Reoperations for carotid artery stenosis: role of primary and secondary reconstructions

This is an analysis of the role of primary and secondary carotid artery reconstructions and systemic risk factors on the incidence and timing of reoperations and their perioperative and late outcomes.

This is a retrospective analysis of prospectively stored data. Between 1981 and 1999, 69 secondary carotid artery procedures were performed on 66 patients (3 were bilateral). Of these, 29 operations and patients came from my series of 1514 primary carotid endarterectomies (CEAs). Overall, secondary operations were performed on 37 women (1 bilateral) and 29 men (2 bilateral) with a mean age of 68 years. Indications for reoperation were transient ischemic attack in 27%, stroke in 12%, global ischemia in 9%, and asymptomatic > or = 70% recurrent stenosis in 52%. Secondary reconstruction was by saphenous vein patching in 57% (n = 39), Dacron patching in 29% (n = 20), polytetrafluoroethylene patch in 1% (n = 1), and interposition bypass graft in 13% (n = 9). The main outcome measures included restenosis, re-restenosis, and perioperative and late stroke and death.

Reoperations were more frequent after originally primarily closed CEA (6.2%) than after patched CEA (1.6%, P =.01). Reoperations after Dacron-patched CEA occurred at a mean of 16 months compared with a mean of 84 months for vein-patched CEA (P <.001). Male sex and history of smoking have a slightly adverse but not statistically significant effect on the incidence and time of reoperation. Restenosis in the distal common carotid artery requiring reoperation had a near-linear rate of occurrence, whereas that in the internal carotid artery segment was bimodal with a higher incidence in the first 3 years and after 7 years. There were no (0%) 30-day perioperative deaths. There were two (2.9%) 30-day strokes (1 major, 1 minor). Over a mean follow-up of 50 months (range, 1-180), the Kaplan-Meier cumulative survival was 74% at 5 years and 54% at 10 years. This is significantly higher than late death after primary CEA independent of age. The cumulative freedom from stroke rate was 90% at 5 years and 86% at 10 years. After secondary procedures re-recurrent stenosis > or = 25% occurred in 25% (n = 17), > or = 50% in 13% (n = 9), and > or = 70% in 4% (n = 3). There was no statistically significant difference in stroke or re-restenosis rates between vein-patched, Dacron-patched, and bypassed reoperations, although re-recurrence tended to occur earlier after Dacron-patched than vein-patched procedures. Analysis of pooled literature data and the results of this study for stroke and re-restenosis outcomes by type secondary reconstruction (patch versus bypass graft) and by material (vein versus synthetic) give a balanced picture of near equality for each. Vein- and Dacron-patched arteries have similar outcomes, whereas polytetrafluoroethylene appears to be superior to vein and Dacron for interposition bypass graft.

Secondary carotid artery operations are more frequent after primarily closed CEA than patched CEA. Perioperative mortality and stroke rates for reoperations are within the acceptable window of primary CEA. The incidence of late death after reoperations is higher than after primary CEA. The perioperative stroke, late stroke, and re-restenosis outcomes of vein- and Dacron-patched secondary operations are similar, as are those for patched and bypassed carotid arteries.