Discussion

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Dr Ali AbuRahma (Charleston, WV). It was not clear to me how many of the female patients were patched; and for the ones who were not patched, did you notice any difference in the perioperative stroke rates?

Dr Walter Dorigo. Female patients underwent patching in more than 75% of the cases. And when we analyzed our results comparing the use of patch or no patch in female patients, we had similar perioperative outcomes between the two groups. The choice not to patch a female patient is made on the basis of anatomical criteria, diameter of internal carotid artery, and the presence of distal tortuosity and kinking, and in that case we use an eversion technique.

Dr AbuRahma. Did you measure the internal carotid artery (ICA) diameter in surgery, or did you compare males and females with the same size ICA?

Dr Dorigo. We don't routinely measure the internal carotid artery during intervention. We have been probably pushed toward an extensive use of patch in female patients due also to the data from the literature.

Dr Robert Zwolak (Lebanon, NH). This is a very large experience. Have your results actually changed how you and your partners choose your female patients?

Dr Dorigo. Not at the moment. But probably in the future we will be more cautious in treating some subgroups of patients. Probably an asymptomatic female patient with diabetes and contralateral occlusion could be better managed also with medical treatment. We're waiting for data of stenting in this subgroup.

Dr Firas Mussa (New York, NY). How many of those patients were symptomatic? And of those who were symptomatic, how many had acute neurological deficit?

Dr Dorigo. From this series, urgent interventions for acute neurological symptoms were excluded. Concerning the influence of preoperative symptoms, we analyzed the role of symptoms in female patients and we found that in symptomatic patients only contralateral occlusion affects the results, while in asymptomatic patients only diabetes. But again, you have to consider that female patients with contralateral occlusion are 45 patients out of 1,200, so the results are not conclusive.

Dr Kumud Rai (New Delhi, India). Your conclusion is based on only nine patients that you had, and out of which one died. I wouldn't read too much into it because the numbers are very small. To state that diabetes and contralateral occlusion are high-risk factors, based on just nine patients, to my mind is not a very valid observation.

Dr Dorigo. I agree with you. But you have to consider that the largest monocentric published series of carotid endarterectomies in female patients is that from the Cleveland Clinic, including 1,100 interventions and only a few numbers with contralateral occlusion. So I agree with you. But to have a larger number of patients we should have at least a double number of females and double number of males, so at least 10,000 interventions. And we are not able at the moment to provide these numbers.

Dr James DeBord (Peoria, Ill). Was there any difference in your patients who were on hormone replacement therapy versus those who were not?

Dr Dorigo. There are interesting papers also in the Journal concerning the effect of hormone replacement in females undergoing carotid endarterectomy, but we didn't have these data at the time of inclusion into the database.