CAROTID ENDARTERECTOMY: GUIDELINES VERSUS REAL-WORLD PRACTICE

Authors

  • Gabriela Teixeira Serviço de Angiologia e Cirurgia Vascular, Hospital de Santo António - Centro Hospital do Porto
  • Pedro Sá Pinto Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Ivone Silva Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • João Gonçalves Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Sérgio Teixeira Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Duarte Rego Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Vítor Ferreira Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Inês Antunes Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Carlos Veiga Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Daniel Mendes Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Paulo Teles Faculdade de Economia do Porto e LIAAD, Universidade do Porto
  • Arlindo Matos Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal
  • Rui Almeida Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto, Portugal

DOI:

https://doi.org/10.48750/acv.273

Keywords:

Carotid disease guidelines, carotid disease symptomatic and asymptomatic, Carotid endarterectomy, Complications

Abstract

Introduction:  A number of guidelines for the management of carotid disease are available to help clinicians in therapeutic decision and provide useful guidance for the best care of the patients. They stated that carotid endarterectomy (CEA) has some benefit in symptomatic patients with carotid stenosis of 50-69% and is highly beneficial in stenosis of 70-99%, with mortality/ stroke rate less than 6%. The maximum benefit is observed when surgery is performed within two weeks after the cerebrovascular event. CEA in asymptomatic patients should be offered to patients with life expectancy higher than 5 years, stenosis of >70%, and perioperative complications should be less than 3%.

The aim of this study is to analyse our clinical practice, review treated patients and referral times and compare the outcomes of our institutional practice with published guidelines.

Material and methods: Retrospective study of patients undergoing carotid endarterectomy at Centro Hospitalar Universitário do Porto between 2010 and 2015.

Results: Between 2010 and 2015, 404 patients underwent CEA, 76% men, and mean age 69 years for both sexes. The degree of stenosis was usually evaluated by ultrasound. The use of complementary study with angio-CT was required in 20% and angiography in 2.2% of the cases. The majority of patients (54.2%) were symptomatic (stroke/ TIA <6 months). In patients with a cerebrovascular event diagnosed at our institution, the time to surgery was 10 days (median). All CEA were performed under general anaesthesia and for arterial closure, a Dacron patch was systematically used. Shunt was used in 4.6% of cases (n=18). The mean surgery time was 101 minutes and the mean clamping time was 40 minutes. Reversal of antioagulation with protamine was performed in 48.3% patients. Morbimortality: 9 post-operative sequelae events (major stroke), 8 minimal / transient deficit (minor stroke) and 4 deaths. In symptomatic patients (n = 219), the rate of postoperative major stroke was 3.6%. In asymptomatic patients (n = 185), a major and a minor stroke was observed (1.1%). Other complications: haematoma 5.9% (n=24); infection 0.2% (n=1); peripheral nerve dysfunction 8.7% (n=35); false aneurysm 0.5% (n=2).

Conclusions: Our results are within the reference values. This study allowed us to know our reality, our ability to give an effective answer for our patients, and to serve as a basis for improving ways of acting.

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References

1. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. 2011ASA/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. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011;124(4):e54-130.
2. Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, et al. Editor's Choice - 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. 2018 Jan;55(1):3-81.
3. Kakisis JD, Antonopoulos CN, Mantas G, Moulakakis KG, Sfyroeras G, Geroulakos G. Cranial Nerve Injury After Carotid Endarterectomy: Incidence, Risk Factors, and Time Trends. Eur J Vasc Endovasc Surg. 2017 Mar;53(3):320-335.
4. Morales Gisbert SM, Sala Almonacil VA, Zaragozá García JM, Genovés Gascó B, Gómez Palonés FJ, Ortiz Monzón E. Predictors of cervical bleeding after carotid endarterectomy. Ann Vasc Surg. 2014 Feb;28(2):366-74.
5. Naylor AR, Payne D, London NJ, Thompson MM, Dennis MS, Sayers RD, Bell PR. Prosthetic patch infection after carotid endarterectomy. Eur J Vasc Endovasc Surg. 2002 Jan;23(1):11-6.
6. Aho K, Harmsen P, Hatano S, Marquardsen J, Smirnov V, Strasser T. Cerebrovascular disease in the community: results of a WHO Collaborative Study. Bull World Health Organ. 1980;58(1):113-30.
7. Aziz F, Lehman EB, Reed AB. Increased Duration of Operating Time for Carotid Endarterectomy Is Associated with Increased Mortality. Annals of vascular surgery. 2016;36:166-74.
8. Holt PJ, Poloniecki JD, Loftus IM, Thompson MM. Meta-analysis and systematic review of the relationship between hospital volume and outcome following carotid endarterectomy. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2007;33(6):645-51.
9. JS JY, Wholey M, Kuntz R, Fayad P, Katzen B, Mishkel G, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351(15):1493-501.
10. Silver FL, Mackey A, Clark WM, Brooks W, Timaran CH, Chiu D, et al. Safety of stenting and endarterectomy by symptomatic status in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke. 2011;42(3):675-80.
11. Mas J-L, Trinquart L, Leys D, Albucher J-F, Rousseau H, Viguier A, et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. The Lancet Neurology. 2008;7(10):885-92.
12. Eckstein H-H, Ringleb P, Allenberg J-R, Berger J, Fraedrich G, Hacke W, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. The Lancet Neurology. 2008;7(10):893-902.
13. Ferreira A, Vieira M, Sampaio S, Cerqueira A, Teixeira J. Predictors of neck bleeding after carotid endarterectomy: A 5 year revision. Angiologia e Cirurgia Vascular. 2016;12(1):12-9.
14. Perri JL, Nolan BW, Goodney PP, DeMartino RR, Brooke BS, Arya S, et al. Factors affecting operative time and outcome of carotid endarterectomy in the Vascular Quality Initiative. Journal of vascular surgery. 2017;66(4):1100-8.
15. Scott JW, Schwartz AL, Gates JD, Gerhard-Herman M, Havens JM. Choosing wisely for syncope: low-value carotid ultrasound use. Journal of the American Heart Association. 2014;3(4).
16. White RP, Markus HS. Impaired Dynamic Cerebral Autoregulation in Carotid Artery Stenosis. Stroke. 1997;28(7):1340-4.
17. Miran M, Suri M, Qureshi M, Ahmad A, Suri M, Basreen R, et al. Syncope in Patient with Bilateral Severe Internal Carotid Arteries Stenosis/Near Occlusion: A Case Report and Literature Review. J Vasc Interv Neurol. 2016;9(1):42-5.
18. Hsu LC, Chang FC, Teng MM, Chern CM, Wong WJ. Impact of carotid stenting in dizzy patients with carotid stenosis. Journal of the Chinese Medical Association : JCMA. 2014;77(8):403-8.
19. Cheng HL, Lin CJ, Soong BW, Wang PN, Chang FC, Wu YT, et al. Impairments in cognitive function and brain connectivity in severe asymptomatic carotid stenosis. Stroke. 2012;43(10):2567-73.
20. Carlin R, McGraw D, Anderson C. Objective tinnitus resulting from carotid artery stenosis. Journal of vascular surgery. 1997;25(3):581-3.
21. Terzi S, Arslanoglu S, Demiray U, Eren E, Cancuri O. Carotid Doppler ultrasound evaluation in patients with pulsatile tinnitus. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India. 2015;67(1):43-7.

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Published

2019-10-16

How to Cite

1.
Teixeira G, Sá Pinto P, Silva I, Gonçalves J, Teixeira S, Rego D, Ferreira V, Antunes I, Veiga C, Mendes D, Teles P, Matos A, Almeida R. CAROTID ENDARTERECTOMY: GUIDELINES VERSUS REAL-WORLD PRACTICE. Angiol Cir Vasc [Internet]. 2019 Oct. 16 [cited 2024 Mar. 28];15(2):49-57. Available from: https://acvjournal.com/index.php/acv/article/view/273

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Original Article