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Risk factors for complications after carotid endarterectomy: a population-based study
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences. (Vascular Surgery)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences. (Vascular Surgery)
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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, 98-103 p.Article 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.

Place, publisher, year, edition, pages
2004. Vol. 28, no 1, 98-103 p.
National Category
Medical and Health Sciences
URN: urn:nbn:se:uu:diva-94423DOI: 10.1016/j.ejvs.2004.03.016PubMedID: 15177238OAI: oai:DiVA.org:uu-94423DiVA: diva2:168263
Available from: 2006-05-03 Created: 2006-05-03 Last updated: 2010-11-18Bibliographically approved
In thesis
1. Carotid Artery Stenosis: Surgical Aspects
Open this publication in new window or tab >>Carotid Artery Stenosis: Surgical Aspects
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. 68 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 151
Surgery, carotid endarterectomy, carotid artery stenosis, carotid clamping, cerebral ischaemia, Kirurgi
urn:nbn:se:uu:diva-6834 (URN)91-554-6564-1 (ISBN)
Public defence
2006-05-24, Auditorium Minus, Museum Gustavianum, 13:30
Available from: 2006-05-03 Created: 2006-05-03Bibliographically approved

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