Characterization of Perioperative Contralateral Stroke After Carotid Endarterectomy

Abstract

Contralateral stroke is an infrequent cause of perioperative stroke after carotid endarterectomy (CEA). Whereas the risks of ipsilateral stroke complicating CEA have been discriminated, factors that lead to contralateral stroke are poorly defined. The goal of this study was to identify the risk of perioperative (30-day) contralateral stroke after CEA as well as predisposing preoperative and operative factors. The Vascular Study Group of New England was queried from April 1, 2003, to February 29, 2016, for all CEAs. Duplicated patients and those without complete data were excluded. Those patients sustaining contralateral stroke in the postoperative period were identified. Demographic, preoperative, and operative factors were analyzed to identify discriminators between those with and without contralateral stroke. Logistic regression modeling was performed to identify factors independently associated with contralateral stroke. There were 10,837 CEAs performed during the study. Average age was 70.4 ± 9.3 years, and 6605 patients (61%) were male; 40% (n = 4324) were performed for symptoms. Most were current or former smokers (n = 8619 [80%]); 8% (n = 831) had serum creatinine concentration ≥1.8 mg/dL, and dialysis dependence was present in 162 (2%). Coronary artery disease and congestive heart failure were identified in 31% and 8.6%, respectively; 59 patients (0.5%) were identified having contralateral perioperative stroke. Preoperative, operative, and postoperative significant univariate factors along with notable factors not affecting perioperative contralateral stroke are presented in Table. After logistic regression analysis of significant factors, with and without contralateral occlusion represented, length of procedure (odds ratio [OR], 1.01/minute; 95% confidence interval [CI], 1.008-1.009; P = .02), urgency of operation (OR, 2.5; 95% CI, 1.3-4.6; P = .006), and concomitant proximal endovascular procedure (OR, 8.7; 95% CI, 4.5-31.2; P = .001) remain predictors of contralateral stroke after CEA. Contralateral stroke after CEA is rare, affecting 0.5% of patients. Traditional risk reduction medical therapy does not affect occurrence. Degree of contralateral stenosis, including contralateral occlusion, does not predict perioperative contralateral stroke. Urgency of operation, length of operation, and performance of a concomitant, ipsilateral endovascular procedure predict risk of contralateral stroke with CEA.TableUnivariate discriminants of perioperative contralateral stroke after carotid endarterectomy (CEA)FactorP valuePreoperative Urgency of operation.0001 Degree of ipsilateral (operated) carotid stenosis.004 Stress test performance.02 Preoperative facility need.03 Beta blocker use.04 Contralateral occlusion.06 Degree of contralateral carotid stenosis.14 Symptomatic.23 Aspirin use.26 Clopidogrel use.43 Dual antiplatelet therapy.46 ACE inhibitor/ARB.57 Statin use.62Operative CEA with coronary bypass (P = .001).0001 Length of operation.0001 CEA with other open arterial component (P = .01).01 Ipsilateral proximal endovascular procedure (P = .02).02 Shunt.19 Dextran.45 Protamine.85 Type of CEA (eversion/longitudinal).91Postoperative Dysrhythmia (P = .0001).0001 Return to OR (P = .0001).0001 Reperfusion syndrome (P = .006).006ACE, Angiotensin-converting enzyme; ARB, angiotensin receptor blocker; OR, operating room. Open table in a new tab