Treatment of Recurrent Carotid Disease

Abstract

The purpose of this study was to determine whether repeat carotid endarterectomy (CEA) poses a greater risk than first-time CEA. The authors analyzed data from 893 consecutive CEA cases (1981-1993). Thirty-three patients (3.7%) had repeat CEA, and 860 (96.3%) had first-time CEA. There were statistically significantly higher incidences of hypertension (60.6% vs 44.6%), smoking (84.8% vs 55%), hypertriglyceridemia (33.3% vs 16.2%), and coronary artery disease (66.6% vs 36%) in the repeat CEA group than in the first-time CEA group.

Symptomatic disease was present in 25 (75.8%) patients in the repeat group and in 576 (67%) patients in the first-time group (P>0.05). The cause of recurrence was atherosclerosis in 25 patients (76%), myointimal hyperplasia in seven patients (21.2%), and intraluminal thrombus without an underlying lesion in one patient (3%). Redo CEA with vein patch angioplasty was performed in 27 patients (82%), vein patch angioplasty alone in five patients (15%), and interposition vein graft in one patient (3%).

The hospital operative mortality was 0% (n=0) in the repeat CEA group and 0.6% (n=5) in the first-time CEA group (P>0.05). The incidence of postoperative stroke was 0% (n=0) in the repeat group and 1.2% (n= 10) in the first-time group (P>0.05). There was one case (3%) of transient ischemic attack (TIA) in the repeat group, and two cases (0.2%) of TIA in the first-time group. There was no difference in the incidence of cranial nerve dysfunction between the repeat group (n=2, 6%) and the first-time group (n=41, 4.8%; P>0.05). Late follow-up data were obtained for 30 patients (mean: 61.4 months, range: 5-158 months) in the repeat CEA group and 501 patients (mean: 55.8 months, range: 17-168 months) in the first-time CEA group. The incidence of late failure (ipsilateral stroke or TIA) was 3.3% (n= 1) in the repeat group and 3.2% (n= 16) in the firsttime CEA group; P>0.05. The overall late mortality was 20% (n=6) in the repeat CEA group and 14.6% (n=73) in the primary CEA group; P>0.05.

Repeat CEA can be performed safely in individuals with severe recurrent carotid stenosis, and perioperative and long-term mortality and neurologic morbidity rates are similar to those for patients undergoing first-time carotid endarterectomy.

Get full access to this article

View all access options for this article.

References

1. Rosenthal D , Archie JP , Rinaldi GR , et al: Carotid patch angioplasty: Immediate and long-term results. J Vasc Surg 12:326-333, 1990.

2. Norrving B , Nillson B , Olsson JE : Progression of carotid disease after endarterectomy: A Doppler ultrasound study. Ann Neurol 12:548-552, 1982.

3. DeGroote RD , Lynch TG , Jamil Z , et al: Carotid restenosis: Long-term noninvasive follow-up after carotid endarterectomy. Stroke 18:1031-1036, 1987.

4. Healy DA , Zierler RE , Nicholls STC , et al: Long-term follow-up and clinical outcome of carotid restenosis. J Vasc Surg 10:662-669, 1989.

5. Eikelboom BC , Ackerstaff RGA , Hoeneveld H , et al: Benefits of carotid patching: A randomized study. J Vasc Surg 8:240-247, 1988.

6. Shumway SJ , Edwards WH , Jenkins JM , et al: Recurrent carotid stenosis: Incidence and managment. Am J Surg 53:61-65, 1987.

7. Turnipseed WD , Berkoff HA , Crummy A : Postoperative occlusion after carotid endarterectomy. Arch Surg 115:573-574, 1980.

8. Das MB , Hertzer NR , Ratliff NB , et al: Recurrent carotid stenosis. Ann Surg 202:28-35, 1985.

9. Cantelmo NL , Cutler BS , Wheeler HB , et al: Noninvasive detection of carotid stenosis following endarterectomy. Arch Surg 116:1005-1008, 1981.

10.

10. Gagne PJ , Riles TS , Imparato AM , et al: Redo endarterectomy for recurrent carotid artery stenosis. Eur J Vasc Surg 5:135-140, 1991.

11.

11. Stoney RJ , String ST : Recurrent carotid stenosis. Surgery 80:705-710, 1976.

12.

12. Nicholls SC , Phillips DJ , Bergelino RO , et al: Carotid endarterectomy: Relationship of outcome to early restenosis. J Vasc Surg 2:375-381, 1985.

13.

13. Bernstein EF , Toren S , Dilley RB : Does carotid restenosis predict an increased risk of late symptoms, stroke, or death? Ann Surg 212:629-636, 1990.

14.

14. Coyle KA , Smith RB , Gray BC , et al: Treatment of recurrent cerebrovascular disease. Review of a 10-year experience. Ann Surg 221:517-524, 1995.

15.

15. AbuRahma AF , Snodgrass KR , Robinson PA , et al: Safety and durability of redo carotid endarterectomy for recurrent carotid artery stenosis. Am J Surg 168:175-178, 1994.

16.

16. Gagne PJ , Riles TS , Jacobowitz GR , et al: Long-term follow-up of patients undergoing reoperation for recurrent carotid artery disease. J Vasc Surg 18:991-1001, 1993.

17.

17. Ricotta J , O'Brien M , DeWeese J : Natural history of recurrent and residual stenosis after carotid endarterectomy: Implications of postoperative surveillance and surgical managment. Surgery 112:656-663, 1992.

18.

18. Barnes R , Nix M , Nichols B , et al: Recurrent versus residual stenosis: Incidence and detection by Doppler ultrasound. Ann Surg 203:652-660, 1986.

19.

19. Plestis KA , Kantis G , Haygood K , et al: Carotid endarterectomy with homologous vein patch angioplasty: A review of 1006 cases. J Vasc Surg 24:109-119, 1996.

20.

20. Volteas N , Labropoulos N , Leon M , et al: Risk factors associated with recurrent carotid stenosis. Int Angiol 13:143-147, 1994.

21.

21. Cossman DV , Treiman RL , Foran RH , et al: Surgical approach to recurrent carotid stenosis. Am J Surg 140:209-211, 1980.

22.

22. Clagett G , Patterson C , Fisher D , et al: Vein patch versus primary closure for carotid endarterectomy. J Vasc Surg 9:213-223, 1989.

23.

23. Hertzer N , Beven E , O'Hara PJ , et al: A prospective study of vein patch angioplasty during carotid endarterectomy: Three year results for 801 patients and 917 operations. Ann Surg 206:628-635, 1987.

24.

24. Katz D , Snyder SO , Gandhi RH , et al: Long-term follow-up for recurrent stenosis: A prospective randomized study of expanded polytetrafluoroethylene patch angioplasty versus primary closure after carotid endarterectomy. J Vasc Surg 19:198-205, 1994.

25.

25. Kremen JE , Gee W , Kaupp HA , et al: Restenosis or occlusion after carotid endarterectomy. Arch Surg 114:608-610, 1979.

26.

26. Bernstein EF , Humber PB , Collins GM , et al: Life expectancy and late stroke following carotid endarterectomy. Ann Surg 198:80-86, 1983.

27.

27. Gelabert HA , El-Massry S , Moore WS : Carotid endarterectomy with primary closure does not adversely affect the rate of recurrent stenosis. Arch Surg 129:648-654, 1994.

28.

28. O'Donnell T Jr , Gallow A , Scott G , et al: Ultrasound characteristics of recurrent carotid disease: Hypothesis explaining the low incidence of symptomatic recurrence. J Vasc Surg 2:26-41, 1985.

29.

29. Meyer FB , Piepgras DG , Fode NC : Surgical treatment of recurrent carotid artery stenosis. J Neurosurg 80:781-787, 1994.

30.

30. Bartlett FF , Rapp JH , Golstone J , et al: Recurrent carotid stenosis: Operative strategy and late results. J Vasc Surg 5:452-456, 1987.

31.

31. Nitzberg RS , Mackey WC , Prendiville E , et al: Longterm follow-up of patients operated on for recurrent carotid stenosis. J Vasc Surg 13:121-127, 1991.