Conservative management of residual and recurrent lesions after carotid endarterectomy: Long-term results

AbstractPurpose: To document the natural history of residual and recurrent carotid stenoses that are initially treated without surgery, and to identify risk factors for recurrent stenosis. Methods: Review of data from a prospective carotid database with clinical and duplex follow-up. Analysis of rate of restenosis and rate of late reoperation by life table. Risk factor analysis by χ2 and LEE-DESU statistics. Results: Three hundred forty-eight patients were available for follow-up, with 12 residual lesions (3.7%) and 22 recurrent lesions (6.6%). Rate of recurrent stenosis by life table analysis was 8.7% and 13% at 3 and 5 years. Restenosis was associated with smoking (p = 0.04) and contralateral progression. Only 21% of patients were underwent an operation within 5 years (p = 0.007) of restenosis developing, but eventually 10 of 22 patients required reoperation at long-term follow-up, eight for symptoms and two for progressive proximal stenoses. The late stroke rate was increased in patients who had residual or recurrent lesions compared with those who had normal duplex study results (18% vs 6%; p = 0.16) and was related to the ipsilateral artery. Conclusions: Recurrent lesions that remain asymptomatic can be managed without operation with likelihood of success in the near term (5 years). However, these patients are at increased risk of late stroke, and almost half will eventually require operation. Therefore, in good-risk patients operation for asymptomatic restenoses should be considered. (J Vasc Surg 1997;26:963-72.

Outcomes after endovascular intervention for chronic critical limb ischemia

ObjectiveThis study evaluated outcomes after endovascular intervention (EVI) for chronic critical limb ischemia (CLI) by Rutherford category (RC) 4, rest pain; and 5, tissue loss.MethodsThe medical records of all EVI performed for RC-4 to RC-5 by vascular surgeons at a single institution during a 3-year period were reviewed for sustained clinical success (SCS), defined as Rutherford improvement score (RIS) 2+, without target extremity revascularization (TER). The RC-5 group was evaluated for patency until healing and healing ≤4 months without recurrence or new ulceration. Secondary sustained clinical success (SSCS) was a RIS of 2+ with TER. The RC-5 group was evaluated for patency until healing and healing at any time during follow-up, without recurrent or new ulceration. Significance was established at the 0.05 level.ResultsOf 106 EVI performed for CLI, 78 (74%) were RC-5. There were 39 (37%) men. Mean age was 73 ± 12 years. Mean follow-up was 19 months (range, 1-44 months). RC-5 patients were significantly more likely than RC-4 to be diabetic (58% vs 32%; P = .020), dialysis dependent (14% vs 0%; P = .036), and to require distal EVI (53% vs 29%; P = .029). RC-4 patients were more likely to be current smokers (57% vs 32%; P = .023). At 24 months, survival was comparable, with RC-4 at 84% ± 8% vs RC-5 at 62% ± 7% (P = .09), but limb salvage was significantly better for RC-4 (100%) vs RC-5 (83% ± 4%; P = .026), as was SCS (48% vs 21%; P = .006) and SSCS (85% vs 39%; P < .001). Independent predictors of failed SSCS were diabetes (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.07-7.46; P = .036), congestive heart failure (CHF; OR, 3.62; 95% CI, 1.19-10.99; P = .023), and RC-5 (OR, 5.5; 95% CI, 2.4-30.3; P = .001). SSCS was 94% in RC-4 patients without diabetes mellitus (DM) or CHF and 10% in RC-5 with DM or CHF (P < .001) but improved to 67% in RC-5 when neither CHF nor DM were present (P = .004).ConclusionsRC-4 have fewer comorbidities, less advanced ischemia, and better outcome than RC-5. These groups should be evaluated individually. Limb salvage was acceptable, yet early wound healing without TER (SCS) occurred in only 21%. RC-5, DM, and CHF were predictors of poor SSCS. Careful selection of patients should improve outcome