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Extrathoracic arterial grafts performed for carotid artery occlusive disease not amenable to endarterectomy
A M Abou-Zamzam1, G L Moneta, J M Edwards
1Department of Surgery, Oregon Health Sciences University, Portland Veterans Affairs Medical Center, 97201, USA.
Insights
Extrathoracic cervical grafts offer durable stroke prevention for patients with complex carotid artery disease. These grafts demonstrate long-term effectiveness and safety when standard endarterectomy is not an option.
Area of Science:
- Vascular Surgery
- Cerebrovascular Disease
- Surgical Outcomes
Background:
- Carotid atherosclerotic occlusive disease poses a significant stroke risk.
- Standard carotid endarterectomy is not suitable for all patients.
- Alternative surgical strategies are needed for complex cases.
Purpose of the Study:
- To evaluate the safety and long-term efficacy of extrathoracic cervical grafts for carotid artery disease.
- To assess stroke prevention rates and graft patency in patients unsuitable for endarterectomy.
Main Methods:
- A review of a prospectively maintained vascular surgical registry from 1988 to 1998.
- Analysis of 60 patients undergoing carotid interposition grafting, subclavian-carotid bypass, or carotid-carotid bypass.
- Perioperative outcomes and life-table analysis of stroke-free survival and graft patency were assessed.
Main Results:
- 60 patients underwent cervical carotid grafting for severe stenosis or occlusion, with 50% having prior endarterectomy.
- The perioperative stroke rate was 5% (3/60), with no perioperative deaths.
- Five-year freedom from stroke was 92%, stroke-free survival was 61%, and primary graft patency was 84%.
Conclusions:
- Cervical carotid artery grafts are a durable and safe option for complex or recurrent carotid atherosclerosis.
- These grafts provide excellent stroke-free survival and long-term patency.
- The procedure offers low perioperative morbidity and mortality for carefully selected patients.
Hypothesis:
Extrathoracic cervical grafts are safe and provide long-lasting stroke prevention in patients with disease not amenable to standard carotid bifurcation endarterectomy.
Design:
Review of a prospectively maintained vascular surgical registry.
Setting:
Combined university and Department of Veterans Affairs vascular surgical service.
Participants:
Patients requiring surgery for carotid atherosclerotic occlusive disease not amenable to endarterectomy from January 1988 to March 1998.
Interventions:
Carotid interposition grafting, subclavian-carotid bypass, or carotid-carotid bypass.
Main Outcome Measures:
Perioperative stroke and death, and life-table determination of freedom from stroke, stroke-free survival, and graft patency.
Results:
Sixty patients (mean age, 65.8 years; range, 36-83) underwent cervically based carotid grafting. All had greater than 70% stenosis or occlusion of the innominate, common carotid, or internal carotid arteries, and 30 (50%) had undergone at least 1 previous ipsilateral carotid endarterectomy. Indication for operation was stroke or transient ischemic attack in 46 (77%) and asymptomatic high-grade stenosis in 14 (23%). Operative procedures included 31 (52%) carotid interposition grafts, 18 (30%) subclavian-carotid grafts, and 11 (18%) carotid-carotid grafts. Mean follow-up was 29 months (range, 1-117 months). Perioperative stroke rate was 5% (3/60) all in symptomatic patients, and there were no perioperative deaths. By life-table analysis, freedom from stroke was 92% at 1 and 5 years. Stroke-free survival was 90% at 1 year and 61% at 5 years. Primary graft patency was 94% at 1 year and 84% at 5 years, with assisted primary patency of 90% at 5 years.
Conclusion:
Cervical carotid artery grafts for complicated or recurrent carotid atherosclerosis not amenable to endarterectomy are durable and provide excellent freedom from stroke with low perioperative morbidity and mortality.