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Published on: August 11, 2015
Treatment of recurrent cerebrovascular disease. Review of a 10-year experience
K A Coyle1, R B Smith, B C Gray
1Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Insights
Repeat carotid endarterectomy for recurrent cerebrovascular disease has similar risks to first-time procedures. This surgery is a safe option for preventing strokes in patients with severe carotid stenosis.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiovascular Medicine
Background:
- Recurrent cerebrovascular disease after initial carotid endarterectomy presents challenges due to scarring.
- Previous reoperations were thought to carry higher perioperative risks than primary procedures.
Purpose of the Study:
- To evaluate the perioperative risk of repeat carotid endarterectomy compared to first-time procedures.
- To determine the safety and efficacy of reoperative carotid endarterectomy in preventing stroke.
Main Methods:
- Retrospective review of 69 repeat carotid endarterectomies over 10 years.
- Analysis of perioperative complications, including stroke, death, and cranial nerve injury.
- Comparison of outcomes with 1003 first-time carotid endarterectomies performed during the same period.
Main Results:
- Repeat carotid endarterectomy had a combined stroke and death rate of 4.3% (2 deaths, 1 stroke).
- No significant cranial nerve injuries occurred in the reoperative group, unlike the 2.0% in the first-time group.
- The overall complication rate was comparable to the 4.0% rate in first-time procedures.
Conclusions:
- Repeat carotid endarterectomy is a safe procedure for severe recurrent carotid stenosis.
- Morbidity and mortality rates for reoperative carotid endarterectomy are similar to first-time procedures.
- Reoperative carotid endarterectomy is an effective stroke prevention strategy.
Objective:
The authors determined whether carotid endarterectomy in patients with recurrent cerebrovascular disease poses a greater perioperative risk than for those individuals undergoing first-time carotid endarterectomy.
Summary Background Data:
A percentage of patients undergoing carotid endarterectomy for atherosclerosis experience recurrent cerebrovascular disease. Reoperation may be difficult because of postoperative scarring of the soft tissues of the neck and the carotid artery itself. Such patients were believed to be at greater risk for perioperative morbidity than those undergoing first-time carotid endarterectomy.
Methods:
To address this concern, the authors retrospectively reviewed their experience with 69 patients who underwent repeat carotid endarterectomies over a recent 10-year period of time. This subgroup represented 6.4% of 1072 total carotid endarterectomies performed during the same time period. The average extent of stenosis on the operated side was 81% and the time elapsed after previous endarterectomy averaged 83 months. Twelve patients (17.4%) had contralateral internal carotid occlusion, and 30 patients (43.5%) had undergone previous endarterectomies on the contralateral side.
Results:
Complications within 30 days of operation included two deaths (2.9%) and one stroke (1.4%), for a combined stroke and death rate of 4.3%. Six patients developed cervical hematomas requiring drainage; one of these had rupture of a saphenous vein patch. No patient had a significant cranial nerve injury in the reoperative group, whereas 2.0% of patients undergoing first-time carotid endarterectomy had cranial nerve injuries. Overall, these results compared favorably with a combined stroke and death rate of 4.0% among 1003 patients who underwent first-time carotid endarterectomy during the same period.
Conclusions:
This review suggests that repeat carotid endarterectomy can be performed safely in individuals with severe recurrent carotid stenosis, with morbidity and mortality rates similar to those for patients undergoing first-time carotid endarterectomies. For this population, reoperative carotid endarterectomy represents a safe and important mechanism for the prevention of stroke.
