REVI EW ARTI CLE
Cr it ica l a na lysis of indica t ions a nd out com e s of sur gica l t r e a t m e nt for
ca r ot id dise a se
Te lm o P. Bona m igoI; M á r cio L. Luca sI I
IAssociate professor, Vascular Surgery, Funda€•o Faculdade Federal de Ci‚ncias Mƒdicas de Porto
Alegre (FFFCMPA), Porto Alegre, RS, Brazil. Head, Vascular Surgery Service, Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil.
IIVascular surgeon, Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil.
Correspondence
J Vasc Bras. 2007;6(4):366-77.
ABSTRACT
Treatment of carotid disease has been in focus over the past years, especially with the advent of the endovascular technique, which supports use of carotid angioplasty and stenting (CAS) in “high-risk” patients for carotid endarterectomy (CAE). We analyzed current outcomes of the treatment for carotid disease using both techniques. Furthermore, we performed some comments based on data from the literature, particularly in high-risk patients. We conclude that, up to the present moment, there is no evidence and justification for large use of CAS in patients with carotid disease, even in high-risk patients, such as in octogenarians. However, we believe that CAS could be useful in the treatment of a small number of patients with carotid disease (less than 4%), such as those with hostile neck, previous cervical radiation and in some cases of high carotid stenosis. When performed using the required technical skills, CAE is still the best choice for patients with carotid disease.
Ke yw or ds: Carotid endarterectomy, carotid angioplasty/stenting.
RESUM O
nas situa€Šes de alto risco, tais como nos octogen‰rios. No entanto, acreditamos que a CAS possa ser um coadjuvante no tratamento de pequeno n‡mero de pacientes com les•o carot†dea (atƒ 4% dos casos), como na presen€a de pesco€o hostil, radioterapia prƒvia e alguns casos de estenose carot†dea alta. Quando realizada com os cuidados tƒcnicos necess‰rios, a ECA ainda continua a melhor op€•o terap‚utica aos doentes com les•o carot†dea.
Pa la vr a s- cha ve : Endarterectomia carot†dea, angioplastia carot†dea com st ent.
I nt r oduct ion
Carotid revascularization for the treatment of brain ischemia – a transposition from the internal to the external carotid artery – was performed for the first time in Argentina, in 1951, by Carrea et al. However, it was published only in 1955.1Although others had tried, it was De Bakey who
successfully performed the first carotid endarterectomy (CEA) in 1953. His seminal work, however, was only published in 1975.2A reason for great repercussion was the case reported by Eastcott et
al., who published what they believed to be the first case of brain revascularization – resection of the atheromatous segment followed by terminoterminal anastomosis of the common with the internal carotid artery, under moderate hypothermia, in 1954.3In the 1950's and 1960's, that
procedure was widely diffused, to the extent of reaching the 1970's with more than 100,000 annual procedures in the USA. That scenario made the American Society of Vascular Surgery hire an independent medical auditing led by the neurologist H. Barnett, who concluded that about 60% of carotid surgeries had questionable or inadequate indication. With the aim of defining indications and results of CEA, two studies were conducted, Nort h Am erican Sym pt om at ic Carot id Endart erect om y
Trial(NASCET) and European Carot id Surgery Trial (ECST), well consolidated trials that defined
indication of carotid procedures.4,5
After confirmation of good CEA outcomes in those studies, compared with the clinical treatment (patients submitted to control of risk factors and use of platelet antiaggregating agents), the number of surgeries grew again in the 1990's.
Over the past years, with the advent of the endovascular technique, carotid angioplasty and
st ent ing (CAS) has been increasingly indicated. The industrial complex has encouraged comparative
studies, with the aim of justifying use of this technique for the treatment of carotid disease,
especially in patients characterized as "high risk," in whom there might be a competitive advantage in favor of this new technique.
There already are eight studies comparing both techniques: LEICESTER, WALLSTENT, CAVATAS, LEXINGTON I and II, SAPPHIRE, EVA-3S and SPACE. However, so far there has been no evidence of CAS superiority over CEA.6-13
In Brazil, practice of carotid surgery has more than 40 years, and a survey has been published about indications and about who would indicate that procedure: neurologists, cardiologists or vascular surgeons.14Increased interest on this theme is shown by the publication of more than 10
papers in Jornal Vascular Brasileiro, and an issue has recently received two editorials: one of them justifying indication of the endovascular technique15and another basically performing a description
of comparative studies, with comments on both techniques by the author at the end of the paper.16
treatment of atherosclerotic carotid disease.
I ndica t ions of ca r ot id e nda r t e r e ct om y
It is worth stressing that CEA is a procedure that has been performed for more than 50 years. Therefore, there has been enough time to analyze its benefits and limitations in the short, medium and long term. It is likely that any other surgical procedure has been so much discussed and audited over the past years.
Indications for CEA were established by classical studies, such as NASCET, ECST and Vet erans
Affairs St udy (VA) in symptomatic patients and by the trials Execut ive Com m it t ee for t he
Asym pt om at ic Carot id At herosclerosis St udy(ACAS) and Asym pt om at ic Carot id Surgery Trial(ACST)
in asymptomatic patients.5,14,17-19 Global surgical risk of stroke and death was 5.5% in NASCET,
7.5% in ECST and 1.1% in VA,4,5,20whereas in ACAS and ACST it was 2.3 and 3.1%, respectively.
Considering the different criteria to measure the degree of stenosis by the studies NASCET and ESCT, the Carot id Endart erect om y Trialist s Collaborat ion (CETC) analyzed the results of the three main studies in symptomatic patients, showing a maximum benefit in symptomatic patients with stenosis between 70-99% (NNT = 6, meaning that only six patients submitted to surgery would be needed to avoid a negative outcome – stroke).19 In addition, certain groups of patients have a
greater benefit with CEA: males; presence of contralateral occlusion; aged over 75 years; hemispheric symptoms; irregular plaque; and associated intracranial disease.21
Many critics stress that such studies do not reliably illustrate CEA results in daily practice. In this context, it was demonstrated through the analysis of the American Medicare data that, from 1985 to 1996, rates of stroke and death were 3% in 61,273 procedures performed in 1985, and 1.6% in 108,275 procedures in 1996.22In that same study, the authors also demonstrated that stroke and
death rates were associated with number of procedures performed per surgeon – 1.9% for surgeons with more than 50 annual procedures and 2.5% for surgeons with less than 20 annual surgeries.
With regard to studies involving asymptomatic individuals, the ACAS demonstrated benefits of the surgery in male patients without significant comorbidities, with carotid stenosis equal or higher than 60%.17The ACST, published in 2004, basically demonstrated that CEA reduced risk of fatal stroke in
half, and both men and women were benefited by the surgery.19The clinical implications of those
two studies were stressed by Naylor, from England: "men with asymptomatic stenosis between 60-99% and with good clinical conditions and aged less than 75 years are benefited by prophylactic CEA, and such benefit is smaller in women."23
Next, situations considered as high risk are presented, in which choice between both procedures can be proposed based on data published over the past 10 years.
Re sidua l or r e cur r e nt st e nosis
Residual stenosis, although rare, characterizes a form of patient undertreatment, since the atheromatous plaque was not completely removed. The previous surgeon maintained a portion of the distal plaque, or performed a plaque dissection in superficial section, inadequate for the surgery objective, i.e., complete removal of the lesion. An example of that can be seen in Figure 1.
carot id art ery, perform ing endart erect om y wit h com plet e rem oval of residual plaque ( Figure 2) . The pat ient had good post operat ive course and is current ly wit h 5 years of follow- up and no lat e
com plicat ions.
layer, wit h m inim al pot ent ial of em bolizat ion. Diagnosis is generally perform ed by auscult at ion of carot id m urm ur and by color- flow Doppler ult rasound or angiographic t om ography. Surgical t reat m ent is rarely required, alt hough t his indicat ion has been exaggerat ed over t he past years.
Recurrent at herom at ous plaque usually has lat e present at ion ( usually aft er 5 years of surgery) . I t can be locat ed in t he area previously subm it t ed t o endart erect om y, in t he proxim al port ion of t he com m on carot id or in t he dist al port ion of art eriorrhaphy. This has been one of t he indicat ions for endovascular t reat m ent , but it should be considered t hat , in recurrent art eriorrhaphy lesion, surgical indicat ion can also be well support ed when perform ed by an experienced surgeon, since t he degree of t echnical dem and is higher.
Personally, in cases of recurrent st enosis due t o at herom at ous plaque, we use convent ional access, avoiding direct dissect ion of t he dist al port ion of t he int ernal carot id art ery, before obt aining cont rol of ret rograde flow using a Fogart y cat het er. That m aneuver allows us t o avoid exaggerat ed and m ore t raum at ic dissect ion in an area wit h fibrosis, which m akes t he procedure m ore difficult . I f t he lat e lesion is a st enosis of t he com m on carot id art ery ost ium , we can use proxim al endart erect om y using t he RI FI FI t echnique ( ret rograde endart erect om y using Vollm ar ring occluding t he com m on carot id art ery em ergence wit h a Fogart y cat het er) .2 4 I t dem ands m ore experience by surgeons. I n
t he last 250 cases we t reat ed, t hat t echnique was necessary in five pat ient s ( 2% ) , who had
proxim al com m on carot id art ery lesion. There were no deat hs or st rokes in t he perioperat ive period ( unpublished dat a) .
Pr e vious ce r vica l r a dia t ion
The lesion usually has a difficult access due t o diffuse fibrosis and longer ext ension, generat ing difficult ies in dissect ion and procedure perform ance. I t can cause a higher num ber of cranial nerve lesions. For som e aut hors, CEA out com es in pat ient s previously subm it t ed t o radiot herapy have been encouraging, such as inexist ent neurological m orbidit y perioperat ive m ort alit y rat es.2 5 , 2 6
However, CAS can be considered t he first opt ion, alt hough it s m edium- t erm out com es are not well known.
Pr e se nce of
k in k in g
in t he int e r na l ca r ot id a r t e r y
Exist ence of a hem odynam ically significant and sym pt om at ic kinking) , usually associat ed wit h at herom at ous plaque of t he proxim al int ernal carot id art ery, can require t reat m ent . I t s anat om ical charact erist ics m ay lim it endovascular t echnique. However, kinking can be correct ed using t he t echnique of endart erect om y wit h eversion, since t here is usually proxim al at herom at ous plaque and, aft er endart erect om y, reim plant at ion of t he int ernal carot id art ery at t he bifurcat ion level, wit h or wit hout resect ion of t he redundant art ery segm ent , has very good result s.2 7 , 2 8 Figure 3 shows a
D ist a l st e nosis
Presence of dist al st enosis of t he int ernal carot id art ery is not a com m on sit uat ion, and it can be det ect ed in less t han 5% of cases subm it t ed t o surgery.2 9 I t is being current ly indicat ed for
endovascular t reat m ent , since CEA result s in higher incidence of cranial nerve lesion.3 0 To avoid t hat
problem , we have used convent ional access and int ralum inal cont rol of reflux, using a Fogart y cat het er placed in dist al posit ion. Thus, t here are condit ions of a high dissect ion of t he plaque and it s consequent rem oval, wit h good out com e. Ot her surgical m aneuvers, such as sect ion of t he digast ric m uscle and m andibular subluxat ion, m ay also be needed.3 0 , 3 1
Old a ge
Pat ient s older t han 80 years have been suggest ed as risk fact or for t he convent ional t echnique, CAS being recom m ended in t hat sit uat ion.3 2 The lit erat ure, however, has dem onst rat ed t hat such
conduct is wrong, since exact ly t he opposit e has been observed. Many st udies have dem onst rat ed ext rem ely high st roke and deat h rat es, bet ween 9.2- 25% in t he endovascular t reat m ent in pat ient s older t han 80 years.3 3 - 3 5 This fact can be due t o several fact ors, such as presence of m ore ext ensive
at herosclerot ic lesions, wit h higher calcificat ion degree in t he bifurcat ion, associat ed wit h presence of ulcers and t hrom bi. There m ay also be proxim al ost ial st enoses, which m ake cat het er passage difficult , or ulcerat ed lesions at t he aort ic arch level, which facilit at e m obilizat ion of fragm ent of plaques or t hrom bi by passing cat het ers and devices used in carot id angioplast y.
As t o t he convent ional t echnique, since t he t reat m ent is direct , t he surgeon can adopt som e cares t hat are essent ial and t hat benefit t he pat ient . I f perform ed wit h excellent t echnique, it can avoid int ravascular m anipulat ion, result ing in st roke and deat h percent ages around 1.9- 4.8% , as shown in Table 1.3 6 - 3 9
I t can be concluded t hat , from t he pract ical perspect ive, in pat ient s aged 80 years or m ore, t he endovascular t reat m ent should be cont raindicat ed, since t he convent ional t reat m ent ( carot id endart erect om y) has bet t er short - and m edium - t erm out com es.
Cont r a la t e r a l occlusion
By analyzing NASCET dat a, it is possible t o observe som e causes t hat m ight have been im port ant for t he poor out com es in t his group of pat ient s. The sam ple of pat ient s wit h CLO was sm all ( n = 21) and t he neurological event s occurred in t he im m ediat e post operat ive period. This is usually due t o a t echnical problem m ore associat ed wit h t he surgeon, and not t o disease severit y. An int ralum inal
shunt was not used in t wo out of t hree pat ient s who progressed wit h st roke aft er t he surgery, which
could have been avoided if int raoperat ive brain prot ect ion had been used. We believe t hat use of
shunt is a crucial issue in carot id surgery, especially for pat ient s wit h CLO. Not using it because one
t hinks it is dangerous m ay charact erize a form of undert reat m ent . I n a recent ly published st udy, we used shunt in alm ost 90% of pat ient s wit h CLO. There was one st roke ( 1.6% ) and t hree deat hs, t wo of t hem due t o acut e m yocardial infarct ion ( AMI ) and anot her result ing from post operat ive st roke ( 4.9% ) . One of t he pat ient s who had a fat al AMI was subm it t ed t o associat ed m yocardial
revascularizat ion ( MR) .4 8 Sam son et al.,4 5 t hrough t he analysis of 27 art icles on carot id
endart erect om y in pat ient s wit h CLO, observed t hat occurrence of st roke in pat ient s in whom t he
shunt was not used ( 6.2% ) was pract ically t he double t han in pat ient s in whom t he device was
rout inely used ( 3% ) .
Anot her int erest ing aspect t o obt ain good out com es in pat ient s wit h CLO is m edical t eam
experience. Bonam igo et al.4 8 ident ified t hat , in st udies report ing less t han 50 pat ient s subm it t ed t o
surgery, m ort alit y and st roke rat es were 6.5 and 9.9% , respect ively, whereas in st udies report ing m ore t han 50 pat ient s, t hose rat es were 1.6 and 4.1% , respect ively.
Associa t e d m yoca r dia l r e va scula r iza t ion
Pat ient wit h carot id and coronary disease wit h indicat ion of MR have also been considered as high risk.5 0
Wit h t hose dat a, it is possible t o conclude t hat CEA associat ed wit h MR can be perform ed wit h adequat e result s if t he cardiologic st at us is reasonable and t he carot id lesion is significant and sym pt om at ic. I n except ional cases, such as MR due t o unst able angina or ext ensive coronary lesion associat ed wit h crit ical carot id lesion wit h CLO, it is obvious t hat t he percent age of st roke/ deat h/ AMI will be higher.
H igh - r isk pa t ie nt s for ca r ot id e nda r t e r e ct om y
Over t he past years, m any aut hors have indicat ed t he endovascular t reat m ent for pat ient s charact erized as high risk. The SAPPHI RE, published by Yadav et al. in 2004, was t he st udy t hat insist ed t he m ost in t hat , j ust ifying indicat ion of t he endovascular t reat m ent wit h 30- day st roke and deat h rat es of 4.8% , com pared wit h 9.8% rat es in t he surgical group ( p = 0.09) .1 1Opposed t o t hat
posit ion, Mozes et al.,5 6 at Mayo Clinic, published a series of 323 cases wit h pat ient s considered as high risk and, t herefore, suit able for endovascular t reat m ent as proposed by t he SAPPHI RE st udy. Mozes et al., using t he convent ional t echnique, had st roke and deat h rat es of only 1.4 and 0.3% , respect ively. The result s of t he surgical group in t he SAPPHI RE st udy and in ot her com parat ive st udies show a significant difference bet ween hist oric series of CEA and t he result s report ed by such com parat ive st udies, as shown in Table 4.5 7 - 5 9
I f one quest ioned t hat reference cent ers do not represent global experience, we could bring dat a from Medicare, published by Hsia et al., in which st roke/ deat h rat es were 3% in 1985 and 1.6% in 1996.2 2
Ot her aut hors published st udies about t he definit ion and conduct in high- risk pat ient s.6 0 - 6 2 Gasparis et al.6 0 defined high risk in t wo groups: physiological risk and anat om ic risk. I n t he form er, t hey included 80 pat ient s older t han 80 years, 11 wit h AMI over t he past 6 m ont hs, 16 wit h heart failure, chronic pulm onary occlusive disease and 13 wit h serum creat inine levels above 3 m g/ dL. I n
pat ient s wit h previous radiot herapy and 53 wit h dist al lesion.6 0 Those aut hors possibly published t he best st udy t o dem onst rat e t he m yst ificat ion creat ed wit h t he widespread use of t he " high risk" classificat ion. They were careful enough t o offer t he 560 low- risk pat ient s t he sam e cares provided t o t he group of 228 high- risk pat ient , nam ely pat ch in 86 and 84% of cases, int ernal shunt in 93 and 97% of cases and general anest hesia in 98% of cases. Thus, t hey had a very sim ilar st roke and deat h rat e, t hat is, 1.1% for t he low- risk group and 1.3% for t he so- called high- risk group.
I t can be concluded t hat t he high- risk fact or, as report ed and accept ed by m any, som et im es is m ore associat ed wit h how t he procedure is perform ed t han t o t he pat ient 's com orbidit y.
Lim it a t ions of t he e ndova scula r t e chnique
St udies aim ing at support ing indicat ion of endovascular t reat m ent are com parat ive, funded by t he indust ry wit h t he purpose of being approved by t he Food and Drug Adm inist rat ion ( FDA) for com m ercializat ion of devices in t he USA. Since t he FDA dem ands, at least , non inferiorit y t o t he result s obt ained wit h convent ional t echnique, it is easy t o underst and how t he st udy is designed and how pat ient s are select ed in t he surgical branch. They have dem onst rat ed surgical result s t hat are m uch different from what is observed in ot her reference services, as well as from t he result s of general experience wit h pat ient s at Medicare ( Table 5) .1 1 - 1 3 , 5 6 , 6 0 , 6 3
By act ing like t hat , t he st udies SAPPHI RE and SPACE showed very sim ilar result s, cert ainly due t o reasons explained above.1 1 , 1 3 The EVA- 3S st udy, funded by t he French Depart m ent of Healt h and
perform ed in universit y cent ers, showed ext rem ely favorable result s regarding endart erect om y ( 3.9% in t he CEA group and 9.6% in t he CAS group) , t he reason why t he et hics com m it t ee det erm ined it s suspension, since t he evidence had already been confirm ed.1 2
Anot her int erest ing aspect is ident ificat ion of select ion crit eria of pat ient s for CEA or CAS, proposed by Becquem in, a French surgeon experienced in bot h t echniques.6 4 I n Table 6, t here are 11
indicat ions for CEA and only t hree for CAS, showing t hat t he anat om ic aspect s is also a lim it ing fact or of using CAS. I f t his det ail is not considered crit ically, it is alm ost cert ain t hat m any
We believe it is im port ant t o include in t his t ext conclusions of a syst em at ic review recent ly perform ed by Biasi et al.6 5 Those aut hors published an im port ant review about indicat ions of CEA
and CAS, focusing on prevent ion of brain em bolizat ion. Aft er a long discussion of t his t hem e, based on t he analysis of classical st udies, such as NASCET, ECST and ACAS, and st udies com paring bot h t echniques, such as CaRESS,6 6 SAPPHI RE,1 1 SPACE,1 3 ARCHeR6 7 and EVA- 3S,1 2 concluded by list ing
10 recom m endat ions or com m ent s, as follows:
The prem ise t hat surgical risk is higher in pat ient s excluded from t he NASCET and ACAS st udy or adequat e for t he ARCHER st udy has not been confirm ed.
There is no accept ed crit erion t o definit ely ident ify high- risk pat ient s for CEA.
I ndicat ions of CAS as an alt ernat ive for CEA in high- risk pat ient s are quest ionable.
The definit ion of high- risk pat ient s should not be considered as reasonable t o abandon CEA in favor of CAS.
Due t o t he low risk associat ed wit h CEA, CAS should be rest rict ed t o st udies of records or t o random ized clinical t rials ( RCT) .
I f t here is a high- risk group, it is sm all and rest rict ed t o recurrent st enosis, host ile neck due t o radiot herapy and only corresponds t o 4% of series.
The series discussed in t his analysis show t hat high- risk pat ient s can be subm it t ed t o CEA wit h st roke rat es equivalent t o t hose observed in low- risk pat ient s. I t is unlikely t hat CAS offers any im provem ent in risk of st roke, com pared wit h CEA.
Much care should be given t o asym pt om at ic individuals wit h m ult iple risk fact ors, in whom a predict able long- t erm benefit by CEA can be m arkedly reduced by survival of only 5 years.
Pat ient s who are really high risk have short life expect ancy and are bet t er t reat ed wit hout int ervent ion.
The aut hors also st udied risk of brain em bolizat ion by bot h t echniques and concluded t hat risk of brain em bolizat ion using t he endovascular t echnique is eight t im es m ore frequent t han using carot id endart erect om y.6 5
That aspect had already been report ed by ot her aut hors.6 8 , 6 9 Occurrence of early dem ent ia was
report ed by Verm eer et al.7 0 Even brain infarct ions considered silent can be associat ed wit h a m aj or
cognit ive decline and dem ent ia, in t he follow- up of pat ient s subm it t ed t o endovascular t reat m ent .
Conclusion
CEA is a well est ablished procedure wit h good short- , m edium - and long- t erm out com es. I t is st ill t he predom inant indicat ion for m ost sit uat ions involving at herosclerot ic carot id disease, present ing good out com es, even in sit uat ions considered as high risk, as long as it is perform ed by an
experienced and well t rained surgeon. CAS m ay have a com plem ent ary role in t he t reat m ent of carot id disease, such as in cases of host ile neck due t o previous radiot herapy and recurrent st enosis of a very dist al lesion. Therefore, in our opinion, it is a procedure lim it ed t o a sm all num ber of pat ient s ( approxim at ely 4% of cases) .
This issue is st ill polem ical and obviously has m any int erpret at ions and crit icism s. A t horough discussion of t his t hem e, involving all relat ed aspect s ( et hical, m edical and econom ic) can and should be encouraged. The pat ient 's int erest should prevail and t he best t reat m ent m ust be provided. Finally, it is im port ant t o rem em ber t hat " light can result from a t horough and open debat e."
Re fe r e nce s
1. Carrea R, Molins M, Murphy G. Surgical t reat m ent of spont aneous t hrom bosis of t he int ernal carot id art ery in t he neck. Carot id- carot ideal anast om osis. Report of a case. Act a Neurol Lat inoam er. 1955: 1: 71- 8.
2. DeBakey ME. Successful carot id endart erect om y for cerebrovascular insufficiency. Ninet een- year follow- up. JAMA 1975; 233: 1083- 5.
3. East cot t HH, Pickering GW, Rob CG. Reconst ruct ion of int ernal carot id art ery in a pat ient wit h int erm it t ent at t acks of hem iplegia. Lancet . 1954; 267: 994- 6.
4. Beneficial effect of carot id endart erect om y in sym pt om at ic pat ient s wit h high grade st enosis. Nort h Am erican Sym pt om at ic Carot id Endart erect om y Trial Collaborat ors. N Engl J Med.
1991; 325: 445- 53.
6. Naylor AR, Bolia A, Abbot t RJ, et al. Random ized st udy of carot id angioplast y and st ent ing versus carot id endart erect om y: a st opped t rial. J Vasc Surg. 1998; 28: 326- 34.
7. Albert s MJ. Result s of a m ult icent er prospect ive random ized t rial of carot id art ery st ent ing versus carot id endart erect om y. St roke. 2001; 32: 325.
8. CAVATAS invest igat ors. Endovascular versus surgical t reat m ent in pat ient s wit h carot id st enosis in t he Carot id and Vert ebral Art ery Translum inal Angioplast y St udy ( CAVATAS) : a random ized t rial. Lancet . 2001; 357: 1729- 37.
9. Brooks WH, McClure RR, Jones MR, Colem an TC, Breat hit t L. Carot id angioplast y and st ent ing versus carot id endart erect om y: random ized t rial in a com m unit y hospit al. J Am Coll Cardiol. 2001; 38: 1589- 95.
10. Brooks WH, McClure RR, Jones MR, Colem an TC, Breat hit t L. Carot id angioplast y and st ent ing versus carot id endart erect om y for t reat m ent of asym pt om at ic carot id st enosis: a random ized t rial in a com m unit y hospit al. Neurosurgery. 2004; 54: 318- 24.
11. Yadav JS, Wholey MH, Kunt z RE, et al. Prot ect ed carot id- art ery st ent ing versus endart erect om y in high- risk pat ient s. N Engl J Med. 2004; 351: 1493- 501.
12. EVA- 3S I nvest igadors. Endart erect om y versus st ent ing in pat ient s wit h severe sym pt om at ic st enosis. N Engl J Med. 2006; 355: 1660- 71.
13. ACE Collaborat ive Group; Ringleb PA, Allenberg J, et al. 30 days result s from t he SPACE t rial of st ent - prot ect ed angioplast y versus carot id endart erect om y in sym pt om at ic pat ient s: a random ised non- inferiorit y t rial. The SPACE Collaborat ive Group. Lancet . 2006; 368: 1239- 47.
14. Bonam igo TP, Nienchenski A, Copal A. Cirurgia carot ídea no Brasil no ano de 1989. Relat o de est udo cooperat ivo. Rev Angiol Cir Vasc. 1992; 1: 146- 52.
15. Karakhanian W. Est enose de carót ida: por que defendo o t rat am ent o endovascular. J Vasc Bras. 2006; 5: 174- 6.
16. Pereira AH. Angioplast ia da carót ida versus endart erect om ia: o velho e o novo. J Vasc Bras. 2006; 5: 169- 73.
17. Execut ive Com m it t ee for t he Asym pt om at ic Carot id At herosclerosis St udy. Endart erect om y for asym pt om at ic carot id art ery st enosis. JAMA. 1995; 273: 1421- 8.
18. Halliday A, Manfield A, Masso J et al. The MRC Asym pt om at ic Carot id Surgery Trial ( ACST) . Prevent ion of disabling and fat al st rokes by succesful carot id endart erect om y in pat ient s wit hout recent neurologic sym pt ons: random ised cont rolled t rial. Lancet . 2004; 363: 1491- 502.
19. Rot hwell PM, Eliasziw M, Gut nikov AS, et al. Analysis of pooled dat a from t he random ised cont rolled t rials of endart erect om y for sym pt om at ic carot id st enosis. Lancet . 2003; 361: 107- 16.
20. Mayberg MR, Wilson SE, Yat su F, et al. Carot id endart erect om y and prevent ion of cerebral ischem ia in sym pt om at ic carot id st enosis. Vet erans Affairs Cooperat ive St udies Program 309 Trialist Group. JAMA. 1991; 266: 3289- 94.
22. Hsia DC, Moscoe LM, Krushat WM. Epidemiology of carotid endarterectomy among Medicare beneficiaries:1985-1996 Update. Stroke. 1998;29:346-50.
23. Naylor AR. An update of the randomized trials of interventions for symptomatic and asymptomatic carotid artery disease. J Vasc Endovasc Surg. 2006;13:111-20.
24. Vollmar J, Laubach K, Gruss JD. [The technique of thrombendarterectomy (spiral ring disobliteration)]. Bruns Beitr Klin Chir. 1969;217:678-90.
25. Hassen-Khodja R, Sala F, Declemy S, Lagrange J-L, Bouillane P-J, Batt M. Surgical management of atherosclerotic carotid artery stenosis after cervical radiation therapy. Ann Vasc Surg.
2000;14:608-11.
26. Kashyap VS, Moore WS, Quinones-Baldrich WJ. Carotid artery repair for radiation-associated atherosclerosis is a safe and durable procedure. J Vasc Surg. 1999;29:90-6.
27. Ballotta E, Thiene G, Baracchini C, et al. Surgical vs medical treatment for isolated internal carotid artery elongation with coiling or kinking in symptomatic patients: a prospective randomized clinical study. J Vasc Surg. 2005;42:838-46.
28. Grego F, Lepidi S, Cognolato D, Frigatti P, Morelli I, Deriu GP. Rationale of the surgical treatment of carotid kinking. J Cardiovasc Surg (Torino). 2003;44:79-85.
29. Hans SS, Shah S, Hans B. Carotid endarterectomy for high plaques. Am J Surg. 1989;157:431-4.
30. Frim DM, Padwa B, Buckley D, Crowell RM, Ogilvy CS. Mandibular subluxation as an adjunct to exposure of the distal internal carotid artery in endarterectomy surgery. Technical note. J
Neurosurg. 1995;83:926-8.
31. Simonian GT, Pappas PJ, Padberg FT Jr., et al. Mandibular subluxation for distal internal carotid exposure: technical considerations. J Vasc Surg. 1999;30:1116-20.
32. Roubin GS, New G, Iyer SS, et al. Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis. Circulation. 2001;103:532-7.
33. Chastain HD 2nd, Gomez CR, Iyer S, et al. Influence of age upon complications of carotid artery stenting. UAB Neurovascular Angioplasty Team. J Endovasc Surg. 1999;6:217-22.
34. Stanziale SF, Marone LK, Boules TN, et al. Carotid artery stenting in octogenarians is associated with increased adverse outcomes. J Vasc Surg. 2006;43:297-304.
35. Hobson RW 2nd, Howard VJ, Roubin GS, et al. Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase. J Vasc Surg. 2004;40:1106-11.
36. Perler BA, Williams GM. Carotid endarterectomy in the very elderly: is it worthwhile?Surgery. 1994;116:479-83.
37. Van Damme H, Lacroix H, Desiron Q, Nevelsteen A, Limet R, Suy R. Carotid surgery in octogenarians: is it worthwhile?Acta Chir Belg. 1996;96:71-7.
in octogenarians: early results and late outcome. J Vasc Surg. 1998;27:860-9.
39. Rockman CB, Jacobowitz GR, Adelman MA, et al. The Benefits of carotid endarterectomy in the octogenarian: a challenge to the results of carotid angioplasty and stenting. Ann Vasc Surg.
2003;17:9-14.
40. Mackey WC, O’Donell TF Jr, Callow AD. Carotid endarterectomy contralateral to an occluded carotid artery: perioperative risk and late results. J Vasc Surg. 1990;11:778-83.
41. Mattos MA, Barkmeier LD, Hodgson KJ, Ramsey DE, Sumner DS. Internal carotid artery
occlusion: operative risks and long term stroke after contralateral carotid endarterectomy. Surgery. 1992;112:670-9.
42. Meyer FB, Fode NC, Marsh WR, Piepgras DG. Carotid endarterectomy in patients with contralateral carotid occlusion. Mayo Clin Proc. 1993;68:337-42.
43. Deriu GP, Franceschi L, Milite D, et al. Carotid artery endarterectomy in patients with contralateral carotid artery occlusion: perioperative hazards and late results. Ann Vasc Surg. 1994;8:337-42.
44. Coyle KA, Smith RB 3rd, Salam AA, Dodson TF, Chaikof EL, Lumsden AB. Carotid
endareterectomy in patients with contralaeral carotid occlusion: review of a 10-year experience. Cardiovasc Surg. 1996;4:71-5.
45. Samson RH, Showalter DP, Yunis JP. Routine carotid endareterectomy without a shunt, even in presence of a contralateral occlusion. Cardiovasc Surg. 1998;6:475-84.
46. Pulli R, Dorigo W, Barbanti E, et al. Carotid endarterectomy with contralateral carotid artery occlusion: is this a higher risk subgroup?Eur J Vasc Endovasc Surg. 2002;24:63-8.
47. Rockman C, Su W, Lamparello PJ, et al. A reassessment of carotid endarterectomy in the face of contralateral occlusion: surgical results in symptomatic and asymptomatic patients. J Vasc Surg. 2002;36:668-73.
48. Bonamigo TP, Weber EL, Lucas ML, Bianco C, Cardozo MA. Carotid endarterectomy in patients with contralateral occlusion: a 10-year experience. J Vasc Bras. 2004;3:197-205.
49. Grego F, Antonello M, Lepidi S, et al. Is contralateral carotid artery occlusion a risk factor for carotid endarterectomy?Ann Vasc Surg. 2005;19:882-9.
50. Chiariello L, Tomai F, Zeitani J, Versaci F. Simultaneous hybrid revascularization by carotid stenting and coronary artery bypass grafting. Ann Thorac Surg. 2006;81:1883-5.
51. Lucas ML, Bonamigo TP, Weber EL, Lucchese F. [Combined carotid endarterectomy and coronary artery bypass grafting]. Analysis of the results. Arq Bras Cardiol. 2005;85:412-20.
52. Naylor R, Cuffe RL, Rothwell PM, Loftus IM, Bell PR. A systematic review of outcome following synchronous carotid and coronary artery bypass: influence of surgical and patients variables. Eur J Vasc Endovasc Surg. 2003;26:230-41.
53. Rizzo RJ, Whittemore AD, Couper GS, et al. Combined carotid and coronary revascularization: the preferred approach to the severe vasculopath. Ann Thorac Surg. 1992;54:1099-08.
influencing perioperative outcome and results. Eur Heart J. 2006;27:49-56.
55. Byrne J, Darling RC 3rd, Roddy SP, et al. Combined carotid endarterectomy and coronary artery bypass grafting in patients with asymptomatic high-grade stenoses: an analysis of 758 procedures. J Vasc Surg. 2006;44:67-72.
56. Mozes G, Sullivan TM, Torres-Russotto DR, et al. Carotid endarterctomy in SAPPHIRE-eligible high-risk patients: implications for selecting patients for carotid angioplasty and stenting. J Vasc Surg. 2004;39:958-65.
57. Sundt TM Jr., Ebersold MJ, Sharbrough FW, Piepgras DG, Marsh WR, Messick JM Jr. The risk-benefit ratio of intraoperative shunting during carotid endarterectomy. Relevancy to operative and postoperative results and complications. Ann Surg. 1986;203:196-204.
58. Riles TS. Surgical management of internal carotid artery stenosis: preventing complications. Can J Surg. 1994;37:124-7.
59. Hertzer NR, O’Hara PJ, Mascha EJ, Krajewski LP, Sullivan TM, Beven EG. Early outcome assessment for 2228 consecutive carotid endarterectomy procedures: the Cleveland Clinic experience from 1989 to 1995. J Vasc Surg. 1997;26:1-10.
60. Gasparis AP, Ricotta L, Cuadra SA, et al. High-risk carotid endarterectomy: fact or fiction. J Vasc Surg. 2003;37:40-6.
61. Reed AB, Gaccione P, Belkin M, et al. Preoperative risk factors for carotid endarterectomy: defining the patient at high-risk. J Vasc Surg. 2003;37:1191-9.
62. Pulli R, Dorigo W, Barbanti E, et al. Does the high-risk patient for carotid endarterectomy really exist?Am J Surg. 2005;189:714-9.
63. Ecker, RD, Pichelmann MA, Meissner I, Meyer FB. Durability of Carotid Endarterectomy. Stroke. 2003;34:2941-4.
64. Becquemin J-P. Endovascular treatment of carotid disease. In: Hallett JW Jr, Mills JL, Earnshaw JJ, Reekers JA, editors. Comprehensive vascular and endovascular surgery. Edinburgh: Mosby; 2004. Chapter 37.
65. Biasi GM, Froio A, Deleo G, Lavitrano M. Indication for carotid endarterectomy versus carotid stenting for the prevention of brain embolization from carotid artery plaques: in search of
consensus. J Endovasc Ther. 2006;13:578-91.
66. CaRESS Steering Committee. Carotid revascularization using endarterectomy or stenting systems (CaRESS) phase I clinical trial: 1-year results. J Vasc Surg. 2005;42:213-9.
67. Gray WA, Hopkins LN, Yadav S, et al. Protected carotid stenting in high-surgical-risk patients: the ARCHeR results. J Vasc Surg. 2006;44:258-69.
68. Jaeger HJ, Mathias KD, Hauth E, et al. Cerebral ischemia detected with diffusion-weighted MR imaging after stent implantation in the carotid artery. AJNR Am J Neuroradiol. 2002;23:200-7.
69. Schluter M, Tubler T, Steffens JC, et al. Focal ischemia of the brain after neuroprotected carotid artery stenting. J Am Coll Cardiol. 2003;42:1007-13.
and the risk of dementia and cognitive decline. N Engl J Med. 2003;348:1215-22.
Cor r e sponde nce :
Telmo P. Bonamigo
Rua Coronel Bordini, 675/304
CEP 90440-001 – Porto Alegre, RS, Brazil Email: telmobonamigo@terra.com.br
