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Carotid Artery Stenosis: Surgical Aspects
Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Surgical Sciences.
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Randomised controlled trials (RCT) have demonstrated a net benefit of carotid endarterectomy (CEA) in stroke prevention for patients with severe carotid artery stenosis as compared to best medical treatment. Results in routine clinical practice must not be inferior to those in the RCTs. The carotid arteries are clamped during CEA which may impair the cerebral perfusion.

The aim of this thesis was to assess population-based outcomes from CEA, investigate risk factors for perioperative complications/late mortality and to evaluate effects of carotid clamping during CEA. In the Swedish vascular registry 6182 CEAs were registered during 1994-2003. Data on all CEAs were retrieved, analysed and validated. In the validation process no death or disabling stroke was unreported. The perioperative stroke or death rate was 4.3% for those with symptomatic and 2.1% for asymptomatic stenosis (the latter decreasing over time). Risk factors for perioperative complications were age, indication, diabetes, cardiac disease and contralateral occlusion. Median survival time was 10.8 years for the symptomatic and 10.2 years for the asymptomatic group.

Tolerance to carotid clamping during CEA under general anaesthesia was evaluated in 62 patients measuring cerebral oximetry, transit time volume flowmetry and stump pressure. High internal carotid artery flow before clamping and low stump pressure was associated with decreased oxygenation after clamping suggesting shunt indication.

In 18 patients undergoing CEA, jugular bulb blood samples demonstrated significantly altered levels of marker for inflammatory activation (IL-6) and fibrinolytic activity (D-dimer and PAI-1) during carotid clamping as compared to radial artery levels. This indicates a cerebral ischaemia due to clamping although clinically well tolerated.

In conclusion, the perioperative outcome after CEA in Sweden compared well with the RCTs results. Tolerance to carotid clamping may be evaluated by combining stump pressure and volume flow measurements. Although clinically tolerated clamping may induce a cerebral ischaemic response.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2006. , p. 68
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 151
Keywords [en]
Surgery, carotid endarterectomy, carotid artery stenosis, carotid clamping, cerebral ischaemia
Keywords [sv]
Kirurgi
Identifiers
URN: urn:nbn:se:uu:diva-6834ISBN: 91-554-6564-1 (print)OAI: oai:DiVA.org:uu-6834DiVA, id: diva2:168268
Public defence
2006-05-24, Auditorium Minus, Museum Gustavianum, 13:30
Opponent
Supervisors
Available from: 2006-05-03 Created: 2006-05-03Bibliographically approved
List of papers
1. Risk factors for complications after carotid endarterectomy: a population-based study
Open this publication in new window or tab >>Risk factors for complications after carotid endarterectomy: a population-based study
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2004 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 28, no 1, p. 98-103Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: The overall benefit of carotid endarterectomy (CEA) is dependent on the outcome from the procedure. However, many reports are from selected centres and not population-based. The aim of this study was to assess the 30-day complication rate for a whole country and also to determine independent risk factors for serious complications.

MATERIALS AND METHODS: One thousand five hundred and eighteen CEA were retrospectively reviewed, covering principally all the CEAs in Sweden, during a three year period. Indications for surgery were; minor stroke 34%, TIA 34%, amaurosis fugax 18%, asymptomatic 11% and others 3%. Data were collected from the Swedish Vascular Registry (Swedvasc). Combined cohort and case-control methodology was used.

RESULTS: Registered complications were; 43 permanent strokes, 32 transient strokes (<30 days), 18 TIA/amaurosis fugax and 22 deaths (seven fatal stokes). In the cohort study, the 30-day permanent stroke and death rate were 4.3% (65/1518). Significant risk factors in multivariate analyses were the indication for surgery (minor stroke vs. other indications) (p=0.02, RR=1.38), diabetes (p=0.02, RR=1.41), cardiac disease (p<0.01, RR 1.43) and operation at a university hospital (p=0.02, RR=1.39). In the case-control study comparing the 65 cases of permanent stroke and/or death with 130 matched controls the only significant risk factor was contralateral occlusion (p<0.01, OR=5.27). One patient (1/130) with a permanent stroke was wrongly reported as a local neurological complication (facial paresis).

CONCLUSION: This national audit demonstrated population-based data on complication rates after CEA well comparable with previous randomised trials. The validity of the Swedvasc data was confirmed. Combined cohort and case-control methodology was useful in analysing risk factors for serious perioperative complications.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-94423 (URN)10.1016/j.ejvs.2004.03.016 (DOI)15177238 (PubMedID)
Available from: 2006-05-03 Created: 2006-05-03 Last updated: 2017-12-14Bibliographically approved
2. Outcomes of carotid endarterectomy in Sweden are improving: resluts from a population based registry
Open this publication in new window or tab >>Outcomes of carotid endarterectomy in Sweden are improving: resluts from a population based registry
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2006 (English)In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 44, no 1, p. 79-85Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: In large randomized trials, carotid endarterectomy (CEA) for asymptomatic stenosis has shown a net benefit compared with best medical treatment. To justify an increased number of procedures for this indication, the perioperative risk of stroke or death must not exceed that of the trials. The aim of this study was to evaluate the outcome in routine clinical practice in Sweden in a population-based study. METHODS: The Swedish Vascular Registry (Swedvasc) covers all centers performing CEA. Data on all registered CEAs during 1994 to 2003 were analyzed both for the whole time period and for two 5-year periods to study alterations over time. Four validation procedures of the registry were performed. Medical records were reviewed for both a random sample and a target sample (a total of 12% of the CEAs for asymptomatic stenosis). Swedvasc data were cross-matched with the In-Patient-Registry (used for reimbursement) and the Population-registry (death). RESULTS: A total of 6182 CEAs were registered, 671 being for asymptomatic stenosis. In the validation process, no missed registration of major stroke or death was found. Patients with asymptomatic stenosis had, when the whole time-period was analyzed, a perioperative combined stroke or death rate of 2.1%. Outcome improved over time; the combined stroke or death rate decreased from 3.3% (11/330) from 1994 to 1998 to 0.9% (3/341) from 1999 to 2003 (P = .026). During the second time period, no patient with a perioperative major stroke or death was reported. CONCLUSIONS: This extensively validated national audit of CEA for patients with asymptomatic carotid artery stenosis showed results well comparable with those of the randomized trials. The results improved over time.

Keywords
Aged, Carotid Stenosis/*surgery, Cerebrovascular Accident/epidemiology, Endarterectomy; Carotid/mortality/utilization, Female, Humans, Logistic Models, Male, Medical Audit/statistics & numerical data, Middle Aged, Morbidity, Outcome Assessment (Health Care), Registries/standards/*statistics & numerical data, Sweden/epidemiology
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-94424 (URN)10.1016/j.jvs.2006.03.003 (DOI)000238821700014 ()16682166 (PubMedID)
Available from: 2006-05-03 Created: 2006-05-03 Last updated: 2017-12-14Bibliographically approved
3. Long-term survival after carotid arterectomy for asymptomatic stenosis
Open this publication in new window or tab >>Long-term survival after carotid arterectomy for asymptomatic stenosis
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(English)Article in journal (Refereed) Submitted
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-94425 (URN)
Available from: 2006-05-03 Created: 2006-05-03 Last updated: 2013-08-14Bibliographically approved
4. Local haemodynamic changes during carotid endarterectomy - the influence on cerebral oxygenation
Open this publication in new window or tab >>Local haemodynamic changes during carotid endarterectomy - the influence on cerebral oxygenation
2004 In: Eur J Vasc Endovasc Surg, Vol. 27, p. 389-402Article in journal (Refereed) Published
Identifiers
urn:nbn:se:uu:diva-94426 (URN)
Available from: 2006-05-03 Created: 2006-05-03Bibliographically approved
5. Cerebral ischemia during carotid endarterectomy - analyses of markers for inflammation and haemostasis
Open this publication in new window or tab >>Cerebral ischemia during carotid endarterectomy - analyses of markers for inflammation and haemostasis
Manuscript (Other academic)
Identifiers
urn:nbn:se:uu:diva-94427 (URN)
Available from: 2006-05-03 Created: 2006-05-03 Last updated: 2010-01-13Bibliographically approved

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