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Carotid endarterectomy in high-risk patients: a challenge for endovascular procedure protocols
Enzo Ballotta1, Giuseppe Da Giau, Claudio Baracchini
1Vascular Surgery Section of the Department of Medical & Surgical Sciences, University of Padua, School of Medicine, Padua, Italy.
Insights
Carotid endarterectomy (CEA) is safe for high-risk patients, showing similar stroke and cardiac complication rates compared to non-high-risk individuals. These findings suggest CEA should remain an option for high-risk patients.
Area of Science:
- Vascular Surgery
- Neurosurgery
- Cardiology
Background:
- Carotid angioplasty and stenting (CAS) protocols often exclude high-risk patients.
- Identifying appropriate patient subsets for CAS remains a focus of research.
- This study aimed to compare outcomes of carotid endarterectomy (CEA) in high-risk versus non-high-risk patient groups.
Purpose of the Study:
- To compare perioperative outcomes of carotid endarterectomy (CEA).
- To evaluate the safety and efficacy of CEA in high-risk patients.
- To determine if high-risk status should preclude CEA.
Main Methods:
- A prospective registry of 392 consecutive carotid endarterectomies (CEA) performed over 54 months.
- High-risk patients defined by severe medical comorbidities or specific anatomical features.
- Perioperative stroke, cardiac complications, and death were the primary endpoints.
Main Results:
- Overall perioperative stroke rate was 1% and cardiac complication rate was 1%.
- Stroke and cardiac complication rates were similar between high-risk and non-high-risk groups.
- Cardiac morbidity was significantly higher in patients with severe medical comorbidity, particularly cardiac dysfunction.
Conclusions:
- Carotid endarterectomy (CEA) can be safely performed in high-risk patients.
- Perioperative complication rates in high-risk patients are comparable to other patient groups.
- High-risk status alone should not be a reason to opt for CAS over CEA.
Background:
Many studies have sought to identify certain patient population subsets that may be more appropriate for carotid angioplasty and stenting (CAS). Current CAS protocols include "high-risk" patients. The goal of this study was to compare the perioperative outcome of carotid endarterectomy (CEA) between high-risk and non-high-risk patients.
Methods:
During a 54-month period, 392 consecutive CEAs were performed in 363 patients (29 bilateral) by a single surgeon and entered prospectively into a registry. A high-risk patient subset (126, 35%) was defined by the presence of a severe medical comorbidity (ie, cardiac dysfunction, pulmonary dysfunction, renal insufficiency) or particular anatomic features (ie, contralateral carotid occlusion, ipsilateral carotid restenosis after CEA, and "high" carotid bifurcation). Of the 126 CEAs, 96 (76%) were performed for symptomatic lesions. Endpoints of the study were perioperative stroke, cardiac complication, or death.
Results:
Overall, there were three ischemic strokes (1%) and four cardiac complications (1%). None of the patients died. The stroke and cardiac complication rates for the high-risk and non-high-risk groups were similar (1/126, 1% versus 2/237, 1% and 3/126, 2% versus 1/237, 1%, respectively), but the cardiac morbidity rate was statistically higher in patients with severe medical comorbidity (P=.03), especially in the subset with cardiac dysfunction (P=.005).
Conclusions:
CEA can be performed in high-risk patients with perioperative neurologic and cardiac complication rates comparable with those recorded in other patients. The definition of a "high-risk" patient should not be considered per se a reason to abandon CEA in favor of CAS.
