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Clinical Outcomes of Carotid Endarterectomy in Symptomatic and Asymptomatic Patients with Ipsilateral Intracranial Stenosis

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Abstract

Background and purpose

The risk of perioperative stroke and the benefits of carotid endarterectomy (CEA) remain uncertain in the case of an ipsilateral intracranial stenosis. The aim of this observational study was to analyze the early and late outcomes of CEA in patients with a carotid tandem lesion (CTL), defined as a severe stenosis at the bifurcation with any concomitant lesion ≥50 % involving the intracranial portion of the ipsilateral internal carotid artery or the main trunk of the anterior or middle cerebral artery.

Methods

From 2000 to 2009, 1143 patients underwent CEA for symptomatic or asymptomatic extracranial carotid stenosis according to the NASCET and ACAS recommendations, respectively. CTLs were diagnosed in 219 patients (19.2 %) by extracranial and transcranial color-coded Doppler sonography combined with noninvasive brain imaging studies. The primary endpoints of the study were perioperative (30-day) stroke and death, and any ipsilateral ischemic adverse events during the follow-up, which ranged from 0.1 to 10 years (mean 4.9 ± 3.3 years). The rates of the primary endpoints were compared between patients with (group I) and without CTL (group II).

Results

Overall, 219 CEAs were performed in group I and 924 in group II. Nearly two in three of the carotid lesions (777 of 1143, 68 %) were symptomatic at presentation (62.1 % in group I vs 69.4 % in group II; p = 0.03), with a 23.8 % rate of stroke (21.9 % in group I vs 24.2 % in group II; p = 0.85). There were 2 (0.9 %) perioperative ipsilateral strokes in group I and 5 (0.5 %) in group II (p = 0.62), and no deaths. The 5-year ipsilateral stroke-free, any stroke-free, and overall survival rates did not differ significantly between patients with and without CTL.

Conclusions

This study has shown that patients with and without CTL who underwent CEA had a similar occurrence of perioperative adverse events (probably due to the extremely low incidence of perioperative complications) and comparable late outcomes, suggesting that the presence of CTL does not justify refusing CEA for patients who could benefit from it.

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References

  1. North American Symptomatic Carotid Endarterectomy Trial Collaborators (1991) Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445–453

    Article  Google Scholar 

  2. European Carotid Surgery Trialists Collaborative Group (1991) MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. Lancet 337:1235–1243

    Article  Google Scholar 

  3. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. J Am Med Assoc 273:1421–1428

    Article  Google Scholar 

  4. Halliday A, Mansfield A, Marro J, MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group et al (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet 363:1491–1502

    Article  CAS  PubMed  Google Scholar 

  5. Brott TG, Halperin JL, Abbara S 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. American College of Cardiology; American Stroke Association; American Association of Neurological Surgeons; American College of Radiology; American American College of Radiology; Society of NeuroInterventional Surgery; Society for Vascular Medicine; Society for Vascular Surgery. 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 124:e54–130. Erratum in: Circulation 2011;124:e146

  6. Sundt TM, Sandok BA, Wisnant JP (1975) Carotid endarterectomy. Complications and pre-operative assessment at risk. Mayo Clin Proc 50:301–306

    CAS  PubMed  Google Scholar 

  7. Thiele BL, Young JV, Chikos PM et al (1980) Correlation of arteriographic findings and symptoms in cerebrovascular disease. Neurology 30:1041–1046

    Article  CAS  PubMed  Google Scholar 

  8. Day AL, Rhoton AL, Quisling RG (1980) Resolving siphon stenosis following endarterectomy. Stroke 11:278–281

    Article  CAS  PubMed  Google Scholar 

  9. Schuler JJ, Flanigan DP, Lim LT et al (1982) The effect of carotid siphon stenosis on stroke rate, death and relief of symptoms following elective carotid endarterectomy. Surgery 92:1058–1067

    CAS  PubMed  Google Scholar 

  10. Roederer GO, Langlois YE, Chan AR et al (1983) Is siphon disease important in predicting outcome of carotid endarterectomy? Arch Surg 118:1177–1181

    Article  CAS  PubMed  Google Scholar 

  11. Lord RSA, Raj B, Graham AR (1987) Carotid endarterectomy, siphon stenosis, collateral hemispheric pressure, and perioperative cerebral infarction. J Vasc Surg 6:391–397

    Article  CAS  PubMed  Google Scholar 

  12. Moore WS (1988) Does tandem lesion mean tandem risk in patients with carotid artery disease? Editorial. J Vasc Surg 7:454–455

    Article  CAS  PubMed  Google Scholar 

  13. Mackey WC, O’Donnell TF Jr, Callow AD (1989) Carotid endarterectomy in patients with intracranial vascular disease: short-term risk and long-term outcome. J Vasc Surg 10:432–438

    Article  CAS  PubMed  Google Scholar 

  14. Mattos MA, van Bemmelen PS, Hodgson KJ et al (1993) The influence of carotid siphon stenosis on short- and long-term outcome after carotid endarterectomy. J Vasc Surg 17:902–911

    Article  CAS  PubMed  Google Scholar 

  15. Goldstein LB, McCroy DC, Landsman PB et al (1994) Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms. Stroke 25:1116–1121

    Article  CAS  PubMed  Google Scholar 

  16. Rothwell PM, Slattery J, Warlow CP (1997) Clinical and angiographic predictors of stroke and death from carotid endarterectomy: systematic review. Br Med J 315:1571–1577

    Article  CAS  Google Scholar 

  17. Rouleau PA, Houston J III, Gilbertson J et al (1999) Carotid artery tandem lesions: frequency of angiographic detection and consequences for endarterectomy. AJNR Am J Neuroradiol 20:621–625

    CAS  PubMed  Google Scholar 

  18. Kappelle LJ, Eliasziw M, Fox AJ, for the North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group et al (1999) Importance of intracranial atherosclerotic disease in patients with symptomatic stenosis of the internal carotid artery. Stroke 30:282–286

    Article  CAS  PubMed  Google Scholar 

  19. Stelagowski M, Bogusiak K, Kasielka A et al (2010) Intracranial occlusions and internal carotid artery stenosis: clinical implications. Ann Vasc Surg 24:786–793

    Article  PubMed  Google Scholar 

  20. Han Y, Park H, Kwon SU et al (2014) Clinical outcomes of carotid endarterectomy in patients with carotid artery tandem lesions. Stroke 45:3443–3446

    Article  PubMed  Google Scholar 

  21. Caplan LR (1993) Brain embolism, revisited. Neurology 43:1281–1287

    Article  CAS  PubMed  Google Scholar 

  22. Caplan LR, Hennerici M (1998) Impaired clearance of emboli (washout) is an important link between, hypoperfusion, embolism, and ischemic stroke. Arch Surg 55:1475–1482

    CAS  Google Scholar 

  23. Siddiqui FM, Hassan AE, Tariq N et al (2012) Endovascular management of symptomatic extracranial stenosis associated with secondary intracranial tandem stenosis. A multicenter review. J Neuroimaging 22:243–248

    Article  PubMed  Google Scholar 

  24. Ballotta E, Toniato A, Da Giau G et al (2014) Durability of eversion endarterectomy. J Vasc Surg 59:1274–1281

    Article  PubMed  Google Scholar 

  25. Baumgartner RW, Mattle HP, Schroth G (1999) Assessment of ≥50% and <50% intracranial stenosis by transcranial color-coded duplex sonography. Stroke 30:87–92

    Article  CAS  PubMed  Google Scholar 

  26. Banks JL, Marotta CA (2007) Outcomes validity and reliability of the modified Rankin scale: implication for stroke clinical trials: a literature review and synthesis. Stroke 38:1091–1096

    Article  PubMed  Google Scholar 

  27. Baker JD, Rutherford RB, Bernstein EF et al (1988) Suggested standards for reports dealing with cerebrovascular disease. J Vasc Surg 8:721–729

    Article  CAS  PubMed  Google Scholar 

  28. Marzewski DJ, Furlan AJ, St. Louis P et al (1982) Intracranial internal carotid artery stenosis: long-term prognosis. Stroke 13:821–824

    Article  CAS  PubMed  Google Scholar 

  29. Chimowitz MI, Kokkinos J, Strong J et al (1995) The warfarin-aspirin symptomatic intracranial disease study. Neurology 45:1488–1493

    Article  CAS  PubMed  Google Scholar 

  30. Park S, Lee DG, Chung WJ et al (2013) Long-term outcomes of drug-eluting stents in symptomatic intracranial stenosis. Neurointervention 8:9–14

    Article  PubMed Central  PubMed  Google Scholar 

  31. Derdeyn CP, Chimowitz MI, Lynn MJ, Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial Investigators et al (2014) Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomized trial. Lancet 383:333–341

    Article  PubMed Central  PubMed  Google Scholar 

  32. Madani A, Beletsky V, Tamayo A et al (2011) High-risk asymptomatic carotid stenosis. Ulceration on 3D ultrasound vs TCD microemboli. Neurology 77:744–750

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. The Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Via N. Giustiniani, 2, 35128, Padua, Italy

    Enzo Ballotta, Antonio Toniato & Anna Da Roit

  2. Department of Neurosciences, University of Padua, School of Medicine, Padua, Italy

    Claudio Baracchini

Authors
  1. Enzo Ballotta
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  2. Antonio Toniato
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  3. Anna Da Roit
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  4. Claudio Baracchini
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Correspondence to Enzo Ballotta.

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Ballotta, E., Toniato, A., Da Roit, A. et al. Clinical Outcomes of Carotid Endarterectomy in Symptomatic and Asymptomatic Patients with Ipsilateral Intracranial Stenosis. World J Surg 39, 2823–2830 (2015). https://doi.org/10.1007/s00268-015-3165-7

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  • DOI: https://doi.org/10.1007/s00268-015-3165-7

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