Carotid thromboendarterectomy for
recent total occlusion of the internal carotid artery.
Kasper GC, Wladis AR, Lohr JM, Roedersheimer LR, Reed RL, Miller
TJ, Welling RE.
Department of Surgery and the John J. Cranley Vascular Laboratory,
Good Samaritan Hospital, Cincinnati, OH 45220, USA. kimberly_hasselfeld@trihealth.com
BACKGROUND: The efficacy of emergency carotid thromboendarterectomy
(CTEA) for acute internal carotid artery (ICA) thrombosis has
been questioned. We evaluated the use of CTEA in patients with
recent ICA occlusion. METHODS: From August 1989 to December 1999
patients who underwent urgent CTEA for recent ICA thrombosis were
retrospectively evaluated. Patient data analyzed included age,
sex, comorbid risk factors, diagnostic evaluation, operative procedure,
and long-term follow-up with clinical assessment and carotid duplex
scan. Neurologic status was evaluated with the Modified Rankin
Scale (MRS) before the operation, immediately after the operation,
and at 3- to 6-months' follow-up. RESULTS: Twenty-nine patients
underwent emergency ipsilateral CTEA for acute ICA thrombosis
over the last 10 years. The average age of the patients was 69.9
+/- 1.7 years, and 66% were men. Patient risk factors included
diabetes (7 [24%]), hypertension (21 [72%]), coronary artery disease
(8 [29%]), and history of tobacco abuse (20 [69%]). Presenting
symptoms included cerebrovascular accident (7 [24%]), transient
ischemic attack (nonamaurosis) (10 [34%]), crescendo transient
ischemic attack (7 [24%]), stroke in evolution (2 [7%]), and amaurosis
fugax (3 [10%]). Diagnostic evaluation included computed tomographic
scan (29 [100%]), magnetic resonance imaging/magnetic resonance
angiography (4 [14%]), duplex scan evaluation of the carotid arteries
(23 [79%]), and cerebral angiography (18 [64%]). Antegrade flow
in the ICA was successfully established in 24 (83%) of 29 patients
and confirmed with intraoperative angiography or duplex sonography.
Postoperative morbidity included 2 hematomas (7%), 4 transient
cranial nerve deficits (14%), and 1 conversion to hemorrhagic
stroke (3.6%), which resulted in the only death (3.6%). MRS scores
averaged 3.4 +/- 0.2 preoperatively. Follow-up averaging 74.1
+/- 21 months (range, 3-140 months) was obtained in 27 (93%) patients.
Improvement or deterioration was defined as a change in MRS +/-
1. Immediately postoperatively, 14 (48%) patients were improved,
2 (7%) deteriorated, and 13 (45%) had no change. At 3 to 6 months,
20 (74%) of 27 patients were improved, seven (26%) had no change,
and none deteriorated. Of patients with successful CTEA, 23 (96%)
of 24 had a patent ICA on follow-up duplex scan evaluation, and
there was no evidence of recurrent ipsilateral neurologic events
at an average of 49 months. CONCLUSION: These data support an
aggressive early surgical intervention for acute ICA thrombosis
in carefully selected patients. In the previous decade we reported
a 46% success rate for establishing antegrade flow in the ICA
long term. Data from this decade show a 79% (P =.0114) success
rate for establishing antegrade flow long term in all patients
undergoing emergency CTEA. New and improved imaging modalities
have allowed better patient selection, resulting in improved outcomes.
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