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Carotid endarterectomy for unstable and compelling neurologic conditions: do results justify an aggressive approach?
J P Gertler1, J D Blankensteijn, D C Brewster
1Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston 02114.
Purpose:
In a retrospective study the outcome of 70 carotid endarterectomies (CEA) in 68 patients with neurologically unstable conditions or anatomically compelling findings on carotid angiography was examined to more accurately identify patients who might benefit from CEA in this setting.
Methods:
Out of a total of 1734 CEAs performed from 1978 to 1992, five groups of patients were selected: group A, stroke in evolution with tight stenosis (n = 5); group C, crescendo transient ischemic attacks (CTIA) continuing despite heparin (n = 14); group D, CTIA (above criteria) ceasing with heparin (n = 21); and group E, anatomically compelling situation on carotid angiography (n = 13). Data collected included preoperative and postoperative Neurologic Event Severity Score (NESS), CHAT classification, arteriosclerosis risk factors, demographics, and long-term overall and transient ischemic attack/stroke-free survival rates.
Results:
Risk factors and demographics were similar in all groups. By NESS criteria the conditions of 97.3% of patients in the neurologically unstable groups A to C were improved or stabilized after operation, with one deterioration (2.7%). All patients in group B either stabilized or improved. In group D, one patient's NESS deteriorated, resulting in 3.5% overall morbidity rate and no deaths for groups A to D. Follow-up showed an overall survival rate by Kaplan-Meier analysis equivalent to a matched control population, with 85% alive at 5 years. The cumulative TIA/stroke-free survival rate at 5 years was 75%.
Conclusions:
In this retrospective series, CEA performed for compelling or unstable neurologic findings carried low morbidity and mortality rates. Early aggressive surgical therapy of neurologically unstable patients may be warranted because our results improved on the anticipated natural history of the conditions studied. Further clarification of proper patient selection is necessary before this principle can be applied broadly.