How to improve results in carotid surgery. Analysis of a 20-year case history of more than 7000 operations

BACKGROUND: In patients with carotid stenosis, whether symptomatic or asymptomatic, the use of technical measures to minimize peri- and postoperative complications is of paramount importance. The aim of the study was to evaluate retrospectively how and whether changes in surgical and anesthetic technique resulted in a significant change in clinical outcomes in our experience. METHODS: Over a 25-year period, 7124 consecutive carotid endarterectomies (CEAs) were performed, of which 3336 from 1996 to 2005 (group 1) and 3788 from 2006 to 2020 (group 2); the two groups were compared in terms of demographic characteristics, comorbidities and risk factors, anatomic-morphological characteristics, and surgical and anesthetic technique. Intraoperative and perioperative outcomes (stroke, death, 30-day IMA) were analyzed by x2 test and Fisher's Exact Test. RESULTS: Patients in group 1 were more frequently symptomatic than in group 2, where interventions were more frequently performed for preocclusive stenosis, in older patients and with more comorbidities. Considering the type of carotid artery reconstruction, patching was more frequent in group 2 (94% vs. 72% in group 1, P<0.001). In addition, the majority of the operations were performed under general anesthesia with a collaborating patient (Co.Pa.Ge.A) in group 2 (76%, P<0.001 compared to group 1) compared to pure general anesthesia, which is now only reserved for patients who are not compatible for clinical or technical reasons, resulting in a higher rate of shunt insertion based on critical changes in monitoring. The rate of intraoperative neurological events and neurological deficits on awakening was 0.8% in group 1 and 0.6% in group 2. The cumulative rate of stroke and death at 30 days was 1.5% in group 1 and 1% in group 2 (P=0.05). CONCLUSIONS: The technical and anesthesiological modifications introduced during the course of our group's experience resulted in a significant improvement in results in both asymptomatic and symptomatic patients. These results have been obtained even in the face of the need to operate on increasingly elderly patients, with much more significant comorbidities than in the early years of our experience and with increasingly marked characteristics of frailty.