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Critical carotid artery stenosis: diagnosis, timing of surgery, and outcome
S S Berman1, V M Bernhard, W K Erly
1Section of Vascular Surgery, University of Arizona Health Sciences Center, Tucson.
Insights
Critical carotid artery stenosis, including atheromatous pseudoocclusion (APO), does not necessitate emergency surgery. Patients can undergo carotid endarterectomy after medical optimization without increased risk of occlusion or adverse outcomes.
Area of Science:
- Vascular Surgery
- Cerebrovascular Disease
- Interventional Cardiology
Background:
- Critical carotid artery stenosis is often associated with high risk of occlusion, prompting urgent endarterectomy.
- Atheromatous pseudoocclusion (APO) is a specific presentation within critical stenosis that requires further investigation.
- The need for emergency intervention in critical stenosis cases remains a subject of clinical debate.
Purpose of the Study:
- To evaluate the impact of critical carotid artery stenosis severity, including APO, on treatment and outcomes.
- To determine if critical stenosis or APO necessitates urgent or emergency carotid endarterectomy.
- To assess the risk of interval thrombosis between diagnosis and surgical intervention.
Main Methods:
- Retrospective review of 203 carotid endarterectomies in 197 patients.
- Stratification into critical (80-99% diameter stenosis) and non-critical groups based on vascular lab and arteriography.
- Comparison of demographics, risk factors, presentation, operative details, and outcomes between groups, including APO subgroup analysis.
Main Results:
- No significant difference in demographics, risk factors, or presentation between critical and non-critical stenosis groups.
- No interval progression to occlusion occurred between arteriography and endarterectomy in any patient.
- Similar perioperative stroke rates (2% critical vs. 3.6% non-critical) and no difference in outcomes for patients with APO.
Conclusions:
- Critical carotid artery stenosis, including APO, does not adversely affect treatment or outcomes of endarterectomy.
- Emergency intervention is not required for critical stenosis to prevent thrombosis.
- Carotid endarterectomy can be safely performed after patient evaluation and optimization of comorbidities.
Purpose:
Patients with critical carotid artery stenoses have been considered to be at high risk for carotid artery occlusion necessitating urgent or emergency endarterectomy once the stenosis is identified. Included in this group of patients are those with carotid string sign or atheromatous pseudoocclusion (APO). This review was conducted to determine the impact of the severity of stenosis including APO on the treatment and outcome of patients undergoing carotid endarterectomy.
Methods:
The records of 203 consecutive carotid endarterectomies performed in 197 patients were reviewed in detail. Patients were stratified into a critical stenosis group (80% to 99% diameter) and noncritical stenosis group based on noninvasive vascular laboratory and carotid arteriography results. Comparisons were performed of demographic data, atherosclerotic risk factors, carotid artery disease presentation, interval between arteriography and endarterectomy, operative details, and surgical results between the critical and noncritical groups and between patients in the critical group with and without APO.
Results:
Carotid endarterectomies were performed on 91 critical carotid artery stenoses and 112 noncritical stenoses. The groups did not differ significantly with regards to demographics, risk factors, carotid artery disease presentation, mean back pressure, and operative use of shunt or patch closure. For the critical group the interval between arteriography and endarterectomy was 8.63 +/- 2.38 days compared with 9.64 +/- 2.14 days for the noncritical group (mean +/- SEM, p = 0.75). No patient in either group progressed to occlusion in the interval between arteriography and endarterectomy. Perioperative strokes occurred in two patients (2%) in the critical group and four patients (3.6%) in the noncritical group (p = 0.09). Likewise, no significant difference was demonstrated in these variables when comparing patients with critical carotid artery stenosis and APO with those without APO.
Conclusions:
The presence of a critical carotid artery stenosis including APO did not impact on the treatment or outcome of patients requiring endarterectomy nor did it imply the need for emergency intervention to prevent thrombosis. Surgical intervention can proceed after evaluation and optimization of comorbid conditions without undue concern for interval thrombosis.