CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 4, September/October 2023 238 AFRICA Control colour duplex sonography (CDS) of the carotid artery was carried out one month, six months and one year later. Our primary goal was 30-day morbidity and mortality, which is defined as any death or post-operative morbidity within 30 days of the treatment, as well as a percentage of carotid restenosis up to one year post-operatively. Indication for CEA was set after CDS of the carotid artery and multislice (MSCT) angiography of supra-aortic branches. Carotid stenosis was ascertained according to the European carotid surgery trial (ECST) criteria, as well as by means of the criteria described by AbuRahma et al.13 Carotid stenosis was defined as significant (> 70% constriction) if systolic velocity was > 150 cm/s and diastolic velocity > 90 cm/s. Peri-operative neurological morbidity was classified as TIA lasting less than 24 hours or permanent stroke (deficiency present on discharge). An adverse post-operative cardiac event has been designated as a post-operative MI and congestive heart failure (CHF). Post-operative restenosis was defined as ultrasound-verified stenosis of the carotid artery on the operated side as larger than 50%. Patients with a history of disease of the coronary artery underwent stress tests and, in some cases, coronarography. Peripheral vascular disease was proven by means of CDS of the lower extremities and, if deemed necessary, using angiography. For evaluation of pre-operative neurological disorders, as well as post-operative neurological condition, a modified scale of Rankin scores was used, with a neurological damage estimate ranging from 0 to 5.14 The patients were operated on under general endotracheal anaesthesia. The CEA eversion technique was applied on all patients. All patients with post-operative complications underwent a computed tomography (CT) of the endocranium post-operatively. Statistical analysis The testing of statistical hypotheses made use of the t-test for two independent samples, Mann–Whitney test, chi-squared test and Fisher’s test of accurate probability. Logistic regression was used for analysing the relationship between binary outcomes and potential predictors. Statistical hypotheses were tested at the level of statistical significance (alpha level) of 0.05. Results The main characteristics are shown in Table 1. Group A (37.7%) consisted of 279 diabetic patients and group B (62.3%) comprised 461 non-diabetic subjects. Except for a slightly higher prevalence of dyslipidaemia in patients with diabetes (χ2 = 5.330; p = 0.021), patients with DM had more frequent coronary artery disease (χ2 = 15.090; p < 0.001) and more persistent peripheral arterial disease (χ2 = 20.607; p < 0.001). Other pre-operative characteristics for the two groups were similar and comparable. Post-operative complications are shown in Table 2. Neurological events (TIA) among patients with diabetes were 3.6% and among non-diabetics (0.9%) (p = 0.009). Post-operative CVI occurred in 1.3% of patients without diabetes and in 3.2% of patients with diabetes (χ2 = 3.241; p = 0.072). Cumulative neurological events TIA/cerebrovascular infarction were also statistically more numerous in the diabetic group (p = 0.02). Adverse post-operative cardiac events (MI, CHF) occurred in 3.6% of patients with diabetes and in 1.1% of non-diabetic patients (Fisher’s test of accurate probability; p = 0.039). Haematoma of the surgical wound occurred in 11 patients (2.4%) without DM and in 10 patients (3.6%) with DM, which was statistically significantly different (χ2 = 0.905; p = 0.341). Infection of the operated wound in our study was present in 1.8% of patients with DM, while none of the patients without DM had wound infection, which was statistically significant (Fisher’s test of accurate probability; p = 0.007). We observed that 0.9% of non-DM patients and 0.7% of DM patients had symptoms of cranial nerve lesions, which was statistically insignificant (Fisher’s test of accurate probability; p = 1.000). Post-operative restenosis occurred in 2.2% of patients without DM and in 1.8% of those with DM. The total rate of complications, shown in Table 3, was within the recommended limits. With regard to the rates of mortality and total morbidity, the two groups differed considerably from one another. Operative and post-operative mortality (neurological and cardiological) was 2.5% in the diabetic group (four cardiac events and three cerebrovascular infarctions) and 0.9% in the non-diabetic group (three MIs and one cerebrovascular infarction) (p = 0.113). The patients with DM had statistically significantly higher total mortality rates. Total post-operative complications were observed in 8.5% of patients without DM and in 18.3% of patients with DM (χ2 = 15.688; p < 0.001). Post-operative complications occurred in DM patients considerably more frequently (two or more times). Table 1. Pre-operative characteristics of diabetics and non-diabetics Characteristics Group A: diabetics 279 (37.7%) Group B: non-diabetics 461 (62.3%) p-value Average age 67.5 ± 7.2 66.8 ± 7.5 NS Male, n (%) 165 (59.1) 278 (60.3) NS Female, n (%) 114 (40.9) 183 (39.7) NS Smoking, n (%) 169 (95.7) 257 (92.4) NS Hypertension, n (%) 267 (61.3) 426 (64.4) NS Dyslipidaemia, n (%) 265 (95.0) 416 (90.2) 0.021 Concomitant coronary disease, n (%) 89 (31.9) 89 (19.3) < 0.001 Concomitant peripheral disease, n (%) 70 (25.1) 56 (12.1) < 0.001 Previous MI, n (%) 38 (13.6) 30 (6.5) 0.001 Previous TIA, n (%) 10 (3.6) 4 (0.9) NS Previous CVI, n (%) 9 (3.2) 6 (1.3) NS Positive CT of endocranium 12 (4.66) 10 (2.17) NS MI, myocardial infarction; TIA, transient ischaemic attack; CVI, cerebrovascular incident. Table 2. Post-operative complications in diabetics and non-diabetics after CEA Characteristics Group A: diabetics Group B: non-diabetics p-value Post-operative TIA, n (%) 10 (3.6) 4 (0.9) 0.009 Post-operative CVI, n (%) 9 (3.2) 6 (1.3) 0.072 CT ischaemic brain lesion, n (%) 11 (3.94) 8 (1.74) 0.424 Cranial nerves lesion, n (%) 2 (0.7) 4 (0.9) NS Myocardial infarction, n (%) 2 (0.7) 1 (0.2) 0.300 Congestive heart failure, n (%) 8 (2.9) 4 (0.9) 0.039 Post-operative respiratory complications, n (%) 8 (2.9) 3 (0.7) 0.024 Haematoma of operated wound, n (%) 10 (3.9) 11 (2.4) 0.341 Infection of operated wound, n (%) 5 (1.8) 0 (0.0) 0.007 Post-operative 50% restenosis, n (%) 5 (1.8) 10 (2.2) 0.724 TIA, transient ischaemic attack; CVI, cerebrovascular incident.
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