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For high-risk patients, stroke-prevention surgical procedure does not equate with high surgical risk

August 14, 2008

New research published in the August issue of the Journal of the American College of Surgeons shows that "high-risk" patients with multiple medical conditions, including high blood pressure and coronary artery disease, can safely undergo carotid endarterectomy - a stroke-preventing surgical procedure that clears blockages from the neck's carotid arteries.

Carotid endarterectomy has been shown to safely and effectively prevent strokes in several clinical trials. However, clinicians have previously suggested that patients with multiple medical comorbidities receive alternative therapies - such as angioplasty and stenting - to avoid complications associated with an open surgical procedure.

"In our study, carotid endarterectomy achieved low rates of post-surgical mortality and morbidity and translated into long-term freedom from stroke in high-risk patients, despite their poor health," says Alan Dardik, MD, PhD, FACS, of the Yale University School of Medicine, New Haven, CT., and the Veterans Affairs Connecticut Healthcare System. "The presence of multiple medical comorbidities is not sufficient to automatically rule out this treatment, which has demonstrated long-term efficacy in preventing stroke in medically high-risk patients."

The retrospective study, which analyzed the outcomes of carotid endarterectomy in 120 patients (98 percent were male; mean age = 70 years) treated in the Veterans Affairs Connecticut Healthcare System, showed low incidences of mortality (0.8 percent), stroke (1.6 percent) and heart attack (0.8 percent) within 30 days of carotid endarterectomy. Survival rates at 5 and 10 years were 75 percent (±4.1 percent) and 35 percent (±6.0 percent), respectively. Median survival was 8.9 years. Freedom from stroke was 90 percent at 12 years. Age (hazards ratio [HR] 1.1, p = 0.004), hypertension (HR 2.6, p = 0.04) and elevated creatinine (HR 3.7, p = 0.001) were all found to be significant, independent risk factors for mortality.

Five- and 10-year survival was examined using Kaplan-Meier analysis, and Cox regression was used to determine the risk factors for mortality and stroke. Prior to the operation, patients had a high incidence of symptomatic presentation (58 percent), hypertension (83 percent), coronary artery disease (64 percent), diabetes (37 percent) and pulmonary disease (22 percent) compared with the general carotid endarterectomy population.

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