Long-term Results Of Carotid Endarterectomy Research Articles

Long-term results of carotid endarterectomy and carotid artery stenting in patients with high bifurcation of common carotid artery: a multiple-center study

To analyze in-hospital and long-term results of eversion carotid endarterectomy (CEE), carotid endarterectomy with patch repair and carotid artery stenting (CAS) in patients with high bifurcation of common carotid artery. A retrospective multiple-center open study included 1983 patients who underwent internal carotid artery (ICA) repair for severe stenosis between 2010 and 2021. Three groups of patients were distinguished depending on revascularization option: group 1 (n=638) - eversion CEE; group 2 (n=351) - CEE with patch repair; group 3 (n=994) - CAS. In-hospital postoperative mortality and incidence of stroke and myocardial infarction were similar. All bleedings (n=39) occurred after CEE. ICA thrombosis was diagnosed in groups 1 and 2 due to intimal detachment after insertion of temporary bypass tube. Incidence of laryngeal paresis, neuropathy of hypoglossal and glossopharyngeal nerves, Horner syndrome, damage to salivary glands was comparable in groups 1 and 2. Long-term mortality was the highest (n=10; 2.8%) after CEE with patch repair due to fatal stroke. In turn, the highest incidence of ICA restenosis and restenosis-induced ischemic stroke was observed after CEE with patch repair and CAS. 1. Classical and eversion CEE in patients with high CCA bifurcation is followed by high in-hospital incidence of damage to cranial nerves and salivary glands, laryngeal paresis, Horner syndrome, bleeding and risk of ICA thrombosis. 2. In patients with high CCA bifurcation, CAS and CEE with patch repair are accompanied by high incidence of ICA restenosis, restenosis-induced stroke and mortality in long-term postoperative period. 3. Eversion CEE demonstrates the lowest rates of all adverse cardiovascular events in long-term follow-up period.

Carotid endarterectomy for atherosclerotic occlusion of the contralateral internal carotid artery

Aim. To analyse perioperative and long-term results of carotid endarterectomy for occlusion or stenosis of the contralateral internal carotid artery.Methods. This study included 184 patients who underwent carotid endarterectomy for either occlusion (group 1, n = 74) or stenosis (group 2, n = 110) of the contralateral internal carotid artery. Carotid endarterectomy with eversion was performed in 97% of the patients while the conventional procedure with a patch was used in the remaining 3%.Results. The incidence of perioperative stroke / transient ischemic attack (TIA) in groups 1 and 2 was 1.35% and 1.82%, respectively (p = 0.806). Stroke / TIA within 30 days after surgery occurred in 2 patients in group 1 and in 1 patient in group 2 (p = 0.346); however, none were associated with death. In contrast, 3 cases of myocardial infarction (MI) were seen in group 1, two of which resulted in death. No instances of MI were seen in group 2. Long-term freedom from stroke and myocardial infarction, estimated using the Kaplan-Meier method, was not significantly different between the groups (p = 0.240 and p = 0.657, respectively). Long-term survival was similar in both groups (p = 0.281). An analysis of the risk factors for major cardiovascular events, both immediate and in the long-term, showed that plaque instability was the most significant (p = 0.004), followed by lesions in the arteries of the lower extremities (p = 0.002).Conclusion. Short-term and long-term cerebral complications were not significantly different between patients with occlusion or stenosis of the contralateral internal carotid artery. However, patients with occlusion were significantly more likely to experience MI, necessitating a detailed diagnosis of coronary artery disease. Instability of the atherosclerotic substrate and multifocal atherosclerosis were identified as independent risk factors for major cardiovascular events. Received 18 May 2021. Revised 30 July 2021. Accepted 11 August 2021. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authors: Authors contributed equally to this article.

Immediate and long-term results of carotid endarterectomy in different periods of ischemic stroke

Aim. Analysis of hospital and long-term results of carotid endarterectomy (CEA) in different periods of acute cerebrovascular event (ACVE).
 Materials and Methods. The given study was retrospective and was conducted using the method of patients sampling. In the period from 2010 to 2019, 1113 patients with ACVE in history who were later conducted CEA, were selected. Depending on the time interval between the last ACVE and CAE, all the patients were divided into 4 groups: the 1st group in the acutest period of ACVE (1-3 days) (n=24; 2.2%); the 2nd group in the acute period of ACVE (up to 28 days) (n=493; 44.3%); the 3rd group in the early rehabilitation period of ACVE (up to 6 months) (n=481; 43.2%); the 4th group in the late rehabilitation period of ACVE (up to 2 years) (n=115; 10.3%). The long-term period was 34.812.5 months.
 Results. In the hospitalization period of observation the following complications were found: lethal outcome ((group 1 0%; group 2 0.4% (n=2); group 3 0.2% (n=1); group 4 0%; р=0.16)); myocardial infarction ((group 1 0%; group 2 0.4% (n=2); group 3 0%; group 4 0.9% (n=1); р=0.35)); ACVE/transient ischemic attack (TIA), ((group 1 4.2% (n=1); group 2 0.4% (n=2); group 3 0.2% (n=1); group 4 0%; р1-2=0.01; р1-3=0.009; р1-4=0.01)). By the end of hospitalization period the composite endpoint consisting of lethal outcome + myocardial infarction + ACVE/TIA made in group 1 4.2% (n=1), in group 2 1.2% (n=6), in group 3 0.4% (n=2), in group 4 2.6% (n=3), р=0.08. Complications of the long-term follow-up period were: lethal outcome from all causes ((group 1 25% (n=6); group 2 5.5% (n=27); group 3 7.3% (n=35); group 4 14% (n=16); р1-2=0.002; р1-3=0.008; р2-4=0.012)); lethal outcome from cardiovascular causes ((group 1 4.2% (n=1); group 2 3.6% (n=18); group 3 4.8% (n=23); group 4 5.2% (n=6); р=0.79)), myocardial infarction ((group 1 12.5% (n=3); group 2 3.6% (n=18); group 3 5.4% (n=26); group 4 6.1% (n=7); р=0.15)), ACVE/TIA ((group 1 16.6% (n=4); group 2 6.3% (n=31); group 3 6% (n=29); group 4 11.3% (n=13); р=0.05)); composite endpoint including lethal outcome + myocardial infarction + ACVE/TIA ((group 1 54.2% (n=13); group 2 15.4% (n=76); group 3 18.7% (n=90); group 4 31.3% (n=36); р1-2=0.0001; р1-3=0.0001; р1-4=0.005; р2-4=0.0006; р3-4=0.012)).
 Conclusion. Application of CEA demonstrated effectiveness and safety in the acute and early rehabilitation period of ACVE.

Comparative Analysis of Carotid Artery Stenting and Carotid Endarterectomy in Clinical Practice

The objective of the study was to describe immediate and long-term results of carotid endarterectomy (CEA) versus carotid stenting (CAS) with embolic protection in patients with severe carotid artery stenosis in clinical practice. Materials and Methods: This is a retrospective cohort study, conducted between 2009 and 2017.During the analyzed period, 2132 operations (2006 patients) were performed: 1215 (57%) CEA and 917 (43%) CAS. 278 patients (13.8% of 2006) were not contactable during the follow-up period (>30 days) leaving 1791 cases (1728 patients) for inclusion in the analysis. Propensity score matching was used to compare the treatment results of groups (561 cases were matched out of 1791). The results of 615 CEA (316 eversion, 299 “classic” with patch) and 615 CAS (using a variety of carotid stents) were compared. Results: In the asymptomatic subgroup (n = 455), the 30-day rate of stroke was not significantly different between the CEA group and the CAS group (1.5% versus 2.4%, P = .48). The 5-year rate of stroke was not significantly higher for CAS than for CEA (4.6% versus 3.3%, P = .3). In the symptomatic subgroup (n = 160), the 30-day rate of stroke was significantly higher in the CAS group than in the CEA group (7.5% versus 2.5%, P = .04). The 5-year rate of stroke was 13% for CAS and 8.7% for CEA (P = .2). Conclusions: In the symptomatic subgroup, the 30-day rate of stroke was significantly higher in the CAS group than in the CEA group, therefore the use of CAS for symptomatic patients in routine practice should be limited. Our study demonstrates that the rates of stroke and survival after CEA and CAS in patients aged 80 years or younger with asymptomatic or symptomatic severe carotid stenosis did not differ significantly over a period of 5 years.

Long-term results of carotid endarterectomy performed in the acute period of ischemic stroke

Long-term results of carotid endarterectomy performed in the acute period of ischemic stroke

Comparison of long-term results of carotid endarterectomy for asymptomatic carotid artery stenosis.

This article summarizes the current study situation on treatment of asymptomatic carotid artery stenosis and discusses the evidence situation in the literature. The 10-year results of the ACST study have shown that in comparison to conservative treatment, carotid endarterectomy (CEA) has retained a positive long-term effect on the reduction of all forms of stroke. All multicenter randomized controlled trials comparing CEA with carotid artery stenting (CAS) and, in particular the SAPHIRE and CAVATAS studies, have in common that despite a basic evidence level of Ib, the case numbers of asymptomatic patients are too small for a conclusive therapy recommendation. In the overall assessment of the CREST study the resulting difference in the questionable endpoint of “perioperative myocardial infarction” in favor of the CAS methods, could not be confirmed for exclusively asymptomatic patients. In the long-term course of the CREST study, both methods were classified as equivalent, even when the 4‑year results of periprocedural and postprocedural stroke rates in the separate assessment of the asymptomatic study participants clearly favored the CEA. The results of the ACST-1 study showed an equivalent effect of both treatment methods with respect to all investigated endpoints; however, the unequal sizes of the groups in addition to the statistically insufficient case numbers put a question mark on the validity of the study results. The results of the ASCT-2 and CREST-2 studies are to be awaited, which also investigate the significance of “CEA versus CAS” (ASCT-2) and “CEA/CAS + best medical treatment (BMT) versus BMT alone” in only asymptomatic stenoses. The current S3 guidelines allow operative therapy to be considered in patients with a 60–99% asymptomatic carotid artery stenosis, because the risk of stroke is statistically significantly reduced.

A Matched Case-Control Study on Early and Late Results of Carotid Endarterectomy Performed in Young Patients.

The aim of the study was to describe the perioperative and long-term results of carotid endarterectomy (CEA) in patients aged 60 or less and compare them to patients of more advanced age in a retrospective single-centre case-control study. From January 1996 to December 2014, 5893 consecutive CEAs were performed in our institution. Data concerning these interventions were prospectively inserted in a dedicated database. A retrospective analysis of that database was performed and 457 interventions performed in patients aged 60 or less were found (group 1). The control group was represented by 457 interventions selected from the remaining 5436 by a one-to-one coarsened exact matching on the basis of all the baseline demographic and clinical covariates significantly different in the two groups (group 2). The two groups were compared in terms of intraoperative technical features and perioperative (<30days) results of interventions (transient ischaemic attack-TIA, stroke and death rates) with χ 2 test. Follow-up data were analysed by life-table analysis (Kaplan-Meier test) in terms of survival, stroke-free and neurological symptom-free survival, freedom from severe restenosis and occlusion and freedom from reintervention, and the results in the two groups were compared by means of log rank test. There were no differences between the two groups in terms of clinical presentation and of degree of carotid stenosis on operated side. Anaesthesiological and surgical details were also similar between the two groups. Thirty-day stroke and death rate was 0.6% in both groups (p=0.9). Follow-up was available for 877 patients (96% of the study group) with a mean duration of 50months. Estimated 10-year survival rates were 85% in group 1 (SE 0.03) and 76% in group 2 (SE 0.04, p=0.003, log rank 8.9). At the same time interval, stroke-free survival was also significantly better in group 1 (85%, SE 0.035) than in group 2 (72.5%, SE 0.03; p=0.002, log rank 10.1). The corresponding figures in terms of any neurological symptom-free survival were 82.8% in group 1 (SE 0.04) and 70.3% in group 2 (SE 0.04, p=0.002, log rank 9.7). Estimated freedom from severe restenosis and occlusion was 76.5% in group 1 (SE 0.04) and 88.5% in group 2 (SE 0.035, p=0.001, log rank 11.9). Disease recurrence was symptomatic in six cases, three in each group. Estimated freedom from reintervention rates at 10years was 87% in group 1 (SE 0.035) and 91.5% in group 2 (SE 0.03; p=0.2, log rank 1.1). CEA in patents aged 60 or less is safe and provides significantly better long-term results than those obtained in patients over 60 in terms of survival and stroke-free survival. Younger patients appear to have higher rates of recurrent carotid stenosis compared to the older cohort; however, these rarely require a secondary intervention.

Long-term performance of the bovine pericardium patch in conventional carotid endarterectomy.

The aim of the study was to analyze long-term results of carotid endarterectomy (CEA) using bovine pericardium patch. This study is a retrospective analysis of 274 consecutive cases (173 in CEA group and 101 patients in an internal control group of eversion endarterectomy [EEA]) operated between January 2005 and May 2007. Operations were performed according to standard surgical technique. Primary endpoints of the study were 30-day mortality, ipsilateral neurologic event rate, and high-grade restenosis in the long-term follow-up. No statistically significance between both groups was found in terms of gender, age, risk factors, medication (statine, platelet inhibition), and incidence of symptomatic stenoses (50.9 vs. 50.5%, n.s.). Early mortality was 0% for EEA and 1% for CEA (nonsignificant [n.s.]) and neurologic event rate (transitory ischemic attack [TIA] + stroke) was 4 versus 4% (n.s.), respectively. After 5 years of follow-up (mean 81 months for CEA and 73 months for EEA), the rate of severe (> 70%) restenosis was 2.9% for EEA and 2.7% for CEA (p =0.729). Bovine pericardium patch yielded promising results with regard to mortality, perioperative neurologic event rate (TIA, stroke), and occurrence of severe restenosis after 5 years of follow-up.

Impact of diabetes mellitus on characteristics of carotid plaques and outcomes after carotid endarterectomy

Published results for carotid endarterectomy (CEA) in symptomatic and asymptomatic severe carotid stenosis with diabetes mellitus (DM) are contradictory. To evaluate perioperative and long-term results of CEA in patients with DM, we retrospectively analyzed data of patients with or without DM who underwent CEA in our institute. Between January 2005 and December 2010, 281 consecutive CEAs were performed in 268 patients under general anesthesia. All patients were subject to cardiac work-ups before surgery, and coronary revascularization was performed prior to CEA if patients were diagnosed with significant coronary artery stenosis. Lesion characteristics were assessed by a duplex ultrasound scan, computed tomography angiography (CTA), and plaque imaging on magnetic resonance imaging (MRI) before surgery, and patients were followed-up by a duplex ultrasound scan at three, six, and 12months, then yearly, after surgery. Of 281 cases, 136 had DM (48%). Diabetic patients more frequently had a history of coronary artery disease than non-diabetic patients (48.5% vs. 36.6%, P = 0.042). Coronary intervention prior to CEA was more frequently performed in diabetic patients than in non-diabetic patients (22.1% vs. 11.0%, P = 0.013). The incidence of perioperative (30day) stroke (P = 1.000), death (P = 1.000), and cardiac complications (P = 0.484) did not differ among groups. Follow-up was available in 77.2% of patients, with a median duration of 50months (interquartile range, 32.1-67.2months). The incidence of ipsilateral stroke (P = 0.720), death (P = 0.351), and severe restenosis (peak systolic velocity > 230cm/sec) (P = 0.905) were not different between groups. DM does not increase the risk of perioperative complications and does not influence long-term outcomes after CEA if preexisting vascular risk factors and cardiac diseases are appropriately evaluated and treated before surgery.

Early and long-term results of carotid endarterectomy in diabetic patients

To evaluate results of carotid endarterectomy (CEA) in diabetic patients in a large single-center experience. Over a 13-year period ending in December 2008, 4305 consecutive CEAs in 3573 patients were performed. All patients were prospectively enrolled in a dedicated database. Interventions were performed in diabetic patients in 883 cases (20.5%; group 1) and in nondiabetics in the remaining 3422 (79.5%; group 2). Early results in terms of 30-day stroke and death rates were analyzed and compared. Follow-up results were analyzed with Kaplan-Meier curves and compared with log-rank test. Diabetic patients were more likely to be females and to have coronary artery disease, peripheral arterial disease, hyperlipemia, and arterial hypertension than nondiabetics. There were no differences between the two groups in terms of preoperative clinical status or degree of carotid stenosis. Interventions were performed under general anesthesia with somatosensory-evoked potentials (SEPs) monitoring in 67% of the patients in both groups, while the remaining interventions were performed under clinical monitoring. Shunt insertion (14% and 11%, respectively) and patch closure rates (79% and 76%, respectively) were similar between the two groups. There were no differences between the two groups in terms of neurological outcomes, while the mortality rate was higher in group 1 than in group 2 (P = .002; odds ratio [OR], 3.5; 95% confidence interval [CI], 1.5-8.3); combined 30-day stroke and death rate was significantly higher in group 1 (2%) than in group 2 (0.9%; P = .006; 95% CI, 1.2-3.9; OR, 2.2). At univariate analysis, perioperative risk of stroke and death in diabetic patients was significantly higher in patients undergoing intervention with SEP cerebral monitoring (95% CI, 0.9-39.9; OR, 5.9; P = .01), and this was also confirmed by multivariate analysis (95% CI, 1.1-23.1; OR, 8.3; P = .04). The same analysis in nondiabetics demonstrated that again the need for general anesthesia significantly increased perioperative risk, but this was not significant at multivariate analysis. Follow-up was available in 96% of patients, with a mean duration of 40 months (range, 1-166 months). There were no differences between the two groups in terms of estimated 7-year survival (87.3% and 88.8%, respectively; 95% CI, 0.57-1.08; OR, 0.8) and stroke-free survival (86.8% and 88.1%, respectively; 95% CI, 0.59-1.07; OR, 0.8). Diabetic patients had decreased severe (>70%) restenosis-free survival rates at 7 years than nondiabetics (77.4% and 82.2%, respectively; 95% CI, 0.6-1; OR, 0.8; P = .05). Univariate analysis demonstrated again that the use of instrumental cerebral monitoring significantly decreased stroke-free survival in diabetics (P = .01; log rank, 10.1), and this was also confirmed by multivariate analysis (95% CI, 1.7-17.7; OR, 5.4; P = .005). In our experience, the presence of diabetes mellitus increases three-fold the risk of perioperative death after CEA, while there are no differences with nondiabetics in terms of perioperative stroke. However, the rate of stroke and death at 30 days still remains below the recommended standards. During follow-up, this difference becomes negligible, and results are fairly similar to those obtained in nondiabetics. Particular attention should be paid to patients undergoing intervention under general anesthesia, who seem to represent a subgroup of diabetics at higher perioperative risk, suggesting neurologic monitoring should be used when possible.

5-year follow-up after endarterectomy of carotid artery thrombosis

The long-term results of carotid endarterectomy were analysed in 119 patients, operated on between January 1979 and December 1980 (135 endarterectomies; preoperative data analysed retrospectively). 43 patients had been in stage I, 39 in stage IIa, 13 in stage IIb, 4 in stage III, and 20 in stage IV. Perioperative mortality was 0.8%, while hospital mortality was 2.5%. Transitory perioperative neurological deficits occurred in 4.2% of all patients, but no permanent ones. Five years postoperatively 44.5% had died, nearly half (43.4%) of cardiovascular disease. Cerebrovascular disease and tumour each caused 15% of deaths. During the five-year follow-up period 12% of all patients had had transitory ischaemic attacks; 16% had suffered a stroke (in 63% on the operated side). With a high prevalence of risk factors, only the quality of diabetic control (mortality rate of well controlled diabetes 38%, of poorly controlled 70%) and the risk factors heart failure and vascular occlusive disease had a significant influence on the mortality rate. But the mortality rate was significantly lowered with the use of platelet aggregation inhibitors (41.6% vs 72.7%).

Immediate and Long-Term Results of Carotid Endarterectomy for Asymptomatic High-Grade Stenosis

We examined the operative risks and long-term results of carotid endarterectomy for asymptomatic patients in terms of stroke, death, and recurrent stenosis. The results of a nonrandomized study with a follow-up of 1 to 104 months (mean 46 months) is reported. A tertiary referral center served as the setting for this report. One hundred consecutive patients with severe but asymptomatic carotid artery stenosis out of a total of 514 patients undergoing carotid endarterectomy were entered into this study. The severity of carotid disease was determined by duplex scanning and confirmed arteriographically. No patients were lost to follow-up after surgery. Eighty-nine operations (77%) were done under cervical block anesthesia and all arteries were closed with saphenous vein patches. Life-table analysis showed that the stroke-free rate at 5 years was 96.3% with an ipsilateral stroke-free rate of 98.2%. The 5-year overall survival rate was 78.2% with a stroke-free survival rate of 75%. Carotid endarterectomy can be performed safely for asymptomatic patients believed to be at risk for stroke. The potential for early death due to myocardial disease, late stroke, and recurrent stenosis do not justify advising patients against undergoing prophylactic carotid endarterectomy for asymptomatic high-grade stenosis.

Carotid Endarterectomy for Asymptomatic Carotid Stenosis: a Ten-Year Experience with 120 Procedures in a Fellowship Training Program

Performance of carotid endarterectomy for asymptomatic carotid stenosis has been restricted during recent years because of concern of reported complications in as high as 10-15% of patients, as well as limited long-term data on stroke protection. During the last 10 years, we have studied immediate and long-term results of carotid endarterectomy for asymptomatic disease in 120 patients. Operations were performed by a clinical vascular fellow with a staff surgeon in attendance in 113 (94%) cases with the remainder performed by the staff surgeon. Patients' mean age was 66 years; 82% were men. Risk factors included hypertension (56%), smoking (52%), coronary artery disease (32%), diabetes (24%), and hypercholesterolemia (6%). Arteriographic severity of stenoses was 80-99% in 74%, 60-79% in 22%, and 40-59% in 4% of cases. Postoperative complications included two transient neurological events (1.7%). No permanent strokes or deaths occurred. Using the life table method, cumulative stroke rate was 4.5% for ipsilateral events and 7.3% for contralateral events, confirming the high degree of stroke protection afforded by carotid endarterectomy in this population. Since these results were accomplished in a fellowship training program, we regard adequacy of this experience as the most influential factor in accomplishing this record. Surgeons who are unable to achieve comparable results should consider abandonment of the procedure or an extended period of additional training.

Immediate and long-term results of carotid endarterectomy.

We review the long-term results of carotid endarterectomy in 200 consecutive patients operated on from 1980 to 1987. The patients were part of an ongoing study using duplex scanning to assess the status of the carotid bifurcation before and after endarterectomy. The average follow-up for the patients was 31 months. The indications for surgery were transient ischemic attacks in 87 (43.5%) and stroke in 36 (18%) patients; 77 patients (38.5%) were asymptomatic. In 176 sides (88%), the degree of stenosis exceeded 50% in terms of diameter reduction. The perioperative stroke rate was 2.3% in patients with transient ischemic attacks, 2.8% in patients with strokes, and 1.3% in asymptomatic patients. There was one perioperative death (0.5%). There were five occlusions of the internal carotid artery, one during the perioperative period and four after discharge; in three patients the occlusion was associated with the development of a stroke. There was a restenosis rate of 19.7% secondary to myointimal hyperplasia; such lesions did not appear to contribute to new ischemic events during or after their development. The mean stroke incidence after the decision was made for carotid endarterectomy was 2.8%/yr in the patients with transient ischemic attacks, 6.2%/yr in the patients with stroke, and 0.65%/yr in the asymptomatic patients. The annual death rate was 6% for the entire group, 5.5%/yr in the patients with transient ischemic attacks, 9.2%/yr in the patients with stroke, and 4.6%/yr in the asymptomatic patients.

The long-term results of carotid endarterectomy for transient ischemic attacks.

One hundred patients who underwent carotid endarterectomy for transient ischemic attacks (TIAs) have been followed up for 3 to 10 years (mean, 5.5 years). Seven patients have been lost to follow-up but none is recorded as dead (National Registry of Deaths) at least 5 years after operation. Fifteen patients (16.5%) have died, four from cerebral and eight from cardiac causes. Three patients had cerebral infarction with permanent deficits, one occurring immediately after operation, one at 3 months, and one at 9 years. Four patients had minor strokes but a full clinical recovery, three patients postoperatively and one patient at 4 years. Fourteen patients had ipsilateral TIAs, four occurred postoperatively and 10 occurred from 1 to 8 years later. Ten patients had contralateral TIAs and five patients then had a contralateral carotid endarterectomy. Another nine patients also had bilateral operations, three for bilateral TIAs, five as prophylactic procedures on the basis of arteriographic findings, and one for a contralateral cerebral event that occurred after arteriography. Thus, at the mean follow-up time (5.5 years) and including the operative complications, four deaths (4%) of cerebral origin and seven serious cerebral problems (7%) have occurred--an annual morbidity and mortality rate of less than 2%. This compares favorably with the commonly predicted rate of stroke occurring after TIAs of 5% per year. These figures support the argument that carotid endarterectomy reduces the incidence of stroke occurring after TIA and stops TIAs caused by emboli from the carotid bifurcation.

The long-term results of carotid endarterectomy for transient ischemic attacks

One hundred patients who underwent carotid endarterectomy for transient ischemic attacks (TIAs) have been followed up for 3 to 10 years (mean, 5.5 years). Seven patients have been lost to follow-up but none is recorded as dead (National Registry of Deaths) at least 5 years after operation. Fifteen patients (16.5%) have died, four from cerebral and eight from cardiac causes. Three patients had cerebral infarction with permanent deficits, one occurring immediately after operation, one at 3 months, and one at 9 years. Four patients had minor strokes but a full clinical recovery, three patients postoperatively and one patient at 4 years. Fourteen patients had ipsilateral TIAs, four occurred postoperatively and 10 occurred from 1 to 8 years later. Ten patients had contralateral TIAs and five patients then had a contralateral carotid endarterectomy. Another nine patients also had bilateral operations, three for bilateral TIAs, five as prophylactic procedures on the basis of arteriographic findings, and one for a contralateral cerebral event that occurred after arteriography. Thus, at the mean follow-up time (5.5 years) and including the operative complications, four deaths (4%) of cerebral origin and seven serious cerebral problems (7%) have occurred—an annual morbidity and mortality rate of less than 2%. This compares favorably with the commonly predicted rate of stroke occurring after TIAs of 5% per year. These figures support the argument that carotid endarterectomy reduces the incidence of stroke occurring after TIA and stops TIAs caused by emboli from the carotid bifurcation.

Long-term results of endarterectomy of the internal carotid artery for cerebral ischemia and infarction.

The immediate and long-term results of carotid endarterectomy for treatment of acute cerebral ischemia or infarction were studied in 95 patients who were observed for an average period of 40 months after the surgical procedure. The operation resulted in death for 12 patients and worsening of the neurological deficit in six others. During the follow-up period, there were 22 additional deaths, most of which were caused by myocardial infarction or other complications of systemic atherosclerotic vascular disease. The significant factors adversely affecting the prognosis of these patients consisted of severe electrocardiographic abnormalities, the presence of bilateral carotid occlusive lesions, cerebral infarction prior to endarterectomy, and the age of the patient. Following endarterectomy only five patients were observed to have recurrent attacks of transient cerebral ischemia which were few in number and stopped spontaneously. Recurrent cerebral infarction developed in only seven patients, six of whom had unsuccessful or incomplete removal of the carotid occlusive lesions. Although this low incidence of recurrent ischemia and infarction seems to be evidence for the therapeutic value of carotid endarterectomy, further observations on a comparable group of patients treated nonsurgically are needed to support this conclusion.