Role of staging in bilateral carotid endarterectomy

Staging of bilateral carotid endarterectomies 1 to 6 weeks apart has been recommended because of presumed excessive morbidity chiefly related to respiratory problems, hypertension, and neurological deficits. Since data regarding the timing of the second procedure are lacking, an analysis of 79 consecutive patients undergoing bilateral endarterectomies staged from 6 days to 34 months apart (median interval, 52 days) was performed. In addition to postoperative neurological deficits, however, transient perioperative mean systolic and diastolic blood pressures (SBP and DBP) were compared after each side and were correlated with the time interval between the two procedures. No significant difference existed between the two sides in terms of preoperative hypertension, administration of steroids prior to clamping, intraoperative clamp time, the use of shunts, and the duration of operation (P greater than 0.05). Seven temporary neurological deficits occurred after operation, six after the first and one after the second endarterectomy. One permanent deficit following operation on the second side led to the only death (0.6%) in this series. Both neurological deficits (one temporary and one permanent) following the second endarterectomy occurred after procedures staged more than 60 days apart. No differences in mean SBP and DBP existed between patients with and without neurological deficits. Statistical analysis of SBP and DBP recordings during and 6, 12, 24, and 36 hours after operation when the two were staged 7 days (nine patients), 8 to 14 days (five patients), 15 to 30 days (10 patients), 30 to 60 days (17 patients), and more than 60 days (38 patients) apart revealed significantly higher readings after the second procedure, only in patients staged greater than 60 days (P less than 0.05). Therefore, in our experience, neurological deficits were less common after the second endarterectomy, and, although postoperative blood pressures were higher after the second side, these were significant only in patients staged more than 60 days apart. We find no evidence to suggest that increasing the waiting period between bilateral procedures will lower the incidence of undesirable neurological sequelae.