title: Carotid endarterectomy for symptomatic low-grade carotid stenosis.
abstract: OBJECTIVE
  Although the management of carotid disease is well established for symptomatic lesions ≥ 70%, the surgical treatment for a symptomatic ≤ 50% stenosis is not supported by data from randomized trials. Factors other than lumen narrowing, such as plaque instability, seem to be involved in cerebral and retinal ischemic events. This study analyzes the early-term and long-term outcomes of carotid endarterectomy (CEA) performed in patients with low-grade (≤ 50% on North American Symptomatic Carotid Endarterectomy Trial criteria) symptomatic carotid stenosis.
  
  
  METHODS
  The study involves 57 consecutive patients undergoing CEA for symptomatic low-grade carotid disease at our institution over 5 years, and 21 (36.8%) had experienced more than one ischemic event. Overall, 48 (84.2%) had a minor stroke, and nine (15.8%) had an episode of retinal ischemia. Diagnosis was made by a vascular neurologist based on an ultrasound examination combined with noninvasive imaging studies, after ruling out other possible causes of embolization. Before CEA, all patients were receiving antiplatelet treatment, and 87% were taking statins. All patients underwent eversion CEA under general deep anesthesia, with selective shunting. All carotid plaques were examined histologically. Long-term follow-up (median, 28 months; mean, 32 ± 5 months; range, 3-56 months) was obtained for 55 patients.
  
  
  RESULTS
  No 30-day strokes or deaths occurred, and no patients had recurrent neurologic events related to the revascularized hemisphere during the follow-up. No late carotid occlusions were detected, but one asymptomatic moderate restenosis was documented. There were seven late deaths (12.7%), none of which were stroke-related. Survival rates were 98% at 1 year and 90% at 3 years. All removed carotid plaques showed different features of ulceration or rupture, with underlying hemorrhage associated with a thrombus.
  
  
  CONCLUSIONS
  This study shows that CEA is a safe, effective, and durable treatment for patients with symptomatic low-grade carotid stenosis associated with unstable plaque. Patients had excellent protection against further ischemic events and survived long enough to justify the initial surgical risk. Plaque instability seems to play a major part in the onset of ischemic events, regardless the entity of lumen narrowing.
authors: Vascular Surgery Group, 2(nd) Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy. Electronic address: enzo.ballotta@unipd.it.
authors: Enzo
authors: E
authors: Ballotta
authors: Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, School of Medicine, Padova, Italy.
authors: Annalisa
authors: A
authors: Angelini
authors: Vascular Surgery Group, 2(nd) Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
authors: Franco
authors: F
authors: Mazzalai
authors: Vascular Surgery Group, 2(nd) Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
authors: Giacomo
authors: G
authors: Piatto
authors: Vascular Surgery Group, 2(nd) Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, School of Medicine, Padova, Italy.
authors: Antonio
authors: A
authors: Toniato
authors: Department of Neurosciences, University of Padua, School of Medicine, Padova, Italy.
authors: Claudio
authors: C
authors: Baracchini
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000209:etiology; D053208:Kaplan-Meier Estimate; D008297:Male; D018579:Patient Selection; D058226:Plaque, Atherosclerotic; D011446:Prospective Studies; D012008:Recurrence; D012164:Retinal Diseases / Q000175:diagnosis / Q000209:etiology; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome