Carotid Endarterectomy Remains Safe in High-Risk Patients

OBJECTIVE Carotid endarterectomy (CEA) is a proven intervention for stroke risk reduction in symptomatic and asymptomatic patients. High-risk patients are often offered carotid stenting to minimize risk and optimize outcomes. As a referral center for high-risk patients, we sought to evaluate and analyze our experience with high-risk CEA patients. METHODS We retrospectively reviewed consecutive patients undergoing CEA at a tertiary referral center. Demographics, indications for surgery, physiologic and anatomic risk factors, intraoperative surgical management, perioperative complications, morbidity, and mortality were analyzed. Physiologic high-risk patients' factors identified ejection fraction <30%, positive preoperative stress test, and compromised pulmonary function tests which included those on home oxygen, pO2<60, and FEV1 < 30%. Anatomic high-risk patients' factors identified were previous head/neck radiation, history of ipsilateral neck surgery, contralateral nerve palsy, redo carotid, previous ipsilateral stent, contralateral occlusion, contralateral CEA, nasotracheal intubation, and digastric muscle division. After propensity score matching, patients with high-risk physiologic and anatomic risk factors were compared to those without. Primary outcomes were a composite of stroke, myocardial infarction, and 30-day mortality. Secondary outcomes were cranial injury or surgical site infection. RESULTS Over a ten-year period, 1347 patients underwent CEA at the Cleveland Clinic Main Campus. 1152 patients met criteria for analysis. Propensity score matching found adequate matches for 424 high-risk patients with 173 having at least one physiologic high-risk criteria and 293 with at least one anatomic high-risk. There were no significant differences in the primary composite outcome or any of its components. Overall, stroke rate in standard risk patients and high-risk patients was 1.9% and 1.4% respectively. High-risk patients were significantly more likely to have a cranial nerve injury with most of them being temporary injuries. When patients with one or multiple risk factors were analyzed, no significant difference in the primary composite outcome or any of its components were observed. Patients with two or more risk factors were significantly more likely to have cranial nerve injuries with most of them being temporary. CONCLUSIONS In our large series, CEA remains a viable and safe surgical solution in patients with high-risk anatomic and physiologic risk factors with acceptable stroke, myocardial infarction, and 30-day mortality rates.