ARTICLE IN PRESS

www.icvts.org
doi:10.1510/icvts.2009.231878
Interactive CardioVascular and Thoracic Surgery 11 (2010) 182184
2010 Published by European Association for Cardio-Thoracic Surgery
Brief communication - Carotid and imaging
Postoperative internal carotid artery restenosis after local
anesthesia: presence of risk factors versus intraoperative shunt
Narcis Hudorovic *, Ivo Lovricevic , Hrvoje Hajnic , Zaky Ahel
a, a b c
Department of Vascular Surgery, University Hospital Sestre Milosrdnice, Vinogradska 29, 10000 Zagreb, Croatia
a
Department of Psychology and Human Resources Management, Koncern AGRAM, Zagreb, Croatia
b
Dr. Zaky Polyclinic, Policlinic for Internal Medicine and Urology, Zagreb, Croatia
c
Received 28 December 2009; received in revised form 11 April 2010; accepted 13 April 2010
Abstract
Published data suggest that the regional anesthetic technique used for carotid endarterectomy (CEA) increases the systolic arterial blood
pressure and heart rate. At the same time local anesthesia reduced the shunt insertion rate. This study aimed to analyze risk factors and
ischemic symptomatology in patients with postoperative internal carotid artery restenosis. The current retrospective study was undertaken
to assess the results of CEA in 8000 patients who were operated during a five-year period in six regional cardiovascular centers. Carotid
color coded flow imaging, medical history, clinical findings and atherosclerotic risk factors were analyzed. Among them, there were 33
patients (0.4%) with postoperative re-occlusion after CEA. The patients with restenosis were re-examined with carotid color coded flow
imaging and data were compared with 33 consecutive patients with satisfactory postoperative findings to serve as a control group. In the
restenosis group eight risk factors were analyzed (hypertension, smoking, hyperlipidemia, diabetes mellitus, history of stroke, transitory
ischemic attack, heart attack and coronary disease), and compared with risk factors in control group. Study results suggested that early
postoperative internal carotid artery restenosis was not caused by atherosclerosis risk factors but by intraoperative shunt usage.
2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Carotid endarterectomy; Local anesthesia; Risk factors; Complications
1. Introduction
Indications for carotid endarterectomy (CEA) were well
established from four level 1A clinical trials; the North
American Symptomatic Carotid Endarterectomy Trial (NAS-
CET)
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1
x
, the European Carotid Surgery Trial (ECST)
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2
x
, the
Asymptomatic Carotid Atherosclerosis Study (ACAS)
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, and
the Asymptomatic Carotid Surgery Trial (ACTS)
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.
Patients who undergo CEA in these study use resources as
recommended by the AHA guidelines for CEA
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5
x
. Currently,
reliable data for defining an acceptable duration and inten-
sity of postoperative monitoring are lacking
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6
x
. Therefore,
the Croatian Society for Neurovascular Disorders took an
active part in the implementation of new concepts of stroke
management and treatment to provide updated recommen-
dations that can be used on adopting new treatment
therapeutic methods and procedures. In this study, we
strictly followed the mentioned rules which state that the
first postoperative outpatient neurosonological control is
recommended three months after CEA
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7
x
. ICA restenosis
usually develops early, within two years after surgery. If
restenosis develops after a longer period of time, it is
usually caused by well-established atherosclerosis risk fac-
tors that caused the original disease. The aim of this study
was to analyze the risk factors, intraoperative usage of the
*Corresponding author. Tel.: q385-1-4640-774; fax: q385-1-3787-290.
E-mail address: [email protected] (N. Hudorovic).
shunt and ischemic symptomatology in patients with post-
operative ICA restenosis.
2. Method
We retrospectively examined records of 8000 patients who
underwent local anesthesia carotid endarterectomy (LA-
CEA) in six regional cardiovascular departments during a
five-year period. According to postoperative computed
tomography angiography (CTA) and carotid color flow imag-
ing (CCDFI) data, there were 33 (0.4%) patients with ICA
restenosis in this group. There was a predominance of male
patients (75.7%), and mean age was 68.7 (age range 50
85) years. A standard open LA-CEA was performed in all
patients. A shunt was inserted if there was deterioration in
the level of consciousness. Patch closure with a polytetra-
fluoroethylene (PTFE) patch material was undertaken in all
study patients. Neurological events were classified as minor
wtransient ischemic attacks (TIA)x and major neurological
deficits. Major neurological deficits were defined as those
deficits that lasted beyond seven days. We confirmed
intraoperative abnormal focal neurological signs by an
electroencephalogram andyor prolonged electroencepha-
lographic monitoring. All the patients with ICA restenosis
were re-examined with CCDFI. Data on 33 consecutive
patients with a satisfactory CTA and CCDFI postoperative
findings were analyzed to serve as a control group. All
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Table 1. Patient characteristics according postoperative restenosis and con-
trol group
Patients Postoperative Satisfactory
restenosis postoperative finding
(ns33) (ns33)
Gender 25 malesy8 females 23 malesy10 females
Age (years; mean"S.D.) 68.7"7.2 70.7"7.2
Age at time of surgery (years) 65.6 65.8
Median postoperative 3.8 4.4
follow-up (years)
Side of CEA 18 righty15 left 21 righty12 left
S.D., standard deviation; CEA, carotid endarterectomy.
Table 2. Influence of eight risk factors for restenosis
Risk factors Patients x -test
2
Binary logistic regression
Postoperative Satisfactory postoperative x
2
P-value B df P-value
restenosis finding
Hypertension 18 18 0.000 1.00 1.117 1 0.47
Smoking 11 10 0.070 0.79 2.826 1 0.02
Hyperlipidemia 13 8 1.746 0.19 3.531 1 0.05
Diabetes melitus 7 9 0.330 0.57 0.195 1 0.93
Previous stroke 7 13 2.583 0.11 3.023 1 0.02
Previous TIA 3 3 0.000 1.00 0.748 1 0.71
Previous IM 4 4 0.000 1.00 1.201 1 0.50
Operative shunt 25 3 30.023 0.00 7.653 1 0.00
All 33 33
x -test was used to examine differences between two groups of patients.
2
Binary logistic regression was used to examine which risk factors are significant predictors for restenosis.
P-value, statistical significance; B, estimate; df, degrees of freedom; TIA, transient ischemic attacks.
follow-up CCDFI examinations (restenosisycontrol group)
were conducted by the same investigator using the same
equipment (ALOKA 5500, 10-MHz linear probe).
x
2
-test was used to examine differences between two
groups of patients considering eight risk factors. Binary
logistic regression analysis (dichotomous variable) was used
to examine which risk factor is the most significant predic-
tor for restenosis. All analyses were carried out using the
SPSS 16.0.1 software package (SPSS Inc, Chicago, IL, USA).
3. Results
The patient demographic data are shown in Table 1.
Significant postoperative ICA restenosis (25 patientsy75%)
was recorded in 11 patients on the left side and in 14
patients on the right side. Combined occlusion of the
common carotid artery and ICA occurred in eight (24%)
patients, four on either side. Contralateral ICA showed non-
significant atherosclerotic changes in 27 (82%) patients, of
which eight had undergone previous CEA. Twenty-four (72%)
patients had moderate ICA restenosis and one (3%) patient
had subtotal ICA restenosis. CCDFI demonstrated ICA res-
tenosis on the first follow-up examination taken three
months after the CEA in 31 (94%) patients, and during the
first- and third-year of follow-up in one (3%) patient each.
Three (9%) patients presented with ischemic symptoms
during the first postoperative days (TIA in two patients and
stroke in one patient). In the group with satisfactory
postoperative finding, 17 patients had CEA on the right
side, 12 on the left, and four patients had bilateral CEA.
Contralaterally, 25 (76%) patients had non-significant ath-
erosclerotic changes, six (18%) patients developed mild ICA
restenosis, and two (6%) patients had occlusion of the
contralateral ICA.
The presence of atherosclerotic risk factors (hypertension,
smoking, hyperlipidemia, diabetes mellitus, history of TIAy
stroke, history of myocardial infarction and coronary dis-
ease), and usage of intraoperative shunt were analyzed in
both groups of patients. The results are presented in
Table 2.
Statistically significant difference between two groups
was found in the operative shunt risk factor (x s30.023,
2
Ps0.00).
Our results suggest that the significant predictors for
restonosis are: operative shunt (Bs7.653; Ps0.00), smok-
ing (Bs2.826; Ps0.02), previous stroke (Bs3.023;
Ps0.02) and hyperlipidemia (Bs3.531; Ps0.05).
4. Discussion
Recognized risk factors for developing early postoperative
ICA occlusionyrestenosis were smoking, smaller diameter of
ICA, defects found during surgery, and certain genotypes
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8
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.
However, systemic risk factors, such as hypertension,
hyperlipidemia, and obesity increase the risk of developing
late postoperative ICA occlusionyrestenosis (two years or
more after CEA). Diabetes mellitus and age over 80 years
have been established as risk factors for developing late
postoperative ICA occlusionyrestenosis as well as being a
predictive factor for the increased risk of perioperative
stroke or death (30 days after CEA)
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8
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.
In our study atherosclerotic risk factors were present in a
high percentage of the postoperative ICA occlusionyresten-
osis group but there was no significant difference from the
control group.
According to the recent literature the incidence of brain
ischemic symptoms in postoperative ICA restenosis varies
between 1% and 4%
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8, 9, 10
x
. In our series, three of 33
patients with postoperative ICA restenosis presented with
ischemic symptoms (one stroke; two TIA), and moderate
ICA restenosis of the contralateral ICA was found in six of
33 (18%) patients and contralateral ICA occlusion in two
(6%) patients. To remove atheromatous plaque, surgeons
must clamp the ICA. A shunt can be inserted to avoid brain
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ischemia during clamping, but the shunt itself might dis-
lodge a part of the plaque or damage the residual intima
of the vessel, thus favoring postoperative restenosis. Our
results suggest that postoperative ICA restenosis after LA-
CEA is rare and mostly asymptomatic, and it is predomi-
nantly caused by intraoperative usage of a shunt (local
shunt-microtrauma).
With road-mapping it is possible to superimpose live
fluoroscopy on a radiographic image. A refurbished oper-
ating room with a fluoroscopy unit for intraoperative angio-
graphic control will be of benefit to both patients and the
operating team. Unfortunately, superior imaging, decreas-
ing radiation and optimal ergonomics are still a barrier for
vascular institutions in which this study was performed.
Obviously, the realization of such an operating suite is
essential for improving the every-day work in vascular
centers.
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