ROUTINE SURVEILLANCE AFTER CAROTID ENDARTERECTOMY - DOES IT AFFECT CLINICAL MANAGEMENT

Purpose: Although routine noninvasive surveillance is recommended afte r carotid endarterectomy (CEA), there are little data to show that ide ntification and eradication of recurrent carotid artery stenosis arc n ecessary to avoid the risk of subsequent neurologic complications. Met hods: We reviewed our experience over a 16-year period in 380 consecut ive patients undergoing 409 CEAs who underwent serial postoperative ul trasonic scanning at 6 weeks, 6 months, and 1 year after CEA and then yearly thereafter. Results: Recurrent stenoses ( greater-than-or-equal -to 50% diameter reduction) were detected in 44 arteries (10.8%) durin g follow-up from 1 to 177 months (mean 42.0 months). Most (70.5%) occu rred within 2 years of CEA. Cumulative recurrence rates were 5.8%, 9.9 %, 13.9%, and 23.4% at 1, 3, 5, and 10 years, respectively. Recurrent stenoses were more frequent in female (p = 0.02) and younger patients (p = 0.01) and less frequent in those having a vein patch repair (p = 0.02). Most recurrences (84%) were in the 50% to 79% stenosis range. I n four patients 80% to 99% stenoses developed and in three patients to tal occlusions developed, for a severe recurrence rate of 2.1%. Only 1 0 (22.7%) of the recurrent stenoses were initially symptomatic, and on ly one (2.9%) of the asymptomatic restenoses later became symptomatic. One patient with recurrent stenosis suffered a stroke (0.3%). Cumulat ive 5-year ipsilateral stroke-free rates in patients with recurrent st enosis (94.4%) were practically identical (p = 0.76) to those in patie nts without recurrent stenosis (94.2%). Life-table ipsilateral stroke- free survival rates at 5 years were 94.2% in patients with recurrent s tenosis and 78.4% in patients without recurrent stenosis (p = 0.16). F our (9%) recurrent stenoses and 12 lesions (27%) in the contralateral artery progressed. Only seven patients (1.7%) underwent repeat operati on for ipsilateral disease, four for symptoms and three for recurrent stenosis. Conclusions: Recurrent carotid artery stenosis occurs early after CEA, is typically benign, and remains stable over a prolonged fo llow-up period. Our results question the importance of routine noninva sive surveillance after CEA and suggest that a more conservative appro ach would be equally beneficial in terms of clinical relevance and cos t-effectiveness.