Risk of Stroke for Carotid Endarterectomy Patients with Contralateral Carotid Occlusion
Article Outline
The role of a contralateral carotid occlusion in the appearance of neurological complications after carotid endarterectomy (CEA) operations is a matter of some debate. In the North American Symptomatic Carotid Endarterectomy Trial, the risk of perioperative stroke was found to be higher in patients with a contralateral carotid occlusion. In a literature survey in 2004, however, a significantly increased risk of perioperative stroke was found in only one out of 17 studies on contralateral carotid occlusion patients. We therefore examined the frequency of stroke in patients with contralateral carotid occlusion at our own institution and performed a meta-analysis based on 19 representative studies, including the data from our own institution. Out of 1,960 CEAs at the authors' institute, a significantly higher frequency of 5.6% compared to 2.1% (p = 0.012) for perioperative stroke risk was seen in patients with contralateral carotid occlusion compared to those without. The meta-analysis, based on 19 studies, also showed in 13,438 CEA operations a significantly higher perioperative stroke rate of 3.7% compared to 2.4% (p = 0.002) in the presence of a contralateral carotid occlusion. Nevertheless, due to the extremely poor outcomes of medically treated symptomatic patients, a surgical or endovascular procedure should be sought for these patients. Since the superiority of angioplasty/stent procedures has not yet been verified compared to surgical procedures in these patients, special indication for an endovascular procedure should also be taken into consideration.
Introduction
The role of a contralateral carotid occlusion in the appearance of neurological complications after carotid endarterectomy (CEA) operations is still a matter of some debate.1, 2, 3, 4, 5, 6, 7 In the North American Symptomatic Carotid Endarterectomy Trial (NASCET),8 the risk of perioperative stroke in patients with a contralateral carotid occlusion was 14.3% compared to 5.1% for patients without a contralateral occlusion. In addition, the Asymptomatic Carotid Atherosclerosis Study (ACAS)9 showed a raised perioperative risk of stroke in the presence of a contralateral carotid occlusion.
Because of the putatively higher risk with surgical therapy, endovascular procedures are being increasingly recommended for such patients. Vascular surgeons regard the surgical results of the NASCET study in patients with contralateral carotid occlusion as unrepresentative because of the small number of just 43 patients assessed.
Over the last years a series of studies have been published on this matter. As part of a literature survey, Rockman10 combined the surgical results from 17 studies.2, 3, 4, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 Since a significantly higher perioperative stroke risk was revealed in only one study23 in patients with contralateral carotid occlusion, a contralateral carotid occlusion in their opinion did not present any raised perioperative stroke risk after a CEA operation.
With this issue in mind, we investigated the occurrence of neurological complications after CEAs in patients with and without contralateral carotid occlusion in our own institution.
In addition, we prepared a meta-analysis on the basis of 19 representative studies, which also included the data from our own clinic.
Patients and Methods
From January 1, 1998, to December 31, 2005, 1,960 CEAs were carried out in our institution on 1,836 patients. Both the clinical and the surgical data were prospectively documented in digital form.
The average age of the patients was 69.1 years (range 39.9-90.6), which was only slightly lower at 68.5 years (range 39.9-88.7) for men compared to 70.4 years (range 41.4-90.6) for women. The proportion of women in our population was 31.1% (Table I).
Table I. Patients and morbidity
| All | No occlusion | Contralateral occlusion | ||
|---|---|---|---|---|
| (n = 1,960) | (n = 1,799) | (n = 161) | P | |
| Age | 69.1 ± 8.5 (70.0) 39.9-90.6 | 69.1 ± 8.5 (70.0) 39.9-88.7 | 68.5 ± 8.8 (69.9) 45.1-90.6 | 0.277a |
| Patients | ||||
 Male | 1,351 (68.9) | 1,234 (91.3) | 117 (8.7) | 0.328b |
| Female | 609 (31.1) | 565 (92.8) | 44 (7.2) | |
| ASA classification | ||||
| Normal healthy | 306 (15.6) | 289 (94.4) | 17 (5.6) | |
| Mild disease | 1.339 (68.3) | 1.229 (91.8) | 110 (8.2) | 0.059b |
| Severe disease | 315 (16.1) | 281 (89.2) | 34 (10.8) | |
| Cardiac arrhythmia | ||||
| No | 1.820 (92.9) | 1.675 (92.0) | 145 (8.0) | 0.151b |
| Yes | 140 (7.1) | 124 (88.6) | 16 (11.4) | |
| Hypertonus | ||||
| No | 551 (28.1) | 514 (93.3) | 37 (6.7) | 0.143b |
| Yes | 1.409 (71.9) | 1.285 (91.2) | 124 (8.8) | |
| Diabetes mellitus | ||||
| No | 1.554 (79.3) | 1.425 (91.7) | 129 (8.3) | 0.840b |
| Yes | 406 (20.7) | 374 (92.1) | 32 (7.9) | |
| Coronary artery disease | ||||
| No | 1.262 (64.4) | 1.163 (92.2) | 99 (7.8) | 0.440b |
| Yes | 698 (35.6) | 636 (91.1) | 62 (8.9) | |
| Chronic renal insufficiency | ||||
| No | 1.891 (96.5) | 1.739 (92.0) | 152 (8.0) | 0.174b |
| Yes | 69 (3.5) | 60 (87.0) | 9 (13.0) | |
| Preop. neurological deficit | ||||
| Symptomatic | 691 (35.3) | 625 (90.5) | 66 (9.5) | 0.121b |
| Asymptomatic | 1.269 (64.7) | 1.174 (92.5) | 95 (7.5) | |
| Stenosis ipsilateralc | ||||
| 70-99% | 951 (48.5) | 874 (91.9) | 77 (8.1) | |
| 60-69% | 906 (46.2) | 831 (81.7) | 75 (8.3) | 0.952b |
| 50-59% | 103 (5.3) | 94 (91.3) | 9 (8.7) | |
aMann-Whitney U-test. |
bExact Fisher test. |
cNASCET method. |
The health status of the patients was categorized according to the American Society of Anesthesiologists (ASA) classification. There were 306 patients (15.6%) who showed no significant general disease (ASA-1). In 1,339 patients (68.3%) a mild (ASA-2) and in 315 patients (16.1%) a severe (ASA-3) general disease existed.
Incidence of cardiac arrhythmia was 7.1%, coronary artery disease 35.6%, hypertonus 28.1%, diabetes mellitus 20.7%, and chronic renal insufficiency 3.5% (Table I). Chronic renal insufficiency was defined as creatinine levels >1.8 mg/dL.
The classification of the ipsilateral stenosis grade was according to NASCET criteria.8 A mid-grade stenosis (50-59%) was found in 103 patients (5.3%), and a high-grade stenosis (60-69%) was found in 906 patients (46.2%). In 951 patients (48.5%) a critical stenosis (70-99%) existed (Table I).
The indication to undertake an operation was a neurological symptom for 691 patients (Table I). In 106 patients (7.0%) there was amaurosis fugax preoperatively, while in 408 patients (20. 8%) a hemispheric transient ischemic attack had occurred. There were 146 patients (7.5%) who suffered a preoperative stroke. In 1,269 asymptomatic patients the indication resulted from the stenosis grading (Table I).
A conventional CEA with a patch flap using an intraluminal shunt was carried out as standard in our clinic. All 1,960 CEAs were performed by 14 surgeons.
A postoperative neurological deficit was defined according to the guidelines of the American Heart Association.24
Significance levels were calculated using the exact Fisher test and the Mann-Whitney U-test where the confidence level was set at 95%.
The distribution of the morbidity parameters in patients with and without contralateral occlusion and the influence of the morbidity parameters on outcome were determined by multivariate analysis. To this, logistic regression was performed and the odds ratios were calculated.
A literature survey was carried out using recognized medical search engines and included the period from 1984 to 2005. The literature search identified papers that specifically addressed the issue of the impact of contralateral carotid occlusion. This includes 17 studies that were considered in the survey by Rockman,10 in addition to one representative, prospective multicenter study published in 1996 by da Silva et al.14 from the United Kingdom and Ireland with 700 cases and 1,960 cases from our own institution presented here.
Every study was evaluated with regard to case number, number of patients with and without contralateral carotid occlusion, as well as number and frequency of strokes in patients with and without contralateral carotid occlusion. For the meta-analysis the total number of all cases was calculated and the number of perioperative strokes was summed up for each group. Using these numbers, the percentage stroke frequency was calculated for each group.
Significance levels were calculated here as well using the exact Fisher test, where the confidence level was set to 95%.
Results
For 161 patients, corresponding to an overall proportion of 8.3%, there was a contralateral carotid occlusion. The average age of the patients with a contralateral occlusion was 68.5 years, which was only insignificantly lower than that of the patients without contralateral occlusion at 69.1 years (Table I).
By bivariate analysis a significant difference in sex distribution was not found between the two patient groups (Table I). Also, with respect to the length of operation and the shunt time, there were no significant differences between patients with and without contralateral carotid occlusion.
Bivariate analysis showed no considerably different frequencies in patients with and without contralateral occlusion with regard to ASA classification (p = 0.059), cardiac arrhythmia (p = 0.151), hypertonus (p = 0.143), diabetes mellitus (p = 0.840), coronary artery disease (p = 0.440), and chronic renal insufficiency (p = 0.174) (Table I).
Regarding the grade of stenosis, the two patient groups were not significantly different (p = 0.952). Significant differences were also not found between the two patient groups regarding preoperative neurological deficit (p = 0.121) (Table I).
Multivariate analysis detected a significant correlation between contralateral occlusion and ASA classification in patients with severe disease (odds ratio [OR] = 1.97, p = 0.033) (Table II).
Table II. Patients and morbidity: multivariate analysis (logistic regression)
| Factor | OR | p | 95% CI |
|---|---|---|---|
| Age | 0.99 | 0.189 | 0.97-1.01 |
| ASA | |||
| Normal healthy | 1.00 | - | - |
| Mild disease | 1.41 | 0.208 | 0.83-2.42 |
| Severe disease | 1.97 | 0.033 | 1.06-3.66 |
| Cardiac arrhythmia | 1.46 | 0.175 | 0.84-2.52 |
| Hypertonus | 1.32 | 0.149 | 0.90-1.94 |
| Diabetes mellitus | 0.88 | 0.520 | 0.59-1.30 |
| Coronary artery disease | 1.11 | 0.553 | 0.79-1.54 |
| Chronic renal insufficiency | 1.71 | 0.143 | 0.83-3.50 |
| Preop. neurological deficit | |||
| Symptomatic | 1.00 | - | - |
| Asymptomatic | 0.77 | 0.130 | 0.55-1.08 |
| Stenosis ipsilateral | |||
| 70-99% | 1.00 | - | - |
| 60-69% | 1.07 | 0.691 | 0.76-1.50 |
| 50-59% | 0.92 | 0.837 | 0.44-1.96 |
A significant correlation was not found between contralateral occlusion and the variables age (OR = 0.99, p = 0.189), cardiac arrhythmia (OR = 1.46, p = 0.175), hypertonus (OR = 1.32, p = 0.149), diabetes mellitus (OR = 0.88, p = 0.520), coronary artery disease (OR = 1.11, p = 0.553), and chronic renal insufficiency (OR = 1.71, p = 0.143) (Table II).
Fifty-six patients of the whole series developed neurological symptoms during the perioperative course, where in nine cases (0.5%) these were due to transitory ischemic attacks. Forty-seven patients (2.4%) suffered a postoperative stroke. In 28 of these patients (1.4%) a nondisabling apoplexia was found, whereas in 19 patients (1.0%) a disabling stroke occurred. A surgeon-specific outcome was not noticed.
Hospital mortality was 0.1%. One patient died as a result of a massive brain hemorrhage and two patients as a result of a cardiac morbidity.
Bivariate analysis did not show significant increase in stroke frequencies with respect to the grade of stenosis (p = 0.801). Thus, the stroke frequency with moderate stenosis was 2.9%, that with high-grade stenosis was 2.2%, and that with critical stenosis was 2.5% (Table III).
Table III. Perioperative stroke
| All | No stroke | Stroke | ||
|---|---|---|---|---|
| (n = 1,960) | (n = 1,913) | (n = 47) | p | |
| Age | 69.1 ± 8.5 (70.0) 39.9-90.6 | 69.0 ± 8.5 (69.9) 39.9-90.6 | 71.7 ± 8.4 (71.6) 56.7-86.9 | 0.058a |
| Sex | ||||
| Male | 1,351 (68.9) | 1,318 (97.6) | 33 (2.4) | 1.000b |
| Female | 609 (31.1) | 595 (97.7) | 14 (2.3) | |
| ASA classification | ||||
| Normal healthy | 306 (15.6) | 301 (98.7) | 5 (1.3) | |
| Mild disease | 1,339 (68.3) | 1,320 (98.6) | 19 (1.4) | 0.000b |
| Severe disease | 315 (16.1) | 292 (92.7) | 23 (7.3) | |
| Cardiac arrhythmia | ||||
| No | 1,820 (92.9) | 1,775 (97.5) | 45 (2.5) | 0.771b |
| Yes | 140 (7.1) | 138 (98.6) | 2 (1.4) | |
| Hypertonus | ||||
| No | 551 (28.1) | 537 (97.5) | 14 (2.5) | 0.870b |
| Yes | 1,409 (71.9) | 1,376 (97.7) | 33 (2.3) | |
| Diabetes mellitus | ||||
| No | 1,554 (79.3) | 1,519 (97.7) | 35 (2.2) | 0.465b |
| Yes | 406 (20.7) | 394 (97.0) | 12 (3.0) | |
| Coronary artery disease | ||||
| No | 1,262 (64.4) | 1,233 (97.7) | 29 (2.3) | 0.758b |
| Yes | 698 (35.6) | 680 (97.4) | 18 (2.6) | |
| Chronic renal insufficiency | ||||
| No | 1,891 (96.5) | 1,850 (97.8) | 41 (2.2) | 0.005b |
| Yes | 69 (3.5) | 63 (92.3) | 6 (8.7) | |
| Preop. neurological deficit | ||||
| Symptomatic | 691 (35.3) | 664 (96.1) | 27 (3.9) | 0.002b |
| Asymptomatic | 1,269 (64.7) | 1,249 (98.4) | 20 (1.6) | |
| Stenosis ipsilateralc | ||||
| 70-99% | 951 (48.5) | 927 (97.5) | 24 (2.5) | |
| 60-69% | 20 (2.2) | 906 (46.2) | 886 (97.8) | 0.801b |
| 50-59% | 103 (5.3) | 100 (97.1) | 3 (2.9) | |
| Stenosis contralateralc | ||||
| 100% (occlusion) | 161 | 152 (95.0) | 9 (5.6) | |
| 70-99% | 336 | 323 (96.1) | 13 (3.9) | 0.002b |
| 0-69% | 1.463 | 1.438 (98.3) | 25 (1.7) | |
aMann-Whitney U-test. |
bExact Fisher test. |
cNASCET method. |
Significant increases in stroke frequency were not shown either with respect to sex (p = 1.000), cardiac arrhythmia (p = 0.771), hypertonus (p = 0.870), diabetes mellitus (p = 0.465), and coronary artery disease (p = 0.758) (Table III).
A significant increase in perioperative stroke frequency was found by bivariate analysis according to the ASA classification (p = 0.000), the occurrence of chronic renal insufficiency, and patients with preoperative neurological symptoms. Thus, the perioperative stroke frequency was 3.9% in symptomatic patients compared to 1.6% in asymptomatic patients. This difference was significantly high (p = 0.002) (Table III).
There was also a significant increase in stroke frequency according to the degree of contralateral carotid stenosis. In nine out of 161 patients with a contralateral occlusion, a stroke occurred during the perioperative course, corresponding to a frequency of 5.6%. The perioperative frequency of strokes in patients with a contralateral stenosis grade of 70-99% was 4.2%, and that in patients with a stenosis grade of 0-69% was 1.7%. This difference was significant (p = 0.002) (Table III).
Multivariate analysis showed a significant correlation between postoperative stroke and ASA classification, occurrence of chronic renal insufficiency, preoperative neurological deficit, and the degree of contralateral carotid stenosis, with lowest risk in patients with mild contralateral carotid stenosis (Table IV).
Table IV. Perioperative stroke: multivariate analysis (logistic regression)
| Factor | OR | p | 95% CI |
|---|---|---|---|
| Age | 1.04 | 0.063 | 1.00-1.08 |
| ASA | |||
| Normal healthy | 1.00 | - | - |
| Mild disease | 0.58 | 0.276 | 0.22-1.55 |
| Severe disease | 2.92 | 0.030 | 1.11-7.64 |
| Cardiac arrhythmia | 0.36 | 0.196 | 0.08-1.69 |
| Hypertonus | 0.87 | 0.680 | 0.46-1.67 |
| Diabetes mellitus | 1.07 | 0.840 | 0.55-2.08 |
| Coronary artery disease | 1.03 | 0.928 | 0.56-1.90 |
| Chronic renal insufficiency | 3.93 | 0.001 | 1.77-8.73 |
| Preop. neurological deficit | |||
| Symptomatic | 1.00 | - | - |
| Asymptomatic | 0.38 | 0.001 | 0.21-0.68 |
| Stenosis ipsilateral | |||
| 70-99% | 1.00 | - | - |
| 60-69% | 1.27 | 0.472 | 0.67-2.41 |
| 50-59% | 0.67 | 0.517 | 0.20-2.26 |
| Stenosis contralateral | |||
| Occlusion | 1.00 | - | - |
| 70-99% | 0.88 | 0.785 | 0.35-2.23 |
| 0-69% | 0.37 | 0.021 | 0.16-0.86 |
A significant correlation was not found between age, sex, cardiac arrhythmia, hypertonus, diabetes mellitus, coronary artery disease, and degree of ipsilateral stenosis (Table IV).
A meta-analysis based on 19 studies from the years 1984-2005 (Table V) including the results from our own institution showed a perioperative stroke frequency of 3.7% in 13,438 CEA patients, 3.9% of whom suffered a stroke with a contralateral carotid occlusion compared to 2.4% without a contralateral occlusion. This difference was highly significant (p = 0.002).
Table V. Representative literature 1984-2006
| Series | Year | All cases | CO cases | Stroke in CO cases | Stroke rate | No-CO cases | Stroke in no-CO cases | Stroke rate | CO rate |
|---|---|---|---|---|---|---|---|---|---|
| Present | 2006 | 1,960 | 161 | 9 | 5.6% | 1,799 | 38 | 2.1% | 8.3% |
| Domenig15 et al. | 2003 | 1,864 | 112 | 4 | 3.6% | 1,752 | 32 | 1.8% | 6.0% |
| Reed23 et al. | 2003 | - | 75 | 5 | 6.7% | - | - | 2.3% | - |
| Rockman4 et al. | 2002 | 2,420 | 338 | 10 | 3.0% | 2,082 | 44 | 2.1% | 14.0% |
| Karmeli17 et al. | 2001 | 144 | 50 | 1 | 2.0% | 94 | 2 | 2.1% | 34.7% |
| Baker13 et al. | 2000 | 823 | 86 | 2 | 2.3% | 737 | 17 | 2.3% | 10.5% |
| Locati20 et al. | 2000 | 1,266 | 198 | 8 | 4.0% | 1,068 | 25 | 2.3% | 15.6% |
| AbuRahma11 et al. | 2000 | 399 | 49 | 1 | 2.0% | 350 | 10 | 2.9% | 12.3% |
| Julia7 et al. | 1998 | 641 | 58 | 1 | 1.9% | 583 | 8 | 1.4% | 9.1% |
| Frawley16 et al. | 1996 | 257 | 52 | 2 | 3.7% | 205 | 1 | 0.5% | 20.2% |
| da Silva14 et al. | 1996 | 700 | 108 | 4 | 3.7% | 592 | 11 | 1.9% | 14.6% |
| Adelman12 et al. | 1995 | - | 135 | 1 | 0.7% | - | - | - | - |
| Lacroix18 et al. | 1994 | 618 | 129 | 6 | 4.7% | 489 | 27 | 5.5% | 20.9% |
| McCarthy22 et al. | 1993 | 526 | 81 | 4 | 4.9% | 445 | 11 | 2.5% | 15.4% |
| Perler3 et al. | 1992 | 205 | 36 | 1 | 2.8% | 169 | 7 | 4.1% | 17.6% |
| Mattos21 et al. | 1992 | 544 | 66 | 2 | 3.0% | 478 | 14 | 2.9% | 12.1% |
| Mackey2 et al. | 1990 | 670 | 63 | 3 | 4.8% | 607 | 18 | 3.0% | 9.4% |
| LaMuraglia19 et al. | 1987 | - | 76 | 1 | 1.3% | - | - | - | - |
| Sachs6 et al. | 1984 | 464 | 54 | 3 | 5.6% | 410 | 8 | 2.0% | 11.6% |
Discussion
The large American and European multicenter studies8, 9, 25 verified the superiority of surgical therapy of carotid stenosis compared to sole medical treatment. Both in the NASCET8 and in the ACAS9 study a raised perioperative stroke risk was shown in the presence of a contralateral carotid occlusion. Nevertheless, the role that contralateral carotid occlusion plays in the occurrence of neurological defects after a CEA remains unsettled.1, 2, 3, 4, 5, 6
In our clinic a perioperative stroke frequency of 5.6% was shown in patients with a contralateral carotid occlusion compared to 2.1% for patients without contralateral occlusion for 1,960 CEAs. This difference was significant (p = 0.012).
As such, at our institution a contralateral carotid occlusion represented an independent risk factor for the appearance of a neurological deficit after CEA.
As part of a literature survey where 17 representative studies on this subject were evaluated by Rockman,10 only one study23 revealed a significantly increased perioperative stroke risk after CEA in patients with a contralateral carotid occlusion.
Upon closer evaluation, however, it became evident that in 102, 4, 6, 7, 15, 16, 20, 21, 22, 23 out of 17 studies the stroke frequency was higher in patients with contralateral occlusion than in patients without contralateral occlusion. Because of the small case numbers for the individual studies, it could not be excluded that the risk for patients with contralateral occlusion compared to patients without contralateral occlusion might indeed have been significantly higher if the case numbers in the studies had been large enough.
A meta-analysis including the data from all 17 studies had not been carried out until now. A meta-analysis on the basis of the 17 studies compiled by Rockman10 showed for patients with a contralateral carotid occlusion a stroke frequency of 3.5% compared to 2.4% for patients without. With a case number of 10,787 this difference was significant (p = 0.016).
One representative, prospective multicenter study published in 1996 by da Silva et al.14 from the United Kingdom and Ireland with 700 cases in all was not considered in the survey by Rockman.10
This study as well showed a far higher perioperative stroke frequency in patients with a contralateral carotid occlusion of 3.9% compared to 1.9% for patients without contralateral occlusion. However, with a case number of just 700 the difference was not found to be significant.
On the basis of 19 studies between the years 1984 and 2005 (Table V), we prepared a meta-analysis that also included the data from our own institution. With a case number of 13,438 CEAs, a perioperative stroke rate of 3.7% was shown for patients with a contralateral carotid occlusion compared to 2.4% for patients without contralateral occlusion. This difference was highly significant (p = 0.002).
In the guidelines of the American Heart Association,24 the raised perioperative stroke risk for patients with contralateral carotid occlusion is only taken into account for asymptomatic patients.
The highest risk for the perioperative appearance of a neurological defect in symptomatic patients was evident in those with a contralateral occlusion in the two studies with the highest number of cases. In Rockman et al.,4 the frequency for this patient group was 3.7%, while in our own institution it was 6.1%.
We feel that the accepted postoperative stroke risk after CEA for patients with contralateral carotid occlusion also had to be taken into account for symptomatic patients.
On the basis of the study data and the results from our institution, patients with a contralateral carotid occlusion should be classified as risk patients for a CEA. This does not justify on its own, however, the indication for a medical therapy for patients with a contralateral carotid occlusion. The studies published until now26, 27, 28 on endovascular procedures of carotid stenosis in patients with contralateral occlusion do not show any superiority of endovascular treatment compared to surgical therapy.
Thus, the study of Sabeti et al.28 showed a postinterventional stroke frequency of 4.7% in patients with contralateral occlusion compared to 3.7% in patients without contralateral occlusion. In symptomatic patients with contralateral occlusion, the stroke frequency was even 7.0%.
In order to allow a comparability of studies on this subject, a precise analysis of the subgroups should be carried out as a matter of principle for all studies. In particular, it is important to know the proportion of symptomatic patients with contralateral occlusion to allow a correct interpretation of the study results.
Since the benefits of angioplasty compared to surgical therapy have not been confirmed until now, the special indications29 for stent procedures must also be considered for patients with a contralateral carotid occlusion.
Due to the extremely poor outcomes of medically treated symptomatic patients, with a 2-year stroke risk of 69.4%, a risk-adjusted surgical or endovascular procedure should be done in patients with high-grade carotid stenosis and contralateral occlusion under full observance of the guidelines of the American Heart Association.24
In patients with contralateral occlusion, CEA should always be carried out by well-practiced surgeons because of the additional neurological risks.
The results on perioperative stroke frequency differentiated according to subgroups should be available at any specialized institution.
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PII: S0890-5096(07)00352-4
doi:10.1016/j.avsg.2007.07.034
© 2008 Annals of Vascular Surgery Inc. Published by Elsevier Inc All rights reserved.
