Predictors of neck bleeding after eversion carotid endarterectomy

IF: 3.851 ABSTRACT Objective To identify predictors for neck bleeding after eversion carotid endarterectomy (eCEA). Methods A prospectively compiled, computerized database of all primary eCEAs performed at a tertiary referral center between September 1998 and December 2009 was analyzed. The endpoint was represented by any neck bleeding after eCEA. Endpoint predictors were identified by univariate analysis. Results Out of 1458 eCEAs performed by the same surgeon on 1294 patients under general anesthesia with continuous electroencephalographic monitoring and selective shunting, there were 5 major and 3 minor perioperative strokes (0.5%), and no deaths. Neck bleeding after eCEA occurred in 120 cases (8.2%), 69 (4.7%) of which needed re-exploration. At univariate analysis preoperative antiplatelet treatment with clopidogrel (odds ratio [95% confidence interval] 1.77 [1.20-2.62], p = .004), particularly when continued up to the day before CEA (3.84 [2.01-7.33], p < .001), and postoperative hypertension (9.44 [6.34-14.06], p < .001) were identified as risk factors for neck bleeding in general and for neck bleeding requiring re-exploration (4.50 [1.85-10.89], p = .001; 15.27 [2.08-104.43], p = .006 and 2.44 [1.12-5.30], p = .02, respectively). An increased risk of neck bleeding in general was associated with clopidogrel plus aspirin (12.00 [2.59-56.78], p = .005), aspirin alone (4.37 [1.99-9.57], p < .001), and ticlopidine (2.49 [1.10-5.63], p = .02) only when they were continued up to the day before CEA. Preoperative dipyridamole or warfarin treatment or no medication were not associated with neck bleeding. No further complications occurred in the re-explored patients. Conclusions The results of this single center University hospital based study show that neck bleeding after CEA is relatively common, but it is not associated with an increased risk of stroke or death. Preoperative treatment with clopidogrel, particularly when it is continued up to the day before surgery, and postoperative arterial hypertension seem to be associated with a higher risk of neck bleeding after CEA, requiring re-exploration in most cases. Other antiplatelet agents appear to be associated with an increased risk of postoperative neck bleeding only if they are continued up to the day before CEA. Larger studies are warranted to confirm our findings and prevent this feared surgical complication.