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Preprocedural risk stratification: identifying an appropriate population for carotid stenting
K Ouriel1, N R Hertzer, E G Beven
1Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA. ourielk@ccf.org
Journal of Vascular Surgery
|April 11, 2001
Summary
Carotid endarterectomy is safe for most, but high-risk patients with severe heart, lung, or kidney disease face greater stroke, heart attack, or death risks. These patients may be ideal for evaluating new carotid stenting procedures.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Nephrology
- Pulmonology
Background:
- Carotid endarterectomy (CEA) is a standard procedure for preventing stroke.
- Patient selection is crucial, especially with emerging endovascular techniques like carotid angioplasty and stenting.
- Identifying patients at higher risk with CEA can inform the evaluation of alternative treatments.
Purpose of the Study:
- To characterize a high-risk subgroup of patients undergoing carotid endarterectomy (CEA).
- To compare CEA outcomes in patients with and without significant medical comorbidities.
- To inform the selection of patients for initial assessment of carotid angioplasty and stenting.
Main Methods:
- A prospective registry of 3061 carotid endarterectomies (CEA) performed over 10 years.
- High-risk subgroup defined by severe coronary artery disease, chronic obstructive lung disease, or renal insufficiency.
- Outcomes assessed included perioperative stroke, myocardial infarction, death, and a composite endpoint.
Main Results:
- The overall composite endpoint (stroke/myocardial infarction/death) rate for CEA was 3.8%.
- High-risk patients had a significantly higher composite endpoint rate (7.4%) compared to low-risk patients (2.9%).
- Stroke (3.5% vs 1.7%) and death (4.4% vs 0.3%) rates were significantly higher in the high-risk group.
Conclusions:
- Carotid endarterectomy (CEA) is highly safe for most patients.
- Patients with severe coronary, pulmonary, or renal disease represent a high-risk subset with less favorable CEA outcomes.
- This high-risk population is suitable for the initial evaluation of carotid angioplasty and stenting due to higher complication rates with standard therapy.