Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Comparative Study
. 2017 Dec;66(6):1727-1734.e2.
doi: 10.1016/j.jvs.2017.04.032. Epub 2017 Jun 24.

The impact of contralateral carotid artery stenosis on outcomes after carotid endarterectomy

Alexander B Pothof  1 , Peter A Soden  2 , Margriet Fokkema  1 , Sara L Zettervall  2 , Sarah E Deery  3 , Thomas C F Bodewes  1 , Gert J de Borst  4 , Marc L Schermerhorn  5 ; Vascular Study Group of New England
Affiliations
Comparative Study

The impact of contralateral carotid artery stenosis on outcomes after carotid endarterectomy

Alexander B Pothof et al. J Vasc Surg. 2017 Dec.

Abstract

Objective: Patients with contralateral carotid occlusion (CCO) have been excluded from randomized clinical trials because of a deemed high risk for adverse neurologic outcomes with carotid endarterectomy (CEA). Evidence for this rationale is limited and conflicting. Therefore, we aimed to compare outcomes after CEA between patients with and without CCO and varying degrees of contralateral carotid stenosis (CCS).

Methods: We identified patients undergoing CEA from 2003 to 2015 in the Vascular Study Group of New England (VSGNE) registry. Patients were stratified by preoperative symptom status and presence of CCO. Multivariable analysis was used to account for differences in demographics and comorbidities. Our primary outcome was 30-day stroke/death risk.

Results: Of 15,487 patients we identified who underwent CEA, 10,377 (67%) were asymptomatic. CCO was present in 914 patients, of whom 681 (75%) were asymptomatic. Overall, the 30-day stroke/death was 2.0% for symptomatic patients (CCO: 2.6%) and 1.1% for asymptomatic patients (CCO: 2.3%). After adjustment, including symptom status, CCO was associated with higher 30-day stroke/death (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.3; P = .001), any in-hospital stroke (OR, 2.8; 95% CI, 1.7-4.6; P < .001), in-hospital ipsilateral stroke (OR, 2.2; 95% CI, 1.2-4.0; P = .02), in-hospital contralateral stroke (OR, 5.1; 95% CI, 2.2-11.4; P < .001), and prolonged length of stay (OR, 1.6; 95% CI, 1.3-1.9; P < .001). CCS of 80% to 99% was only associated with a prolonged length of stay (OR, 1.3; 95% CI, 1.1-1.6; P = .01), not with in-hospital stroke. Neither CCO nor CCS was associated with 30-day mortality.

Conclusions: Although CCO increases the risk of 30-day stroke/death, in-hospital strokes, and prolonged length of stay after CEA, the 30-day stroke/death rates in symptomatic and asymptomatic patients with CCO remain within the recommended thresholds set by the 14 societies' guideline document. Thus, CCO should not qualify as a high-risk criterion for CEA. Moreover, there is no evidence that patients with CCO have lower stroke/death rates after carotid artery stenting than after CEA. We believe that CEA remains a valid and safe option for patients with CCO and that CCO should not be applied as a criterion to promote carotid artery stenting per se.

PubMed Disclaimer

Conflict of interest statement

Conflict of interest statement

Marc L. Schermerhorn is a consultant for Endologix and Medtronic. The remaining authors do not have any competing interests to declare.

Figures

Figure 1
Figure 1
a–f Association between degree of contralateral stenosis and outcomes after carotid endarterectomy. 1a: 30-day stroke/death.1 1b: 30-day mortality.1 1c: Any in-hospital stroke.1 1d: In-hospital ipsilateral stroke.1 1e: In-hospital contralateral stroke.1 1f: Prolonged length of stay.1 1: Adjusted for: age, gender, symptom status, preoperative renal insufficiency, preoperative dual antiplatelet usage, degree of ipsilateral carotid stenosis (i.e. <80%, ≥80%), urgency. CCS <50% is referent in each multivariable model. CCS: contralateral carotid stenosis; CCO: contralateral carotid occlusion; OR: odds ratio; CI: confidence interval; *=P < .05
See this image and copyright information in PMC

References

    1. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients with Extracranial Carotid and Vertebral Artery Disease. J Am Coll Cardiol. 2011;57(8):e16–94. - PubMed
    1. Liapis CD, Bell PRF, Sir, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, et al. ESVS Guidelines. Invasive Treatment for Carotid Stenosis: Indications, Techniques. Eur J Vasc Endovasc Surg. 2009;37(4 SUPPL):1–19. - PubMed
    1. de Borst GJ, Schermerhorn M, Moll FL. Why the definition of high risk has been inappropriately used in previous carotid trials. J Cardiovasc Surg (Torino) 2015 Apr;56(2):145–52. - PubMed
    1. Capoccia L, Speziale F, Gazzetti M, Mariani P, Rizzo A, Mansour W, et al. Comparative study on carotid revascularization (endarterectomy vs stenting) using markers of cellular brain injury, neuropsychometric tests, and diffusion-weighted magnetic resonance imaging. J Vasc Surg. 2010 Mar;51(3):584–91. 591.e1–3. discussion 592. - PubMed
    1. Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, et al. Randomized Trial of Stent versus Surgery for Asymptomatic Carotid Stenosis. N Engl J Med. 2016 Mar;374(11):1011–20. - PubMed

MeSH terms

LinkOut - more resources