The importance of intraoperative detection of residual flow abnormalities after carotid artery endarterectomy

Abstract

Purpose: The efficacy of carotid endarterectomy in the prevention of strokes mandates low perioperative morbidity, as well as a low incidence of late ipsilateral stroke. This prospective study involving 430 patients (461 carotid endarterectomies) correlated the results of intraoperative assessment with end points of stroke and residual/recurrent internal carotid artery (ICA) stenosis.Methods: Adequacy of the repair was assessed by ultrasound studies (duplex scan and pulsed Doppler spectral analysis) alone (n = 142), ultrasound studies and arteriography (n = 268), or clinical inspection (n = 51). After operation, duplex ultrasonography was used to confirm patency and categorize severity of ICA stenosis. At operation 26 carotid endarterectomy sites (5.6%), were revised based on intraoperative studies.Results: Perioperative (30-day) morbidity rates were similar in patients with normal, mildly abnormal, or no ultrasound completion studies. There were six permanent (1.3%) and 12 temporary (2.6%) neurologic deficits and six deaths, including four fatal strokes and two fatal myocardial infarctions. By life-table analysis, the incidence of greater than 50% diameter-reducing ICA stenosis or occlusion was increased (p < 0.007, log-rank test) in patients with residual flow abnormality or no study. More important, patients with normal intraoperative flow studies had a significantly lower rate of late ipsilateral stroke compared with the remaining patient cohort (p = 0.04, log-rank test). During the mean 30-month follow-up interval, the incidence of late stroke was increased (p = 0.00016) in patients with ICA restenosis or occlusion (3/35) compared with patients without recurrent stenosis (3/426).Conclusion: Confirmation of a normal repair at operation affords the best opportunity to minimize ischemic neurologic events and anatomic restenosis after carotid endarterectomy.