CRITICAL CAROTID-ARTERY STENOSIS - DIAGNOSIS, TIMING OF SURGERY, AND OUTCOME

Purpose: Patients with critical carotid artery stenoses have been cons idered to be at high risk for carotid artery occlusion necessitating u rgent or emergency endarterectomy once the stenosis is identified. Inc luded in this group of patients are those with carotid string sign or atheromatous pseudoocclusion (APO). This review was conducted to deter mine the impact of the severity of stenosis including APO on the treat ment and outcome of patients undergoing carotid endarterectomy. Method s: The records of 203 consecutive carotid endarterectomies performed i n 197 patients were reviewed in detail. Patients were stratified into a critical stenosis group (80% to 99% diameter) and noncritical stenos is group based on noninvasive vascular laboratory and carotid arteriog raphy results. Comparisons were performed of demographic data, atheros clerotic risk factors, carotid artery disease presentation, interval b etween arteriography and endarterectomy, operative details, and surgic al results between the critical and noncritical groups and between pat ients in the critical group with and without APO. Results: Carotid end arterectomies were performed on 91 critical carotid artery stenoses an d 112 noncritical stenoses. The groups did not differ significantly wi th regards to demographics, risk factors, carotid artery disease prese ntation, mean back pressure, and operative use of shunt or patch closu re. For the critical group the interval between arteriography and enda rterectomy was 8.63 +/- 2.38 days compared with 9.64 +/- 2.14 days for the noncritical group (mean +/- SEM,p = 0.75). No patient in either g roup progressed to occlusion in the interval between arteriography and endarterectomy. Perioperative strokes occurred in two patients (2%) i n the critical group and four patients (3.6%) in the noncritical group (p = 0.09). Likewise, no significant difference was demonstrated in t hese variables when comparing patients with critical carotid artery st enosis and APO with those without APO. Conclusions: The presence of a critical carotid artery stenosis including APO did not impact on the t reatment or outcome of patients requiring endarterectomy nor did it im ply the need for emergency intervention to prevent thrombosis. Surgica l intervention can proceed after evaluation and optimization of comorb id conditions without undue concern for interval thrombosis.