Safety and Long-Term Benefit of Carotid Endarterectomy in the Asymptomatic Patient

In order to determine the safety and long-term salutary effects of carotid endarterectomy in the asymptomatic patient, we retrospectively reviewed all asymptomatic patients who underwent carotid endarterectomy from 1980 through 1986. There were 60 carotid endarterectomies performed in 54 patients, 53 men and one woman. The mean age was 64 years. Arteriography revealed a high grade stenosis of 70% or greater in 46 carotid arteries (77%), ulceration in five (8%), and both in nine (15%). Risk factors included coronary artery disease in 60% of patients, smoking in 87%, hypertension in 67%, and diabetes in 22%. Perioperative morbidity included three cranial nerve injuries, one myocardial infarction and one contralateral stroke. There were no deaths. Mean follow-up was 47 months with only two patients being lost to follow-up. During follow-up three patients suffered ipsilateral transient ischemic attacks without recurrent carotid stenosis and one patient had a transient ischemic attack secondary to contralateral carotid occlusion. There was one ipsilateral stroke occurring two years after operation secondary to restenosis that required reoperation and four late contralateral strokes. Ten patients died in the follow-up period. Causes of death were stroke (1), cardiac (4), malignancy (2), pulmonary (2), and unknown (1). All surviving patients were evaluated by duplex scan at a mean interval following surgery of 47 months. Restenosis of endarterectomized arteries was seen at the following rates: less than 50% in 41 (87%); 50–75% in four (8.5%); 80% in one (2%); and 90% in one (2%). Life table analysis revealed a 98% ipsilateral stroke-free rate at five and eight years. In summary, (1) carotid endarterectomy in the asymptomatic patient can be done with low morbidity and virtually no mortality. (2) Late stroke occurs rarely in the hemisphere ipsilateral to the operated carotid artery. (3) Objective follow-up by duplex scanning shows only a 4% incidence of significant restenosis. (4) The low restenosis rate correlates with the low long-term stroke rate.