title: Carotid artery disease progression and related neurologic events after carotid endarterectomy.
abstract: OBJECTIVE
  During the last decade, there has been a dramatic improvement in best medical treatment for patients with vascular disease. Yet, there is a paucity of contemporary long-term data for restenosis and contralateral internal carotid artery (ICA) progression. This study assessed ipsilateral and contralateral disease progression and cerebrovascular events after carotid endarterectomy (CEA).
  
  
  METHODS
  A consecutive cohort of CEAs between January 1, 2000, and December 31, 2010, was retrospectively analyzed. End points were restenosis ≥50% and ≥70%, contralateral carotid disease progression (50%-69%, 70%-99%, or occlusion) and stroke. Survival analysis and Cox regression models were used to assess the effect of baseline predictors.
  
  
  RESULTS
  During the 11-year study period, 1639 patients underwent 1782 CEAs (50.0% patch closure, 23.9% primary closure, 26.1% eversion, and 2.5% combined with coronary artery bypass grafting). The combined stroke/death rate was 2.6% overall and 1.8% in the asymptomatic cohort. The rate of restenosis ≥50% at 2, 5, and 10 years was 8.5%, 15.6%, 27.2%, and the rate for restenosis ≥70% was 3.4%, 6.5%, 10.2%, respectively. Restenosis ≥50% was predicted by hypertension (hazard ratio [HR], 2.09; P = .027), female gender (HR, 1.43; P = .042), and younger age (≤65 years; HR, 1.56; P = .016), but not by statins, surgical technique, symptoms, or other baseline risk factors. Restenoses remained asymptomatic in 125 of 148 (84.5%). Progression of contralateral ICA disease at 2, 5, and 10 years was estimated at 5.4%, 15.5%, and 46.8%, respectively. Contralateral progression was only predicted by smoking (HR, 1.74; P = .008). The stroke rate in patients with disease progression of the contralateral ICA was not different compared with those without progression (7.0% vs 3.3%; P = .063). Any-stroke rates at 2, 5, and 10 years were 4.6%, 7.3%, and 15.7%, respectively. Predictors were symptomatic lesion (HR, 1.48; P = .039), renal insufficiency, defined as a glomerular filtration rate (GFR) of 30 to 59 vs <30 mL/min/1.73 m2(HR, 0.34; P = .009) or GFR ≥60 vs GFR <30 mL/min/1.73 m2(HR, 0.55; P = .109), and statin use (HR, 0.59; P = .006).
  
  
  CONCLUSIONS
  Restenosis or contralateral disease progression after CEA, to a level that might warrant consideration for treatment, is very low. The potentially associated stroke rates are also very low and not clearly related to disease progression. With the exception of the postoperative duplex, surveillance within short intervals of <1 or 2 years cannot be justified.
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: avgerinose@upmc.edu.
authors.forename: Efthymios D
authors.initials: ED
authors.lastname: Avgerinos
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Catherine
authors.initials: C
authors.lastname: Go
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Ling
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Abdallah
authors.initials: A
authors.lastname: Naddaf
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Amy
authors.initials: A
authors.lastname: Steinmetz
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Adham N
authors.initials: AN
authors.lastname: Abou Ali
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Michel S
authors.initials: MS
authors.lastname: Makaroun
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Rabih A
authors.initials: RA
authors.lastname: Chaer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D058070:Asymptomatic Diseases; D002340:Carotid Artery Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000601:surgery*; D018450:Disease Progression; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex