MANAGEMENT OF RECURRENT CAROTID STENOSIS - SHOULD ASYMPTOMATIC LESIONS BE TREATED SURGICALLY

Purpose: The purpose of this study was to determine factors that may i nfluence patient selection for surgery in recurrent carotid stenosis ( RCS) and to contrast the results of primary and secondary carotid enda rterectomy (CENDX) with regard to operative morbidity and stroke preve ntion. Methods: Forty-eight patients who underwent CENDX for RCS (RCS- OP group) were compared with a contemporaneous group of 40 patients wh o on at least one post-CENDX duplex ultrasonography study had a greate r than 50% stenosis but did not undergo operation (RCS-NO-OP group). T his latter group was drawn from 1053 follow-up duplex studies in 348 p atients who underwent primary CENDX between the years 1983 and 1993. E ach of these two groups was compared with a metanalysis of six key ser ies derived from the literature. Results: No significant differences;w ere seen in the demographics or the incidence of risk factors between the two groups except for a higher incidence of coronary artery diseas e (p < 0.03) and peripheral vascular disease (p < 0.001) in the RCS-OP group, The operation-specific stroke rate was 2.1%, and the all-day m ortality was also 2.1%. Symptomatic RCS was the indication in 56% of c ases, Important anatomic differences were found between groups. The du plex/arteriographic degree of stenosis was greater than 90% in 75% of the patients in the RCS-OP group, whereas only 10% of the patients in the RCS-NO-OP group had greater than 80% stenosis, most being in the 5 0% to 80% range. An unexpected finding was the sudden progression to o cclusion in 10 (25%) of 40 in the RCS-NO-OP group, with 2 (5%) of 10 o f the occlusions presenting as unheralded strokes. Overall, a stroke w ithout an antecedent transient ischemic attack occurred in 3 (7.5%) of 40 of patients in the RCS-NO-OP group, all in patients with greater t han 75% stenosis on their last documented scan preceding the stroke. C onclusion: Given the relatively low stroke rate with surgery in the RC S-OP group (2.1%) and the higher incidence of unheralded strokes (7.5% ) in the RCS-NO-OP group, a more aggressive approach may be warranted in patients with asymptomatic high-grade (> 75%) RCS, a strategy not u nlike that adopted for primary CENDX.