Perioperative risk and late outcome of nonelective carotid endarterectomy

Purpose: In an earlier report of our database for 1924 isolated carotid end arterectomies (CEAs) from 1989 to 1995, multivariable analysis results indi cated that the urgency of operation unfavorably influenced the combined str oke and mortality rate (CSM). This study was conducted in an attempt to doc ument the features that contribute to perioperative complications and late outcome in 314 patients for whom CEA was considered to be nonelective becau se of the severity of previous symptoms, carotid stenosis, or medical comor bidities. Methods: All the hospital charts and outpatient records were reviewed retro spectively for the 209 men and 105 women who had undergone nonelective CEAs (median age, 69 years). Information regarding the clinical risk factors, t he operative indications (CHAT classification), the severity and distributi on of carotid disease, and the surgical management were analyzed to assess the impact on the 30-day CSM and on the long-term survival rate and neurolo gic events during a median follow-up period of 34 months. Results: Previous symptoms had occurred in 285 patients (91%) and included cortical transient ischemic attacks in 47%, amaurosis fugax in 20%, complet ed strokes in 14%, unstable strokes in 2%, and nonspecific or miscellaneous symptoms in 8%. Preoperative angiography was performed in 308 patients (98 %), which confirmed the presence of 80% to 99% ipsilateral carotid stenosis in 79% of the patients and >90% stenosis in 43%. The median interval betwe en presentation and surgical treatment was 2 days, but 48% of the 314 CEAs were performed within 24 hours of presentation. The 30-day CSM was 6.7% and ranged from 3.4% for 29 patients with severe asymptomatic carotid stenosis to 14% for those patients with unstable strokes. The cardiac and pulmonary risk factors were the only variables that were related statistically to th e CSM. During the follow-up period, the risk for ipsilateral stroke was sig nificantly higher in women (risk ratio [RR], 2.38; 95% confidence interval [CI], 1.02 to 5.56; P = .04) and in patients with higher gradients of cardi ac and pulmonary risk factors (RR, 2.8; 95% CI, 1.6 to 4.8 per gradient inc rease; P < .001). The risk was significantly lower in patients who had unde rgone vein patch angioplasty (RR, 0.29; 95% CI, 0.12 to 0.71; P = .006) in comparison with synthetic patching. However, 38 of the 55 patients (69%) wh o underwent synthetic patching also had widespread atherosclerosis for whic h the saphenous veins already had been harvested for coronary bypass grafti ng surgery or infrainguinal revascularization. Conclusion: In our experience, the perioperative risk of nonelective CEA pr imarily is determined by incidental cardiopulmonary disease. Vein patch ang ioplasty appears to enhance late results, but the late stroke rate associat ed with synthetic patching also may have been influenced by the extent of v ascular disease in our study group.