Carotid endarterectomy in high-risk patients: A challenge for endovascular procedure protocols.

ABSTRACT Background. Many studies have sought to identify certain patient population subset that may be more appropriate for carotid angioplasty and stenting (CAS). Current CAS protocols include high-risk patients. To compare the perioperative outcome of carotid endarterectomy (CEA) between high-risk and non-high-risk patients. Methods. During a 54-months period, 392 consecutive CEAs were performed in 363 patients (29 bilateral) by a single surgeon and entered prospectively into a registry. A high-risk patient subset (126, 34.7% /126 CEAs, 32.1%) was defined by the presence of a severe medical comorbidity (i.e. cardiac dysfunction, pulmonary dysfunction, renal insufficiency) and/or particular anatomic features (i.e. contralateral carotid occlusion, ipsilateral carotid restenosis after CEA and “high” carotid bifurcation). Of the 126 CEAs, 96 (76.2%) were performed for symptomatic lesions. Endpoints of the study were perioperative stroke, cardiac complication or death. Results. Overall, there were three ischemic strokes (0.8%) and four cardiac complications (1.1%). None of the patients died. The stroke (1/126, 0.8% vs 2/237, 0.8%) and cardiac complication rates (3/126, 2.4% vs 1/237, 0.4%) were similar in high-risk and non-high-risk groups, but the cardiac morbidity rate was statistically higher in patients with medical co-morbidity (p = .03), especially in the subset with cardiac dysfunction (p = .005). Conclusion. CEA can be performed in high-risk patients with perioperative neurologic and cardiac complication rates comparable with those recorded in other patients. The definition of “high-risk” patient should not be considered per se a reason to eschew CEA in favor of CAS.