Carotid endarterectomy at the millennium: what interventional therapy must match.
OBJECTIVE
Carotid endarterectomy (CEA) is supported by level 1 evidence as the standard treatment of severe carotid stenosis in both symptomatic and asymptomatic patients. As interventional techniques are emerging for treatment of this disease, this study was undertaken to provide a contemporary surgical standard for comparison to carotid stenting.


METHODS
During the interval 1989 to 1999, 2236 isolated CEAs were performed on 1897 patients (62% male, 36% symptomatic, 4.6% reoperative procedures). Study endpoints included perioperative events, patient survival, late incidence of stroke, anatomic durability of CEA, and resource utilization changes during the study. Variables associated with complications, long-term and stroke free survival, restenosis, and resource utilization were analyzed by univariate and multivariate analysis.


RESULTS
Perioperative complications occurred in 5.5% of CEA procedures, including any stroke/death (1.4%), neck hematoma (1.7%), cardiac complications (0.5%), and cranial nerve injury (0.4%). Actuarial survival at 5 and 10 years was 72.4% (95% confidence interval [CI] 69.3-73.5) and 44.7% (95% CI 41.7-47.9) respectively, with coronary artery disease (P < 0.0018), chronic obstructive pulmonary disease (P < 0.00018) and diabetes mellitus (P < 0.0011) correlating with decreased longevity. The age- and sex-adjusted incidence of any stroke during follow-up was reduced by 22% (upper 0.35, lower 0.08) of predicted with the patient classification of hyperlipidemia (P < 0.0045) as the only protective factor. Analysis of CEA anatomic durability during a median follow-up period of 5.9 years identified a 7.7% failure rate (severe restenosis/occlusion, 4.5%; or reoperative CEA, 3.2%) with elevated serum cholesterol (P < 0.017) correlating with early restenosis. Resource utilization diminished (first versus last 2-year interval periods) for average hospital length of stay from 10.3 +/- 1.5 days to 4.3 +/- 0.7 days (P < 0.01) and preoperative contrast angiography from 87% +/- 1.4% to 10.3% +/- 4%.


CONCLUSIONS
These data delineate the safety, durability, and effectiveness in long-term stroke prevention of CEA. They provide a standard to which emerging catheter-based therapies for carotid stenosis should be compared.
LaMuraglia
Glenn M
GM
Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA. glamuraglia@partners.org
Brewster
David C
DC
Moncure
Ashby C
AC
Dorer
David J
DJ
Stoner
Michael C
MC
Trehan
Samir K
SK
Drummond
Elizabeth C
EC
Abbott
William M
WM
Cambria
Richard P
RP
D000368:Aged; D000800:Angioplasty, Balloon; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery* / Q000628:therapy; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D015996:Survival Rate; D016896:Treatment Outcome