High-risk patients for carotid endarterectomy: turned down cases are rare
G Marcucci1, F Accrocca, R Antonelli
1Unit of Vascular and Endovascular Surgery, San Paolo Hospital, Civitavecchia, Rome, Italy. gmarcroma©alice.it
Insights
Carotid endarterectomy (CEA) is safe for high-risk patients, with no increased 30-day stroke or death. However, long-term survival is worse for high-risk patients with severe comorbidities.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Neurosurgery
Background:
- Carotid artery stenting (CAS) is increasingly used for high-risk patients.
- Carotid endarterectomy (CEA) is an alternative treatment for carotid artery disease.
- Defining high-risk patients for CEA is crucial for optimal treatment selection.
Purpose of the Study:
- To evaluate the safety of CEA in high-risk patients.
- To determine if high-risk patients experience increased stroke or death rates after CEA.
- To compare short-term and long-term outcomes between high-risk and normal-risk patients undergoing CEA.
Main Methods:
- Retrospective analysis of 625 CEAs in 545 patients (2005-2010).
- Comparison of a high-risk cohort (N.=173) with normal-risk patients.
- Statistical analyses included univariate, multivariate, Kaplan-Meier, and Poisson regression models.
Main Results:
- Overall 30-day stroke and death rate was 0.96%.
- No significant difference in 30-day outcomes between high-risk and normal-risk patients.
- Long-term survival (24 months) was poorer in high-risk patients, particularly those with severe comorbidities (renal failure, pulmonary/cardiac disease, age >80).
Conclusions:
- CEA is a safe procedure for high-risk patients regarding short-term outcomes.
- Current trial criteria may be insufficient for accurately classifying high-risk patients for CEA.
- Severe comorbidities significantly impact long-term survival after CEA.
Aim:
The increasing use of carotid artery stenting (CAS) is justified in patients at high-risk for carotid endarterectomy (CEA). The aim of this study was to evaluate the hypothesis that the high-risk patients can be submitted to CEA without increased risk of stroke and death.
Methods:
A retrospective analysis of 625 consecutive CEA in 545 patients (M/F 386/159, age 75 ± 7) performed from January 2005 to December 2010 was carried out. Definite anatomical and pathophysiological high-risk cohort of patients (N.=173, 31.7%) was evaluated and compared to normal risk patients. Univariate, multivariate and Kaplan-Meier analysis were used as appropriate. Poisson regression (Pr) model was used to study all univariate criteria in combination. A P value <0.05 was statistically significant.
Results:
The overall 30-day stroke and death rate was 0.96%. No difference between high-risk vs. normal patient cohort regarding physiological and anatomical risk factors was detected. Univariate and multivariate analysis did not show statistical difference for 30-day outcome in any of the variables examined. No increase of risk in cases of presence of more risk factors resulted to the Pr analysis. The 24-month survival rate was worse in high-risk patients, especially when more physiologic risk as chronic renal failure, severe pulmonary and cardiac diseases and age over eighty were present.
Conclusion:
CEA is a safe procedure in patients at high-risk carotid artery disease. A better classification of high-risk patients may be necessary because trials criteria appear ineffective to define the patients at real high surgical risk. Long-term outcome was affected by the presence of severe comorbidities.
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