error 33 and because meaningful increments in stroke risk occur between decile levels 34 .…”

CT Angiographic Features of Symptom-Producing Plaque in Moderate-Grade Carotid Artery Stenosis

“…4,6,7 Although hypoperfusion and resultant slow flow from carotid disease likely play a role in a subset of strokes occurring in carotid stenosis, plaque instability causing distal embolus may be a relatively more influential etiologic factor for stroke in carotid disease in general. 8 Although multisequence MR imaging characterization of plaque has allowed the in vivo discrimination of high-risk plaque tissue elements, [9][10][11] its use in clinical practice has been limited, given the time, expense, and challenge of performing multisequence carotid plaque MR imaging by using a dedicated carotid coil. CTA-based measurements of soft and hard (calcified) plaque determined on axial CTA source images have recently been proposed as potential simple alternative markers of vulnerable plaque in high-grade ICA stenosis.…”

Eversion Carotid Endarterectomy in Patients with Near-Total Internal Carotid Artery Occlusion - Diagnostic Modalities, Indications and Surgical Technique

“…A comparison of treatment differences indicated that surgery reduces the risk of stroke at 1 year by approximately one-half ( p < 0.001) in patients with near ICA occlusion. [4] In contrast, a report after reanalysis of the final results of the ECST trial concluded that surgery was of little benefit in symptomatic patients with near total occlusion. This study included 125 patients with near occlusion, of whom 78 were treated surgically and 47 medically.…”

“…The results of these studies are conflicting and provide little benefit in clinical decision making. [4,5] Therefore, the aim of the present study was to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total ICA occlusion.…”