The Effect of Severe Contralateral Carotid Stenosis or Occlusion on Early Outcomes after Carotid Endarterectomy

Muhamed Djedovic; Amel  Hadzimehmedagic; Nermir Granov; Ilirijana  Haxhibeqiri-Karabdic; Slevenka Štraus; Bedrudin Banjanovic; Edin Kabil; Tarik Selimovic

doi:10.3889/oamjms.2022.9475

Authors

Muhamed Djedovic Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina https://orcid.org/0000-0003-1752-5666
Amel Hadzimehmedagic Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Nermir Granov Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Ilirijana Haxhibeqiri-Karabdic Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Slevenka Štraus Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Bedrudin Banjanovic Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina https://orcid.org/0000-0003-2248-2445
Edin Kabil Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina https://orcid.org/0000-0001-7023-6244
Tarik Selimovic Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina

DOI:

https://doi.org/10.3889/oamjms.2022.9475

Keywords:

CEA, Stenosis, Stroke, Mortality

Abstract

BACKGROUND: Stenosis of the carotid arteries, as a consequence of atherosclerosis is the most common cause of cerebrovascular insult (CVI). Severe (>70%) contralateral stenosis or occlusion (SCSO) of the carotid artery may represent an additional pre-operative risk factor for neurologic incidents.

AIM: The aim of this study was to confirm and compare early perioperative results (0-30 days) of carotid endarterectomy (CEA) in patients with and without SCSO.

PATIENT AND METHODS: In our retrospective-prospective study, we analysed the results of 273 CEA, divided into two groups based on the presence of significant contralateral stenosis or occlusion (non-SCSO and SCSO groups)

RESULTS: 273 CEA’s were performed, divided into two groups: SCSO groups 40 (14.7%) and non-SCSO group 233 (85.3%). Between the two groups, a statistically significant difference between patients was found (54.1% compared to 87.5%; p<0.0005), CEA with patch angioplasty (25.3% compared to 52.5%; p=0.001), and CEA with the use of a shunt (3.9% compared to 35%; p<0.0005) in favour of the SCSO group. There was no statistically significant difference (SCSO was not identified as a risk factor) for any type of stroke or mortality. Logistically regression confirmed SCSO to be an independent predictor of 30-day mortality (OR 21.58; 95% CI 1.27-36.3; p= 0.033) and any type of stroke or mortality (OR 9.27; 95% CI 1.61-53.22; p= 0.012). SCSO was not a predictor of any type of stroke within 30 days. Predictors of any type of stroke was dyslipidemia (OR 0.12, 95% CI 0.02-0.76; p= 0.024).

CONCLUSIONS: There was no statistically significant difference in the incidence of early (30 day) perioperative complications between the analysed groups. The percentage of perioperative complications remains within the accepted parameters, and thus, SCSO should not be qualified as a significant risk factor for CEA. We are of the opinion that CEA remains a safe and acceptable options for patients with SCSO, and SCSO should not be a reason for preferential use of carotid stenting.

Downloads

Download data is not yet available.

Metrics

Metrics Loading ...

Plum Analytics Artifact Widget Block

References

Wolf PA, Clagett GP, Easton JD, Goldstein LB, Gorelick PB, Kelly-Hayes M, et al. Preventing ischemic stroke in patients with prior stroke and transient ischemic attack: A statement for healthcare professionals from the stroke council of the American heart association. Stroke. 1999;30(9):1991-4. https://doi.org/10.1161/01.STR.30.9.1991 PMid:10471455 DOI: https://doi.org/10.1161/01.STR.30.9.1991

Centers for Disease Control and Prevention. Prevalence of disabilities and associated health conditions among adults-United States 1999. MMWR Morb Mortal Wkly Rep. 2001;50(7):120-5. PMid:11393491

Eckstein HH, Kühnl A, Dorfler A, Kopp IB, Lawall H, Ringleb PA. The diagnosis, treatment and follow-up of extracranial carotid stenosis. Multidisciplinary German-Austrian guideline based on evidence and consensus. Dtsch Arztebl Int. 2013;110:468-76. https://doi.org/10.3238/arztebl.2013.0468 PMid:23964303 DOI: https://doi.org/10.3238/arztebl.2013.0468

Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke. 2011;42(8):e464-540. https://doi.org/10.1161/STR.0b013e3182112cc2 PMid:21282505 DOI: https://doi.org/10.1016/j.jacc.2010.11.005

Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clement D, Collet JP, et al. ESC guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: The task force on the diagnosis and treatment of peripheral artery diseases of the European society of cardiology (ESC). Eur Heart J. 2011;32(22):2851-906. https://doi.org/10.1093/eurheartj/ehr211 PMid:21282505 DOI: https://doi.org/10.1093/eurheartj/ehr211

Naylor AR, Ricco JB, De Borst GJ, Debus S, De Haro J, Halliday A, et al. Management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;55(1):3-81. https://doi.org/10.1016/j.ejvs.2017.06.021 PMid:28851594 DOI: https://doi.org/10.1016/j.ejvs.2018.03.023

Gasecki AP, Eliasziw M, Ferguson GG, Hachinski V, Barnett HJ. Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: Results from NASCET. North American symptomatic carotid endarterectomy trial (NASCET) group. J Neurosurg. 1995;83(5):778-82. https://doi.org/10.3171/jns.1995.83.5.0778 PMid:7472542 DOI: https://doi.org/10.3171/jns.1995.83.5.0778

Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace CM, et al. The North American symptomatic carotid endarterectomy trial: Surgical results in 1415 patients. Stroke. 1999;30(9):1751-8. https://doi.org/10.1161/01.STR.30.9.1751 PMid:10471419 DOI: https://doi.org/10.1161/01.STR.30.9.1751

Baker WH, Howard VJ, Howard G, Toole JF. Effect of contralateral occlusion on long-term efficacy of endarterectomy in the asymptomatic carotid atherosclerosis study (ACAS). ACAS investigators. Stroke. 2000;31(10):2330-4. https://doi.org/10.1161/01.STR.31.10.2330 PMid:11022059 DOI: https://doi.org/10.1161/01.STR.31.10.2330

Menyhei G, Björck M, Beiles B, Halbakken E, Jensen LP, Lees T, et al. Outcome following carotid endarterectomy: Lessons learned from a large international vascular registry. Eur J Vasc Endovasc Surg. 2011;41(6):735-40. https://doi.org/10.1016/j.ejvs.2011.02.028 PMid:21450496 DOI: https://doi.org/10.1016/j.ejvs.2011.02.028

Ricotta JJ 2nd, Upchurch GR, Landis GS, Kenwood CT, Siami FS, Tsilimparis N, et al. The influence of contralateral occlusion on results of carotid interventions from the society for vascular surgery vascular registry. J Vasc Surg. 2014;60(4):958-65. https://doi.org/10.1016/j.jvs.2014.04.036 PMid:25260471 DOI: https://doi.org/10.1016/j.jvs.2014.04.036

Maatz W, Köhler J, Botsios S, John V, Walterbusch G. Risk of stroke for carotid endarterectomy patients with contralateral carotid occlusion. Ann Vasc Surg. 2008;22(1):45-51. https://doi.org/10.1016/j.avsg.2007.07.034 PMid:18083336 DOI: https://doi.org/10.1016/j.avsg.2007.07.034

Antoniou GA, Kuhan G, Sfyroeras GS, Georgiadis GS, Antonious SA, Murray D, et al. Contralateral occlusion of the internal carotid artery increases the risk of patients undergoing carotid endarterectomy. J Vasc Surg. 2013;57(4):1134-45. https://doi.org/10.1016/j.jvs.2012.12.028 PMid:23462196 DOI: https://doi.org/10.1016/j.jvs.2012.12.028

Mozes G, Sullivan TM, Torres-Russotto DR, Bower TC, Hoskin TL, Sampaio SM, et al. Carotid endarterectomy in SAPPHIRE-eligible high-risk patients: Implications for selecting patients for carotid angioplasty and stenting. J Vasc Surg. 2004;39(5):958-66. https://doi.org/10.1016/j.jvs.2003.12.037 PMid:15111844 DOI: https://doi.org/10.1016/j.jvs.2003.12.037

Ballotta E, Da Giau G, Guerra M. Carotid endarterectomy and contralateral internal carotid artery occlusion: Perioperative risks and long-term stroke and survival rates. Surgery. 1998;123(2):234-40. https://doi.org/10.1016/S0039-6060(98)70263-6 PMid:9481411 DOI: https://doi.org/10.1016/S0039-6060(98)70263-6

Rockman CB, Su W, Lamparello PJ, Adelman MA, Jacobowitz GR, Gagne PJ, et al. A reassessment of carotid endarterectomy in the face of contralateral carotid occlusion: Surgical results in symptomatic and asymptomatic patients. J Vasc Surg. 2002;36(4):668-73. PMid:12368723 DOI: https://doi.org/10.1067/mva.2002.127957

Grego F, Antonello M, Lepidi S, Zaramella M, Galzignan E, Menegolo M, et al. Is contralateral carotid artery occlusion a risk factor for carotid endarterectomy? Ann Vasc Surg. 2005;19(6):882-9. https://doi.org/10.1007/s10016-005-7719-2 PMid:16200472 DOI: https://doi.org/10.1007/s10016-005-7719-2

Kretz B, Abello N, Astruc K, Terriat B, Favier C, Bouchot O, et al. Influence of the contralateral carotid artery on carotid surgery outcome. Ann Vasc Surg. 2012;26(6):766-74. https://doi.org/10.1016/j.avsg.2011.12.009 PMid:22717355 DOI: https://doi.org/10.1016/j.avsg.2011.12.009

Pulli R, Dorigo W, Barbanti E, Azas L, Russo D, Matticari S, et al. Carotid endarterectomy with contralateral carotid artery occlusion: Is this a higher risk subgroup? Eur J Vasc Endovasc Surg. 2002;24(1):63-8. https://doi.org/10.1053/ejvs.2002.1612 PMid:12127850 DOI: https://doi.org/10.1053/ejvs.2002.1612

Dalainas I, Nano G, Bianchi P, Casana R, Malacrida G, Tealdi DG. Carotid endarterectomy in patients with contralateral carotid artery occlusion. Ann Vasc Surg. 2007;21(1):16-22. https://doi.org/10.1016/j.avsg.2006.06.003 PMid:17349330 DOI: https://doi.org/10.1016/j.avsg.2006.06.003

Calligaro KD, Dougherty MJ. Correlation of carotid artery stump pressure and neurologic changes during 474 carotid endarterectomies performed in awake patients. J Vasc Surg. 2005;42(4):684-9. https://doi.org/10.1016/j.jvs.2005.06.003 PMid:16242555 DOI: https://doi.org/10.1016/j.jvs.2005.06.003

De Bakey ME, Crawford ES, Cooley DA, Moriss GC Jr. Surgical considerations of occlusive disease of innominate, carotid, subclavina and vertebral arteries. Ann Surg. l959;149(5):690-710. https://doi.org/10.1097/00000658-195905000-00010 PMid:13637687 DOI: https://doi.org/10.1097/00000658-195905000-00010

Barnett HJ, Taylor DW, Eliasziw M, Fox A, Gary F, Brian H, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American symptomatic carotid endarterectomy trial collaborators. N Engl J Med. 1998;339(20):1415-25. https://doi.org/10.1056/NEJM199811123392002 PMid:9811916 DOI: https://doi.org/10.1056/NEJM199811123392002

Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms; Randomized controlled trial. Lancet. 2004;363(9420):1491-502. https://doi.org/10.1016/S0140-6736(04)16146-1 PMid:15135594 DOI: https://doi.org/10.1016/S0140-6736(04)16146-1

Kang J, Conrad MF, Patel VI, Mukhopandhyay S, Garg A, Cambria MR, et al. Clinical and anatomic outcomes after carotid endarterectomy. J Vasc Surg. 2014;59(4):944-9. https://doi.org/10.1016/j.jvs.2013.10.059 PMid:24661892 DOI: https://doi.org/10.1016/j.jvs.2013.10.059

Goodney PP, Likosky DS, Cronenwett JL. Factors associated with stroke or death after carotid endarterectomy in Northern New England. J Vasc Surg. 2008;48(5):1139-45. https://doi.org/10.1016/j.jvs.2008.05.013 PMid:18586446 DOI: https://doi.org/10.1016/j.jvs.2008.05.013

Tu JV, Wang H, Bowyer B, Green L, Fang J, Kucey D. Risk factors for death or stroke after carotid endarterectomy: Observations from the ontario carotid endarterectomy registry. Stroke. 2003;34(11):2568-73. https://doi.org/10.1161/01.STR.0000092491.45227.0F PMid:14526040 DOI: https://doi.org/10.1161/01.STR.0000092491.45227.0F

AbuRahma AF, Stone PA, Abu-Halimah S, Welch CA. Natural history of carotid artery occlusion contralateral to carotid endarterectomy. J Vasc Surg. 2006;44(1):62-6. https://doi.org/10.1016/j.jvs.2006.03.010 PMid:16828427 DOI: https://doi.org/10.1016/j.jvs.2006.03.010

Chiriano J, Abou-Zamzam AM, Nguyen K, Molkara AM, Zhang WW, Bianchi C, et al. Preoperative carotid duplex findings predict carotid stump pressures during endarterectomy in symptomatic but not asymptomatic patients. Ann Vasc Surg. 2010;24(8):1038-44. https://doi.org/10.1016/j.avsg.2010.05.014 PMid:21035695 DOI: https://doi.org/10.1016/j.avsg.2010.05.014

AbuRahma AF, Mousa AY, Stone PA, Hass SM, Dean LS, Keiffer T. Correlation of intraoperative collateral perfusion pressure during carotid endarterectomy and status of the contralateral carotid artery and collateral cerebral blood flow. Ann Vasc Surg. 2011;25(6):830-6. https://doi.org/10.1016/j.avsg.2011.04.002 PMid:21680143 DOI: https://doi.org/10.1016/j.avsg.2011.04.002

Hans SS, Jareunpoon O. Prospective evaluation of electroencephalography, carotid artery stump pressure, and neurologic changes during 314 consecutive carotid endarterectomies performed in awake patients. J Vasc Surg. 2007;45(3):511-5. https://doi.org/10.1016/j.jvs.2006.11.035 PMid:17275248 DOI: https://doi.org/10.1016/j.jvs.2006.11.035

Brewster LP, Beaulieu R, Kasirajan K, Corriere MA, Ricotta JJ 2nd, Patel S, et al. Contralateral occlusion is not a clinically important reason for choosing carotid artery stenting for patients with significant carotid artery stenosis. J Vasc Surg. 2012;56(5):1291-5. https://doi.org/10.1016/j.jvs.2012.04.033 PMid:22840742 DOI: https://doi.org/10.1016/j.jvs.2012.04.033

Paraskevas KI, Veith FJ. The indications of carotid artery stenting in symptomatic patients may need to be reconsidered. Ann Vasc Surg. 2015;29(1):154-9. https://doi.org/10.1016/j.avsg.2014.08.010 PMid:25305422 DOI: https://doi.org/10.1016/j.avsg.2014.08.010

Yang SS, Kim YW, Kim DI, Kim KH, Jeon P, Kim GM, et al. Impact of contralateral carotid or vertebral artery occlusion in patients undergoing carotid endarterectomy or carotid artery stenting. J Vasc Surg. 2014;59(3):749-55. https://doi.org/10.1016/j.jvs.2013.10.055 PMid:24360588 DOI: https://doi.org/10.1016/j.jvs.2013.10.055

Samson RH, Cline JL, Showalter DP, Lepore MR. Contralateral carotid artery occlusion is not a contraindication to carotid endarterectomy even if shunts are not routinely used. J Vasc Surg. 2013;58(4):935-40. https://doi.org/10.1016/j.jvs.2013.04.011 PMid:24075103 DOI: https://doi.org/10.1016/j.jvs.2013.04.011

Demirel S, Attigah N, Bruijnen H, Ringleb P, Eckstein HH, Fraedrich G, et al. Multicenter experience on eversion versus conventional carotid endarterectomy in symptomatic carotid artery stenosis: Observations from the stent-protected angioplasty versus carotid endarterectomy (SPACE-1) trial. Stroke. 2012;43(7):1865-71. https://doi.org/10.1161/STROKEAHA.111.640102 PMid:22496334 DOI: https://doi.org/10.1161/STROKEAHA.111.640102

Entz L, Jaranyi ZS, Nemes A. Comparison of perioperative results obtained with eversion endarterectomy and with conventional patch plasty. Cardiovasc Surg. 1997;5(1):16-20. https://doi.org/10.1016/S0967-2109(96)00078-6 PMid:9158117 DOI: https://doi.org/10.1016/S0967-2109(96)00078-6

Green RM, Greenberg R, Illig K, Shortell C, Ouriel K. Eversion endarterectomy ofthe carotid artery: Technical considerations and recurrent stenosis. J Vasc Surg. 2000;32(6):1052-61. https://doi.org/10.1067/mva.2000.111283 PMid:11107076 DOI: https://doi.org/10.1067/mva.2000.111283