Intraoperative assessment of technical perfection in carotid endarterectomy: a prospective analysis of 1305 completion procedures

Objective: to define the incidence of technical defects and the impact of t echnical errors on ipsilateral carotid occlusion, ipsilateral stroke, and e arly restenosis rates, we analysed 1305 patients undergoing carotid complet ion procedures. Design: prospective multicentre study. Patients and methods: adequacy of CEA was assessed intraoperatively by angi ography in 1004 (77%), by angioscopy in 299 (22%), and by duplex scan in tw o patients (1%). Arteriograms and angioscopic findings were interpreted at the time of Me procedure by the operating surgeon, who also established the need for immediate surgical revision. Results: perioperatively, 13 major strokes (0.9%, all ipsilateral) and six deaths (0.4%) were recorded. Overall, 112 defects (9%) were identified intr aoperatively: 81 (72%) were located in the common carotid artery(CCA) or in ternal carotid artery (ICA), and 31 (28%) in the external carotid artery. I n 48 patients (4%) the defects were revised. Logistic regression analysis r evealed that carotid plaque extension >2 cm on the ICA was a positive indep endent predictor of CEA defects (odds untie (OR) 1.5; p = 0.03). A signific ant association was found between the incidence of revised defects of the C CA and ICA and perioperative ipsilateral stroke (OR 11.5; p = 0.0002). In c ontrast, patients with minor non-revised defects had an ipsilateral stroke rate comparable to Mat of patients with no defects (p = 0.4). No significan t association was found between revised or non-revised defects and occurren ce of restenosis/occlusion at 6-month follow-up. Conclusions: the incidence of major technical defects during CEA is low, ye t the perioperative neurological prognosis of patients with major defects w arranting revision is poor. Completion angiography or angioscopy and possib le correction of defects did not protect per se from an unfavourable early outcome after CEA, Therefore, surgical excellence is mandatory to achieve s atisfactory results after CEA.