High-risk patients for carotid endarterectomy: turned down cases are rare.
OBJECTIVE
The increasing use of carotid artery stenting (CAS) is justified in patients at high-risk for carotid endarterectomy (CEA). The aim of this study was to evaluate the hypothesis that the high-risk patients can be submitted to CEA without increased risk of stroke and death.


METHODS
A retrospective analysis of 625 consecutive CEA in 545 patients (M/F 386/159, age 75 ± 7) performed from January 2005 to December 2010 was carried out. Definite anatomical and pathophysiological high-risk cohort of patients (N.=173, 31.7%) was evaluated and compared to normal risk patients. Univariate, multivariate and Kaplan-Meier analysis were used as appropriate. Poisson regression (Pr) model was used to study all univariate criteria in combination. A P value <0.05 was statistically significant.


RESULTS
The overall 30-day stroke and death rate was 0.96%. No difference between high-risk vs. normal patient cohort regarding physiological and anatomical risk factors was detected. Univariate and multivariate analysis did not show statistical difference for 30-day outcome in any of the variables examined. No increase of risk in cases of presence of more risk factors resulted to the Pr analysis. The 24-month survival rate was worse in high-risk patients, especially when more physiologic risk as chronic renal failure, severe pulmonary and cardiac diseases and age over eighty were present.


CONCLUSIONS
CEA is a safe procedure in patients at high-risk carotid artery disease. A better classification of high-risk patients may be necessary because trials criteria appear ineffective to define the patients at real high surgical risk. Long-term outcome was affected by the presence of severe comorbidities.
Unit of Vascular and Endovascular Surgery, San Paolo Hospital, Civitavecchia, Rome, Italy. gmarcroma©alice.it
G
G
Marcucci
F
F
Accrocca
R
R
Antonelli
A G
AG
Giordano
R
R
Gabrielli
F
F
Mounayergi
A
A
Sbroscia
A
A
Siani
D000368:Aged; D016893:Carotid Stenosis / Q000401:mortality / Q000601:surgery*; D016894:Endarterectomy, Carotid; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007431:Intraoperative Complications / Q000453:epidemiology* / Q000517:prevention & control; D007558:Italy / Q000453:epidemiology; D053208:Kaplan-Meier Estimate; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology* / Q000517:prevention & control; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D012308:Risk Management; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome