Carotid surgery in private practice: what kind of change in the last 15 years?

Abstract

Background: This retrospective study analyzes and compares the results of patients undergoing carotid endarterectomy (CE) for atherosclerotic stenosis obtained by 2 surgeons during two 5-year periods. Group 1 (G1) represents the first period (January 1994-December 1998) and group 2 (G2) represents the second period (January 2006-December 2010). Our objective was to answer the 2 following questions: (1) Has the population changed between these 2 periods with regard to age, risk factors, and symptoms? (2) Have the techniques we used in G2--local anesthesia and eversion technique--improved the results?

Methods: G1 included 682 CE procedures on 610 patients and G2 included 629 procedures on 592 patients. The following factors were analyzed in G1 and G2: distribution of age and sex, the main risk factors (diabetes and cardiovascular risk), symptomatology, the degree of stenosis, the preoperative computed tomography (CT) data, the type of anesthesia (general or local), the use of an intraoperative shunt, surgical techniques, postoperative patency, cardiac complications, central and peripheral neurologic complications, and reoperations. In conformity with the North American Symptomatic Carotid Endarterectomy Trial classifications, stenosis of >70% was included in this survey. Loops, tumors, aneurysms, and restenosis were excluded. Heparin (300 U.I./kg) was administered. Shunt placing was selective. The 3 most common techniques used were eversion, longitudinal CE with patch angioplasty, and CE with direct closure. Postoperative patency was controlled by intravenous digital angiography or duplex ultrasonography. Follow-up occurred until postoperative day 30.

Results: Compared with G1, the incidence of arterial hypertension, diabetes, and coronary atherosclerosis treated by angioplasty increased significantly in G2; local anesthesia replaced general anesthesia in G2, and fewer intraoperative shunts were used (P = 0.034). The technique of direct closure of the arteriotomy was no longer used. In contrast to G1, in G2 no postoperative carotid thromboses (P = 1.8) and no lethal strokes (P = 5.44) were observed. The incidence of major adverse cardiovascular events on postoperative day 30 was 1.7% in G1 compared with 0.79% in G2. The combined mortality and morbidity rate--including reoperations and peripheral neurologic deficits--was 3.95% in G1 compared with 3.81% in G2.

Conclusion: Despite a major increase in risk factors, the combined use of local anesthesia and eversion technique, when technically feasible, improved our results in G2.