Impact of Routine Completion Angiography on the Results of Primary Carotid Endarterectomy: A Prospective Study in a Teaching Hospital

AbstractObjectiveTo assess the usefulness of completion angiography in the prevention of stroke, carotid occlusion and residual stenosis after primary carotid endarterectomy (CEA) in the setting of a teaching hospital.Material and MethodsFrom January 1995 to August 2009, 1055 consecutive patients having 1179 CEAs were entered in a prospective study excluding patients with severe renal insufficiency, allergy to contrast media and patients with repeat CEA or carotid bypass. In this cohort, 552 patients (52.3%) were asymptomatic, 318 (30.2%) had a transient ischaemic attack (TIA) and 185 (17.5%) had a stroke. Routine completion angiography was obtained in all 1055 patients. The decision to perform a surgical revision was decided for any of the following defects: (1) a residual stenosis of more than 50% of the internal carotid artery (ICA) or common carotid artery (CCA) and of more than 70% of the external carotid artery (ECA), (2) any flap and (3) any intraluminal-filling defect. A postoperative duplex scan was obtained within a week after surgery and thereafter on a yearly basis. Median follow-up was 7 years.ResultsCEA was performed by a senior surgeon as first operator in 812 cases (69%) and by a trainee, with a scrubbed senior surgeon, in 367 cases (31%). Completion angiography revealed significant defects in 72 cases (6.1%) warranting revision for ECA flap (n = 30), thrombus in contact with the patch (n = 7), distal ICA flap or stenosis (n = 20) and CCA flap or residual plaque (n = 15).Logistic regression analysis showed that total length of the carotid plaque >6 cm (p = 0.02, Odds ratio: 2.31; 95% confidence interval (CI) (1.21–3.72)), eversion endarterectomy of the ECA (p = 0.01, Odds ratio 3.41; 95%CI (2.10–5.94)) and trainee as first operator (p = 0.02, Odds ratio 2.42; 95%CI (1.81–4.23)) were independent predictors of operative defects seen on completion angiography. No complication in relation to carotid catheterisation or injection of contrast media occurred in this series.The 30-day combined stroke and death rate was 1.5%, comparable between senior surgeons and trainees (p = 0.60). There was no significant difference in the combined stroke and death rate observed in patients with normal completion angiography (1.4%) compared with that of the patients with a defect corrected (2.8%) (p = 0.28, Odds ratio: 0.67; 95%CI (0.22–2.09)). But there was an increased incidence of postoperative TIA in the group with revision (p = 0.001, odds ratio: 5.8, 95%CI: 1.8–18.9).At 7 years, the freedom rate from >50% carotid restenosis or occlusion was 87.5 ± 6.7% in patients with normal completion angiography and 92 ± 5.4% in patients, who undergo a surgical revision.ConclusionIn a single centre, CEA with routine completion angiography resulted in good perioperative outcome. Plaque length, technique for external carotid artery (ECA) endarterectomy and trainee as first operator were independent predictors of operative defects seen on completion angiography