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Natural History of ≥60% Asymptomatic Carotid Stenosis in Patients With Contralateral Carotid Occlusion

AbuRahma, Ali F. MD*; Metz, Matthew J. MD*; Robinson, Patrick A. MD

doi: 10.1097/01.sla.0000089856.64262.66
Original Papers and Discussions
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Objective: Although the Asymptomatic Carotid Atherosclerosis Study (ACAS) reported that carotid endarterectomy (CEA) is beneficial for patients with asymptomatic ≥60% carotid stenosis (ACS), several other studies have reported mixed results. Our prospective study analyzed the natural history of ≥60% ACS in patients with contralateral carotid occlusion (CCO).

Patient Population and Methods: During a 10-year period, patients with 60-<70% ACS with CCO were entered into a protocol of clinical examination and duplex surveillance every 6 months. All patients underwent maximum medical therapy. Late CEAs were considered if lesions became symptomatic or progressed to ≥70% stenosis. A Kaplan-Meier lifetable analysis was performed to estimate the freedom from both ipsilateral strokes and all strokes.

Results: Eighty-two patients were enrolled with a mean follow-up of 59.5 months (range, 7–141 months). Late strokes were noted in 27 of 82 patients (33%); 19 (23%) were ipsilateral and 8 (10%) were contralateral (side of CCO). Late transient ischemic attacks (TIAs) were noted in 22 of 82 (27%, 7 ipsilateral and 15 contralateral). The combined neurologic event (TIA/stroke) rate was 60% (49 of 82, 32% ipsilateral and 28% contralateral). Kaplan-Meier lifetable analysis showed that the rates of freedom from ipsilateral strokes, all strokes, and progression to ≥70% stenosis at 1, 2, 3, 4, and 5 years were 94%, 90%, 85%, 80%, 73%; 94%, 89%, 84%, 77%, 67%; and 99%, 96%, 92%, 86%, and 82%, respectively. The ipsilateral stroke-free survival rates at l, 2, 3, 4, and 5 years were 94%, 88%, 78%, 70%, and 63%. Twenty-one late CEAs were performed with no perioperative stroke/deaths (5 for ipsilateral TIAs, 9 for ipsilateral strokes, and 7 for ≥70% ACS). Overall, 20 (24%, 11 with symptoms and 9 asymptomatic) progressed to ≥70% stenosis.

Conclusions: Patients with 60-<70% ACS and CCO with maximal medical therapy carry a higher incidence of ipsilateral strokes and all strokes than what was reported by the ACAS study; therefore, prophylactic CEA may be justified in these patients.

Eighty-two patients with 60-<70% asymptomatic carotid stenosis with contralateral carotid occlusion were enrolled into a protocol of clinical examination and duplex surveillance with a mean follow-up of 59.5 months. Late strokes were noted in 27 (33%); 19 (23%) were ipsilateral and 8 (10%) were contralateral. The Kaplan-Meier lifetable analysis showed that the freedom from ipsilateral strokes and all strokes at 1, 2, 3, 4, and 5 years was 94%, 90%, 85%, 80%, 73%; and 94%, 89%, 84%, 77%, and 67%, respectively. These stroke rates were higher than that reported by the Asymptomatic Carotid Atherosclerosis Study; therefore, prophylactic carotid endarterectomy may be justified in these patients.

From the *Department of Surgery, Robert C. Byrd Health Sciences Center, Of West Virginia University, Charleston Area Medical Center, Charleston, WV; and †Ridgefield, CT.

Presented at the 123rd Annual Meeting of the American Surgical Association, April 24–26, 2003, Washington, DC.

Reprints: Ali F. AbuRahma, MD, 3100 MacCorkle Ave., SE, Suite 603, Charleston, WV 25304. E-mail: Ali.aburahma@camc.org.

© 2003 Lippincott Williams & Wilkins, Inc.