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Surgical therapy for the patient with internal carotid artery occlusion and contralateral stenosis
Insights
Carotid endarterectomy is a safe and effective stroke prevention method for patients with internal carotid artery (ICA) occlusion. This surgical approach offers favorable outcomes compared to other treatments for high-risk individuals.
Area of Science:
- Neurology
- Vascular Surgery
- Stroke Prevention
Background:
- Extracranial-intracranial (EC-IC) bypass has failed to demonstrate stroke risk reduction in internal carotid artery (ICA) occlusion patients.
- Optimal stroke prevention strategies for high-risk individuals with ICA occlusion remain debated.
- Contralateral carotid bifurcation endarterectomy has been utilized for patients with ICA occlusion.
Purpose of the Study:
- To evaluate the efficacy and safety of contralateral carotid endarterectomy for stroke prevention in patients with ICA occlusion.
- To compare the outcomes of endarterectomy with historical data from EC-IC bypass studies.
Main Methods:
- Retrospective analysis of 145 patients with ICA occlusion undergoing contralateral carotid bifurcation endarterectomy over 25 years.
- Data collection included presenting symptoms (TIAs, CVA, asymptomatic), perioperative complications, and long-term stroke incidence.
- Follow-up averaged 4 years to assess late stroke events and mortality.
Main Results:
- Nine patients (6.2%) experienced perioperative strokes, with three ipsilateral to the endarterectomy.
- Three perioperative deaths (2.1%) occurred.
- During follow-up, 13 new strokes (9.2%) occurred, four of which were fatal, comparing favorably to EC-IC bypass study outcomes.
Conclusions:
- Contralateral carotid endarterectomy is a viable and effective stroke prevention strategy for patients with ICA occlusion.
- Close observation of the non-occluded internal carotid artery and timely endarterectomy for stenosis are recommended.
- Surgical intervention should be considered except in specific cases where reopening an occluded ICA is feasible.
Abstract:
With demonstration of the failure of extracranial-intracranial (EC-IC) bypass to reduce the incidence of stroke in patients with internal carotid artery (ICA) occlusion, controversy continues regarding the best method of stroke prevention in these high-risk persons. One approach, endarterectomy of stenotic lesions of the contralateral carotid bifurcation, has been used for 145 patients with ICA occlusion during the past 25 years. Presenting symptoms included focal transient ischemic attacks (TIAs) in 62 patients, stroke (CVA) in 57, and nonfocal TIAs in 16. Ten patients were asymptomatic. Nine patients (6.2%) sustained perioperative strokes, only three of which were ipsilateral to the endarterectomy. There were three perioperative deaths (2.1%). During the follow-up period (mean 4 years) there were 13 new strokes (9.2%), four of which were fatal. These late results compare favorably with patients from the cooperative study of EC-IC bypass with occlusion of one ICA, whether they received surgical treatment or were managed nonoperatively. With the exception of select situations where an occluded ICA may be reopened, we conclude that the best current therapy for these patients is close observation of the nonoccluded ICA and endarterectomy once a stenotic lesion is encountered.