Carotid endarterectomy remains the gold standard.

BACKGROUND: To compare the safety and efficacy of carotid endarterectomy (CEA) as performed in a community medical center with the Asymptomatic Carotid Atherosclerosis Study (ACAS) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) standards and with representative published results regarding carotid angioplasty and stenting (CAS). METHODS: Between 1 January 1994 and 31 July 2000, 267 CEA procedures were performed on 236 patients at Madigan Army Medical Center (MAMC). Prospectively acquired patient demographics, operative indications, and surgical outcomes were reviewed using clinical records, carotid duplex evaluations, and follow-up examinations. The resultant data were compared with ACAS, NASCET, and published results of CAS. RESULTS: The perioperative stroke rate was 2.2% (6 of 267) overall, 0.7% (1 of 139) among asymptomatic patients, and 3.9% (5 of 128) among symptomatic patients. There were no perioperative deaths from any cause in the entire series. The respective ACAS and NASCET early stroke-death rates were 2.3% (19 of 825) and 5.8% (19 of 328). The largest published series of CAS reported stroke-death rates of 5.7% (299 of 5,210) overall, and 3.4% (46 of 1,361) and 5.8% (93 of 1,614) for asymptomatic and symptomatic patients, respectively. CONCLUSIONS: CEA remains the standard of care. It is a safe, effective, and durable procedure that can be performed in a facility such as MAMC with outcomes that compare favorably with ACAS and NASCET. Results of CEA at MAMC are superior to similar data regarding CAS. Widespread use of CAS should be deferred pending completion of on-going prospective trials versus CEA.

Intraoperative duplex ultrasonography as an adjunct to technical excellence in 100 consecutive carotid endarterectomies.

PURPOSE: To evaluate the relationship of intraoperative duplex ultrasonography (duplex) results to neurologic outcomes and restenosis among patients undergoing carotid endarterectomy (CEA). METHODS: One hundred consecutive CEAs were performed at a military medical center over 28 months. Prospectively acquired demographics, duplex results, revisions, and surgical outcomes were reviewed. RESULTS: Thirty-four percent (34 of 100) of sites were abnormal by completion duplex. Of these, 70% (24 of 34) were B-mode flap type defects located in the common carotid artery (CCA), internal carotid artery (ICA), or external carotid artery (ECA). Twenty-one percent of the defects (7 of 34) were technically unacceptable and immediately revised. Subsequently, 3 perioperative neurologic events occurred, 2 strokes and 1 transient ischemic attack (TIA), all among patients with an identified but unrepaired defect involving the ICA or CCA. This association of unrepaired defect with early stroke or TIA was significant (P = 0.02). No significant association (P >0.05) between unrepaired defects and late ipsilateral stroke or TIA or restenosis was identified. CONCLUSIONS: Intraoperative duplex scanning is a useful adjunct to CEA that can identify correctable mechanical problems. Residual elevated velocities or B-mode flaps 2 mm or greater in the ICA warrant consideration for immediate repair. Findings not requiring revision include flaps <2 mm, as well as isolated ECA defects. Prospectively validated duplex criteria are needed to further define which defects require immediate repair.