Original Articles from the New England Society for Vascular Surgery
Late stroke after carotid endarterectomy: The role of recurrent stenosis*

Presented at the Eighteenth Annual Meeting of the New England Society for Vascular Surgery, Quebec, Canada, Sept. 26–27, 1991.
https://doi.org/10.1016/0741-5214(92)90460-PGet rights and content

Abstract

Perioperative stroke after carotid endarterectomy has been well studied, although little information is available regarding later strokes. We determined the etiology of late stroke after carotid endarterectomy by examining the records of those patients in our carotid registry who had a stroke more than 30 days after surgery. Thirty-five (5.1%) of the 688 patients in our registry had a stroke more than 30 days after surgery (mean follow-up, 59.3 months; standard error, 1.8 months; range, 1 to 292 months). The cause of late stroke was established by input from consulting neurologists, CT scanning of the head, magnetic resonance imaging results, angiograms, noninvasive studies, and postmortem examinations. Eight of the 11 strokes of unknown origin were massive fatal events for which no further evaluation was undertaken. Restenosis or occlusion accounted for fewer strokes (3 of 20, 15%) in the 1- to 36-month postoperative interval than in the greater than 36-month interval (8 of 15, 53.7%) (p < 0.02 by Fisher's Exact Test). These data support the hypothesis that the early pseudointimal hyperplastic lesion is less likely to result in stroke than is later recurrent stenosis, which is usually related to atherosclerosis. (J Vasc Surg 1992;15:1032–7.)

Section snippets

Methods

The carotid registry at Tufts-New England Medical Center contains complete data on 688 patients who have undergone at least one carotid endarterectomy at our institution between 1961 and 1987 and for whom current or determinant follow-up data are available. Follow-up data are updated at the time of regular office visits or, when necessary, by periodic telephone interview or mailed questionnaire. Registry methods are more fully described in an earlier publication.1

For patients coded as suffering

Results

The 688 patients in our registry underwent 1015 carotid endarterectomies. There were 20 perioperative strokes (2.9% patient-specific incidence and 2.0% operation-specific incidence). There were 35 late strokes (5.1% incidence). Earlier reports based on our registry data suggested a higher incidence of late stroke (44 of 597, 7.4% in patients for whom angiographic data could be retrieved).7 Under scrutiny of the more detailed review carried out in this study, however, several events were

Discussion

Late stroke occurs in 5% to 13% of patients undergoing carotid endarterectomy, and the crude postendarterectomy stroke incidence (including perioperative strokes) is 1.6% to 3% annually. 1, 8, 9, 10 The annual stroke rate for all persons 55 to 64 years is 0.29%, for those 65 to 74 years it is 0.55%, and for those 75 to 84 years it is 1.2%.11 Thus despite the proven efficacy of carotid endarterectomy in stroke prevention in selected patients, after patients have had endarterectomy they are 1.3

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*

Reprint requests: William C. Mackey, MD, Box 1035, New England Medical Center, 750 Washington St., Boston, MA 02111.

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