Safety and efficacy of reoperative carotid endarterectomy: A 14-year experience

• Published in: Journal of vascular surgery Vol. 41; no. 6; pp. 942 - 949
• Main Authors: Stoner, Michael C., Cambria, Richard P., Brewster, David C., Juhola, Kendra L., Watkins, Michael T., Kwolek, Christopher J., Hua, Hong T., LaMuraglia, Glenn M.
• Format: Journal Article Conference Proceeding
• Language: English
• Published: New York, NY Mosby, Inc 01.06.2005; Elsevier
• Subjects: Aged; Biological and medical sciences; Carotid Stenosis - mortality; Carotid Stenosis - surgery; Endarterectomy, Carotid; Female; Humans; Male; Medical sciences; Multivariate Analysis; Neurology; Neurosurgery; Recurrence; Reoperation; Skull, brain, vascular surgery; Stroke - prevention & control; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Treatment Outcome; Vascular diseases and vascular malformations of the nervous system; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Cardiovascular disease; Endarteriectomy; Carotid; Surgery
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2005.02.047

Reoperative carotid endarterectomy (CEA) is an accepted treatment for recurrent carotid stenosis. With reports of a higher operative morbidity than primary CEA and the advent of carotid stenting, catheter-based therapy has been advocated as the primary treatment for this reportedly “high-risk” subgroup. This study reviews a contemporary experience with reoperative CEA to validate the high-risk categorization of these patients. From 1989 to 2002, 153 consecutive, isolated (excluding CEA/coronary artery bypass graft and carotid bypass operations) reoperative CEA procedures were reviewed. Clinical and demographic variables potentially associated with the end points of perioperative morbidity, long-term durability, and late survival were assessed with multivariate analysis. There were 153 reoperative CEA procedures in 145 patients (56% men, 36% symptomatic) with an average age of 69 ± 1.3 years. The average time from primary CEA (68% primary closure, 23% prosthetic, 9% vein patch) to reoperative CEA was 6.1 ± 0.4 years (range, 0.3 to 20.4 years). At reoperation, patch reconstruction was undertaken in 93% of cases. The perioperative stroke rate was 1.9%, with no deaths or cardiac complications. Other complications included cranial nerve injury (1.3%) and hematoma (3.2%). Average follow-up after reoperative CEA was 4.4 ± 0.3 years (range, 0.1 to 12.7 years), with an overall total stroke-free rate of 96% and a restenosis rate (>50%) by carotid duplex of 9.2%. Among variables assessed for association with restenosis after reoperative CEA, only younger age was found to be significant (66 ± 2.5 years vs 70 ± 0.7 years, P < .05). The all-cause long-term mortality rate was 29%. Multivariate analysis of long-term survival identified diabetes mellitus as having a negative impact (hazard ratio, 3.4 ± 0.3, P < .05) and lipid-lowering agents as having a protective effect (hazard ratio, 0.42 ± 0.4, P < .05) on survival. Reoperative CEA is a safe and durable procedure, comparable to reported standards for primary CEA, for long-term protection from stroke. These data do not support the contention that patients who require reoperative CEA constitute a “high-risk” subgroup in whom reoperative therapy should be avoided.