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The Importance of the Circle of Willis in Carotid Interventions Outcomes: A Real-Life Study
Rafael de Athayde Soares1, Zêmia Maria Câmara Costa Ferreira1, Matheus Vegas Viana Portela1
1Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil.
Insights
The completeness of the Circle of Willis (CoW) did not impact stroke or death rates after carotid endarterectomy (CEA) or stenting (CAS). However, chronic kidney disease increased perioperative stroke risk.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiology
Background:
- Internal carotid artery stenosis poses a significant risk for stroke.
- Carotid interventions like endarterectomy (CEA) and stenting (CAS) are common treatments.
- The Circle of Willis (CoW) completeness may influence cerebrovascular event risk.
Purpose of the Study:
- To compare outcomes of CEA versus CAS in patients with internal carotid artery stenosis.
- To evaluate the impact of Circle of Willis (CoW) completeness on operative mortality, stroke, and survival rates.
- To identify risk factors for adverse outcomes after carotid interventions.
Main Methods:
- Prospective, consecutive cohort study of 98 patients undergoing carotid interventions (CEA or CAS).
- Patients were categorized based on complete or incomplete Circle of Willis (CoW) anatomy.
- Outcomes including operative mortality and ipsilateral stroke were compared between CoW groups.
Main Results:
- No significant difference in CAS or CEA prevalence between CoW complete and incomplete groups.
- Perioperative mortality (2%) and postoperative stroke incidence (3.1%) were similar in both CoW groups.
- Chronic kidney failure was the only factor associated with an increased risk of perioperative stroke (HR=1.89).
Conclusions:
- Circle of Willis (CoW) completeness does not affect postoperative stroke or mortality after carotid endarterectomy (CEA) or stenting (CAS).
- Chronic kidney disease is a significant risk factor for perioperative stroke in patients undergoing carotid interventions.
- Further research may explore specific management strategies for patients with compromised CoW anatomy.
Background:
The main objective of this study is to evaluate and compare the outcomes regarding operative mortality rate, ipsilateral stroke, and overall survival rate among patients with internal carotid artery stenosis submitted to carotid endarterectomy (CEA) or stenting regarding the completeness of circle of Willis (CoW).
Methods:
Prospective, consecutive cohort study of patients submitted to carotid interventions (CEA and carotid stenting: CAS) for internal carotid artery stenosis diagnosis evaluated according complete or incomplete CoW. The patients were divided into 2 groups: group I, the patients with complete CoW and group II, the patients with incomplete CoW, with the disruption of anterior and/or ipsilateral posterior circulation, regarding the ipsilateral significant carotid stenosis.
Results:
Overall, 98 patients submitted to carotid intervention were evaluated. Two groups of patients were identified: group CoW complete with 54 patients and group CoW incomplete with 44 patients. Regarding the type of intervention, the prevalence of CAS in CoW complete group and CoW incomplete group were statistically similar (54.1% vs. 55.1%, P = 0.22). Notwithstanding, CEA was also statistically similar in CoW incomplete group and CoW complete group (44.2% vs. 45.9%, P = 0.22). The perioperative mortality rate was 2% in total cohort (2 patients), with no differences among CoW complete and incomplete groups (3.7% vs. 0%, P = 0.50, respectively). Furthermore, the incidence of postoperative stroke was 3.1% (asymptomatic 2%, symptomatic 1.1%), with no differences among CoW complete and incomplete groups (3.7% vs. 2.3%, P = 0.68, respectively). A univariate and multivariate linear regression showed that among the factors evaluated, only chronic kidney failure was related with hazard ratio = 1.89, P = 0.003, confidence interval 1.058-2.850.
Conclusions:
The completeness of the CoW, independently of the type of carotid intervention (CEA and CAS), did not interfere in the results regarding postoperative outcomes for stroke and death. Chronic kidney disease was associated to increased risk of perioperative stroke.
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