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Introduction: Patients with internal carotid artery occlusion contralateral to a diseased carotid artery are at an increased risk of stroke. It is our practice to offer carotid intervention to symptomatic patients and patients with severe ipsilateral carotid stenosis and contralateral occlusion. Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are acceptable modes of therapy. Contralateral carotid occlusion has been suggested as an indication for CAS because of the theoretical advantages of reduced ischemic procedural time and the lack of need for a vascular shunt or the assistance of general anesthesia. However, CEA can also be done safely in this population and has been associated with a decreased procedural stroke rate. Thus, it is not clear if contralateral occlusion by itself is an appropriate indication to prefer CAS over CEA. Here we compare our institution’s perioperative and one-year follow up experience with both CEA and CAS for patients with severe carotid artery stenosis and contralateral internal carotid artery occlusion.
Methods: This is a retrospective review of our institution’s collective consecutive patient experience with CAS and CEA from 2/2007-7/2011. Choice of therapy was determined by operator preference among vascular surgery, cardiology, and interventional radiology, and the data collection was performed using our computerized patient record after approval from the Institutional Review Board. Patients were considered for review when treated for carotid artery stenosis with contralateral carotid occlusion.
Results: Out of a total of 713 patients treated for carotid artery stenosis during this time period, 60 had contralateral occlusion. 40 of these patients were treated with CAS, and 20 with CEA. The most common indication for CAS were prior neck surgery (18), contralateral carotid occlusion alone (9), and prior neck radiation (7). The average age was 69.8 (+/- 8.1) for CEA and 67.2 (+/-8.7) for CAS. There was a male bias in both groups (CEA 13/20; CAS 29/40; P=.56), and both groups had similar amount of symptomatic patients (CEA 10/20, CAS 19/40). Two patients died within 30 days in the CAS group (5%) and no deaths occurred within 30 days in the CEA group. No perioperative strokes or myocardial infarction occurred in either group. One transient ischemic attack occurred after CAS. At mean follow up of 28+/- 16 months (CEA) and 28+/-15 months (CAS) (range 1.5-48.5 months), 7 deaths occurred in the CAS group and two in the CEA group (17.5% vs. 10%, p=.7). There were no reoperations in the CEA group and one intervention in the CAS group for in-stent stenosis.
Conclusion: Although CEA and CAS can both be performed with good perioperative and midterm results, we find no reason to prefer CEA over CAS in patients whose only reason for consideration of CAS is contralateral occlusion.