Durability of carotid endarterectomy for treatment of symptomatic and asymptomatic stenoses

Abstract. Purpose. Although many studies have well established that carotid endarterectomy (CEA) is beneficial for selected patients with severe carotid disease, only a few large studies focused on the surgical procedure’s durability. Carotid angioplasty/stenting (CAS) has recently been proposed as a potential alternative to CEA. We sought to analyze the incidence of late occlusions and recurrent stenoses after CEA. Methods. Over a 13-year period, a total of 1000 patients underwent 1150 CEAs for symptomatic and asymptomatic high-grade carotid stenoses. CEA procedures involving either traditional CEA with patching (n = 302) or eversion CEA (n = 848) were all performed by the same surgeon with patients under deep general anesthesia and cerebral protection involving continuous electroncephalografic monitoring for selective shunting. All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at 1, 6 and 12 months, and yearly thereafter. New neurological events and late occlusions or recurrent stenoses ≥ 50% and ≥ 70% were recorded. A complete follow-up (mean 6.2 years; range, 6-156 months) was obtained in 95% (949/1000) of the patients for an overall of 95% (1092/1150) of the procedures. Survival analyses were performed by using Kaplan-Meier life-tables. Results. The perioperative (30-day) mortality and stroke rates were 0.3% (3/1000) and 0.9% (11/1150), respectively, with a combined mortality/stroke rate of 1.2 %. The incidence of late occlusions and recurrent stenoses ≥ 70% was 0.6% and 0.5%, respectively, with a combined occlusion/restenosis rate of 1.1%. Kaplan-Meier analysis showed that the rates of freedom from occlusion, restenosis ≥ 70% and combined occlusion/ restenosis ≥ 70% at 12 years were 99,4%, 99.5%, and 98.8%, respectively. Occlusions and restenoses developed asymptomatically. Conclusions. CEA is a low-risk procedure for treating severe symptomatic and asymptomatic carotid disease, with excellent long-term durability. Proponents of CAS should bear this in mind before considering CAS as a routine alternative to CEA.