Clinical and anatomic outcomes after carotid endarterectomy

ObjectiveThe purpose of this study was to examine 30-day and long-term outcomes after carotid endarterectomy (CEA) in a contemporary series and to identify variables associated with stroke and death after CEA.MethodsThis was a retrospective review of patients undergoing an isolated CEA at a single institution between January 1989 and December 2005. Primary study end points were 30-day and long-term overall stroke, ipsilateral stroke, and death. Secondary end points were recurrent stenosis (>70% stenosis) and reintervention. Kaplan-Meier analysis was used to create survival curves for the long-term study end points. Multivariate models were created to identify variables associated with the study end points.ResultsDuring the study period, 3014 CEAs were performed on 2644 patients (mean age, 71.0 ± 8.9 years; 60.9% male; 33.5% symptomatic; 37% primary closure), with mean follow-up of 7.0 years. The 30-day ipsilateral stroke, death, and combined ipsilateral stroke/death rates were 1.3%, 1.1%, and 2.2%, respectively. Previous ipsilateral CEA or neck dissection for cancer (hazard ratio [HR], 3.68; P = .0081) and symptomatic disease (HR, 2.45; P = .0071) were predictive of 30-day ipsilateral stroke. Stroke-free survival was 93.8% at 4 years and 86.9% at 10 years. Diabetes (HR, 1.94; P < .0001), symptomatic disease (HR, 1.75; P < .0001), female gender (HR, 1.34; P = .035), and increasing age (HR, 1.02; P < .0001) were predictors of long-term overall stroke. Ipsilateral stroke-free survival was 97.6% at 5 years and 94.6% at 10 years, respectively. Contralateral occlusion (HR, 2.06; P = .025) and symptomatic disease (HR, 1.87; P = .003) were predictors of ipsilateral stroke, whereas antilipid therapy was protective (HR, 0.65; P = .049). Overall survival was 70.1% at 5 years and 42.2% at 10 years, with no difference between symptomatic and asymptomatic patients. Although a variety of comorbidities were associated with inferior late survival, as anticipated, female gender (HR, 0.89; P = .016) and lipid-lowering therapy (HR, 0.69; P < .0001) were protective. Reintervention was 3.4% at 5 years and 6.6% at 10 years, with primary closure (vs patch angioplasty/eversion) increasing the risk of reintervention (HR, 1.72; P = .007).ConclusionsCEA has favorable perioperative and long-term clinical and anatomic outcomes with respect to its goal of stroke prevention for symptomatic and asymptomatic patients. Adjuvant medical therapy (antilipid) has increased overall and ipsilateral stroke-free survival.