Outcome in patients with symptomatic occlusion of the internal carotid artery.

OBJECTIVES: to assess whether the risk of recurrent ischaemic stroke in patients with symptomatic internal carotid artery (ICA) occlusion has changed over the past decades, to determine risk factors for the occurrence of ischaemic stroke and to assess the risk of endarterectomy (CEA) of a severe contralateral ICA stenosis. DESIGN: retrospective cohort study. PATIENTS AND METHODS: patients with symptomatic ICA occlusion were identified from duplex registry files between 1991 and 1995. Information was obtained on vascular risk factors, performance of CEA for a contralateral ICA stenosis and on recurrence of ischaemic stroke. The rate of complications occurring within 30 days after CEA of the contralateral ICA in patients with symptomatic ICA occlusion was compared with the risk of CEA in patients with asymptomatic ICA occlusion and severe contralateral ICA stenosis (symptomatic or asymptomatic). RESULTS: ninety-seven patients were identified. Mean follow-up time was 26 months. The annual risk of (non-)fatal stroke was 5.3% for all strokes (95% CI 2. 9%-9.6%) and 3.8% for ipsilateral stroke (95% CI 1.9%-7.7%). Hyperlipidaemia and severe stenosis of the contralateral ICA were independent risk factors. Twenty-two of 32 patients with a severe stenosis of the contralateral ICA underwent CEA, of which one patient died and three suffered a minor ischaemic stroke. The perioperative risk of CEA in the control group of 20 patients with asymptomatic contralateral ICA occlusion was 0% (0 of 20). CONCLUSIONS: outcome in patients with symptomatic ICA occlusion has not substantially improved over the years. CEA for severe stenosis of the contralateral ICA carried a relatively high risk in our series, but deserves to be studied in a controlled design.

The importance of revision of early restenosis after endovascular remote endarterectomy in SFA occlusive disease.

OBJECTIVES: to investigate the results of revision of recurrent stenoses after superficial femoral artery (SFA) remote endarterectomy. DESIGN: prospective, non-open, study. MATERIALS: eighty-eight consecutive patients with long segmental SFA occlusive disease underwent 101 remote end-arterectomy procedures. All patients had chronic lower extremity ischaemia necessitating surgical intervention. METHODS: clinical, haemodynamic, and duplex examinations were performed postoperatively at regular intervals, identifying 46 recurrent stenosed (PSV ratio >2.5) limbs, which formed the cohort for this study. The median follow-up was 25 months. Secondary revision was performed in 23 limbs, based on recurrent symptoms and individual preference of the attending vascular surgeon. Cumulative primary and primary assisted-patency rates were compared using the log-rank test of significance. RESULTS: univariate analysis did not show any significant differences for other demographic and lesion characteristics apart from recurrent symptoms (all revised). Multivariate analysis revealed that revision "adjusted for time-of-onset" predicted reocclusion (p=0.007; HR 0. 21; 95% CI 0.06, 0.66). Among subjects in whom restenoses developed within 1 year, revision of recurrent stenoses improved primary patency rates from 47% to 77% at 30 months. CONCLUSIONS: revision of early (<1 year) recurrent stenoses improves the mid-term patency rates of SFA remote endarterectomy.

Incidence, time-of-onset, and anatomical distribution of recurrent stenoses after remote endarterectomy in superficial femoral artery occlusive disease.

PURPOSE: The incidence, time-of-onset, and anatomical distribution of recurrent stenoses after remote endarterectomy in superficial femoral artery (SFA) occlusive disease were studied. METHODS: Patients undergoing SFA remote endarterectomy procedures were examined with duplex surveillance. Patients were examined at 6 weeks, 3, 6, 9, and 12 months, and then annually. Recurrent stenosis was defined as a peak systolic velocity ratio of 2.5 or higher. Duplex results were also compared with clinical and hemodynamic changes. RESULTS: Restenoses were identified in 46 of 101 (46%) limbs treated after a mean interval of 5.8 months (range, 1 to 18 months). These 46 limbs formed the base of this study. The median follow-up period was 25 months. Thirty-eight (83%) of all restenoses were detected within 1 year. The lesions were located within the entire SFA and were not specifically related to the adductor canal or distal stented region only. Multiple stenoses were found in 21 limbs. Only 10 (22%) restenoses were correlated with worsening of clinical symptoms, change of ankle-brachial index, or both. Ten of 23 cases (43%) of nonrevised restenoses progressed to occlusion. These 10 occlusions occurred in all patients with restenosis that developed within the first year. Nonrevised late restenoses (more than 1 year) were not associated with any reocclusion. CONCLUSION: Recurrent stenoses after SFA remote endarterectomy were noticed in 46 of 101 (46%) limbs. Most restenoses (83%) developed within the first year. In the nonrevised group, time-of-onset restenosis (less than 1 year) was correlated with a higher risk for occlusion ( P =.02). The location of restenoses were found without any anatomical site of preference along the entire endarterectomized SFA segment.