Second Carotid Endarterectomies May Be Particularly Risky

Talk to your doctor about the dangers of stroke due to the endarterectomy procedure and why you would want to put inflexible metal stents in flexible arteries. Don't listen to me, but ask your doctor plenty of questions.   Ask for a guarantee of no stroke due to any procedure.
https://www.medpagetoday.com/cardiology/prevention/69173?

But adverse events more common only for asymptomatic patients, study finds

• by Nicole Lou, Reporter, MedPage Today/CRTonline.org November 09, 2017

Action Points

• Note that this observational study found that redo carotid endarterectomy is associated with higher perioperative risk than initial carotid endarterectomy (CEA), though this increase is limited to asymptomatic patients.
• Be aware that CEA in toto is being more frequently replaced with carotid artery stenting, particularly in asymptomatic disease.

Patients who returned to the operating room for carotid endarterectomy (CEA) revision were at higher risk for adverse events the second time around, a study suggested -- though this was only true for asymptomatic return patients.
From those identified in the Vascular Quality Initiative database as having undergone a CEA at an academic or community hospital in the U.S., overall event rates at 30 days seemed to favor primary CEA recipients in comparison with those getting redo CEA:

• Ipsilateral strokes: 0.9% versus 1.8% (adjusted OR 1.75, 95% CI 1.13-2.73)
• Death: 0.7% versus 1.4% (adjusted OR 1.82, 95% CI 1.12-2.94)
• Stroke or death: 1.5% versus 2.6% (adjusted OR 1.49, 95% CI 1.02-2.19)

Yet it turned out that driving this were asymptomatic patients, who were at more than double the risk after redo surgery, according to Mahmoud Malas, MD, director of Endovascular Surgery at Johns Hopkins Bayview Medical Center in Baltimore, and colleagues in their study published online in JAMA Surgery:

• Stroke: 0.7% versus 1.9% (adjusted OR 2.82, 95% CI 1.69-4.71)
• Death: 0.6% versus 1.4% (adjusted OR 2.15, 95% CI 1.21-3.79)
• Stroke or death: 1.2% versus 2.9% (adjusted OR 2.06, 95% CI 1.32-3.23)

"These results show that the excess risk associated with redo CEA relative to primary CEA is similar to the excess risk associated with primary CEA treatment for symptomatic disease relative to primary CEA for asymptomatic disease," the authors said.
At all points in time, however, redo CEA was not associated with more myocardial infractions (MIs) whether patients were symptomatic or asymptomatic.
At 1 year, stroke or death was equally likely whether symptomatic patients had primary or redo CEA (HR 0.94, 95% CI 0.67-1.31) -- while asymptomatic peers continued to have worse outcomes in this regard after redo CEA (HR 1.36, 95% CI 1.08-1.69).
"One possible reason for this finding is that the procedural risk associated with high-risk plaque in symptomatic patients obscures the difference between patients undergoing symptomatic redo CEA and patients undergoing primary CEA but not among asymptomatic patients," the researchers suggested. "It is also possible that the association between symptomatic status and adverse events during the first CEA extends to the redo CEA even if the patient is classically asymptomatic for the redo operation.
"We are of the opinion that the treatment of patients with restenosis should be based on evidence of progressive disease over a surveillance period."
Nevertheless, the researchers admitted that despite the worse outcomes associated with redo CEA in asymptomatic individuals, the 2.9% odds of combined stroke and death still fall under the 3% acceptable maximum stipulated by Society for Vascular Surgery guidelines.
Surgeries included in the authors' analysis were performed in the endovascular era (2003-2016). Primary CEAs made up the bulk of procedures (97.9%), and patients were followed for an average of 7 months after both primary and redo CEA.
Notably, 70% of patients were asymptomatic. The general cohort also went into CEA for an 80% stenosis more than 60% of the time.
Symptomatic individuals had the same 30-day outcomes after CEA regardless of whether it was their first time or not:

• Stroke: 1.5% versus 1.4% (adjusted 0.79, 95% CI 0.33-1.95)
• Death: 0.9% versus 1.4% (adjusted OR 1.32, 95% CI 0.53-3.26)
• Stroke/death: 2.2% versus 2.1% (adjusted OR 0.85, 95% CI 0.39-1.82)

"The concern about the treatment of asymptomatic patients must be balanced with the fact that symptoms of carotid stenosis are not entirely benign. More than 40% of the symptomatic patients in this study had a stroke as their initial symptom, suggesting the need for prophylactic treatment. This concern also underscores the ongoing drive by professional bodies to develop innovative methods for differentiating asymptomatic patients who have low risk versus high risk of stroke so as to limit the exposure of low-risk patients to surgery at population levels."
Missing details of the interval between the index surgery and prior CEA were a major caveat of this study. Moreover, the authors lacked follow-up data beyond 1 year, they noted.
"Results from a multi-institutional study of comparable sample size to ours are largely nonexistent, leaving room for validation of this unusual finding in subsequent studies."
But will these future studies even be clinically relevant?
In an invited commentary, Rishi Roy, MD, and Gilbert Upchurch, Jr., MD, both of the University of Virginia Medical Center in Charlottesville, wrote: "To our knowledge, without strong literature supporting this practice, CAS [carotid artery stenting] has become the de facto primary therapy for almost all recurrent high-grade carotid stenoses.
"Our bias is that other than a few exceptions, very few clinicians in the near future will even perform redo CEA, instead opting for CAS for redo carotid artery stenosis," the editorial continued. "In considering redo CEA, there are multiple additional factors independent of percent stenosis and status of contralateral occlusion that influence the decision of proceeding with intervention. Most often, in addition to stroke/ death/MI, practitioners are concerned with debilitating cranial nerve injuries, which are reported in multiple studies to be higher in redo CEA."

Malas, Roy, and Upchurch reported having no conflicts of interest.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

• Primary Source

  JAMA Surgery

  Source Reference: Arhuidese IJ, et al "Risks associated with primary and redo carotid endarterectomy in the endovascular era" JAMA Surg 2017; DOI: 10.1001/jamasurg.2017.4477.

• Secondary Source

  JAMA Surgery

  Source Reference: Roy RA and Upchurch GR "Outcomes in asymptomatic redo carotid endarterectomy: a word of caution" JAMA Surg 2017; DOI: 10.1001/jamasurg.2017.4492.