Elsevier

Annals of Vascular Surgery

Volume 24, Issue 2, February 2010, Pages 185-189
Annals of Vascular Surgery

Clinical Research
Eversion Carotid Endarterectomy Versus Best Medical Treatment in Symptomatic Patients with Near Total Internal Carotid Occlusion: A Prospective Nonrandomized Trial

https://doi.org/10.1016/j.avsg.2009.07.010Get rights and content

Background

We sought to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total internal carotid artery (ICA) occlusion.

Methods

From January 2003 to December 2006, a total of 309 recently (within 12 months) symptomatic patients with near total ICA occlusion who were eligible for surgery were identified in our institution. Patients were nonrandomly divided into group A (259 patients), who underwent ECEA surgery, and group B (50 patients), who refused surgery. Patients in group B received the best medical treatment based on the opinion of the attending vascular surgeon and/or angiologist. Patients were followed for ipsilateral stroke, transient ischemic accident, and neurologic mortality for 12 months.

Results

There were no intraoperative and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients. There were no differences between the groups with respect to medications on discharge. Cumulative 12 month incidence of TIA, ipsilateral stroke and neurologic mortality was lower in patients who underwent ECEA than in patients on medical therapy (13 [5%] versus 12 [24%], p < 0.001; 4 [1.5%] versus 7 [14%], p < 0.001; and 4 [1.5%] versus 4 [8%], p = 0.034, respectively). Restenosis of the operated ICA was noted in 7 (3%) patients, and progression of near to total occlusion was seen in 15 (37%) patients in group B.

Conclusion

Our data indicate that recently (within12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

Introduction

There is a general agreement that symptomatic patients with high-grade stenosis of internal carotid artery (ICA) should be treated with either surgery or percutaneous intervention.1, 2 On the other hand, there is considerable controversy with respect to the approach to the patients with near total ICA occlusion. These patients are considered to be at lower risk for transient ischemic attack (TIA), stroke, and death than patients with a lesser degree of stenosis.3 There are no prospective randomized clinical trials dealing with this issue, and the available data mostly originate from the post-hoc analysis of the large trials performed in the late 1990s. The results of these studies are conflicting and provide little benefit in clinical decision making.4, 5

Therefore, the aim of the present study was to prospectively evaluate clinical effects of eversion carotid endarterectomy (ECEA) versus best medical treatment of symptomatic patients with near total ICA occlusion.

Section snippets

Patients

From January 2003 to December 2006, a total of 359 patients with near total ICA occlusion were referred to Dedinje Cardiovascular Institute for evaluation and therapy. Patients were excluded from the study if they were asymptomatic (32 patients), had occlusion of the contralateral ICA (8 patients), or were considered to have unacceptably high surgical risk due to associated comorbidities (10 patients). Therefore, the final study group consisted of 309 patients. Symptoms were identified as TIA

Results

Table I depicts basic demographic and clinical data. Briefly, there was no difference between the groups with respect to age, sex, symptoms, and risk factors for atherosclerosis except for the smoking and hyperlipoproteinemia. Importantly, there was also no difference in incidence of peripheral vascular and coronary artery disease between the groups.

There were no intra- and perioperative deaths and strokes in patients who were subjected to surgery. TIA was noted in 4 (1.5%) of these patients.

Discussion

Our data indicate that recently (within12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have better prognosis over 12-month follow-up compared with medically treated patients in terms of increased neurologic mortality and morbidity.

The prevalence of near total occlusion is uncertain and it has been estimated in the range of 0.5-10% of all patients undergoing surgery.6 The issue of management of patients with near total ICA occlusion is highly controversial as it

Conclusions

Our data indicate that recently (within 12 months) symptomatic patients with near total ICA occlusion who underwent ECEA have lower incidence of TIA, ipsilateral stroke, and neurologic death during follow-up than medically treated patients. It appears that, at least in high-volume centers, ECEA should be favored over medical treatment for the management of these patients.

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