Virendra I. Patel, Jeanwan Kang, Shankha Mukhopadhyay, Mark F. Conrad, David C. Brewster, Christopher J. Kwolek, Richard P. Cambria, Glenn M. LaMuraglia
Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
OBJECTIVES: The impact of severe (>70%) contralateral carotid stenosis or occlusion (SCSO) on outcomes following carotid endarterectomy (CEA) is controversial. This study evaluated the effect of SCSO on outcomes following CEA.
METHODS: All patients undergoing carotid endarterectomy at a single institution were retrospectively stratified according to the presence of SCSO. The perioperative outcomes of CEA in the presence of SCSO were analyzed using univariate and multivariable methods.
RESULTS: There were 2,945 CEA performed from 1/89 to 1/06, including 736 (25%) patients with SCSO. Patients identified with SCSO had a higher rate of prior contralateral CEA (44% vs. 21%; P<0.01), positive intra-operative EEG changes (31% vs. 17%; p<0.01), and use of an intra-operative shunt (40%. vs. 28%; p<0.01). Univariate analysis identified SCSO as a risk factor for any stroke (2.8% vs. 1.5%; p=0.02), death (2.2% vs. 1.1%; p=0.03), and any stroke/death (4.3% vs. 2.4%; p<0.01), but not ipsilateral stroke (1.6% vs. 1.2%; p=0.4). Multivariable regression demonstrated SCSO as an independent predictor of any stroke (OR1.8 [95%CI:1-3.3]; p=0.05) and any stroke/death (OR1.7 [95%CI:1.1-2.7]; p=0.02), without increasing risk of ipsilateral stroke (OR1.3 [95%CI:0.6-2.7]; p=0.2). The presence of SCSO was also associated with a higher risk of late mortality (HR1.3 [95%CI:1.1-1.4]; p<0.01).
CONCLUSIONS: Although the presence of SCSO is a risk factor for any stroke/death with CEA, it does not increase the risk of ipsilateral stroke. These data suggest that increased attention to perioperative medical and hemodynamic management should be especially considered in this patient cohort, as the observed strokes do not occur in the territory at risk from the surgical procedure.
AUTHOR DISCLOSURES: D. C. Brewster: Nothing to disclose; R. P. Cambria: Nothing to disclose; M. F. Conrad: Nothing to disclose; J. Kang: Nothing to disclose; C. J. Kwolek: Nothing to disclose; G. M. LaMuraglia: Nothing to disclose; S. Mukhopadhyay: Nothing to disclose; V. I. Patel: Nothing to disclose.
Posted April 2013