engleski

Stroke prevention by carotid endarterectomy: current state and future perspective

Own experience and results obtained with carotid endarterectomy (CEA) from January 1970 till August 31, 2004 are presented. A total of 2342 CEA procedures were performed in 2223 patients (bilateral operation in 5.4% of patients), 692 (31.1%) women and 1531 (68.9%) men, mean age 65.8±9.3 (range 38-98) years. Most operations were performed in general anesthesia, and from October 14, 2002 90% of the procedures were done in locoregional anesthesia. The techniques of open, conventional and eversion CEA (from 1985) were employed. The best results in the perioperative period to postoperative day 30 were recorded on operating on asymptomatic patients (341 CEA ; 14.5% of total). There was no lethal outcome, and the rate of stroke was 0.3%. A total of 2001 symptomatic stenoses were operated on, i.e. 1098 after transient ischemic attack (TIA), 894 after completed stroke, and 9 on stroke in evolution, yielding the respective rates of stroke and mortality of 1%, 3.1% and 55.5%. The results obtained in asymptomatic and symptomatic stenoses operated on (except those in progressive stroke) are very satisfactory and comaparable with the best in the world. Due to the disastrous results of the procedure performed on stroke in evolution, we believe that, in our circumstances, this indication is not justifiable and that these patients are better treated at neurologic intensive care units. In spite of the observed trend and encouraging results of urgent carotid surgery, we have no such experience of our own. The current indications for CEA and controversies about indications in asymptomatic patients are discussed, with special reference to recently (2004) published results of the ACST and ACSRS studies. It is quite clear that categorization of patients candidates for CEA, which is based solely on the degree of stenosis and presence or absence of neurologic symptoms is not precise enough for assessment of the real individual risk of stroke. As CEA has been definitely scientifically verified as an efficient method of surgical treatment for carotid occlusive disease and for stroke prevention, all the possibilities it offers should be maximally used. Unfortunately, in Croatia only 15% of the real needs for CEA are managed by this method. The future developments of endovascular approach should not be based on competition but on complementarity, however, provided the same validation as for CEA.

carotid endarterectomy ; stroke prevention ; carotid occlusive disease ; atherosclerosis

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