VESS10. Early Carotid Endarterectomy (CEA) Performed 2 to 5 Days After the Onset of Neurologic Symptoms Leads to Comparable Results to CEA Performed at Later Time Points

PurposeTo evaluate the long term durability and outcomes of carotid angioplasty and stenting (CAS) compared with carotid endarterectomy (CEA).MethodsUsing multiple comprehensive databases, we searched for randomized controlled trials comparing CAS with CEA for carotid stenosis. Studies were classified according to symptom status: symptomatic, asymptomatic, or all inclusive stenosis. Postprocedural ipsilateral stroke, restenosis/occlusion after revascularization, procedural stroke/death/myocardial infarction (MI), and postprocedural ipsilateral stroke were evaluated. Subgroup analysis was performed according to follow-up duration.Results22 studies were included and classified for meta-analyses in relation to specific outcomes. The maximum follow-up duration was 10 years. The risk of postprocedural ipsilateral stroke in CEA was equivalent to that in CAS, irrespective of symptom status or follow-up time points. The CAS group had a greater risk of restenosis/occlusion after revascularization compared with CEA in studies of all inclusive stenosis. A similar tendency was found in studies of symptomatic stenosis, but without statistical significance. However, subgroup analysis showed that the risk of restenosis/occlusion in CAS decreased gradually with time, to the extent that these risks became comparable 1 year after the procedure. Procedural stroke/death/MI and postprocedural ipsilateral stroke occurred more frequently in the CAS group in studies of symptomatic stenosis although not in studies of asymptomatic or all inclusive stenosis. However, this association did not persist when studies were divided according to follow-up time points.ConclusionsAlthough CAS may be more strongly associated with periprocedural stroke/death compared with CEA, it could be a good alternative to CEA in terms of long term durability and outcomes.

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Prevention of Disabling and Fatal Strokes by Successful Carotid Endarterectomy in Patients Without Recent Neurologic Symptoms: Randomized Controlled Trial

Perspectives in Vascular Surgery and Endovascular Therapy ◽

10.1177/153100350501700112 ◽

2005 ◽

Vol 17 (1) ◽

pp. 62-1-63

Author(s):

W. S. Moore

Keyword(s):

Randomized Controlled Trial ◽

Carotid Endarterectomy ◽

Controlled Trial ◽

Neurologic Symptoms ◽

Randomized Controlled

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Evaluation of a Cerebral Oximeter as a Monitor of Cerebral Ischemia during Carotid Endarterectomy

Anesthesiology ◽

10.1097/00000542-200010000-00015 ◽

2000 ◽

Vol 93 (4) ◽

pp. 964-970 ◽

Cited By ~ 235

Author(s):

Satwant K. Samra ◽

Eric A. Dy ◽

Kathy Welch ◽

Pema Dorje ◽

Gerald B. Zelenock ◽

...

Keyword(s):

Cerebral Ischemia ◽

Positive Predictive Value ◽

Carotid Endarterectomy ◽

Predictive Value ◽

Cervical Plexus ◽

Neurologic Symptoms ◽

Cerebral Oximeter ◽

Cervical Plexus Block ◽

Neurologic Function ◽

Plexus Block

Background Stroke is an important contributor to perioperative morbidity and mortality associated with carotid endarterectomy (CEA). This investigation was designed to compare the performance of the INVOS-3100 cerebral oximeter to neurologic function, as a means of detecting cerebral ischemia induced by carotid cross-clamping, in patients undergoing carotid endarterectomy with cervical plexus block. Methods Ninety-nine patients undergoing 100 CEAs with regional anesthesia (deep or superficial cervical plexus block) were studied. Bilateral regional cerebrovascular oxygen saturation (rSO2) was monitored using the INVOS-3100 cerebral oximeter. Patients were retrospectively assigned to one of two groups: those in whom a change in mental status or contralateral motor deficit was noted after internal carotid clamping (neurologic symptoms; n = 10) and those who did not show any neurologic change (no neurologic symptoms; n = 90). Data from 94 operations (neurologic symptoms = 10 and no neurologic symptoms = 84) were adequate for statistical analyses for group comparisons. A relative decrease in ipsilateral rSO2 after carotid occlusion (calculated as a percentage of preocclusion value) during all operations (n = 100) was also calculated to determine the critical level of rSO2 decrease associated with a change in neurologic function. Results The mean (+/- SD) decrease in rSO2 after carotid occlusion in the neurologic symptoms group (from 63.2 +/- 8.4% to 51.0 +/- 11.6%) was significantly greater (P = 0.0002) than in the no neurologic symptoms group (from 65.8 +/- 8.5% to 61.0 +/- 9.3%). Logistic regression analysis used to determine if a change in rSO2, calculated as a percentage of preclamp value, could be used to predict change in neurologic function was highly significant (likelihood ratio chi-square = 13.7; P = 0.0002). A 20% decrease in rSO2 reading from the preclamp baseline, as a predictor of neurologic compromise, resulted in a sensitivity of 80% and specificity of 82.2%. The false-positive rate using this cutoff point was 66.7%, and the false-negative rate was 2.6%, providing a positive predictive value of 33.3% and a negative predictive value of 97.4%. Conclusion Monitoring rSO2 with INVOS-3100 to detect cerebral ischemia during CEA has a high negative predictive value, but the positive predictive value is low.

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