Results of Carotid Endarterectomy in Patients With Asymptomatic Carotid Artery Stenosis With or Without Criteria for Surgery on the Basis of the Recent European Guidelines

Abstract

The objective was to retrospectively compare perioperative outcomes of carotid endarterectomy (CEA) performed for >60% asymptomatic stenosis in patients with or without preoperative clinical and imaging features suggesting the need for intervention on the basis of the 2018 European Society of Cardiology-European Society for Vascular Surgery guidelines. From January 2008 to December 2018, there were 2501 consecutive CEAs performed in a single academic institution. Data concerning these interventions were prospectively collected in a dedicated database. A retrospective analysis of the database was performed, and 1956 interventions performed in asymptomatic patients were found. Those patients were divided in two subgroups: patients not candidates for intervention on the basis of the 2018 European Society of Cardiology-European Society for Vascular Surgery guidelines (life expectancy <5 years, predominantly hyperechoic plaques on preoperative duplex ultrasound, absence of silent brain infarction at preoperative computed tomography scan; 876 interventions, group 1) and patients fulfilling the suggested indications (1080 interventions, group 2). The two groups were compared in terms of clinical, anatomic, and surgical characteristics and perioperative (<30 days) outcomes with the χ2 test. There were no differences between the two groups in terms of demographics, risk factors, and comorbidities and preoperative features, except for the cited characteristics. Intraoperative features were also similar in the two groups, with >85% of the interventions performed under clinical monitoring of the neurologic status and about 95% of polyurethane patch angioplasty closures in both groups. Shunt insertion rate was significantly higher in group 1 (19.7%) than in group 2 (16%; P = .03). Perioperative mortality was 0.3% in group 1 (three patients) and 0.3% in group 2 (three cases; P = .7). At 30 days, there were seven neurologic events in group 1 (0.8%) and eight events in group 2 (0.7%; P = .8), of which six and five were strokes, respectively. Thirty-day stroke and death rates were 1% in group 1 and 0.75% in group 2 (P = .5). There were no differences between the two groups in terms of neck hematoma requiring surgical revision, cranial nerve injuries, and perioperative myocardial infarction. Patients in group 1 more frequently experienced a perioperative atrial fibrillation (13 cases [1.4%]) than patients in group 2 (5 cases [0.4%]; P = .02). CEA performed in patients who should not undergo intervention on the basis of the recent guidelines provided excellent perioperative results, similar to those of patients inside the suggested indications. A long-term comparison is necessary.