Carotid endarterectomy in high-risk patients: A challenge for endovascular procedure protocols

Background. Many studies have sought to identify certain patient population subsets that may be more appropriate for carotid angioplasty and stenting (CAS). Current CAS protocols include "high-risk" patients. The goal of this study was to compare the perioperative outcome of carotid endarterectomy (CEA) between high-risk and non-high-risk patients. Methods. During a 54-month period, 392 consecutive CEAs were performed in 363 patients (29 bilateral) by a single surgeon and entered prospectively into a registry. A high-risk patient subset (1 6, 35%) was defined by the presence of a severe medical comorbidity (ie, cardiac dysfunction, pulmonary dysfunction, renal insufficiency) or particular anatomic features (ie, contralateral carotid occlusion, ipsilateral carotid restenosis after CEA, and "high" carotid bifurcation). Of the 126 CEAs, 96 (76%) were performed for symptomatic lesions. Endpoints of the study were perioperative stroke, cardiac complication, or death. Results. Overall, there were three ischemic strokes (1%) and four cardiac complications (1%). None of the patients died. The stroke and cardiac complication rates for the high-risk and non-high-risk groups were similar (1/126, 1% versus 2/237, 1% and 3/126, 2% versus 1/237, 1%, respectively), but the cardiac morbidity rate was statistically higher in patients with severe medical comorbidity (P =.03), especially in the subset with cardiac dysfunction (P =.005). Conclusions. CEA can be performed in high-risk patients with perioperative neurologic and cardiac complication rates comparable with those recorded in other patients. The definition of a "high-risk" patient should not be considered per se a reason to abandon CEA in favor of CAS.