The cause of perioperative stroke after carotid endarterectomy
T S Riles1, A M Imparato, G R Jacobowitz
1Department of Surgery, New York University Medical Center, New York 10016.
Insights
Most perioperative strokes after carotid endarterectomy result from technical errors, not patient factors. Improving surgical technique can prevent these serious complications.
Area of Science:
- Vascular Surgery
- Neurology
- Medical Quality Improvement
Background:
- Carotid endarterectomy is a procedure to remove plaque from carotid arteries.
- Perioperative stroke is a significant complication following this surgery.
- Understanding stroke mechanisms is crucial for prevention.
Purpose of the Study:
- To investigate the causes of perioperative stroke after carotid endarterectomy.
- To identify patient and surgeon-related factors contributing to stroke.
- To analyze trends in stroke occurrence over time.
Main Methods:
- Retrospective review of 3062 carotid endarterectomies performed between 1965 and 1991.
- Analysis of 66 cases with perioperative stroke to determine mechanisms.
- Evaluation of patient risk factors and surgeon-dependent factors.
Main Results:
- Identified over 20 stroke mechanisms, primarily postoperative thrombosis/embolism (n=25), intracerebral hemorrhage (n=12), and ischemia during clamping (n=10).
- Perioperative stroke rates decreased from 2.7% (1965-1979) to 1.5% (1986-1991), partly due to improved patient selection.
- Postoperative thrombosis and embolism remain the leading cause of neurologic complications.
Conclusions:
- While patient selection is important, most perioperative strokes are preventable.
- Technical errors during carotid endarterectomy or reconstruction are the primary cause.
- Focusing on surgical technique can reduce stroke incidence.
Purpose:
The purpose of this study was to examine the cause of perioperative stroke after carotid endarterectomy.
Methods:
The records of 2365 patients undergoing 3062 carotid endarterectomies from 1965 through 1991 were reviewed. Sixty-six (2.2%) operations were associated with a perioperative stroke. The mechanism of stroke was determined in 63 of 66 cases. Patient risk factors and surgeon-dependent factors were analyzed.
Results:
More than 20 different mechanisms of perioperative stroke were identified, but most could be grouped into broad categories of ischemia during carotid artery clamping (n = 10), postoperative thrombosis and embolism (n = 25), intracerebral hemorrhage (n = 12), strokes from other mechanisms associated with the surgery (n = 8), and stroke unrelated to the reconstructed artery (n = 8). Dividing the operative experience approximately into thirds, during the years 1965 to 1979, 1980 to 1985, and 1986 to 1991 the perioperative stroke rates were 2.7%, 2.2%, and 1.5%, respectively. This, in part, is associated with a better selection of patients (more symptom free, fewer with neurologic deficits). There has been a notable decrease in perioperative stroke caused by ischemia during clamping and intracerebral hemorrhage, but postoperative thrombosis and embolism remain the major cause of neurologic complications.
Conclusions:
Although patient selection seems to play a role, most perioperative strokes were due to technical errors made during carotid endarterectomy or reconstruction and were preventable.
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