Print this pageSafety and Efficacy Of Reoperative Carotid Endarterectomy: A Twelve Year Experience
Massachusetts General Hospital, Boston, MA
Background: Reoperative carotid endarterectomy (CEA) is the accepted treatment for recurrent carotid stenosis. With reports of higher operative morbidity than primary CEA and the advent of carotid stenting, catheter-based therapy has been advocated as the primary treatment for this high-risk subgroup with carotid stenosis. This study reviews a contemporary experience with reoperative CEA.
Methods: From 1990-2002, 153 isolated (excluding CEA/CABG and bypasses) reoperative CEA procedures were retrospectively reviewed. Clinical and demographic variables potentially associated with the endpoints of perioperative morbidity, long-term durability and late survival were assessed with multivariate measures.
Results: There were 153 reoperative CEA procedures (151 secondary , 2 tertiary) in 145 patients (56% male, 30% 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 0.3-20.4). At reoperation, patch reconstruction was undertaken in 92% of cases. The perioperative stroke rate was 1.9% with no deaths or cardiac events. Other complications included cranial nerve injury (1.3%) and a hematoma (3.2%). Average follow-up after reoperative CEA was 4.4±0.3 years (range 0.1-12.7), with an overall stroke-free rate of 96% and a restenosis rate by carotid duplex of 8.9%. Reoperative CEA failure (at least moderate restenosis) was seen in younger patients (66±2.5 vs 70±0.7 years, P<0.05). The all-cause mortality rate was 29%. Multivaraite analysis identified diabetes and male gender as having a negative impact (P<0.01) and lipid-lowering agents as having a protective effect (P<0.01) on survival.
Conclusion: Reoperative CEA is a safe and effective procedure, comparable to accepted standards for primary CEA, for long-term protection from stroke. These data do not support the contention that patients requiring reoperative CEA constitute a high-risk subgroup in whom reoperation should be avoided in deference to stent revascularizaion.