An outcome analysis of carotid endarterectomy: The incidence and natural history of recurrent stenosis

Purpose: This report identifies the incidence of recurrent carotid stenosis after carotid endarterectomy (CEA) and records the natural history of the disease process to gain further insight into its proper management. Methods: A prospective surveillance protocol with duplex imaging and velocity spectral analysis was used to detect recurrent stenosis (>50% diameter reduction) and to document the clinical outcomes of patients who underwent CEA. Between 1984 and 1993, 619 consecutive CEAs were performed in 587 patients. Results: Recurrent carotid stenosis developed in 48 CEA sites (7.8%) during a mean follow-up interval of 34 months (range, 2 to 118 months). Normal results on intraoperative assessment correlated with a 5.6% incidence of recurrent stenosis, compared with a 19% incidence when a residual hemodynamic abnormality was present (p < 0.0003). In the first year after surgery, there were no transient ischemic attacks, strokes, or carotid occlusions from recurrent stenosis, compared with a 27% morbidity rate in later follow-up (p < 0.01). Three patients with recurrent stenosis subsequently had occlusion at the CEA site, two of whom had severe ipsilateral strokes. Conclusions: The incidence of recurrent carotid stenosis is low. Patients are at significant risk for neurologic morbidity when a recurrent stenosis occludes. With a 0.3% incidence of late stroke resulting from carotid bifurcation disease, these data confirm that CEA does provide long-term protection from stroke.