Risk reduction in carotid surgery is still possible: a 10-year experience

Aim. Aim of this study was to assess the impact on the risk rate of early complications after carotid endarterectomy (CEA) of modifications in surgical and anesthesiological techniques introduced in the last decade. Methods. Between January 1996 and December 2006, 3 658 consecutive CEAs were performed in the Department of Vascular Surgery. All data concerning these interventions were prospectively collected in a dedicated database. Patients operated from 1996 to 1998 (971 interventions, Group 1) were compared with those who underwent CEA from 2004 to 2006 (1 094 interventions. Group 2) to evaluate significant modifications in terms of demographics, indications, surgical and anesthesiological strategies and perioperative (<30 days) results. Results. Patients in Group 2 had significantly higher percentages of severe comorbidities and were significantly older than patients in Group 1 (mean age 72.9 and 69.9, respectively, P<0.001). Moreover, patients in Group 2 were more likely to be asymptoniatic (69.5% vs 56.5%, P<0.001). Interventions were performed under general anesthesia with somatosensory evoked potentials (SEPs) monitoring and selective shunt insertion in all cases but one in Group 1 and in 27.3% of patients in Group 2 (P<0.001). while the remaining 72.7% of interventions in Group 2 were performed under local anesthesia with clinical monitoring and selective shunt insertion. Cumulative shunt insertion rate was 9.4% in Group 1 and 13.1% in Group 2 (P=0.04). In all the interventions in Group 2 early distal clamping of internal carotid artery was performed, while in Group 1 standard technique with dissection of carotid bifurcation followed by arterial clamping was used. In Group 2 there was a significantly higher number of patch closures than in Group 1 (90.5% and 47.5%, respectively; P<0.001). Mean total clamping time was significantly shorter in Group 1 than in Group 2 (28.1 and 34.1 minutes, respectively, P<0.001). Perioperative (<30 days) results in terms of neurological events, strokes and deaths were significantly better in Group 2 than in Group 1 (30-day stroke and death rate of 0.5% and 1.6%, respectively, P=0.01). Conclusion. Results confirm that CEA remains a strongly effective method of stroke prevention in patients with carotid artery stenosis. The adoption of a safe surgical strategy (early distal control of internal carotid artery, wide use of patch, local anesthesia with clinical monitoring and selective shunt insertion) allowed, in the last decade, to improve significantly results.