Long-term clinical outcomes and cardiovascular events after carotid endarterectomy
Catherine Go1, Efthymios D Avgerinos1, Rabih A Chaer1
1Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Insights
Patients undergoing carotid endarterectomy (CEA) face long-term risks of stroke and other vascular events. Statins show protective effects, while existing vascular disease and renal insufficiency predict worse outcomes, necessitating closer follow-up.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Clinical Epidemiology
Background:
- Long-term adverse events after carotid endarterectomy (CEA) are expected.
- However, the precise incidence and predictors of these events remain unclear.
Purpose of the Study:
- To determine the long-term incidence of major adverse events following CEA.
- To identify clinical predictors of these adverse events.
Main Methods:
- Analysis of a consecutive cohort of 1,136 CEAs performed between 2000 and 2007.
- Utilized survival analysis and Cox regression models to identify risk predictors.
- End points included stroke, coronary events, major vascular interventions, and death.
Main Results:
- The 5- and 10-year risks for stroke were 7.2% and 16.1%, respectively.
- Coronary and major vascular interventions had 5- and 10-year risks of 18.4%/31.5% and 20.6%/28.5%.
- Statins significantly reduced stroke and death risk. Baseline vascular disease and renal insufficiency were significant predictors of adverse outcomes.
Conclusions:
- Patients undergoing CEA benefit from a low long-term stroke rate.
- However, they remain at risk for significant coronary events and require further vascular interventions.
- Intensified medical management and rigorous follow-up are crucial for this patient group.
Background:
Long-term atherosclerotic adverse events are anticipated in patients undergoing carotid endarterectomy (CEA); however, their incidence and risk predictors remain unknown.
Methods:
A consecutive cohort of CEAs between 1/1/2000-12/31/2007 was analyzed. End points were any stroke, coronary event (myocardial infarction, coronary bypass, or stenting), vascular interventions for critical limb ischemia, aortic aneurysm or carotid disease, and death. Survival analysis and Cox regression models were used to identify clinical predictors.
Results:
A total of 1,136 CEAs (bilateral, 89; mean age, 71.2 ± 9.2 years; 56.5% male; 36.3% symptomatic, and 3.9% combined with coronary bypass) were performed during the study period with a mean clinical follow-up of 60 months (0-155 months). The postoperative combined stroke and/or death rate was 2.7% and 1.9% for asymptomatic and 4.1% for symptomatic patients. Five and 10-year risks of the end points were 7.2% and 16.1% for stroke, 18.4% and 31.5% for coronary interventions, 20.6% and 28.5% for major vascular interventions, and 25.8% and 50.1% for death. Statins conferred a significant protective effect for stroke (hazard ratio [HR], 0.53; P = 0.016) and death (HR, 0.66; P < 0.0001). Baseline vascular disease predicted future vascular interventions: aortic aneurysm (HR, 1.90; P = 0.003), peripheral arterial disease (HR, 2.03; P < 0.0001), and contralateral internal carotid artery (ICA) stenosis ≥50% (HR, 4.61; P < 0.0001). Renal insufficiency predicted worse outcomes for all other end points (HR, 2.21; P = 0.023 for stroke; HR, 1.62; P = 0.008 for coronary events; HR, 2.38; P < 0.0001 for death).
Conclusions:
Patients undergoing CEA continue to derive long-term low stroke rate benefit but still sustain major coronary events and require vascular interventions, indicating a need for more intensive medical treatment and rigorous follow-up.
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