Surgical treatment of recurrent carotid artery stenosis and carotid artery stenosis after neck irradiation: evaluation of operative risk.

Surgical treatment of recurrent carotid artery stenosis after endarterectomy and carotid artery stenosis after neck irradiation purportedly has a higher complication rate than primary carotid endarterectomy (CEA). Accordingly, carotid angioplasty has been proposed as a safer alternative. The purpose of this study was to evaluate operative risks on the basis of our experience with these lesions. A series of 679 carotid revascularizations (CRV) performed over a period of 9 years was retrospectively reviewed. Immediate outcome and operative technique was analyzed in three groups: group 1 included 549 "routine" CRV, group 2 included 8 CRV for recurrent stenosis after CEA, and group 3 consisted of 11 CRV for stenosis after neck irradiation. No difference in revascularization techniques was found between groups 1 and 2. In contrast there were fewer CEA and resection-anastomosis procedures in group 2 than in group 1 (62.5% vs. 98.2%; p < 0.0006) and more bypass procedures (37.5% vs. 1.8%; p = 0.0015). The cumulative neurological morbidity/mortality rate (CMMR) was 0% in groups 2 and 3 as compared to 4.4% in group 1. In comparison with group 1, early and permanent neurological morbidity rates were significantly higher in both group 2 (2.2% vs. 25.0%; p = 0.015 and 0.2% vs. 12.5%; p = 0.028, respectively) and group 3 (2.2% vs. 18.2%; p = 0.028 and 0.2% vs. 9.1%; p = 0.039, respectively). Surgical treatment of recurrent stenosis after CEA and stenosis after neck irradiation is not associated with a higher CMMR. The only potentially valid justification for using percutaneous transluminal angioplasty in these patients would be a higher risk of cervical neurological morbidity.

Long-term outcome of 121 iliofemoral endarterectomy procedures.

Iliofemoral endarterectomy (EA) is now considered by most vascular surgeons to be an obsolete technique that is difficult and unreliable. The purpose of this retrospective study was to reassess the place of iliofemoral EA on the basis of long-term outcome in our experience. From 1982 to 1995, we performed a total of 121 iliofemoral EA procedures on 98 patients with a mean age of 57 years. The anatomical presentation involved iliac occlusion in 55 cases and complex iliac stenosis in 63. The indication for treatment was critical ischemia in 28 cases. Operative mortality was nil. Major amputation was required in only one patient because of contralateral thrombosis during the procedure. Postoperative thrombosis requiring early thrombectomy occurred in five cases. At 5 and 10 years, actuarial rates were 77.6% and 61.3%, respectively, for survival, 98.3% and 90.1%, respectively, for limb salvage, 78.9% and 65.1%, respectively, for primary patency, and 88.2% and 73.8%, respectively, for secondary patency. On the basis of these findings, we consider iliofemoral EA to be a viable alternative to iliac bypass in patients ineligible for transluminal angioplasty.