Determinants of carotid endarterectomy anatomic durability: effects of serum lipids and lipid-lowering drugs

J Vasc Surg. 2005 May;41(5):762-8. doi: 10.1016/j.jvs.2005.01.035.

Abstract

Objectives: Carotid endarterectomy (CEA) remains the gold standard for treatment of carotid stenosis. With inevitable comparisons of catheter-based therapy to all aspects of CEA, this study of a large contemporary series was undertaken to evaluate the determinants of anatomic durability of CEA.

Methods: During the interval (1989 through 1999), 2,127 primary, isolated CEAs with selective patching (50.2%) were performed in 1,853 patients (61.8% male, 36.1% symptomatic). End points included patient longevity and perioperative morbidity as well as evidence of CEA anatomic durability as defined by duplex evaluation: CEA restenosis (moderate, >50%, or greater recurrent stenosis), which included CEA anatomic failure (severe, >70%, restenosis/carotid occlusion). The incidence of CEA recurrent stenosis was temporally assessed early (<2 years) and late (>2 years) after operation. Clinical and surgical variables potentially associated with the study endpoints were analyzed by univariate and multivariate methods.

Results: The perioperative stroke and death rate was 1.4% and the 2-year and 10-year survival was 88.1% and 44.9%, respectively. Anatomic failure after CEA developed in 3.9% at 2 years and in 8.5% at 5 years; only 3.2% of CEA patients underwent reoperation during a mean follow-up of 73.4 months. Early (<2 years) analysis revealed 12.2% restenosis, whereas late (>2 years) results identified 9.8% progression of carotid stenosis and a 5.8% rate of anatomic failure. Multivariate analysis determined elevated creatinine (odds ratio [OR], 1.719, P < .001) and female gender (OR, 1.564; P < .02) correlated with early restenosis. Surgical patch closure and lipid-lowering drugs were protective for both early restenosis, with ORs of 0.543 (P < .0.001) and 0.601 (P < .007) and early anatomic failure ORs of 0.469 (P < .02) and 0.517 (P < .03), respectively. Although only elevated serum cholesterol (OR, 1.009; P < .03) correlated with late anatomic failure, only lipid-lowering drugs were protective for both late freedom from progression of disease (OR, 0.202; P < .0002) or late CEA anatomic failure (OR, 0.128; P < .0003).

Conclusions: The association of female gender and elevated cholesterol with recurrent carotid stenosis is confirmed, elevated creatinine is introduced as a risk factor, and surgical patch repair is protective for early CEA recurrent carotid stenosis. The unique findings of the significant, beneficial effects of lipid-lowering drugs on both early and late CEA anatomic durability and patient survival indicate that such therapy should be instituted in most patients after CEA.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Carotid Arteries / diagnostic imaging
  • Carotid Arteries / drug effects
  • Carotid Stenosis / blood
  • Carotid Stenosis / drug therapy
  • Carotid Stenosis / surgery*
  • Endarterectomy, Carotid / methods
  • Endarterectomy, Carotid / standards*
  • Female
  • Follow-Up Studies
  • Humans
  • Hydroxymethylglutaryl-CoA Reductase Inhibitors / therapeutic use*
  • Incidence
  • Lipids / blood*
  • Male
  • Massachusetts / epidemiology
  • Postoperative Complications / epidemiology
  • Recurrence
  • Retrospective Studies
  • Survival Rate
  • Treatment Outcome
  • Ultrasonography, Doppler, Duplex

Substances

  • Hydroxymethylglutaryl-CoA Reductase Inhibitors
  • Lipids