Comorbid Conditions No Bar to Safe Endarterectomy

By John Gever
NEW HAVEN, Conn., 18 aug 2008-- Carotid endarterectomies can be performed safely even in patients with multiple comorbidities, researchers here said.
Explain that the study mainly included men and therefore cannot be generalized to women.
In a 120-patient series, patients with a high prevalence of hypertension, coronary artery disease, and other conditions showed median survival of 8.9 years, with nearly 90% remaining free from stroke, reported Alan Dardik, M.D., Ph.D., of Yale, and colleagues in the August issue of the Journal of the American College of Surgeons.
"'Medical high risk' does not necessarily imply 'surgical high risk' for carotid endarterectomy," the researchers wrote. "The presence of multiple associated medical comorbid conditions is not sufficient to automatically exclude the potential for referral for carotid endarterectomy."
They said most studies of the procedure, intended to prevent strokes in patients with significant atherosclerotic plaques in the carotid artery, have excluded patients with other cardiovascular diseases or major risk factors such as diabetes or pulmonary disease.
"Some clinicians suggest that patients with a large number of medical conditions form a 'high-risk' group and should be offered alternative therapies to avoid complications associated with surgery," they said.
The current study suggests that carotid endarterectomy can safely be offered to most patients, except the few with anatomic risk factors such as tracheostomy or previous radiation exposure to the neck.
Dr. Dardik and colleagues reviewed records of all procedures conducted at the VA hospital in West Haven, Conn., from 1995 to 1999, with mean follow-up of 8.5 years.
They identified 128 endarterectomies performed in 120 patients, with a mean age of 69.7 (SD 0.73) at surgery.
Most patients showed symptoms of severe carotid stenosis prior to surgery, with 18% presenting with transient ischemic attacks, 17% with amaurosis fugax, and 17% with stroke.
Rates of comorbid conditions and risk factors included:
Hypertension: 82%
Coronary artery disease: 64%
Smoking history: 73%
Previous angioplasty: 17%
Previous CABG: 22%
Diabetes: 37%
Renal disease: 33%
Within 30 days of carotid endarterectomy, two patients had strokes and one had a myocardial infarction. One of the strokes was fatal; there were no other deaths within 30 days.
Two patients had ipsilateral transient ischemic attacks in the recovery room followed by immediate surgical re-exploration. Nothing was found in one case, while a common carotid artery occlusion was found in the other and treated.
Seven patients had cranial nerve injuries, six of which resolved without treatment.
Dr. Dardik and colleagues found that, of 59 deaths following surgery, only three were from stroke, one of which occurred within 30 days of the procedure.
The five-year rate of ipsilateral stroke was 6.7%. After 12 years, the rate increased to 11%.
Risk factors for late ipsilateral stroke included age at surgery and diastolic blood pressure during follow-up, the researchers found.
Notably, Charlson Index scores measuring the burden of comorbid disease were not a significant predictor of late ipsilateral stroke.
The most common causes of death were cancer (22%), cardiac disease (19%), and COPD, pneumonia, and renal failure (7% each).
Among patients with 12 years of follow-up, the overall survival rate was 13%, which the authors said was consistent with the patients' generally poor health and high level of risk factors.
Significant, independent predictors of overall late mortality included age and serum creatinine at surgery and hypertension during follow-up.
The researchers said limitations to the study included its retrospective design and the lack of systematic neurological exams, which might have allowed some minor strokes and neurological abnormalities to go unnoticed.
More importantly, nearly all the patients were men. Hence the results may not be generalizable to women, the researchers said, especially in light of earlier research finding higher rates of death and stroke following carotid endarterectomy in women compared with men.
The work was supported by the National Institutes of Health, the American Vascular Association, and the VA Connecticut Healthcare System. No potential conflicts of interest were reported.
Primary source: Journal of the American College of SurgeonsSource reference:Fitzgerald T, et al "Success of carotid endarterectomy in veterans: high medical risk does not equate with high surgical risk" Journal of the American College of Surgeons 2008; 207: 219-26.