title: Safety and efficacy of reoperative carotid endarterectomy: a 14-year experience.
abstract: BACKGROUND
  Reoperative carotid endarterectomy (CEA) is an accepted treatment for recurrent carotid stenosis. With reports of a higher operative morbidity than primary CEA and the advent of carotid stenting, catheter-based therapy has been advocated as the primary treatment for this reportedly "high-risk" subgroup. This study reviews a contemporary experience with reoperative CEA to validate the high-risk categorization of these patients.
  
  
  METHODS
  From 1989 to 2002, 153 consecutive, isolated (excluding CEA/coronary artery bypass graft and carotid bypass operations) reoperative CEA procedures were reviewed. Clinical and demographic variables potentially associated with the end points of perioperative morbidity, long-term durability, and late survival were assessed with multivariate analysis.
  
  
  RESULTS
  There were 153 reoperative CEA procedures in 145 patients (56% men, 36% symptomatic) with an average age of 69 +/- 1.3 years. The average time from primary CEA (68% primary closure, 23% prosthetic, 9% vein patch) to reoperative CEA was 6.1 +/- 0.4 years (range, 0.3 to 20.4 years). At reoperation, patch reconstruction was undertaken in 93% of cases. The perioperative stroke rate was 1.9%, with no deaths or cardiac complications. Other complications included cranial nerve injury (1.3%) and hematoma (3.2%). Average follow-up after reoperative CEA was 4.4 +/- 0.3 years (range, 0.1 to 12.7 years), with an overall total stroke-free rate of 96% and a restenosis rate (>50%) by carotid duplex of 9.2%. Among variables assessed for association with restenosis after reoperative CEA, only younger age was found to be significant (66 +/- 2.5 years vs 70 +/- 0.7 years, P < .05). The all-cause long-term mortality rate was 29%. Multivariate analysis of long-term survival identified diabetes mellitus as having a negative impact (hazard ratio, 3.4 +/- 0.3, P < .05) and lipid-lowering agents as having a protective effect (hazard ratio, 0.42 +/- 0.4, P < .05) on survival.
  
  
  CONCLUSIONS
  Reoperative CEA is a safe and durable procedure, comparable to reported standards for primary CEA, for long-term protection from stroke. These data do not support the contention that patients who require reoperative CEA constitute a "high-risk" subgroup in whom reoperative therapy should be avoided.
authors.affiliation: Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Stoner
authors.forename: Richard P
authors.initials: RP
authors.lastname: Cambria
authors.forename: David C
authors.initials: DC
authors.lastname: Brewster
authors.forename: Kendra L
authors.initials: KL
authors.lastname: Juhola
authors.forename: Michael T
authors.initials: MT
authors.lastname: Watkins
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Kwolek
authors.forename: Hong T
authors.initials: HT
authors.lastname: Hua
authors.forename: Glenn M
authors.initials: GM
authors.lastname: LaMuraglia
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000401:mortality / Q000601:surgery*; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D012008:Recurrence; D012086:Reoperation; D020521:Stroke / Q000517:prevention & control; D016896:Treatment Outcome