Carotid endarterectomy remains safe in high-risk patients

Carotid endarterectomy (CEA) is a proven intervention for stroke risk reduction in symptomatic and asymptomatic patients. High-risk patients are often offered carotid stenting to minimize the risk and optimize the outcomes. As a referral center for high-risk patients, we evaluated and analyzed our experience with high-risk CEA patients.

We retrospectively reviewed consecutive patients who had undergone CEA at a tertiary referral center. The demographics, indications for surgery, physiologic and anatomic risk factors, intraoperative surgical management, perioperative complications, morbidity, and mortality were analyzed. The high-risk physiologic factors identified included an ejection fraction <30%, positive preoperative stress test results, and compromised pulmonary function test results. The high-risk patients included those requiring home oxygen, those with a partial pressure of oxygen of <60 mm Hg, and patients with a forced expiratory volume in 1 second of <30%. The high-risk anatomic factors identified included previous head and/or neck radiation, a history of ipsilateral neck surgery, contralateral nerve palsy, redo CEA, previous ipsilateral stenting, contralateral occlusion, contralateral CEA, nasotracheal intubation, and digastric muscle division. After propensity score matching, patients with and without high-risk physiologic and anatomic factors were compared. The primary outcomes were a composite of stroke, myocardial infarction, and 30-day mortality. The secondary outcomes were cranial injury and surgical site infection.

During a 10-year period, 1347 patients had undergone CEA at the Cleveland Clinic main campus. Of the 1347 patients, 1152 met the criteria for analysis. Propensity score matching found adequate matches for 424 high-risk patients, with 173 patients having at least one physiologic high-risk factor and 293 at least one anatomic high-risk factor. No significant differences were found in the primary composite outcome or any of its components. Overall, the stroke rate for the standard-risk and high-risk patients was 1.9% and 1.4%, respectively. The high-risk patients were significantly more likely to have experienced a cranial nerve injury, although most were temporary. When patients with one or multiple risk factors were analyzed, no significant difference was found in the primary composite outcome or any of its components. Patients with two or more risk factors were significantly more likely to have experienced a cranial nerve injury, with most being temporary.

In our large series, CEA remained a viable and safe surgical solution for patients with high-risk anatomic and physiologic risk factors, with acceptable stroke, myocardial infarction, and 30-day mortality rates.