Introduction:
Despite considered being a safe and efficacious procedure in patients with moderate to severe symptomatic carotid artery stenosis, carotid endarterectomy (CEA) carries a risk of postoperative cerebrovascular accident (POCVA). There is currently a lack of evidence pertaining to the relationship between cranial vascular integrity and its interaction with intraoperative haemodynamic fluctuations and risk of POCVA.
Methods:
In this retrospective case-control study, we utilised data collected from patients undergoing CEA for symptomatic carotid artery disease between Dec’05 and Oct’19 in the South Mersey Arterial Centre, UK. Patients with three-dimensional CT angiogram (3D-CTA) and evidence of POCVA were considered as cases, matched with those without such evidence that were considered as controls. 3D-CTAs were analysed following a structured proforma, and haemodynamic changes were obtained from operative notes.
Results:
Out of 951 patients, a total of 21 cases and 55 matched controls were identified. Presence of atherosclerotic disease in the vertebral arteries (VA) in either side, intracranial atherosclerosis (ICAS) (81% vs 40% and 57% vs 27%; <0.01, p<0.05 respectively), and drop in the systolic blood pressure (mean
+
SD 61
+
23 mmHg vs. 44
+
20 mmHg, p<0.01) were significantly different between the cases and the controls (fig 1). A multivariate logistic regression model showed that odds of stroke were increased with VA stenosis on either side (OR 6·5, 95% CI 1·7-24·6, p=0.006) and intraoperative systolic blood pressure drop greater than 44 mmHg (OR 6·6, 95% CI 1·6-27·6, p=0.01).
Conclusions:
These findings highlight the importance of routinely identifying posterior circulation abnormalities during the preoperative assessment, and judicious blood pressure management during the intraoperative period, both of which have the potential to help to develop a personalised risk stratification pre-CEA and greater intraoperative monitoring during CEA.
Carotid endarterectomy contralateral to an occluded carotid artery: A retrospective case-control study