Reoperation for recurrent carotid stenosis: Early results and late outcomein 199 patients

Purpose: This study was undertaken to determine the safety and efficacy of reoperations for recurrent carotid stenosis (REDOCEA) at the Cleveland Clin ic. Materials and Methods: From 1989 to 1999, 206 consecutive REDOCEAs were per formed in 199 patients (131 men, 68 women) with a mean age of 68 years (med ian, (69 years;range, 47-86 years). A total of 119 procedures (57%) were pe rformed for severe asymptomatic stenosis, 55 (27%) for hemispheric transien t ischemic attacks or amaurosis fugax, 26 (13%) for prior stroke, and 6 (3% ) for vertebrobasilar symptoms. Eleven REDOCEAs (5%) were combined with myo cardial revascularization, and another 19 (9%) represented multiple carotid reoperations (17 second reoperations and 2 third reoperations). Three REDO CEAs (1%:) were closed primarily, and nine (4%) required interposition graf ts, whereas the remaining 194 (95%) were repaired with either vein patch an gioplasty (139 [68%]) or synthetic patches (55 [27%]). Three patients (2%) were lost to follow-up, but late information was available for 196 patients (203 operations) at a mean interval of 4.3 years (median, 3.9 years; maxim um, 10.2 years). Results: Considering all 206 procedures, there were 7 early (< 30 days) pos toperative neurologic events (3.4%), including 6 perioperative strokes (2.9 %) and 1 occipital hemorrhage (0.5%) on the 12th postoperative day. Sevente en additional neurologic events occurred during the late follow-up period, consisting of eight strokes (3.9%) and nine transient ischemic attacks (4.4 %). With the Kaplan-Meier method, the estimated 5-year freedom from stroke was 92% (95% CI, 88%-96%). There were two early postoperative deaths (1%), both from cardiac complications after REDOCEAs combined with myocardial rev ascularization procedures. With the Kaplan-Meier method, the estimated 5-ye ar survival was 81% (range, 75%-88%). A univariate Cox regression model yie lded the presence of coronary artery disease as the only variable that was significantly associated with survival (P = .024). The presence of pulmonar y disease (P = .036), diabetes (P = .01), and advancing age (P = .006) was found to be significantly associated with stroke after REDOCEA. Causes of 5 3 late deaths were cardiovascular problems in 25 patients (47%), unknown in 14 (26%), renal failure in 4 (8%), stroke in 3 (6%), and miscellaneous in 7 (13%). Conclusions: We conclude that REDOCEA may be safely performed in selected p atients with recurrent carotid stenosis and that most of these patients enj oy long-term freedom from stroke.