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December 23, 2005
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Stephanie Saltzberg, M.D., Neal Cayne, MD, Thomas Maldonado, MD, Glenn Jacobowitz, MD, Paul Gagne, MD, Matthew Nalbandian, MD, Mark Adelman, MD, Patrick Lamparello, MD, Thomas Riles, MD, Caron Rockman, MD.
New York University, New York, NY, USA.
OBJECTIVES: Urgent carotid endarterectomy for crescendo transient ischemic attacks (TIAs) or stroke in evolution (SIE) has been controversial due to its reported high mortality and morbidity rates. However, the outcome of these cases has not been well studied. The purpose of this study was to review our results with urgent carotid endarterectomy at a university hospital.
METHODS: A total of 2492 carotid endarterectomies were performed during the 11 year period between 1992 and 2003. Of these procedures, 25 (1.0%) carotid endarterectomies were categorized as urgent being performed within 24 hours after the onset of crescendo TIAs or SIE with fluctuating neurologic deficits or global cerebral ischemia in the appropriate setting. A retrospective comparison was performed: 25 patients undergoing urgent carotid endarterectomy versus 25 age and sex matched patients undergoing elective carotid endarterectomy for symptomatic carotid stenoses.
RESULTS: The mean age of patients was 74.1 years (range 56 to 93 years) with 64% (n=16) male. Comorbidities included hypertension (69.2%), diabetes (38.5%), coronary artery disease (50%), and smoking history (30.8%). Indications for operation were crescendo TIAs (n=16) and SIE (n=9). Specific symptoms for the urgent group included extremity weakness or paralysis (n=11), amaurosis fugax (n=4), speech difficulty (n=2), syncope or global cerebral hypoperfusion (n=3), and a combination of speech difficulty and extremity weakness (n=3). Three urgent carotid endarterectomies were thrombectomies performed for acute symptomatic occlusion. A comparison was performed between urgent and elective symptomatic patients. No difference in comorbidities or indications existed between the two groups. Urgent patients were less likely to receive regional anesthesia (56.0% vs 72.0%, p=ns), less likely to tolerate clamping under regional anesthesia (71.4% vs 88.9%, p=ns), and more likely to require shunt placement (66.7% vs 45.8%, p=ns) than the elective group. Postoperative 30-day myocardial infarction, stroke, and mortality rates in the urgent patients compared to the elective patients were 0% vs 0% (p=ns), 7.7% vs 0% (p=ns), and 3.8% vs 0% (p=ns), respectively. The urgent patients were also more likely to require reoperation secondary to postoperative neurologic deficit (n=1) and hematoma (n=2) (11.5% vs 0%, p=ns).
CONCLUSIONS: Our data suggest that urgent carotid endarterectomy can be performed safely and with outcomes not significantly different than elective carotid endarterectomy performed for symptomatic disease. While there was a stroke rate of 7.7%, this high risk group of patients portends more dismal outcomes without surgical intervention. Careful selection of patients for urgent carotid endarterectomy can result in acceptable perioperative outcomes and will likely reduce permanent neurologic deficits in this high risk group.
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Outcomes of Urgent Carotid Endarterectomy
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Stephanie Saltzberg, M.D., Neal Cayne, MD, Thomas Maldonado, MD, Glenn Jacobowitz, MD, Paul Gagne, MD, Matthew Nalbandian, MD, Mark Adelman, MD, Patrick Lamparello, MD, Thomas Riles, MD, Caron Rockman, MD.
New York University, New York, NY, USA.
OBJECTIVES: Urgent carotid endarterectomy for crescendo transient ischemic attacks (TIAs) or stroke in evolution (SIE) has been controversial due to its reported high mortality and morbidity rates. However, the outcome of these cases has not been well studied. The purpose of this study was to review our results with urgent carotid endarterectomy at a university hospital.
METHODS: A total of 2492 carotid endarterectomies were performed during the 11 year period between 1992 and 2003. Of these procedures, 25 (1.0%) carotid endarterectomies were categorized as urgent being performed within 24 hours after the onset of crescendo TIAs or SIE with fluctuating neurologic deficits or global cerebral ischemia in the appropriate setting. A retrospective comparison was performed: 25 patients undergoing urgent carotid endarterectomy versus 25 age and sex matched patients undergoing elective carotid endarterectomy for symptomatic carotid stenoses.
RESULTS: The mean age of patients was 74.1 years (range 56 to 93 years) with 64% (n=16) male. Comorbidities included hypertension (69.2%), diabetes (38.5%), coronary artery disease (50%), and smoking history (30.8%). Indications for operation were crescendo TIAs (n=16) and SIE (n=9). Specific symptoms for the urgent group included extremity weakness or paralysis (n=11), amaurosis fugax (n=4), speech difficulty (n=2), syncope or global cerebral hypoperfusion (n=3), and a combination of speech difficulty and extremity weakness (n=3). Three urgent carotid endarterectomies were thrombectomies performed for acute symptomatic occlusion. A comparison was performed between urgent and elective symptomatic patients. No difference in comorbidities or indications existed between the two groups. Urgent patients were less likely to receive regional anesthesia (56.0% vs 72.0%, p=ns), less likely to tolerate clamping under regional anesthesia (71.4% vs 88.9%, p=ns), and more likely to require shunt placement (66.7% vs 45.8%, p=ns) than the elective group. Postoperative 30-day myocardial infarction, stroke, and mortality rates in the urgent patients compared to the elective patients were 0% vs 0% (p=ns), 7.7% vs 0% (p=ns), and 3.8% vs 0% (p=ns), respectively. The urgent patients were also more likely to require reoperation secondary to postoperative neurologic deficit (n=1) and hematoma (n=2) (11.5% vs 0%, p=ns).
CONCLUSIONS: Our data suggest that urgent carotid endarterectomy can be performed safely and with outcomes not significantly different than elective carotid endarterectomy performed for symptomatic disease. While there was a stroke rate of 7.7%, this high risk group of patients portends more dismal outcomes without surgical intervention. Careful selection of patients for urgent carotid endarterectomy can result in acceptable perioperative outcomes and will likely reduce permanent neurologic deficits in this high risk group.
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