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Interact CardioVasc Thorac Surg 2009;8:100-103. doi:10.1510/icvts.2008.189167
© 2009 European Association of Cardio-Thoracic Surgery
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ESCVS article - Carotid and imaging

Carotid endarterectomy in high-risk Arab patients{star}

Mohamed A. Elsharawy*

Department of Vascular Surgery, King Faisal University, P.O. Box 40081, Al-Khobar 31952, Eastern Province, Kingdom of Saudi Arabia

Received 28 July 2008; received in revised form 19 September 2008; accepted 23 September 2008

{star} Presented at the 57th International Congress of the European Society for Cardiovascular Surgery, Barcelona, Spain, April 24–27, 2008.

*Corresponding author. Tel.: +966-50-1852057; fax: +966-3-8966728.

E-mail address: elsharawya{at}yahoo.co.uk (M.A. Elsharawy).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Objective: Carotid artery angioplasty and stenting (CAS) has developed quickly and has started to replace carotid endarterectomy (CE) in high-risk cases. However, there are conflicting reports about the results of CAS in such cases. The current study was undertaken to assess the results of CE in high-risk Arab patients over two years at a single center. Patients and methods: The study was performed on all Arab patients referred to King Fahd Hospital of the University for CE with high risk for surgery from August 2004 to August 2006. High-risk factors were recorded. The primary end points were the occurrence of stroke, myocardial infarction and death in the first 30 postoperative days and in follow-up for one year. Results: Thirty-one CE procedures were performed in 29 high-risk Arab patients. Twenty-five patients had severe ischemic heart disease and were prepared for coronary artery bypass grafting. One patient (3%) had preoperative cardiac arrest and after resuscitation developed stroke. One patient died (3%) suddenly nine months after surgery. No recurrence or stroke was recorded over a one-year follow-up period. Conclusion: This short report showed that CE can be performed safely in high-risk Arab patients.

Key Words: Carotid endarterectomy; High-risk Arab patients; Stroke


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Carotid surgery for significant stenosis is validated by large international trials and long-term results after more than 50 years experience. Indications for carotid endarterectomy (CE) were well established from four level 1A clinical trials; North American Symptomatic Carotid Endarterectomy Trial (NASCET) [1], European Carotid Surgery Trial (ECST) [2], Asymptomatic Carotid Atherosclerosis Study (ACAS) [3] and Asymptomatic Carotid Surgery Trial (ACST) [4]. These trials addressed the use of CE for symptomatic patients with more than 50% stenosis and asymptomatic with more than 80%. However, it is important to realize that these trials have excluded most of the high-risk patients. Moreover, results of CE in both standard and high-risk Arab patients have never been assessed before. Recently some studies reported the outcome of CE in high-risk patients [5–11]. Carotid artery angioplasty and stenting (CAS) has developed quickly and has started to replace CE in high-risk cases. However, there are conflicting reports about the results of CAS in such cases [12–14]. The current study was undertaken to assess the results of CE in high-risk Arab patients over two years at a single center.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
A prospective study was performed on high-risk Arab patients referred for CE to the vascular surgery unit of King Fahd Hospital, Al-khobar, Saudi Arabia between August 2004 and August 2006. All patients underwent computed tomography angiography and Duplex-scanning for the study of the extra-cranial carotid vessels. The degree of stenosis was determined by means of the NASCET method [1]. High-risk patients were defined as those who met the definition of high risk according to criteria used in SAPPHIRE study [8]. The criteria included risk factors that have been suggested as predictors of adverse outcome associated with CE (Table 1). The enrollment criteria for this study were symptomatic carotid stenosis ≥50% or asymptomatic ≥80% plus one or more of the risk factors listed in Table 1. In patients with concomitant coronary and carotid artery disease, and in whom both CE and coronary artery bypass graft surgery (CABG) were required, the surgical technique was individualized for each patient. Patients without severe cardiac disease were considered for CE followed by CABG and the rest for combined procedure at the same time.


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  		Table 1 Criteria for high-risk carotid endarterectomy

 
All CE operations were performed by one vascular surgeon and mostly under regional anesthesia. Regional anesthesia was performed by superficial cervical plexus block with additional analgesia provided by local infiltration using a mixture of 0.5% bupivacaine (10 ml) and 1% lidocaine (10 ml). Additionally, local anesthetic was given during the dissection if required. The degree of pain was also measured on a 100 mm (0=corresponds to no pain and 100=corresponds to maximum imaginable pain) visual analogue scale (VAS). CE was performed through a standard oblique neck incision. Before clamping, intravenous heparin (5000 U) was administered. A linear arteriotomy extended from the common into the internal carotid artery beyond the plaque end point. Selective shunting was used on the basis of neurological changes with regional anesthesia or trans-cranial Doppler signal changes with general anesthesia. Selective patching for carotid reconstruction was performed based on the size of the internal carotid artery and distal extension of the plaque. At the end of interventions, completion study was performed with intra-operative Doppler. All patients received aspirin (81 mg daily) routinely preoperatively which continued with clopidogrel (75 mg daily) long-term postoperatively. Peri-operative β-blockade was used selectively, based on the recommendation made at the preoperative medical evaluation. Formal postoperative neurology consultation was obtained if there was any clinical suspicion of a neurologic event. Primary end points included peri-operative stroke, death, and combined stroke–death rate, defined by the reporting standards of an ad hoc committee of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery on Cerebrovascular Reporting [15]. Stroke was defined as persistence of a clinical neurologic deficit beyond 24 h.

The frequency of postoperative in-hospital MI was calculated. Major postoperative bleeding was defined as the need for repeat operation. Cranial nerve injuries were classified as major (symptomatic or detectable for >30 days) or minor (asymptomatic and detectable for <30 days). Two sets of cardiac isoenzymes (creatinine kinase, troponin) and electrocardiograms were obtained routinely after operation if the patient had severe ischemic heart disease.

2.1. Follow-up

Clinical and ultrasonography follow-up was performed at 6 weeks, 3, 6 and 12 months after operation. History, clinical examination, investigations, operative and follow-up data were prospectively recorded.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
Thirty-one CE procedures in 29 patients were included in this study. Two patients had bilateral CE. The mean age was 66.2 years (range 44–83) (Table 2). CE was performed on the left side in 18 cases and on the right side in the rest. Twenty-five patients had severe ischemic heart disease and were prepared for CABG. Twenty-one patients had CE before CABG, two had synchronous CE and CABG, and one had CE on the left side before CABG and on the right side after CABG. One patient CE was complicated by stroke and CABG was postponed. In 5 (17%) patients more than one high-risk criterion was present (two criteria in 14% and three criteria in 3%) (Table 2). Twelve patients (41%) had a history of transient ischemic attack or stroke and the rest were asymptomatic. The median (range) VAS during surgery was 30 (25–45).


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  		Table 2 Patient characteristics

 
One patient (3%) had peroperative cardiac arrest and after resuscitation developed stroke. This patient had severe cardiac disease and chronic renal failure. In another patient, the operation was complicated postoperatively by small operative site hematoma. There were no postoperative deaths, major bleeding or cranial nerve injuries. One patient died suddenly nine months after surgery. Death was attributed to extensive myocardial infarction. No recurrence or stoke was recorded over the one-year follow-up period. Therefore, the combined death–stroke rate at one year was 7%.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
Although NASCET and ACAS have validated the role of CE in selected patients, these trials have also been criticized for not being applicable to the typical population of patients with atherosclerosis with multiple risk factors. Carotid artery angioplasty and stenting has been developed over the last decade to replace CE, especially in high-risk cases. Several level 1 studies were conducted to compare CE and CS. Examples of these studies were stent protected percutaneous angioplasty vs. carotid endarterectomy (SPACE) [13], endarterectomy vs. angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) [14] and long-term results of stenting and angioplasty with protection in patients at high risk of endarterectomy (SAPPHIRE) [12]. All these trials did not show advantage of CAS over CE.

Several studies have been reported on the outcome of CE in high-risk patients. Peri-operative stroke rate varies from 0.5–9% [5–11] compared to 3% in the present study. Thirty-day mortality rate varies as well from 0–1.3% in several studies [5–11] compared to 0% in the present study. Peri-operative acute myocardial infarction varies from 0–3.1% in several studies [5–11] compared to 3% in the present study.

Review of recent literature identified several risk factors that have been suggested as predictors of adverse outcome associated with CE. Several retrospective studies have found that age is a risk factor for CE [16]. However, many studies also showed no statistical association between increasing age and peri-operative morbidity and mortality [17]. Recently, Lepore et al. [10] revised the results of CE in NASCET-ACAS ineligible patients. In this study, octogenarians were analyzed separately; the overall stroke and death rates were not significantly different from that in younger patients. Octogenarians were shown to have results similar to younger patients in terms of early and late mortality and neurologic outcome in several studies [9, 18, 19] as well as in the present one.

Few studies have shown that CE was risky in the presence of severe medical dysfunction (cardiac, pulmonary, renal) [20]. Nevertheless, numerous studies found that the stroke and death rates were similar in both the high-risk and non-high-risk groups [5, 6, 8]. Others found no differences in stroke rate between patients with no risk factors compared to those with one or more risk factors. However, 30-day mortality rate was lower in patients with no risk factors [7]. The stroke and death rates in the present study, which includes only risky patients, are within accepted standards and comparable with other series [5, 6].

Several studies [5, 6, 12] have included high carotid lesion as a high risk criterion for CE. It increases difficulty of the procedure and length of the operation. However, all the previous reports as well as the present one did not show any increase in mortality or stroke rate.

The management of patients with concomitant coronary artery and carotid artery disease is difficult and controversial. There are no randomized controlled studies to guide treatment recommendations. The options include operating on the carotid lesion first, with an increased risk of morbidity and mortality from myocardial infarction; operating on the coronary lesion first, with an increased risk of peri-operative stroke or operating on both lesions during the same period of anesthesia. Advantages of the simultaneous approach are decreased exposure to anesthetic drugs, shorter hospital stay and cost saving [21]. Many studies suggest that simultaneous combined CE and CABG is the safest approach [22]. However, a meta-analysis of 56 reports reviewed three operative strategies: simultaneous CE and CABG, CE followed by CABG, and CABG followed by CE showed that the peri-operative stroke rate was similar if carotid and coronary surgeries were combined or if carotid surgery proceeded coronary bypass grafting. The frequency of stroke was significantly greater if CABG preceded carotid surgery [23]. Another analytical overview of the strategies for the management of concomitant coronary and carotid artery stenosis comparing, combined (CE and CABG), reverse (CABG then CE) and prior staged (CE then CABG). There was no significant difference in the overall stroke and mortality risks between the various strategies; however, subgroup analysis suggests that, when carefully selected, patients do better by staging the operations [24]. In the present study, surgical technique was individualized for each patient and was similar to the last recommendation i.e. patients without severe cardiac disease should be considered for prior staging and the rest for combined procedure.

This study has some limitations. Firstly, the number of patients was small. Although the prevalence of significant carotid artery disease among Saudi or other Arab population has never been reported before, it is known from unpublished data that Arabs, like Chinese patients [25], have a lower incidence of significant extra-cranial carotid artery disease compared to Western population. Another limitation of the present study is that it is not a comparative study. Because the type of patients referred to our unit are those who usually have high risk factors for CE, the number of low-risk patients is very small. This reason, combined with low prevalence of some risk factors, limits the statistical power if we try to compare both groups and analyze the influence of each individual risk factor.

In conclusion, CE can be performed safely in Arab patients with multiple risk factors. Although it was observed that there is a trend toward higher peri-operative mortality in patients with multiple co-morbid conditions, the death/stroke rates noted in patients with these risk factors still fall within the range of those reported in randomized trials and within those proposed by the American Heart Association [15] as practice guidelines, i.e. combined stroke–death rate of 3% in patients with asymptomatic disease and 6% in those with symptomatic disease.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

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