Carotid endarterectomy: experience in 5425 cases.
From 1992 to December 2002, 3967 patients (2619 males; 1348 females) with a mean age of 68.4A years (range 32-92) underwent 5425 carotid endarterectomy (CE) procedures at our institute. Neurological history was positive for stroke in 1130 cases (21%) and for transient ischemic attack (TIA) in 2121 cases (39%). In 2174 cases (40%) patients were neurologically asymptomatic or presented nonspecific symptoms. Our current clinical protocol has been designed to optimize resources and reduce complications. Some of the major features, along with the respective percentages in this series, are as follows. Duplex scanning was performed at a validated laboratory as the principal preoperative exam (86.9%). Locoregional anesthesia and neurological monitoring were performed during carotid cross-clamping (96.3%). Selective shunting was carried out with a Javid shunt (10.7%). The choice of surgical technique was made according to carotid anatomy and cerebral tolerance of cross-clamping. Those used were a standard technique (now abandoned, 12.1%), synthetic patching (46.4%), and eversion endarterectomy (41.5%). Intraoperative completion arteriography was routinely performed for eversion endarterectomy and only in dubious cases with other techniques. The option of staying in an postoperative intensive care unit (ICU) was available (selective use, 2%). In uncomplicated cases, early discharge (after 1.5 postoperative days) was considered safe. The overall perioperative mortality was 0.37% (20/5425). Causes of death were myocardial infarction in seven cases, ischemic stroke in six cases, hemorrhagic stroke in five cases, respiratory failure caused by cervical hematoma in one case, and wound infection in one case. Perioperative neurological morbidity was 1.31% (71/5425); there were 43 major and 28 minor strokes. In conclusion, CE is effective for stroke prevention when there is significant symptomatic and asymptomatic carotid stenosis, as low mortality and morbidity may be achieved in an experienced center. At our institute, the reduction of costs did not have negative consequences on the quality of the surgical care.
Chiesa
Roberto
R
Department of Vascular Surgery, Vita-Salute University, Scientific Institute H. San Raffaele, Milano, Italy.
Melissano
Germano
G
Castellano
Renata
R
Frigerio
Sillia
S
Catenaccio
Barbara
B
D000368:Aged; D003952:Diagnostic Imaging; D016894:Endarterectomy, Carotid / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007430:Intraoperative Care; D002546:Ischemic Attack, Transient / Q000601:surgery; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D020521:Stroke / Q000601:surgery; D013997:Time Factors