Redo Carotid Endarterectomy Versus Primary Carotid Endarterectomy
Background/Purpose: Several authorities have recently advocated carotid stenting for recurrent carotid stenosis because of the perception that redo surgery carries a higher complication rate than primary carotid endarterectomy (CEA). This study will compare early and late results of reoperations versus primary CEA. Patient Poplulation and Methods: All redo operations for recurrent carotid stenosis performed during a recent 7-year period by a single vascular surgeon were compared with primary CEA. Since all redo CEAs were done using polytetrafluoroethylene (PTFE) or vein patch closure, only primary CEAs using the same patching were analyzed. A Kaplan Meier life-table analysis was used to estimate stroke-free survival rates and freedom from ≥50% recurrent stenosis. Results: Out of 510 primary CEAs, 265 had PTFE or vein patch closure. One hundred twenty-four reoperations using PTFE or vein patch closure were done during the same period. Both groups had similar demographic characteristics. Indications for reoperations and primary CEAs were symptomatic stenosis in 78% and 58%, and asymptomatic ≥80% stenosis in 22% and 42%, respectively (p<0.001). The 30-day perioperative stroke and transient ischemic attack rates for reoperation and primary CEA were 4.8% versus 0.8% (p=0.015) and 4% versus 1.1%, respectively, with no perioperative deaths in either group. Cranial nerve injury was noted in 17% in reoperation patients versus 5.3% in primary CEA patients, however most of these were transient (p<0.001). The mean hospital stay was 1.8 days for reoperation versus 1.6 days for primary CEA. The cumulative stroke-free survival and freedom from ≥50% recurrent stenosis rates for reoperation at 1, 3, and 5 years were 96%, 91%, 82%, and 98%, 96%, 95%, respectively; and 94%, 92%, 91% and 98%, 96%, 96%, respectively for primary CEA (no statistically significant differences). Conclusions: Reoperation carries higher perioperative stroke and cranial nerve injury rates than primary CEA. However, redo operations are durable and have stroke-free survival rates that are similar to primary CEA. These considerations should be kept in mind when recommending carotid stenting versus reoperation.