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J Golledge

Publications and source records attributed to J Golledge.

At least 37 records · Page 2Linked to original sources
PubMed2000

Systematic comparison of the early outcome of angioplasty and endarterectomy for symptomatic carotid artery disease.

BACKGROUND AND PURPOSE: Endoluminal treatment is being increasingly used for carotid artery disease. The aim of this study was to compare the stroke and death risk within 30 days of endovascular treatment or endarterectomy for symptomatic carotid artery disease. METHODS: systematic comparison of the 30-day outcome of angioplasty with or without stenting and endarterectomy for symptomatic carotid artery disease reported in single-center studies, published since 1990, was performed. RESULTS: Thirty-three studies (13 angioplasty and 20 carotid endarterectomy) were included in this analysis. Carotid stents were deployed in 44% of angioplasty patients. Mortality within 30 days of angioplasty was 0.8% compared with 1.2% after endarterectomy (OR 0.68, 95% CI 0.43 to 1.05; P=0.6). The stroke rate was 7.1% for angioplasty and 3.3% for endarterectomy (OR 2.22, CI 1.62 to 3.04; P<0.001), while the risk of fatal or disabling stroke was 3.2% and 1.6%, respectively (OR 2.09, CI 1.3 to 3.33; P<0.01). The risk of stroke or death was 7.8% for angioplasty and 4% for endarterectomy (OR 2.02, CI 1.49 to 2.75; P<0.001), while disabling stroke or death was 3.9% after angioplasty and 2.2% after endarterectomy (OR 1.86, CI 1.22 to 2.84; P<0.01). CONCLUSIONS: In the treatment of symptomatic carotid artery disease, the risk of stroke is significantly greater with angioplasty than carotid endarterectomy. At present, carotid angioplasty is not recommended for the majority of patients with symptomatic carotid artery disease.

Angioplasty, Balloon↗
PubMed1999

Arterial flow conditions downregulate thrombomodulin on saphenous vein endothelium.

BACKGROUND: The antithrombogenic properties of venous endothelium may be attenuated when vein is implanted in the arterial circulation. Such changes may facilitate thrombosis, which is the final common pathway for saphenous vein arterial bypass graft occlusion. METHODS AND RESULTS: Using human saphenous vein in a validated ex vivo flow circuit, we investigated (1) the possibility that arterial flow conditions (mean pressure, 100 mm Hg, 90 cpm, approximately 200 mL/min) alter the concentration of proteins involved in regulating thrombosis at the vessel wall and (2) the influence of ion channel blockade on such effects. Concentrations of thrombomodulin and tissue factor were quantified by Western blotting (ratio of von Willebrand factor staining) and immunohistochemistry (as a percentage of CD31-staining area). Thrombomodulin concentrations after 90 minutes of venous and arterial flow conditions were quantified by immunostaining (68.9+/-4.8% and 41.0+/-3.0% CD31, respectively; P<0.01) and by Western blotting (1.35+/-0.20 and 0. 15+/-0.03 ratio of von Willebrand factor, respectively; P<0.01). The ability of endothelial cells to generate activated protein C also decreased from 62+/-14 to 19+/-10 ng. min-1. 1000 cells-1 (P=0.01). The significant reduction in thrombomodulin was attenuated if calcium was removed from the perfusate but not by external vein stenting. Inclusion in the vein perfusate of drugs that reduce calcium entry (including Gd3+, to block stretch-activated ion channels, and nifedipine) abolished the reduction in thrombomodulin concentration observed after arterial flow conditions. In freshly excised vein, negligible concentrations of tissue factor were detected on the endothelium and concentrations did not increase after 90 minutes of arterial flow conditions, although the inclusion of nifedipine caused the immunostaining to increase from 3.0+/-0.4% to 8.5+/-0.7% CD31 (P<0.02). CONCLUSIONS: In saphenous vein endothelium exposed to arterial flow conditions, there is rapid downregulation of thrombomodulin, sufficient to limit protein C activation, by a calcium-dependent mechanism.

Calcimycin↗
PubMed1999

Selection of patients for carotid endarterectomy.

OBJECTIVE: The aim of this study was the definition of the duplex scan parameters that best select patients for carotid endarterectomy. METHODS: This study was set in a regional vascular unit. Duplex scanning and angiography were performed prospectively on 50 patients who were symptomatic (100 carotid bifurcation) to identify the most accurate and sensitive duplex scan criteria to identify an 80% to 99% stenosis according to the European Carotid Symptomatic Trial. With data from the European Carotid Symptomatic Trial, we estimated the effect of three different approaches used to select patients for carotid endarterectomy. The first approach was the selection of patients for carotid surgery on the basis of duplex scanning alone with the most accurate duplex scan criteria (approach I). The second approach was the selection of patients for carotid surgery on the basis of duplex scanning alone with a 100% sensitive duplex scan criteria (approach II). The third approach was the selection of patients for angiography with duplex scanning (100% sensitive criteria) and then the use of angiography to define which patients should undergo surgery (approach III). RESULTS: All three approaches appeared to have a similar potential in stroke reduction. However, approach I, which minimized the number of patients who underwent surgery (19% less than approach II) or invasive imaging (65% less than approach III), appeared to be the most appropriate. CONCLUSION: These data support the selection of patients for carotid endarterectomy on the basis of duplex scanning alone. The duplex scan criteria should be validated against angiography.

Aged↗
PubMed1999

Outcome of primary radiocephalic fistula for haemodialysis.

BACKGROUND: Patient characteristics may help select the most appropriate type of permanent vascular access for haemodialysis. The aim of this study was to assess the influence of patient-related variables on the outcome of radiocephalic fistulas. METHODS: Over 3 years 107 consecutive patients underwent formation of a radiocephalic fistula for permanent haemodialysis access. Patients receiving prosthetic, ulnar, brachial or secondary fistulas were excluded. Patients were followed prospectively until access failure, transplantation or death, or for a minimum of 6 months (median follow-up 24 months). RESULTS: Primary patency was 69 per cent at 12 months and 56 per cent at 24 months. Endovascular and surgical intervention led to limited improvement in secondary patency to 63 per cent at 24 months. Regression analysis showed that fistula failure was more common in women (P = 0.02), diabetics (P = 0.03) and young patients (P = 0.02). By life-table analysis, primary and secondary patency were significantly better (P = 0.01) for men and non-diabetics, while the outcome was similar for all age groups. CONCLUSION: One-third of radiocephalic fistulas fail irreversibly within 2 years. Failure is more likely in women and diabetic patients.

Aged↗
PubMed1999

Morphology of ruptured abdominal aortic aneurysms.

OBJECTIVES: it has been suspected that the position at which aneurysm rupture occurs would affect outcome. The aim of this prospective study was to relate the morphology of the ruptured abdominal aortic aneurysm (RAAA) to the clinical characteristics and outcome of the patient. DESIGN, PATIENTS AND METHODS: over a five-year period 46 patients with RAAAs (11 identified at operation and 35 at post-mortem (PM)) were examined to identify the number and site of aneurysm rupture, the characteristics of the aneurysm (site, shape, length, diameter and associated iliac aneurysm) and the presence and site of retroperitoneal or intraperitoneal haematoma. The patients were also assessed for a range of associated medical conditions. Univariate analysis was used to identify variables predicting the site of aneurysm rupture and survival following rupture. RESULTS: most aneurysm ruptures (73%) occurred in the middle third where the aneurysm diameter was greatest. Relatively few ruptures (13%) were in the left posterior quadrant of the aneurysm. A history of chronic lung disease (p =0.04) significantly predicted the quadrant of aneurysm rupture, while a history of carcinoma (p =0.02) predicted the level of rupture. Nine of the 46 (20%) patients survived. Survival was predicted by the transverse site of rupture (p =0.0004) and the absence of ischaemic heart disease (p =0.02). CONCLUSION: these data suggest that the site of aneurysm rupture, which may be in part predicted by the clinical characteristics of the patient, influences outcome.

Aged↗
PubMed1999

Outcome of femoropopliteal angioplasty.

OBJECTIVE: To assess prospectively the outcome of femoropopliteal angioplasty and investigate prognostic indicators of success. BACKGROUND: Percutaneous transluminal angioplasty is commonly used to treat symptomatic femoropopliteal stenoses or occlusions, but the durability of the procedure is uncertain. METHODS: Seventy-four consecutive patients treated by femoropopliteal angioplasty for intermittent claudication (43), rest pain (4), and tissue loss (27) were followed by assessment of symptoms, ankle-brachial pressure index (ABPI) to measure hemodynamic outcome, and duplex monitoring of velocity gradient at the angioplasty site to identify restenosis at 1 day and 3, 6, 9, and 12 months. Univariate comparisons, life table analysis, and backward stepwise regression were used to investigate factors predicting the symptomatic and hemodynamic outcome and restenosis. RESULTS: Technical success was obtained in 67 patients (91%); failure occurred in 7 patients. At 1 year, a successful symptomatic outcome was achieved in 35 patients (51%), hemodynamic success was achieved in 41 patients (58%), and restenosis developed in 39%. ABPI at 24 hours after angioplasty was the most significant variable predicting a symptomatic outcome, hemodynamic outcome, and restenosis at 12 months. Life table analysis demonstrated that in 24% of patients with a 24-hour ABPI > or =0.9, restenosis developed by 12 months, compared with 64% of patients with a 24-hour ABPI <0.9. CONCLUSION: Only half of the patients treated by femoropopliteal angioplasty had symptomatic improvement at 1 year, raising concern about the cost-benefit ratio of this procedure. Restoration of ABPI to >0.9 predicted a favorable outcome.

Angioplasty, Balloon↗
PubMed1999

Rapid changes in the coagulant proteins on saphenous vein endothelium in response to arterial flow.

Healthy endothelium provides a nonthrombogenic surface. In this study the authors investigated the effect of arterial flow on the saphenous vein endothelial expression of proteins controlling thrombosis. Human saphenous vein segments, freshly excised from patients, were placed in a validated in vitro circuit with flow conditions shown to simulate arterial or venous circulations. In separate experiments, placement of an external polytetrafluoroethylene (PTFE) stent was used to differentiate the effects of pulsatile wall deformation and shear stress, while addition of drugs to the vein perfusate allowed study of the role of ion channels in transducing the response of the vein to arterial flow. Endothelial concentrations of thrombomodulin, nitric oxide synthase, tissue factor, and tissue plasminogen activator were assessed by quantitative immunohistochemistry and Western blotting of endothelial cell lysates, in paired vein samples, in comparison to control proteins. Arterial flow conditions caused a rapid and significant reduction in the endothelial concentration of thrombomodulin: The immunostaining area decreased from 80.1 +/- 7.0 to 48.3 +/- 5.0 and 32.9 +/- 3.0% at 45 and 90 minutes respectively, p = 0.01. These findings were confirmed by Western blotting. The reduction in thrombomodulin concentration was unaffected by eliminating vein wall deformation by placement of an external PTFE stent or by including the K+ channel blocker tetraethylammonium (TEA) in the vein perfusate. In contrast, thrombomodulin concentrations remained high when blockers of stretch-activated cation and calcium channels were included in the vein perfusate. The endothelial concentration of nitric oxide synthase increased after 90 minutes of arterial flow and this change was abolished when TEA was included in the vein perfusate. Arterial flow induced rapid changes in saphenous vein antithrombotic proteins. Different cation channels mediated the flow-induced changes in thrombomodulin and nitric oxide synthase.

Blood Flow Velocity↗
PubMed1997

Circumferential deformation and shear stress induce differential responses in saphenous vein endothelium exposed to arterial flow.

Adaptation of saphenous vein to the hemodynamic stresses of the arterial circulation is critical to the maturation of vein bypass grafts. We have investigated early adaptive responses of venous endothelium by placing excised human saphenous vein in a bypass circuit with either venous or arterial flow conditions, using external stenting to resolve the effects of longitudinal (shear) from circumferential stress. Endothelial protein concentrations were assessed by immunostaining area (ratio of protein/CD31) and Western blotting of endothelial cell lysates (staining ratio protein/vWf). In both unstented and stented veins nitric oxide synthase increased after 90 min of arterial flow: twofold increase of immunostaining area (P = 0.001), four- to fivefold increase by Western blotting (P = 0.02), and increased A23187mediated maximum endothelium-dependent relaxation of vein rings (P = 0.01). In unstented veins, ICAM-1 concentration was increased after 45 min of arterial flow: twofold increase by immunostaining (P = 0.001) and Western blotting (P = 0.038), with maximum fibrinogen-mediated endothelium-dependent relaxation increasing from 55.9+/-4.9 to 97+/-2.1% (P = 0.01). In contrast, in unstented veins there was a threefold decrease of VCAM-1 and no change in P-selectin after arterial flow for 45 and 90 min, respectively. However, no changes in ICAM-1 and VCAM-1 were observed in stented veins. The flow-induced alterations in nitric oxide synthase, ICAM-1, and VCAM-1 were abolished when 3 mM tetraethylammonium ion (K+ channel blocker) was included in the vein perfusate. The very rapid changes in ICAM-1 and VCAM-1 expression are a response to circumferential stress, whereas the slower upregulation of nitric oxide synthase is a response to longitudinal (shear) stress. Similar changes could influence the adhesiveness of endothelium in newly implanted saphenous vein bypass grafts.

Arteries↗
PubMed1997

Duplex imaging findings predict stenosis after carotid endarterectomy.

PURPOSE: This study was performed to determine whether early duplex findings predicted restenosis after carotid endarterectomy. METHODS: One hundred ninety-two symptomatic patients who underwent carotid endarterectomy were studied with color duplex imaging at 1 day and 1 week after surgery to identify minor residual disease (causing < 50% stenosis), arterial kinking, and suture stricture, and to measure the external and luminal diameters of the carotid bulb and distal internal carotid artery. Patients were then observed prospectively with duplex surveillance for a median of 24 months to identify > 50% restenosis. RESULTS: Twenty-five stenoses > 50% of the operated carotid artery (13%) were identified, four at 1 day (residual) and 21 at a median follow-up of 6 months (restenosis). On multiple logistic regression analysis, > 50% restenosis was found to be associated with minor day-1 residual stenosis (p = 0.01) and with small luminal diameter of the distal internal carotid artery (p = 0.03) as measured 1 week after carotid endarterectomy. Life table analysis showed restenosis at 24 months to be more common for patients with below-median than patients with above-median carotid bulb external diameter (18% vs 5%, respectively; p = 0.01). CONCLUSIONS: Duplex scanning within a week of carotid endarterectomy identifies > 50% residual stenosis, in addition to minor residual 25% to 50% stenosis and small carotid dimensions, which are good predictors of > 50% restenosis at 6 months.

Adult↗
PubMed1997

Clinical follow-up rather than duplex surveillance after carotid endarterectomy.

PURPOSE: The value of duplex surveillance and the significance of contralateral carotid disease after endarterectomy have been assessed. METHODS: Three hundred five patients were observed prospectively after carotid endarterectomy for a median time of 36 months (range, 6 to 96 months), with duplex surveillance performed at 1 day; 1 week; 3, 6, 9, and 12 months; and then each year after endarterectomy. RESULTS: Thirty patients (10%) had ipsilateral symptoms (13 strokes, 17 transient ischemic attacks [TIAs]) at a median time of 6 months (range, 0 to 60 months). Life table analysis demonstrated that ipsilateral stroke was equally common for patients who had > or = 50% restenosis (3% at 36 months) and those who did not (6% at 36 months, p > 0.5). Twenty-three patients (8%) developed symptoms (stroke 5, TIA 14) attributable to the contralateral carotid artery at a median time of 9 months (range, 0 to 36 months) after endarterectomy. By life table analysis, 40% of patients with 70% to 99%, 6% with 50% to 69%, 1% with < 50% contralateral internal carotid stenosis, and 5% with contralateral carotid occlusion at the time of endarterectomy had a contralateral TIA in the 36 months after endarterectomy (p < 0.01). However, contralateral stroke was not significantly more common for patients with severe contralateral internal carotid stenosis demonstrated at the time of endarterectomy (< 50% stenosis, 0%; 50% to 69%, 3%; 70% to 99%, 7%; occlusion, 6% stroke rate at 36 months). Seven of the 32 patients who developed progression of contralateral disease had a TIA, compared with 11 of 227 patients who did not develop progression of contralateral disease (p < 0.01). None of the 12 patients who progressed from a < 70% to a 70% to 99% contralateral stenosis had a stroke. CONCLUSIONS: After carotid endarterectomy restenosis is rarely associated with symptoms; contralateral stroke is rare and is not associated with progressive internal carotid artery disease suitable for endarterectomy. This study has shown no benefit from long-term duplex surveillance after carotid endarterectomy. Selective clinical follow-up of patients who have high-grade contralateral stenoses would appear more appropriate.

Carotid Artery, Internal↗
PubMed1997

Quality of life assessment in vascular disease: towards a consensus.

OBJECTIVES: To review the assessment of quality of life in vascular disease, with particular reference to the Nottingham Health Profile and Medical Outcomes Study Short Form 36. DESIGN AND METHODS: A detailed literature search of relevant publications. Trans-national and trans-cultural convergence and validity of these scales were assessed. RESULTS: The Short Form 36 was found to be the most valid and reliable quality of life measure for use in an international vascular setting. CONCLUSION: In the absence of a specific dedicated vascular disease quality of life measure, the Medical Outcomes Study Short Form 36 should be used as a quality of life measure in the assessment of vascular disease in an international setting.

Humans↗
PubMed1997

Development of an in vitro model to study the response of saphenous vein endothelium to pulsatile arterial flow and circumferential deformation.

OBJECTIVES: To develop an in vitro model of human saphenous vein bypass to facilitate study of the early adaptive responses of venous endothelium to arterial flow conditions. DESIGN MATERIAL AND METHODS: Segments of human saphenous vein (with or without external polytetrafluoroethylene (PTFE) stents to limit circumferential and radial deformation) were mounted in a bypass circuit and subjected to pulsatile flow with oxygenated Krebs solution to simulate arterial or venous flow conditions for a period of 90 min. The viability of the vein was assessed by the tissue ATP concentration and vasomotor responses to phenylephrine, sodium nitroprusside and bradykinin (endothelium-dependent). Immunohistochemistry was used to assess both endothelial preservation (CD31) and the expression of proteins involved in leukocyte adhesion: E-selectin, P-selectin and ICAM-1. Freshly excised veins were used as controls. RESULTS: The concentration of ATP was 320 +/- 11 nmol/g in freshly excised vein (n = 8) and following exposure to the arterial flow circuit increased to 566 +/- 60 nmol/g (n = 8, paired t-test, p = 0.003) in unstented veins and to 421 +/- 49 nmol/g (n = 8, paired t-test, p = 0.002) in externally stented veins (with PTFE). Both endothelium-dependent and sodium nitroprusside-induced vasodilatation responses were preserved after veins were exposed to the arterial flow circuit, but the sensitivity to phenylephrine was increased: EC50 decreasing from 9 microM, p = 0.008. There was a 5-10% decrease in staining area for CD31 after veins, stented or unstented, were exposed to the arterial flow circuit. However, after exposure to the arterial flow circuit, the staining area ratio for ICAM-1/CD31, which remained unchanged in externally stented veins, increased two-fold in unstented veins, p > 0.01: there were no changes in the staining area ratio P-selectin/CD31 and no staining for E-selectin was observed. CONCLUSION: Vasomotor responses and tissue ATP concentration indicate that the viability of saphenous vein can be maintained for up to 90 min in an ex vivo flow circuit and the CD31 staining indicated endothelial preservation. This opens up the possibility of investigating the early changes in saphenous vein endothelium following exposure to arterial pressure, as at bypass surgery. First results suggest that there is rapid upregulation of the leukocyte adhesion molecule ICAM-1, which can be prevented by limiting the circumferential deformation of the vein with an external PTFE stent.

Adaptation, Physiological↗
PubMed1997

Dilatation of saphenous vein grafts by nitric oxide.

OBJECTIVES: To investigate firstly whether flow-dependent vasodilation is maintained in vein grafts, and secondly whether nitric oxide donors dilate vein grafts to improve the flow through graft stenoses. DESIGN, MATERIALS AND METHODS: The vasodilatation of mature patent vein grafts, in response to reactive hyperaemia and glyceryl trinitrate (GTN), was assessed by the change in external diameter using duplex ultrasonography. The severity (ratio of proximal systolic velocity, V1, to peak systolic velocity at the stenosis, V2, of vein graft stenoses was determined by duplex ultrasonography before and after 24 h of local application of GTN patches. RESULTS: In post-occlusion hyperaemia the diameter of patent distal vein grafts (n = 7) increased to a maximum of 112 +/- 1.9% of resting diameter after 2 min, p = 0.026. The diameter increased further to 117 +/- 2.5% of the resting value 5 min after oral GTN (n = 5), p = 0.007. The velocity ratio, V2/V1, through graft stenoses (n = 6) decreased by 20 +/- 5% after application of GTN patches, principally as a result of reduction in V2, mean difference 0.8, p = 0.15. The changes in response to GTN were more evident for proximal than distal vein graft stenoses. CONCLUSION: Flow-induced vasodilatation responses, which have been attributed to the endothelial release of nitric oxide, are maintained in patent vein grafts: the grafts dilate even further in response to GTN. The application of GTN patches close to a vein graft stenoses appears to reduce the velocity ratio through vein graft stenoses. GTN patches might be used to reduce the risk of graft occlusion when there is a delay between the detection and the treatment of haemodynamically significant graft stenoses.

Administration, Cutaneous↗
PubMed1997

Vein grafts: haemodynamic forces on the endothelium--a review.

OBJECTIVE: To review the mechanisms believed to be important in the development of vein graft stenosis, with particular attention placed on the adaptation of saphenous vein endothelium to a new haemodynamic environment. DESIGN AND METHODS: Discussion based on review of published research. RESULTS: The aetiology of vein graft stenosis remains to be established and appears to be multi-factorial. The increasing evidence for an important role of haemodynamic forces is discussed, particularly via the interaction of these force with the endothelium. CONCLUSION: Further understanding of the interaction between haemodynamic forces, blood constituents and the newly implanted vein graft is required. Use of in vitro models is contributing increasing knowledge to this area, but ultimately better non-invasive methods of assessing haemodynamic forces in vivo are required.

Animals↗
PubMed1997

Carotid plaque characteristics and presenting symptom.

BACKGROUND: The importance of identifying features of carotid artery disease, in addition to degree of stenosis, which predict subsequent stroke is becoming increasingly clear. This study assessed the relationship between carotid plaque characteristics and presenting symptoms. METHODS: Some 285 symptomatic (transient ischaemic attack (TIA) 127, amaurosis fugax 58, transient stroke 15, established stroke 55, progressive stroke 11, crescendo TIA 19) and 65 asymptomatic patients were studied with colour-flow duplex imaging. All patients had 60-99 per cent internal carotid stenosis. Carotid plaque morphology (classified according to Gray-Weale) and plaque surface features were assessed. RESULTS: Plaque types I and II were more common in symptomatic patients (83 per cent versus 44 per cent; P < 0.0001). Plaque surface was classified as smooth (34 per cent), irregular (44 per cent) or ulcerated (22 per cent). Ulceration was also more common in symptomatic patients (23 versus 14 per cent; P = 0.04). In symptomatic patients there was no association between presenting symptom and plaque morphology or surface features (P = 0.9 and P = 0.8 respectively). On multiple regression analysis plaque morphology did not distinguish between patients who presents with stroke without warning and other symptomatic patients (who had TIA, amaurosis fugax, crescendo TIA or stroke with warning). CONCLUSION: There was an association between echolucent type I and II carotid plaques and the presence of symptoms but not their type. Plaque morphology was not characteristic in a subgroup of patients who had stroke without warning. Further prospective study of plaque morphology in asymptomatic patients might help identify high-risk groups.

Adult↗
PubMed1996

Vasoactive effects of fibrinogen on saphenous vein.

Normal plasma fibrinogen concentrations are critical to haemostasis. Higher fibrinogen concentrations are associated with increasing risk of atherosclerotic disease and with graft stenosis and occlusion after saphenous vein bypass surgery. Vein graft stenosis is characterized by the localized proliferation of intimal smooth muscle cells, causing narrowing of the graft with increased risk of thrombotic occlusion. In rabbit arteries, fibrinopeptide B is reported to have both vasoconstrictor and mitogenic properties. We report here that fibrinopeptides had no vasoactive effects on saphenous vein rings; however, fibrinogen (0-2 microM) affected an endothelium-dependent relaxation, followed by recontraction at higher concentrations. The fibrinogen-mediated relaxation was inhibited by K+-channel blockers and antibodies to ICAM-1. Coupled signalling pathways for the synthesis of vasoactive mediators and mitogens could underlie the association between fibrinogen and the development of vein graft pathology.

Animals↗
PubMed1996

Influence of patient-related variables on the outcome of carotid endarterectomy.

PURPOSE: Variability in outcome after carotid endarterectomy is well recognized. This study examines the importance of patient-related factors in determining outcome. METHODS: Four hundred and sixty consecutive patients undergoing carotid endarterectomy for symptomatic severe (60% to 99%) internal carotid stenosis performed by one vascular surgeon have been studied prospectively. Patients were followed-up at 3, 6, 9, and 12 months and then yearly. Pre-, intra-, and perioperative details and follow-up information were entered on a database. RESULTS: Multiple logistic regression identified a number of factors significantly associated with death and stroke. A history of crescendo transient ischemic attacks (TIAs) (p = 0.003, p = 0.0002) and being female (p = 0.03, p = 0.0001) were associated with both perioperative death and stroke within 30 days of operation, respectively. Deaths between 1 and 36 months were associated with ischemic heart disease (p = 0.03) and diabetes (p = 0.04), whereas stroke was associated with small internal carotid diameter (p = 0.02). The importance of symptoms at presentation on outcome was further emphasized by life-table analysis. In 98% of patients with amaurosis fugax, only 67% of those with crescendo TIAs were alive at 18 months (p < 0.01). The survival of patients with amaurosis was significantly better than those with TIAs (p < 0.01), transient stroke (p < 0.01), and progressive, stroke (p < 0.05). Similarly, postoperative stroke was significantly more common for patients with crescendo TIAs than those with amaurosis (p < 0.01), established stroke (p < 0.05), and TIA (p < 0.05). Transient stroke was associated with a poor outcome, with only 66% of patients being alive in 36 months and 14% having suffered a stroke (p < 0.05 compared with established stroke). CONCLUSION: Presenting symptoms significantly predict outcome after carotid endarterectomy. This should be considered both in patient selection and comparison of patient series.

Carotid Artery, Internal↗