CEA Can Be Safe Even With Multiple Comorbidities

Multiple medical comorbidities, including coronary artery disease and diabetes, should not be used as exclusion criteria for carotid endarterectomy, according to a retrospective study showing good results in veterans undergoing the procedure at a single facility.

High-medical risk patients have traditionally been excluded from carotid endarterectomy (CEA) studies and have been offered alternative therapies because of perceived risk, according to a report.

Dr. Tamara N. Fitzgerald and her colleagues from the VA Connecticut Healthcare System, West Haven, and Yale University, New Haven, both in Connecticut, reviewed the records of all 120 patients who had CEA between 1995 and 1999 at the VA facility. In all, 128 procedures were performed, with a mean follow-up of 8.5 years. The patients had a mean age of almost 70 years at the time of surgery, and 98% were men; 83% were white, 3% were nonwhite, and 14% were of unknown race. Their aggregate measure of comorbidity using the Charlson index was a mean of 3.98, and their mean Charlson Comorbidity-Age score was 7.2, according to the researchers.

The patients in this study had a high incidence of comorbidities, such as renal disease (33%). In addition, their rate of coronary artery disease was particularly high (64%) compared with 33% seen in another study that analyzed the general CEA population. A total of 52% of the patients presented symptomatically, compared with 15% in the rest of the state of Connecticut.

Other preoperative comorbidities included hypertension (82%), smoking history (73%), peripheral arterial disease (43%), diabetes (37%), and chronic obstructive pulmonary disease (22%).

The perioperative (30-day) mortality rate of 0.8% (one patient) was low, and was comparable with the 0.3%-1.1% range reported in elective patients. The rate of perioperative stroke was 1.6% (two patients), and myocardial infarction was 0.8%, according to Dr. Fitzgerald and her colleagues.

Given the patients' age, mortality during follow-up was high; 59 patients (nearly half) died. The cause of death was determined from review both of patient records and of death certificates, and no inconsistencies were found; however, data were unavailable for six patients.

According to Kaplan-Meier analysis, long-term survival rates in patients undergoing CEA at 5 and 10 years were 75% and 35%, respectively, with a median survival of 8.9 years. Cancer was the most common cause of death (22% of patients), followed by cardiac disease (18.6%), chronic obstructive pulmonary disease (6.8%), pneumonia (6.8%), and renal failure (6.8%) in the 53 patients for whom data were available. There were just three deaths from stroke. At 12 years, only 13% of patients remained alive (J. Am. Coll. Surg. 2008;207:219-26).

There were only seven (5.8%) ipsilateral neurologic events and nine (7.5%) contralateral or vertebral events throughout the follow-up period. Cumulative freedom from ipsilateral stroke values were 97%, 93%, and 90% at 1, 5, and 12 years, respectively.

"Despite the generalized poor health of VA patients, with high rates of symptomatic presentation, they were able to safely undergo carotid endarterectomy with low rates of perioperative mortality and morbidity. So 'medical high risk' does not necessarily imply 'surgical high risk' for CEA," the authors stated.

"The presence of multiple comorbid conditions is not sufficient to automatically exclude the potential for referral for CEA, a treatment with demonstrated long-term efficacy in preventing stroke in a population at risk," they concluded.

The authors reported that they had no conflicts of interest to disclose