Ee. Rigdon et al., IS CAROTID ENDARTERECTOMY JUSTIFIED IN PATIENTS WITH SEVERE CHRONIC RENAL-INSUFFICIENCY, Annals of vascular surgery, 11(2), 1997, pp. 115-119
Citations number
23
Categorie Soggetti
Peripheal Vascular Diseas","Cardiac & Cardiovascular System
We evaluated the effect of chronic renal insufficiency (CRI) and commo
nly associated co-morbid conditions on the risk of adverse events (str
oke, cardiac events, and death) within 30 days after carotid endartere
ctomy (CEA). Renal function of patients undergoing CEA from 1980 to 19
94 was categorized as normal (creatinine<1.5 mg/dl), mild CRI (creatin
ine 1.5-2.9 mg/dl), or severe CRI (creatinine>2.9 mg/dl). Renal functi
on, age, gender, indications for surgery, cardiac disease, chronic pre
operative hypertension, diabetes mellitus, smoking history, severe per
ioperative hypertension or hypotension, intraoperative shunting, and p
atch closure of the carotid artery were evaluated for their influence
on the incidence oi adverse events within 30 days after surgery. The t
iming of postoperative stroke and mechanism of stroke was determined w
hen possible. A total of 237 patients underwent 285 CEAs. No significa
nt differences were found in demographic or clinical characteristics b
etween patients with normal or abnormal renal function. Postoperative
stroke and death occurred following three (43%) of seven CEAs in six p
atients with severe CRI, significantly greater than the 6% incidence o
f stroke and 1% mortality following 264 CEAs in 221 patients with norm
al renal function (p<0.001 and p<0.001, respectively). Of three patien
ts with severe CPI suffering postoperative stroke, two had severe, dif
ficult to control perioperative hypertension. Two patients with severe
CRI who survived 30 days after operation suffered strokes 3 and 4 mon
ths postoperatively with one stroke-related death and another death no
t directly related to the stroke. One patient with severe CRI who surv
ived CEA without stroke was alive 6 months after surgery. The 0% incid
ence of stroke and death following 14 CEAs in 10 patients with mild CR
I was not significantly different from that in patients with normal re
nal function. Postoperative stroke was not associated with age, gender
, history of cardiac disease, chronic preoperative hypertension, diabe
tes, smoking, or use of intraoperative shunts or patch closure. All th
ree cardiac events occurred in diabetic patients, although they consti
tuted only 26% of operations (p=0.003). Other clinical characteristics
were not associated with the occurrence of cardiac events. Patients w
ith severe CRI are at significantly greater risk than others for posto
perative stroke and death following CEA, possibly related to difficult
y controlling severe perioperative hypertension. Age, gender, smoking,
preoperative hypertension, diabetes, and known cardiac disease are no
t associated with an increased risk of postoperative stroke in any pat
ient group. CEA can be justified only for carefully selected patients
with severe CPI who have symptomatic carotid disease, acceptable opera
tive risk factors, and a good long-term life expectancy. CEA in patien
ts with mild CRI is associated with low risk, and these patients may b
e treated with the same consideration as patients with normal renal fu
nction.