Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: results from NASCET

View More View Less
  • 1 The John P. Robarts Research Institute, and Departments of Clinical Neurological Sciences, and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

✓ The purpose of this study was to examine how the prognosis of patients who presented with a recent ischemic event referable to a 70% to 99% stenosis of one carotid artery (ipsilateral) was altered by stenosis and occlusion of the contralateral carotid artery. The benefit of performing carotid endarterectomy on the recently symptomatic artery, in the presence of contralateral artery disease, was also examined.

A total of 659 patients were grouped into one of three categories according to the extent of stenosis in the contralateral carotid artery: less than 70% (559 patients), 70% to 99% (57 patients), and occlusion (43 patients). Strokes that occurred during the follow-up period were designated as ipsilateral if they arose from the same carotid artery as the symptom for which the patient had been entered into the study. Medically treated patients with an occluded contralateral artery were more than twice as likely to have had an ipsilateral stroke at 2 years than patients with either severe (hazard ratio: 2.36; 95% confidence interval (CI): 1.00–5.62) or mild-to-moderate (hazard ratio: 2.65; 95% CI: 1.43–4.90) contralateral artery stenosis. The perioperative risk of stroke and death was higher in patients with an occluded contralateral artery (4.0% risk) or mild-to-moderate (5.1% risk) contralateral stenosis. Regression analyses indicated that the results were not affected by other risk factors.

An occluded contralateral carotid artery significantly increased the risk of stroke associated with a severely stenosed ipsilateral carotid artery. Despite higher perioperative morbidity in the presence of an occluded contralateral artery, the longer-term outlook for patients who had endarterectomy performed on the recently symptomatic, severely stenosed ipsilateral carotid artery was considerably better than for medically treated patients.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address for Dr. Gasecki: University of Nebraska Medical Center, Omaha, Nebraska.Address reprint requests to: Gary G. Ferguson, M.D., The John P. Robarts Research Institute, 100 Perth Drive, P. O. Box 5015, London, Ontario N6A 5K8, Canada.
  • 1.

    Allcock JM: Occlusion of the middle cerebral artery: serial angiography as a guide to conservative therapy. J Neurosurg 27:353363, 1967 Allcock JM: Occlusion of the middle cerebral artery: serial angiography as a guide to conservative therapy. J Neurosurg 27:353–363, 1967

    • Search Google Scholar
    • Export Citation
  • 2.

    Andersen CA, , Rich NM, & Collins GJ Jr, et al: Unilateral internal carotid arterial occlusion: special considerations. Stroke 8:669671, 1977 Andersen CA, Rich NM, Collins GJ Jr, et al: Unilateral internal carotid arterial occlusion: special considerations. Stroke 8:669–671, 1977

    • Search Google Scholar
    • Export Citation
  • 3.

    Bozzao L, , Fantozzi LM, & Bastianello S, et al: Early collateral blood supply and late parenchymal brain damage in patients with middle cerebral artery occlusion. Stroke 20:735740, 1989 Bozzao L, Fantozzi LM, Bastianello S, et al: Early collateral blood supply and late parenchymal brain damage in patients with middle cerebral artery occlusion. Stroke 20:735–740, 1989

    • Search Google Scholar
    • Export Citation
  • 4.

    Eliasziw M, , Streifler JY, & Fox AJ, et al: Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis. Stroke 25:304308, 1994 Eliasziw M, Streifler JY, Fox AJ, et al: Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis. Stroke 25:304–308, 1994

    • Search Google Scholar
    • Export Citation
  • 5.

    Fields WS, & Lemak NA: Joint study of extracranial carotid artery arterial occlusion. X. Internal carotid artery occlusion. JAMA 235:27342738, 1976 Fields WS, Lemak NA: Joint study of extracranial carotid artery arterial occlusion. X. Internal carotid artery occlusion. JAMA 235:2734–2738, 1976

    • Search Google Scholar
    • Export Citation
  • 6.

    Fox J: How to measure carotid stenosis. Radiology 186:316318, 1993 Fox J: How to measure carotid stenosis. Radiology 186:316–318, 1993

    • Search Google Scholar
    • Export Citation
  • 7.

    Friedman SG, , Riles TS, & Lamparello PJ, et al: Surgical therapy for the patient with internal carotid artery occlusion and contralateral stenosis. J Vasc Surg 5:856861, 1987 Friedman SG, Riles TS, Lamparello PJ, et al: Surgical therapy for the patient with internal carotid artery occlusion and contralateral stenosis. J Vasc Surg 5:856–861, 1987

    • Search Google Scholar
    • Export Citation
  • 8.

    Hammacher ER, , Eikelboom BC, & Bast TJ, et al: Surgical treatment of patients with a carotid artery occlusion and a contralateral stenosis. J Cardiovasc Surg 25:513517, 1984 Hammacher ER, Eikelboom BC, Bast TJ, et al: Surgical treatment of patients with a carotid artery occlusion and a contralateral stenosis. J Cardiovasc Surg 25:513–517, 1984

    • Search Google Scholar
    • Export Citation
  • 9.

    Lacroix H, , Beets G, & Van Hemelrijck J, et al: Carotid artery surgery in the presence of an occlusion of the contralateral carotid artery. Perioperative risk analysis and follow-up. Cardiovasc Surg 2:2631, 1994 Lacroix H, Beets G, Van Hemelrijck J, et al: Carotid artery surgery in the presence of an occlusion of the contralateral carotid artery. Perioperative risk analysis and follow-up. Cardiovasc Surg 2:26–31, 1994

    • Search Google Scholar
    • Export Citation
  • 10.

    Lee ET: tatistical Methods for Survival Data Analysis. New York: John Wiley & Sons, 1992, pp 250251 Lee ET: tatistical Methods for Survival Data Analysis. New York: John Wiley & Sons, 1992, pp 250–251

    • Search Google Scholar
    • Export Citation
  • 11.

    Lees CD, & Hertzer NR: Postoperative stroke and neurologic complications after carotid endarterectomy. Arch Surg 116:15611568, 1981 Lees CD, Hertzer NR: Postoperative stroke and neurologic complications after carotid endarterectomy. Arch Surg 116:1561–1568, 1981

    • Search Google Scholar
    • Export Citation
  • 12.

    Mackey WC, , O'Donnell TF Jr, & Callow AD: Carotid endarterectomy contralateral to an occluded carotid artery: perioperative risk and late results. J Vasc Surg 11:778785, 1990 Mackey WC, O'Donnell TF Jr, Callow AD: Carotid endarterectomy contralateral to an occluded carotid artery: perioperative risk and late results. J Vasc Surg 11:778–785, 1990

    • Search Google Scholar
    • Export Citation
  • 13.

    Maldonado G, & Greenland S: Simulation study of confounder-selection strategies. Am J Epidemiol 138:923936, 1993 Maldonado G, Greenland S: Simulation study of confounder-selection strategies. Am J Epidemiol 138:923–936, 1993

    • Search Google Scholar
    • Export Citation
  • 14.

    Markus HS, , Harrison MJ, & Adiseshiah M: Carotid endarterectomy improves haemodynamics on the contralateral side: implications for operating contralateral to an occluded carotid artery. Br J Surg 80:170172, 1993 Markus HS, Harrison MJ, Adiseshiah M: Carotid endarterectomy improves haemodynamics on the contralateral side: implications for operating contralateral to an occluded carotid artery. Br J Surg 80:170–172, 1993

    • Search Google Scholar
    • Export Citation
  • 15.

    Moore DJ, , Modi JR, & Finch WT, et al: Influence of the contralateral carotid artery on neurologic complications following carotid endarterectomy. J Vasc Surg 1:409414, 1984 Moore DJ, Modi JR, Finch WT, et al: Influence of the contralateral carotid artery on neurologic complications following carotid endarterectomy. J Vasc Surg 1:409–414, 1984

    • Search Google Scholar
    • Export Citation
  • 16.

    North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445453, 1991 North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445–453, 1991

    • Search Google Scholar
    • Export Citation
  • 17.

    North American Symptomatic Carotid Endarterectomy Trial (NASCET) Steering Committee: North American Symptomatic Carotid Endarterectomy Trial: Methods, patient characteristics, and progress. Stroke 22:711720, 1991 North American Symptomatic Carotid Endarterectomy Trial (NASCET) Steering Committee: North American Symptomatic Carotid Endarterectomy Trial: Methods, patient characteristics, and progress. Stroke 22:711–720, 1991

    • Search Google Scholar
    • Export Citation
  • 18.

    Patterson RH Jr: Risk of carotid surgery with occlusion of the contralateral carotid artery. Arch Neurol 30:188189, 1974 Patterson RH Jr: Risk of carotid surgery with occlusion of the contralateral carotid artery. Arch Neurol 30:188–189, 1974

    • Search Google Scholar
    • Export Citation
  • 19.

    Phillips MR, , Johnson WC, & Scott RM, et al: Carotid endarterectomy in the presence of contralateral carotid occlusion. The role of EEG and intraluminal shunting. Arch Surg 114:12321239, 1979 Phillips MR, Johnson WC, Scott RM, et al: Carotid endarterectomy in the presence of contralateral carotid occlusion. The role of EEG and intraluminal shunting. Arch Surg 114:1232–1239, 1979

    • Search Google Scholar
    • Export Citation
  • 20.

    Redekop G, & Ferguson GG: Correlation of contralateral stenosis and intraoperative electroencephalogram change with risk of stroke during carotid endarterectomy. Neurosurgery 30:191194, 1992 Redekop G, Ferguson GG: Correlation of contralateral stenosis and intraoperative electroencephalogram change with risk of stroke during carotid endarterectomy. Neurosurgery 30:191–194, 1992

    • Search Google Scholar
    • Export Citation
  • 21.

    Riles TS, , Imparato AM, & Kopelman I: Carotid artery stenosis with contralateral internal carotid occlusion: long-term results in fifty-four patients. Surgery 87:363368, 1980 Riles TS, Imparato AM, Kopelman I: Carotid artery stenosis with contralateral internal carotid occlusion: long-term results in fifty-four patients. Surgery 87:363–368, 1980

    • Search Google Scholar
    • Export Citation
  • 22.

    Sachs SM, , Fulenwider JT, & Smith RB III, et al: Does contralateral carotid occlusion influence neurologic fate of carotid endarterectomy? Surgery 96:839844, 1984 Sachs SM, Fulenwider JT, Smith RB III, et al: Does contralateral carotid occlusion influence neurologic fate of carotid endarterectomy? Surgery 96:839–844, 1984

    • Search Google Scholar
    • Export Citation
  • 23.

    Saito I, , Segawa H, & Shiokawa Y, et al: Middle cerebral artery occlusion: correlation of computerized tomography and angiography with clinical outcome. Stroke 18:863868, 1987 Saito I, Segawa H, Shiokawa Y, et al: Middle cerebral artery occlusion: correlation of computerized tomography and angiography with clinical outcome. Stroke 18:863–868, 1987

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 787 330 36
Full Text Views 261 50 3
PDF Downloads 147 31 1
EPUB Downloads 0 0 0