Perioperative Outcome of Carotid Endarterectomy According to Type and Timing of Neurologic Symptoms and Computed Tomography Findings

Abstract

Carotid endarterectomy (CEA) in the early period after the onset of cerebral neurologic symptoms seems to be useful in the prevention of recurrent stroke while safety is still under debate. Asymptomatic carotid artery stenosis could be associated with silent cerebral ischemic events (CIEs) detectable on cerebral computed tomographic (CT) scans, but is not clear if (or how) silent cerebral lesions could influence the outcome of CEA. The aim of our work was to analyze the outcome of CEA according to the timing and type of neurologic symptoms and to evaluate the outcome of CEA in asymptomatic patients with silent cerebral events detected with preoperative cerebral CT scans. Consecutive patients who underwent CEA between January 2006 and December 2010 were collected in a dedicated database and divided into a symptomatic group (with CEA performed within 2weeks, 2-4weeks, and 4-24weeks after occurrence of the symptoms) and an asymptomatic group (with either positive-according to the classification of Stevens etal.-or negative preoperative cerebral CT scan) to evaluate the perioperative outcome in terms of CIEs, myocardial infarction (MI), and death. Results were compared using the chi-squared test, analysis of variance, and multivariate analysis. During the study period, 610 CEAs were performed, resulting in 16 (2.6%) CIEs (10[1.6%] strokes and 6 [1.0%] transient CIEs), 6 (1.0%) MIs, and 3 (0.5%) deaths. Symptomatic patients (n = 162; 22.6%) were independently associated with a higher incidence of stroke and MI compared with asymptomatic patients (7 [5.1%] vs. 3 [0.7%]; P < 0.002; 2 [1.4%] vs. 4[0.9%]; P < 0.02; respectively). The analysis of CEA outcome according to the timing of revascularization found no differences among groups within 2weeks (5 [7.9%]), 2-4weeks (no events), and after 4weeks (6 [7.4%]); in the same manner, the type of preoperative symptom was not associated with significant differences in outcome. Preoperative positive cerebral CT scans were present in 88 (19.6%) asymptomatic patients and were associated with a higher incidence of perioperative CIEs (7 [7.9%] vs. 2 [0.5%]; P = 0.001), transient CIEs (4 [4.5%] vs. 2[0.5%]; P = 0.004), and stroke (3 [3.0%] vs. 0 [0.0%]; P = 0.001). Although symptomatic patients have a higher risk of perioperative complications compared with asymptomatic patients, early CEA after symptom onset does not influence the results. Asymptomatic patients with positive CT scans who undergo CEA have a higher rate of neurologic complications.