From the Center for Clinical Health Policy Research (L.B.G., G.P.S.,
D.B.M., E.Z.O.), the Duke Center for Cerebrovascular Disease (L.B.G.), and the
Divisions of Neurology (L.B.G.) and General Internal Medicine (D.B.M.,
E.Z.O.), Department of Medicine, Duke University, and the Center for Health
Services Research in Primary Care (D.B.M., E.Z.O.) and Division of Neurology
(L.B.G.), Durham Department of Veterans Affairs Medical Center, Durham, NC.
Correspondence to Larry B. Goldstein, MD, Box 3651, Duke University Medical Center, Durham, NC 27710. E-mail golds004{at}mc.duke.edu
Background and Purpose—The benefit
of carotid endarterectomy is highly dependent on
surgical risk. However, little data are available concerning factors
affecting the risk of endarterectomy performed for
asymptomatic carotid artery stenosis outside the
setting of a randomized controlled trial. The purpose of this study was
to analyze the impact of potential preoperative risk factors on
the frequency of postoperative complications in patients undergoing the
operation for asymptomatic disease in academic medical
centers.
Methods—Data regarding postoperative complications were
systematically abstracted from the medical records of a random
sample of patients who underwent carotid
endarterectomy at 12 academic medical centers.
Results—Of 1160 procedures reviewed, 463 (40%) were performed
for asymptomatic disease. Postoperative stroke or death
occurred in 13 (2.8%), and myocardial infarction occurred in 8
(1.7%). The rate of postoperative stroke or death was lower in
asymptomatic patients than in those with a history of
cerebrovascular symptoms in a different vascular distribution, but the
difference was not significant (1.8% versus 4.2%;
P=.21). There were no significant differences in these
rates based on race, a history of angina, recent myocardial infarction,
chronic obstructive pulmonary disease, hypertension, the degree
of stenosis of the contralateral or ipsilateral carotid artery,
or the presence of angiographically recognized ulceration, intraluminal
thrombus, or siphon stenosis in the ipsilateral vessel
(
Conclusions—The overall risk of postoperative stroke or death was
nearly twice that reported by Asymptomatic Carotid
Atherosclerosis Study (ACAS) investigators in the
setting of a clinical trial but was within acceptable guidelines. Women
were at higher postoperative risk than men, which supported ACAS
findings. Additional high-risk groups were those aged 75 years or
older, those with a history of congestive heart failure, and those
undergoing prophylactic endarterectomy
for asymptomatic stenosis in combination with
coronary surgery. Knowledge of these rates may help to better
assess an individual's postoperative risk and therefore the
anticipated benefit of surgery.
© 1998 American Heart Association, Inc.
Original Contributions
Multicenter Review of Preoperative Risk Factors for Endarterectomy for Asymptomatic Carotid Artery Stenosis
2; P>.05). Postoperative stroke or
death was more frequent in women (5.3% versus 1.6% in men;
P=.02), in those aged 75 years or older (7.8% versus
1.8% in those younger than 75 years; P=.01), and in
those with a history of congestive heart failure (8.6% versus 2.3% in
those without a history of congestive heart failure;
P=.03). The risk of stroke or death was higher in the 16
patients who had carotid endarterectomy performed
in combination with coronary artery bypass surgery than in
those who had only endarterectomy (18.7% versus
2.1%; P<.001).
Key Words: angiography • carotid endarterectomy • prognosis • risk factors
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