Intraoperative use of stents for the management of unacceptable distal internal carotid artery end points during carotid endarterectomy: Short-term and midterm results

Abstract

Purpose: The management of unacceptable distal internal carotid artery (ICA) end points during carotid endarterectomy presents multiple dilemmas. The problem may be expeditiously solved by placement of an intraluminal stent, but reported clinical experience with this technique is limited. We retrospectively reviewed our experience with intraoperative stenting of the ICA for the correction of unacceptable distal ICA end points during carotid endarterectomy. We report our techniques and document the 30-day stroke morbidity-death rate and midterm outcomes of patients treated in this manner. Method: The records of 316 consecutive carotid endarterectomies performed by the authors from January 1997 through June 1999 were reviewed to identify those cases in which adjunctive intraoperative stenting of the distal ICA was used. For those patients treated with adjunctive ICA stents, we assessed technique, 30-day outcomes, and midterm outcomes. Results: The 30-day combined stroke and death rate for the entire group of 316 carotid endarterectomies was 1.9%. Adjunctive distal ICA stents were used in 13 cases—4.1% of the total carotid endarterectomy group—for the correction of unacceptable distal ICA end points. All patients were male; the average age was 70 years. Stents were used in 11 patients because in each of these cases the surgeon recognized an unacceptable end point and desired to limit further distal anatomic exposures and/or ischemia times. Stents were used in two patients to correct unexpected defects identified on intraoperative completion ultrasound scan. No 30-day periprocedural deaths, strokes, or transient ischemic attacks were observed. Average postoperative length of stay was 1.8 days (range, 1-5 days). All patients have been followed up with serial carotid duplex scans, and one patient has been studied by means of angiography. No patients have died, and all remain in active clinical follow-up. Mean length of follow-up has been 15 months. No significant asymptomatic recurrences have been observed, but one patient experienced an isolated episode of amaurosis fugax without demonstrable restenosis at 8 months postoperatively. Conclusion: Our experience suggests that the adjunctive use of stents for the correction of unacceptable distal ICA end points during carotid endarterectomy is safe and provides acceptable short-term and midterm outcomes. Continued follow-up will be required before this technique can be considered a primary choice rather than an expeditious secondary alternative in this infrequent clinical circumstance. (J Vasc Surg 2000;32:420-8.)