Clinical and anatomic outcomes after carotid endarterectomy

The purpose of this study was to examine 30-day and long-term outcomes after carotid endarterectomy (CEA) in a contemporary series and to identify variables associated with stroke and death after CEA.

This was a retrospective review of patients undergoing an isolated CEA at a single institution between January 1989 and December 2005. Primary study end points were 30-day and long-term overall stroke, ipsilateral stroke, and death. Secondary end points were recurrent stenosis (>70% stenosis) and reintervention. Kaplan-Meier analysis was used to create survival curves for the long-term study end points. Multivariate models were created to identify variables associated with the study end points.

During the study period, 3014 CEAs were performed on 2644 patients (mean age, 71.0 ± 8.9 years; 60.9% male; 33.5% symptomatic; 37% primary closure), with mean follow-up of 7.0 years. The 30-day ipsilateral stroke, death, and combined ipsilateral stroke/death rates were 1.3%, 1.1%, and 2.2%, respectively. Previous ipsilateral CEA or neck dissection for cancer (hazard ratio [HR], 3.68; P = .0081) and symptomatic disease (HR, 2.45; P = .0071) were predictive of 30-day ipsilateral stroke. Stroke-free survival was 93.8% at 4 years and 86.9% at 10 years. Diabetes (HR, 1.94; P < .0001), symptomatic disease (HR, 1.75; P < .0001), female gender (HR, 1.34; P = .035), and increasing age (HR, 1.02; P < .0001) were predictors of long-term overall stroke. Ipsilateral stroke-free survival was 97.6% at 5 years and 94.6% at 10 years, respectively. Contralateral occlusion (HR, 2.06; P = .025) and symptomatic disease (HR, 1.87; P = .003) were predictors of ipsilateral stroke, whereas antilipid therapy was protective (HR, 0.65; P = .049). Overall survival was 70.1% at 5 years and 42.2% at 10 years, with no difference between symptomatic and asymptomatic patients. Although a variety of comorbidities were associated with inferior late survival, as anticipated, female gender (HR, 0.89; P = .016) and lipid-lowering therapy (HR, 0.69; P < .0001) were protective. Reintervention was 3.4% at 5 years and 6.6% at 10 years, with primary closure (vs patch angioplasty/eversion) increasing the risk of reintervention (HR, 1.72; P = .007).

CEA has favorable perioperative and long-term clinical and anatomic outcomes with respect to its goal of stroke prevention for symptomatic and asymptomatic patients. Adjuvant medical therapy (antilipid) has increased overall and ipsilateral stroke-free survival.