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Late outcome of untreated asymptomatic carotid disease following cardiovascular operations
Insights
Patients with asymptomatic carotid disease face late postoperative neurologic deficits, primarily transient ischemic attacks, not perioperative stroke. Careful follow-up is crucial for managing these risks after arterial reconstruction.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiology
Background:
- Asymptomatic carotid artery disease is often detected during screening for other vascular procedures.
- The risk of perioperative stroke in these patients is a concern, but late outcomes are less understood.
Purpose of the Study:
- To review the late postoperative outcomes of patients with asymptomatic carotid artery disease who underwent major arterial reconstruction without prophylactic carotid endarterectomy.
- To assess the incidence and nature of neurologic deficits and stroke in the late postoperative period.
Main Methods:
- Retrospective review of 67 patients with asymptomatic carotid disease (bruit and/or >50% obstruction) who survived major arterial reconstruction without perioperative deficit.
- Analysis of late postoperative outcomes, including mortality, neurologic events, and progression of carotid disease, over a mean follow-up of 35 months.
Main Results:
- 16% of patients died late postoperatively (4 myocardial infarction, 2 stroke).
- 32.8% experienced late neurologic deficits, predominantly transient ischemic attacks (22.4%), with only 4.5% experiencing stroke in the territory of preoperatively detected disease.
- Carotid disease progression occurred in 34% of patients, including three with carotid occlusion, two of whom had fatal strokes.
Conclusions:
- Patients with asymptomatic carotid disease undergoing arterial reconstruction are not at high risk for perioperative stroke.
- Late postoperative neurologic deficits, mainly transient ischemic attacks, are significant and necessitate long-term patient surveillance.
- Progression of carotid disease, including occlusion, poses a late risk, contributing to fatal strokes in some cases.
Abstract:
In a previous prospective study of 449 patients undergoing coronary or peripheral arterial reconstruction, 85 patients had preoperative evidence of asymptomatic bruit and/or greater than 50% carotid obstruction by routine Doppler screening. No patient had prophylactic carotid endarterectomy. This article reviews the late postoperative outcome (2 to 61 months, mean 35 months) of 67 patients with asymptomatic carotid disease who survived operation without perioperative deficit. Eleven patients died (16%) including four of myocardial infarction and two of stroke. Neurologic deficits occurred in the late postoperative period in 22 patients (32.8%) after an average interval of 31 months, including transient ischemic attacks in 15 patients (22.4%); only four of these 15 were appropriate to the side of carotid disease documented preoperatively. Seven patients (10.4%) suffered stroke, only three (4.5%) of which were in the territory of carotid disease detected preoperatively. The cumulative rate of carotid disease progression was 34%, including three patients who suffered carotid occlusion. Two of the latter had the only fatal strokes. This study suggests that patients with asymptomatic carotid disease, although not at significant risk of perioperative stroke, require careful follow-up for late postoperative neurologic deficits, the majority of which (68%) are transient ischemic attacks.