Repeat Carotid Endarterectomy Research Articles

Transcarotid artery revascularization of a symptomatic carotid artery with a tortuous intrathoracic component

We present the case of a tortuous intrathoracic common carotid artery (CCA) with a symptomatic right internal carotid artery lesion. This patient had a complex medical history, including a previous intraoperative cardiac arrest during attempted carotid endarterectomy (CEA) initially attributed to heparin anaphylaxis. She received maximum medical management but presented 6 months later to our institution with a secondary transient ischemic attack. Surgical options for the case were discussed amongst a multidisciplinary team. Transfemoral and transradial stenting were deemed non-viable due to the tortuous nature of the CCA. Repeat CEA under general anesthesia was deemed risk-prohibitive from a cardiac risk perspective. For these reasons, the patient was offered transcarotid artery revascularization (TCAR) under regional anesthesia. Intraoperatively, the “sheath stopper” was removed from the TCAR device, allowing the sheath to be advanced to 6 cm, effectively removing the tortuous component of the CCA. Flow reversal was established, and the operation proceeded in the standard fashion without neurologic change. The patient has remained on dual antiplatelet therapy and completed 2-year follow-up without evidence of restenosis, access site complication, or repeat neurologic event. This case demonstrates the potential applicability of TCAR to benefit a subset of patients who previously lacked a surgical option due to anatomical constraints.

Results of Carotid Endarterectomy for Free-Floating Thrombus of the Carotid Artery

<h3>Introduction and Objective</h3> Free-floating thrombus (FFT) of the carotid artery is an uncommon occurrence with little published data. The etiology likely involves atherosclerotic plaque forming a nidus for thrombus formation. However, evidence suggests other conditions may be involved, including more recently Covid-19. Clinical management is debated, and it remains unclear whether surgical, endovascular intervention, or anticoagulation alone is superior. The purpose of this study is to report our recent experience with FFT treated by carotid endarterectomy (CEA). <h3>Methods</h3> We retrospectively reviewed the medical records and imaging studies of patients who underwent CEA for FFT at a single community hospital. Patient demographics, diagnostic methods, clinical presentation, past medical histories, and surgical outcomes were analyzed. <h3>Results</h3> Between November 2014 and June 2020, 312 carotid endarterectomies (CEA) were performed. A total of 6 CEA's was performed for FFT identified by CTA, duplex U/S, or both. The 5 women (83%) and 1 man (17%) had an average age of 59.9 years (range 39 to 76.5 years). Atherosclerosis risk factors included: smoking 4 (66%), diabetes 2 (33%), HTN 6 (100%), dyslipidemia 6 (100%). Two patients had an additional thrombotic or autoimmune condition. The FFT originated in the CCA in 2 cases (33%) and the proximal ICA in the remaining 4 cases (66%). The degree of carotid stenosis varied from 0 to 90%. All six patients presented with an ischemic stroke with an average NIH stroke scale of 4.7 (range, 1 – 10). Urgent CEA was performed in 5 patients with no worsening of their neurological symptoms. One patient with the FFT extending to the skull base was treated with apixaban, had complete resolution of the thrombus at six weeks, and subsequently underwent an uncomplicated elective CEA. The average length of stay was 5.8 days (range 2 to 17 days). Mean length of follow up was 4.2 years (range 2.7 to 6 years). During follow up, one patient required a repeat CEA for an early symptomatic recurrent stenosis. As compared to patients undergoing CEA without FFT, patients with FFT were younger (P=.02), more likely to be women (p=.01), and more likely to present with ischemic CVA (p<.001).Fig. 1Duplex scan, CTA and intraoperative photograph of FFT of the carotid artery.Fig 1 <h3>Conclusion</h3> In our series, FFT of the carotid artery always presented as an acute ischemic stroke and was more common in women. Although recommendations cannot be made based on this small retrospective study, our experience suggests that prompt CEA is a safe treatment option. Anticoagulation resulting in thrombus resolution has been previously reported and deserves further study.

CAROTID ARTERY ENDARTERECTOMY VERSUS CAROTID ARTERY STENTING FOR RESTENOSIS AFTER CAROTID ARTERY ENDARTERECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Carotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). It remains unclear whether carotid artery stenting (CAS) or a repeat CEA (redoCEA) is the best treatment strategy for carotid artery restenosis. This study was performed according to the PRISMA and MOOSE guidelines

CRT-200.29 Carotid Artery Endarterectomy vs. Carotid Artery Stenting For Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-analysis

Carotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). It remains unclear whether carotid artery stenting (CAS) or a repeat CEA (redoCEA) is the best treatment strategy for carotid artery restenosis. This study was performed according to the PRISMA and MOOSE guidelines

Abstract 115: Is Routine Patching Necessary Following Carotid Endarterectomy (CEA)?

Objectives: Large medicare databases and meta-analyses recommend routine patching following carotid endarterectomy (CEA). Routine patching reduces perioperative stroke, carotid thrombosis, and restenosis. This 30 year experience evaluates the long term outcome of CEA with selective patching and without routine postoperative duplex examination. Methods: An IRB-approved retrospective review of all CEAs peformed by two surgeons over a 30 year period (1984-2014). Pre-operative imaging studies, operative reports, physical findings, co-morbid conditions, and pre- and postoperative medications were evaluated. Results: Over a 30-year period, 439 CEAs were performed for symptomatic carotid disease using a selective patch technique depending on gender, internal carotid artery diameter, cardiovascular risk factors, and preoperative arteriogram. In this group of 439 patients, 17 (3.9%) had patch closure of the carotid artery and the other 422 (96.1%) had primary closure. There were 2 (0.47%) perioperative strokes in the primary closure group and 4 (0.95%) patients in this group developed symptomatic carotid restenosis at a mean follow-up of 49.5 months (range 1 to 237 months). There was 1 (5.8%) carotid thrombosis in the patch closure group who also had a perioperative stroke and was serologically positive for a hypercoagulable disorder. The 4 patients who developed symptomatic restenosis had arteriographically proven &gt; 90% stenosis and required repeat CEA. The remaining 418 (99.0%) patients having primary closure remained neurologically asymptomatic (mean follow-up 10.3 years, range 2.5 to 17 years). There was 1 (0.23%) operative death that occurred following the induction of general anesthesia. Conclusions: In this experience, there is no statistically significant difference in restenosis in the primary closure group and selective patch group following CEA. Although this data set is a small, single center, two surgeon, retrospective review, it does not support the generally well accepted view of routine patching following CEA

Abstract 3: Restenosis following Carotid Artery Stenting and Endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial

Objectives The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) showed no difference in the composite endpoint of stroke, myocardial infarction, or death between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in patients with symptomatic or asymptomatic carotid stenosis (CS). We compared restenosis or occlusion, and repeat revascularization, between CAS and CEA over 2 years of follow-up. Methods Restenosis, occlusion, and repeat revascularization were assessed at 1, 6, 12 and 24 months post-randomization. Hemodynamically significant restenosis (≥70% diameter reduction) was defined by a peak systolic velocity (PSV) ≥300 cm/second on standardized duplex ultrasonography (DUS), occlusion by an absence of flow within the target artery on DUS, and repeat revascularization by any additional procedure (CEA, angioplasty or CAS) performed on the index artery. Studies were performed in CREST-certified laboratories and interpreted in the CREST Ultrasound Core Lab. Patients included in this report were those who received their assigned treatment within 30 days of randomization and had an ultrasound reviewed at the Core Lab (n=2191). Treatment differences were assessed using proportional hazards models adjusting for age, sex, and symptomatic status. Results In the analytic cohort, 1086 patients received CAS and 1105 received CEA. Over 2 years 113 patients developed restenosis, 56 (rate 5.8%) in the CAS group and 57 (rate 5.8%) in the CEA group; and 8 developed an occlusion, 3 (rate 0.3 %) in the CAS group and 5 (rate 0.5%) in the CEA group. The combined restenosis-occlusion rate was 6.0% (n=58) for CAS and 6.3% (n=62) for CEA (HR=0.90, 95% CI=0.63-1.29, p=0.58). Forty-three patients of the 2191 underwent repeat revascularization (20 CAS, 23 CEA, p=0.69) of which 28 had restenosis by our criteria and so were included ( Figure ). Stroke occurred in 13 (4 CAS; 9 CEA) of the 120 patients with restenosis or occlusion; 1 of the 4 CAS strokes occurred after restenosis was detected, and 5 of 9 CEA strokes occurred after restenosis was detected. Conclusions This analysis of carotid restenosis is the largest reported to date from any randomized clinical trial. Restenosis and occlusion were infrequent and similar up to 2 years following CAS or CEA among 2191 patients. The rates of revascularization likewise did not differ between CAS and CEA. Follow-up out to 10 years is ongoing. Figure. Kaplan-Meier curves of restenosis and occlusion over 2 years.

Impact of Routine Completion Angiography on the Results of Primary Carotid Endarterectomy: A Prospective Study in a Teaching Hospital

Objective: To assess the usefulness of completion angiography in the prevention of stroke, carotid occlusion and residual stenosis after primary carotid endarterectomy (CEA) in the setting of a teaching hospital. Material and Methods: From January 1995 to August 2009, 1055 consecutive patients having 1179 CEAs were entered in a prospective study excluding patients with severe renal insufficiency, allergy to contrast media and patients with repeat CEA or carotid bypass. In this cohort, 552 patients (52.3%) were asymptomatic, 318 (30.2%) had a transient ischaemic attack (TIA) and 185 (17.5%) had a stroke. Routine completion angiography was obtained in all 1055 patients. The decision to perform a surgical revision was decided for any of the following defects: (1) a residual stenosis of more than 50% of the internal carotid artery (ICA) or common carotid artery (CCA) and of more than 70% of the external carotid artery (ECA), (2) any flap and (3) any intraluminal-filling defect. A postoperative duplex scan was obtained within a week after surgery and thereafter on a yearly basis. Median follow-up was 7 years. Results: CEA was performed by a senior surgeon as first operator in 812 cases (69%) and by a trainee, with a scrubbed senior surgeon, in 367 cases (31%). Completion angiography revealed significant defects in 72 cases (6.1%) warranting revision for ECA flap (n = 30), thrombus in contact with the patch (n = 7), distal ICA flap or stenosis (n = 20) and CCA flap or residual plaque (n = 15). Logistic regression analysis showed that total length of the carotid plaque >6 cm (p = 0.02, Odds ratio: 2.31; 95% confidence interval (CI) (1.21–3.72)), eversion endarterectomy of the ECA (p = 0.01, Odds ratio 3.41; 95%CI (2.10–5.94)) and trainee as first operator (p = 0.02, Odds ratio 2.42; 95%CI (1.81–4.23)) were independent predictors of operative defects seen on completion angiography. No complication in relation to carotid catheterisation or injection of contrast media occurred in this series. The 30-day combined stroke and death rate was 1.5%, comparable between senior surgeons and trainees (p = 0.60). There was no significant difference in the combined stroke and death rate observed in patients with normal completion angiography (1.4%) compared with that of the patients with a defect corrected (2.8%) (p = 0.28, Odds ratio: 0.67; 95%CI (0.22–2.09)). But there was an increased incidence of postoperative TIA in the group with revision (p = 0.001, odds ratio: 5.8, 95%CI: 1.8–18.9). At 7 years, the freedom rate from >50% carotid restenosis or occlusion was 87.5 ± 6.7% in patients with normal completion angiography and 92 ± 5.4% in patients, who undergo a surgical revision. Conclusion: In a single centre, CEA with routine completion angiography resulted in good perioperative outcome. Plaque length, technique for external carotid artery (ECA) endarterectomy and trainee as first operator were independent predictors of operative defects seen on completion angiography.

Eversion Carotid Endarterectomy for Recurrent Stenosis After Carotid Angioplasty/Stenting

Restenosis requiring treatment after carotid angioplasty/stenting is uncommon in clinical practice. Treatment options include repeat angioplasty (with or without another stent) or carotid endarterectomy. This report describes a patient with recurrent stenosis treated with eversion carotid endarterectomy and stent removal.

Impact of Routine Completion Angiography on the Results of Primary Carotid Endarterectomy: A Prospective Study in a Teaching Hospital

Objective To assess the usefulness of completion angiography in the prevention of stroke, carotid occlusion and residual stenosis after primary carotid endarterectomy (CEA) in the setting of a teaching hospital. Material and Methods From January 1995 to August 2009, 1055 consecutive patients having 1179 CEAs were entered in a prospective study excluding patients with severe renal insufficiency, allergy to contrast media and patients with repeat CEA or carotid bypass. In this cohort, 552 patients (52.3%) were asymptomatic, 318 (30.2%) had a transient ischaemic attack (TIA) and 185 (17.5%) had a stroke. Routine completion angiography was obtained in all 1055 patients. The decision to perform a surgical revision was decided for any of the following defects: (1) a residual stenosis of more than 50% of the internal carotid artery (ICA) or common carotid artery (CCA) and of more than 70% of the external carotid artery (ECA), (2) any flap and (3) any intraluminal-filling defect. A postoperative duplex scan was obtained within a week after surgery and thereafter on a yearly basis. Median follow-up was 7 years. Results CEA was performed by a senior surgeon as first operator in 812 cases (69%) and by a trainee, with a scrubbed senior surgeon, in 367 cases (31%). Completion angiography revealed significant defects in 72 cases (6.1%) warranting revision for ECA flap ( n = 30), thrombus in contact with the patch ( n = 7), distal ICA flap or stenosis ( n = 20) and CCA flap or residual plaque ( n = 15). Logistic regression analysis showed that total length of the carotid plaque >6 cm ( p = 0.02, Odds ratio: 2.31; 95% confidence interval (CI) (1.21–3.72)), eversion endarterectomy of the ECA ( p = 0.01, Odds ratio 3.41; 95%CI (2.10–5.94)) and trainee as first operator ( p = 0.02, Odds ratio 2.42; 95%CI (1.81–4.23)) were independent predictors of operative defects seen on completion angiography. No complication in relation to carotid catheterisation or injection of contrast media occurred in this series. The 30-day combined stroke and death rate was 1.5%, comparable between senior surgeons and trainees (p = 0.60). There was no significant difference in the combined stroke and death rate observed in patients with normal completion angiography (1.4%) compared with that of the patients with a defect corrected (2.8%) ( p = 0.28, Odds ratio: 0.67; 95%CI (0.22–2.09)). But there was an increased incidence of postoperative TIA in the group with revision ( p = 0.001, odds ratio: 5.8, 95%CI: 1.8–18.9). At 7 years, the freedom rate from >50% carotid restenosis or occlusion was 87.5 ± 6.7% in patients with normal completion angiography and 92 ± 5.4% in patients, who undergo a surgical revision. Conclusion In a single centre, CEA with routine completion angiography resulted in good perioperative outcome. Plaque length, technique for external carotid artery (ECA) endarterectomy and trainee as first operator were independent predictors of operative defects seen on completion angiography.

The patients’ perspective of carotid endarterectomy

Introduction: No studies as yet have directly evaluated the patients’ perspective of carotid endarterectomy (CEA). Here, we determine patient satisfaction, understanding, and perception of CEA. Methods: Consecutive patients were identified from a prospectively maintained carotid database. A validated 10-point telephone questionnaire was conducted. Questions related to preoperative symptoms, experience of procedure, future interventions, and overall patient satisfaction. Results: Of the 192 patients included, 136 completed the questionnaire (71% response rate). Ninety-two percent were satisfied with the explanation received, however, only 48% understood that CEA aimed to prevent future stroke. Eighty-five percent of patients received local anesthesia (LA) CEA, with 16% reporting severe or unbearable pain. Most patients (83%) would repeat CEA if necessary and 67% stated a future preference for LA CEA. The majority of patients (96%) were satisfied with their treatment overall. Conclusions: Most patients were...

The Patients’ Perspective of Carotid Endarterectomy

No studies as yet have directly evaluated the patients' perspective of carotid endarterectomy (CEA). Here, we determine patient satisfaction, understanding, and perception of CEA. Consecutive patients were identified from a prospectively maintained carotid database. A validated 10-point telephone questionnaire was conducted. Questions related to preoperative symptoms, experience of procedure, future interventions, and overall patient satisfaction. Of the 192 patients included, 136 completed the questionnaire (71% response rate). Ninety-two percent were satisfied with the explanation received, however, only 48% understood that CEA aimed to prevent future stroke. Eighty-five percent of patients received local anesthesia (LA) CEA, with 16% reporting severe or unbearable pain. Most patients (83%) would repeat CEA if necessary and 67% stated a future preference for LA CEA. The majority of patients (96%) were satisfied with their treatment overall. Most patients were satisfied with CEA. Greater emphasis could be placed on improving preoperative information-giving and intraoperative analgesia.

Comparison of Inhospital Outcomes of Patients With Versus Without Previous Carotid Endarterectomy Undergoing Carotid Stenting (from the German ALKK CAS Registry)

Repeat carotid endarterectomy (CEA) for recurrent stenosis remains a challenging treatment option associated with high morbidity and mortality. Carotid artery stenting (CAS) is an attractive alternative management option for these patients. However, data about the effectiveness and safety of CAS in a large number of unselected patients are less known. We evaluated 3,070 patients who underwent CAS enrolled in a German registry from 1996 to 2006 at 31 sites. We compared clinical and angiographic features and in-hospital outcomes of patients with and without previous CEA who underwent CAS. Of 3,070 patients in the registry, 223 (7.3%) underwent CAS for restenosis after previous CEA. Median age was similar in patients with and without previous CEA (70 years, interquartile range 64 to 76 vs 71 years, interquartile range 65 to 76). Ipsilateral neurologic symptoms occurred in approximately 1/2 the patients in both groups. Other co-morbid conditions and angiographic or procedural factors did not differ between the 2 groups. In-hospital events including death (0% vs 0.4%), ipsilateral major stroke (1.4% vs 1.5%), death or major ipsilateral stroke (1.4% vs 1.7%), ipsilateral transient ischemic attack (1.9% vs 2.8%), myocardial infarction (0.4% vs 0.1%), and reintervention (0.7% vs 0.4%) were all low and not significantly different between those with and without previous CEA (p >0.05 for all comparisons). In conclusion, our data for a large number of patients who underwent CAS in a recent contemporary community-based practice attests to the low risk of periprocedural events in patients with recurrent stenosis after previous CEA. This low risk along with the less invasive nature of the procedure should make CAS an attractive and perhaps preferred option for the treatment of these patients.

Carotid angioplasty and stenting for postendarterectomy stenosis: Long-term follow-up

Carotid angioplasty and stenting (CAS) for recurrent stenosis after carotid endarterectomy (CEA) has been proposed as an alternative to redo CEA. Although early results are encouraging, the extended durability remains unknown. We present the long-term surveillance results of CAS for post-CEA restenosis. Between 1998 and 2004, 57 CAS procedures were performed in 55 patients (36 men) with a mean age of 70 years. The mean interval between CEA and CAS was 83 months (range, 6 to 245). Nine patients (16%) were symptomatic. CAS was performed successfully in all patients. No deaths or strokes occurred. A periprocedural transient ischemic attack (TIA) occurred in two patients. During a mean follow-up of 36 months (range, 12 to 72 months), two patients exhibited ipsilateral cerebral symptoms (1 TIA, 1 minor stroke). In 11 patients (19%), in-stent restenosis (> or =50%) was detected post-CAS at month 3 (n = 3), 12 (n = 3), 24 (n = 2), 36 (n = 1), 48 (n = 1), and 60 (n = 1). The cumulative rates of in-stent restenosis-free survival at 1, 2, 3, and 4 years were 93%, 85%, 82%, and 76%, respectively. Redo procedures were performed in six patients, three each received repeat angioplasty and repeat CEA with stent removal. The cumulative rates of freedom from reintervention at 1, 2, 3, and 4 years were 96%, 94%, 90%, and 84%, respectively. Carotid angioplasty and stenting for recurrent stenosis after CEA can be performed with a low incidence of periprocedural complications with durable protection from stroke. The rate of in-stent recurrent stenosis is high, however, and does not only occur early after CAS but is an ongoing process.

Multistate improvement in process and outcomes of carotid endarterectomy

ObjectivesThe purpose of this study was to assess the effect of community-wide performance measurement and feedback on key processes and outcomes of carotid endarterectomy (CEA). MethodsComplete medical record (hospital chart) review for indications, care processes, and outcomes was performed on a random sample of Medicare patients undergoing CEA in 10 states (Arkansas, Georgia, Illinois, Indiana, Iowa, Kentucky, Michigan, Nebraska, Ohio, Oklahoma) during baseline (Jun 1, 1995 to May 31, 1996) and remeasurement (Jun 1, 1998 to May 31, 1999) periods. In addition to review of the index hospital stay, hospital admissions within 30 days of the procedure were reviewed and the Medicare enrollment database queried to identify out-of-hospital deaths, to determine 30-day outcome results. The baseline data by state were provided to the Medicare Quality Improvement Organizations (QIOs) in the respective states, and quality improvement initiatives were encouraged. ResultsWe reviewed 9945 primary CEA alone procedures, 236 CEA and coronary artery bypass grafting (CABG) procedures, and 380 repeat CEA operations during the baseline period (B), and 9745 primary CEA alone procedures, 233 CEA and CABG procedures, and 401 repeat CEA operations during the remeasurement period (R). There was a significant decrease in the combined event rate (30-day stroke or mortality) for CEA alone procedures between baseline and remeasurement (B, 5.6%; R, 5.0%). A decrease occurred in each of the indication strata; transient ischemic attack or stroke (B, 7.7%; R, 6.9%), nonspecific symptoms (B, 5.9%; R, 5.4%), and no symptoms (B, 4.1%; R, 3.8%). The combined event rate also decreased for CEA and CABG (B, 17.4%; R, 13.3%) and repeat CEA operations (B, 6.8%; R, 5.7%). The remeasurement period state-to-state variation in combined event rate for CEA alone ranged from 2.7% (Georgia) to 5.9% (Indiana) for all indications combined, from 4.4% (Georgia) to 10.9% (Michigan) in patients with recent transient ischemia or stroke, from 1.4% (Georgia) to 6.0% (Oklahoma) in patients with no symptoms, and from 3.7% (Georgia) to 7.9% (Indiana) in patients with nonspecific symptoms. There were significant increases in preoperative antiplatelet administration (62%-67%; P < .0001) and patching (29%-45%; P = .05) from baseline to remeasurement in the CEA alone subset. Preoperative antiplatelet administration and patching were associated with improved outcomes in the combined baseline and remeasurement data. ConclusionsCommunity-wide quality improvement initiatives with performance measurement and confidential reporting of provider level data can lead to improvement in important care processes and outcomes. There is considerable variation between states in outcome and process, and thus continued room for improvement. Quality improvement projects that include standardized confidential outcome reporting should be encouraged. Preoperative antiplatelet therapy administration and patching rates should be considered as evidence-based performance measures.

Carotid Surgery Following Previous Carotid Endarterectomy Is Safe and Effective

With the perceived high risk of repeat carotid surgery, carotid angioplasty and stenting have been advocated recently as the preferred treatment of recurrent carotid disease following carotid endarterectomy. An experience with the operative treatment of recurrent carotid disease to document the risks and benefits of this procedure is presented. A review of a prospectively acquired vascular registry over a 10-year period (Jan. 1990-Jan. 2000) was undertaken to identify patients undergoing repeat carotid surgery following previous carotid endarterectomy. All patients were treated with repeat carotid endarterectomy, carotid interposition graft, or subclavian-carotid bypass. The perioperative stroke and death rate, operative complications, life-table freedom from stroke, and rates of recurrent stenosis were documented. During the study period 56 patients underwent repeat carotid surgery, comprising 6% of all carotid operations during this period. The indication for operation was symptomatic disease recurrence in 41 cases (73%) and asymptomatic recurrent stenosis >/=80% in 15 cases (27%). The average interval from the prior carotid endarterectomy to the repeat operation was 78 months (range 3 weeks-297 months). The operations performed included repeat carotid endarterectomy with patch angioplasty in 31 cases (55%), interposition grafts in 19 cases (34%), and subclavian-carotid bypass in 6 cases (11%). There were three perioperative strokes with one resulting in death for a perioperative stroke and death rate of 5.4%. One minor transient cranial nerve (CN IX) injury occurred. Mean follow-up was 29 months (range, 1-116 months). Life-table freedom from stroke was 95% at 1 year and 90% at 5 years. Recurrent stenosis (>/=80%) developed in three patients (5.4%) during follow-up, including one internal carotid artery occlusion. Two patients (3.6%) underwent repeat surgery. Repeat surgery for recurrent cerebrovascular disease following carotid endarterectomy is safe and provides durable freedom from stroke. Most patients are candidates for repeat endarterectomy with patching, but interposition grafting is often required. These results strongly support the continued role of repeat carotid surgery in the treatment of recurrent carotid disease.

Multistate utilization, processes, and outcomes of carotid endarterectomy

Objectives: The purpose of this study was to describe variation in utilization, care processes, and outcomes for carotid endarterectomy (CEA) procedures in 10 states. Methods: We reviewed the medical records of Medicare patients who underwent 10,561 CEA procedures between June 1, 1995, and May 31, 1996, in 10 different states to determine indications, care processes, and outcomes. This study also included medical record review of hospital readmissions within 30 days of the procedure and identification of out-of-hospital deaths from the Medicare beneficiary files. Results: Utilization rates of CEA varied from 25.7 to 38.4 procedures per 10,000 Medicare beneficiaries among states. The overall combined event rate (30-day stroke or mortality) was 5.2% for primary CEA alone (n = 9945). The mortality rate was 1.5%, and the nonfatal stroke rate was 3.7%. Combined event rates (CEA alone) by surgical indication were 7.7% for stroke (n = 1037), 7.4% for transient ischemic attack (n = 1304), 5.3% for nonspecific symptoms (n = 3713), and 3.7% for asymptomatic patients (n = 3891). The combined event rates (CEA alone) among states ranged from 4.1% to 7.7% with the event rates in asymptomatic patients ranging from 2.3% to 6.7%. In a multivariate analysis (correcting for indication), the use of preoperative antiplatelet agents (odds ratio [OR], 0.70), intraoperative heparin (OR, 0.49), and patch angioplasty (OR, 0.73) was significantly associated with lower combined event rates. There were significant differences among states in the use of preoperative antiplatelet therapy (range, 56%-70%) and patch angioplasty (range, 11%-49%). Combined event rates for repeat procedures (n = 380) and CEA combined with coronary artery bypass grafting (n = 236) were 6.3% and 17.4%, respectively. Conclusions: The striking variation among states suggests that there is room for improvement in the utilization, care processes, and outcomes of CEA. All surgeons performing CEA should participate in outcome assessment and adopt protocols that include the routine administration of antiplatelet agents preoperatively, the use of heparin intraoperatively, and patch angioplasty of the endarterectomy site. (J Vasc Surg 2001;33:227-35.)

Cranial and cervical nerve injuries after repeat carotid endarterectomy

Background and Purpose: The incidence of cranial and/or cervical nerve injuries after primary carotid endarterectomy (CEA) ranges from 3% to 48%; however, the clinical outcome of these injuries after repeat CEA has not been thoroughly analyzed in the English-language medical literature. This prospective study analyzes the incidence and outcome of cranial nerve injuries after repeat CEA. Patients And Methods: This study includes 89 consecutive patients who had repeat CEAs. Preoperative and postoperative cranial nerve evaluations were performed, including clinical examinations (neurologic) and direct laryngoscopy. Patients with vagal or glossopharyngeal nerve injuries also underwent comprehensive speech evaluations, video stroboscopy, fluoroscopy, and methylene blue testing for aspiration. Patients with postoperative cranial nerve injuries were followed up for a long time to assess their recovery. Results: Twenty-five cranial and/or cervical nerve injuries were identified in 19 patients (21%). They included 8 hypoglossal nerves (9%), 11 vagal nerves or branches (12%) (6 recurrent laryngeal nerves [7%], 3 superior laryngeal nerves [3%], and 2 complex vagal nerves (2%]), 3 marginal mandibular nerves (3%), 2 greater auricular nerves (2%), and 1 glossopharyngeal nerve (1%). Twenty-two (88%) of these injuries were transient with a complete healing time ranging from 2 weeks to 28 months (18 of 22 injuries healed within 12 months). The remaining three injuries (12%) were permanent (1 recurrent laryngeal nerve, 1 glossopharyngeal nerve, and 1 complex vagal nerve injury). The recurrent laryngeal nerve injury had a longer healing time than the other cranial nerve injuries. Conclusions: Repeat CEA is associated with a high incidence of cranial and/or cervical nerve injuries, most of which are transient. However, some of these have a long healing time, and a few can be permanent with significant disability. (J Vasc Surg 2000;32:649-54.)

Treatment of restenosis after percutaneous transluminal angioplasty for internal carotid artery stenosis.

The efficacy of repeated percutaneous transluminal angioplasty (PTA) and carotid endarterectomy (CEA) was examined in patients with restenosis after PTA for carotid stenosis. After percutaneous transluminal angioplasty (PTA) for 63 cases of internal carotid stenoses 13 cases of restenosis appeared. They were treated by PTA or carotid endarterectomy. The treatment was chosen by the patient after explanation of each treatment. We initially treated seven patients by repeat PTA and six by carotid endarterectomy. The degree of stenosis improved from 82% to 30% on average after repeated PTA. However, one patient in the PTA group had restenosis, and carotid endarterectomy was then performed. The other cases also had restenosis and were treated by PTA. The six cases treated by carotid endarterectomy were successfully treated without difficulty. The success rate of PTA was 5/7 (71%) in the restenosis cases. Patients with a greater residual stenosis after initial PTA had significantly more frequent restenosis. Repeat PTA and CEA both appeared effective treatment for restenosis after initial PTA, although PTA had a restenosis rate similar to that of initial PTA.

Outpatient Carotid Artery Stenting: A Case Report

Purpose: To report a case of carotid artery stenting for asymptomatic carotid restenosis performed in an outpatient setting. Methods and Results: A 68-year-old man with right carotid restenosis after repeat carotid endarterectomy underwent carotid angioplasty and stenting on an ambulatory basis. The procedure to implant a Smart stent required 45 minutes; the femoral access site was closed with a puncture closure device. The patient experienced no sequelae to this procedure and is well 6 months after treatment. Conclusions: Outpatient delivery of percutaneous carotid stenting may be feasible in appropriately selected patients.

Treatment of Recurrent Carotid Disease

The purpose of this study was to determine whether repeat carotid endarterectomy (CEA) poses a greater risk than first-time CEA. The authors analyzed data from 893 consecutive CEA cases (1981-1993). Thirty-three patients (3.7%) had repeat CEA, and 860 (96.3%) had first-time CEA. There were statistically significantly higher incidences of hypertension (60.6% vs 44.6%), smoking (84.8% vs 55%), hypertriglyceridemia (33.3% vs 16.2%), and coronary artery disease (66.6% vs 36%) in the repeat CEA group than in the first-time CEA group. Symptomatic disease was present in 25 (75.8%) patients in the repeat group and in 576 (67%) patients in the first-time group (P&gt;0.05). The cause of recurrence was atherosclerosis in 25 patients (76%), myointimal hyperplasia in seven patients (21.2%), and intraluminal thrombus without an underlying lesion in one patient (3%). Redo CEA with vein patch angioplasty was performed in 27 patients (82%), vein patch angioplasty alone in five patients (15%), and interposition vein graft in one patient (3%). The hospital operative mortality was 0% (n=0) in the repeat CEA group and 0.6% (n=5) in the first-time CEA group (P&gt;0.05). The incidence of postoperative stroke was 0% (n=0) in the repeat group and 1.2% (n= 10) in the first-time group (P&gt;0.05). There was one case (3%) of transient ischemic attack (TIA) in the repeat group, and two cases (0.2%) of TIA in the first-time group. There was no difference in the incidence of cranial nerve dysfunction between the repeat group (n=2, 6%) and the first-time group (n=41, 4.8%; P&gt;0.05). Late follow-up data were obtained for 30 patients (mean: 61.4 months, range: 5-158 months) in the repeat CEA group and 501 patients (mean: 55.8 months, range: 17-168 months) in the first-time CEA group. The incidence of late failure (ipsilateral stroke or TIA) was 3.3% (n= 1) in the repeat group and 3.2% (n= 16) in the firsttime CEA group; P&gt;0.05. The overall late mortality was 20% (n=6) in the repeat CEA group and 14.6% (n=73) in the primary CEA group; P&gt;0.05. Repeat CEA can be performed safely in individuals with severe recurrent carotid stenosis, and perioperative and long-term mortality and neurologic morbidity rates are similar to those for patients undergoing first-time carotid endarterectomy.