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PubMed1985

Experimental arteriosclerosis treated by argon ion and neodymium-YAG laser endarterectomy.

The argon ion laser (488 and 514.5 nm) and the Nd-YAG laser (1.06 micron) have been used in most studies of laser radiation for treatment of arteriosclerotic cardiovascular disease because their beams can be directed through a delivery fiber. We compared the effects of argon ion and Nd-YAG lasers in vivo on arteriosclerotic rabbit aortas with open laser endarterectomy. A thoracoabdominal exploration was performed in 16 rabbits to isolate the aorta. Laser beams were directed through delivery fibers to produce a line of laser craters at the proximal and distal ends of an atheroma. The lines of laser craters were connected by continuous-wave laser radiation to loosen the plaque and the cleavage plane was developed within the media by continuous-wave laser radiation. End points were fused by continuous-wave laser radiation and the aortas were harvested for light and scanning electron microscopy. Argon ion laser endarterectomy (eight rabbits) required an energy density of 98 +/- 19 J/cm2. Nd-YAG laser endarterectomy (eight rabbits) required an energy density of 1147 +/- 129 J/cm2. Perforation did not occur with the argon ion laser but occurred in six of eight Nd-YAG experiments. Even depths of plaque removal resulted from argon ion laser endarterectomy but not from Nd-YAG laser endarterectomy. Gross and microscopic grading of the aortas showed that argon ion endarterectomy surfaces were significantly better than Nd-YAG surfaces (p less than .05). Similarly, argon ion end points were significantly better than Nd-YAG end points (p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1984

Intraoperative assessment of carotid endarterectomy.

The use of operative arteriography during carotid endarterectomy facilitates identification and correction of technical errors. Although arteriography is the standard for assessing surgical results, it prolongs the operation and may increase the overall risk. The purpose of this study was to evaluate pulsed Doppler spectral analysis and arteriography as methods of intraoperative assessment. Operative arteriography was performed in 150 consecutive carotid endarterectomies. In 50 of these cases a sterile 20 MHz pulsed Doppler probe and real-time spectrum analyzer were used to evaluate internal carotid velocity patterns before and after endarterectomy. Operative arteriograms were normal in 127 cases, whereas abnormalities were noted in 16 internal and seven external carotid arteries. Thirteen of the arteriographic defects were considered minor and accepted. Major defects requiring immediate repair occurred in eight (5%) internal and two external carotid arteries. In the 50 cases assessed by both techniques, seven internal carotid arteries had mild flow disturbances both before and after endarterectomy, whereas 38 of the remaining 43 arteries showed improvement in spectral characteristics after endarterectomy. In two patients who failed to show improvement on the initial postendarterectomy evaluation, operative arteriography demonstrated residual defects that required immediate repair. No other technical errors were encountered, and there were no perioperative deaths or neurologic complications in the 150 operations. Intraoperative assessment by pulsed Doppler spectral analysis is a safe, rapid, and accurate method for detecting technical errors during carotid endarterectomy. The high sensitivity of this method (no false negative assessments) makes it an ideal screening test to be used for selection of patients for operative arteriography. By indicating when a technical error is most likely, this approach precludes the need for routine operative arteriography.

Arterial Occlusive Diseases↗
PubMed1984

Noninvasive carotid artery evaluation following endarterectomy.

There has been recent interest in carotid restenosis following endarterectomy. To evaluate the significance of this complication, 2549 consecutive patients who were evaluated for suspected carotid artery occlusive disease by carotid phonoangiography, ocular plethysmography, and B-mode scanning techniques over a 21-month period were reviewed. Within this group a total of 155 patients had previously undergone a carotid endarterectomy. Of these, only four patients manifested clinically significant restenosis. In the majority of patients the carotid bifurcation was free of significant disease. The "carotid shelf" that represents the superior aspect of residual intimal plaque following endarterectomy could be clearly identified in the early postoperative period; however, it later blended to become less distinct. In a few instances, however, the amount of residual plaque at the lower extent of the endarterectomy was very prominent and remained so during follow-up studies, suggesting the possibility that this might represent a focus for future thrombosis. We conclude that noninvasive testing as used herein is an accurate method of assessing the carotid artery following endarterectomy. The accuracy of these techniques has been of such high degree that 16 carefully selected patients have subsequently undergone carotid endarterectomy without preoperative angiography.

Arterial Occlusive Diseases↗
PubMed1980

Effect of carotid endarterectomy on baroreflex sensitivity in man. Intraoperative studies.

In six patients subjected to carotid reconstructive surgery, the reflex effect on systemic pressure of unilateral carotid artery occlusion was studied before and after endarterectomy. Before endarterectomy, carotid occlusion lowered carotid sinus pressure by 45 mmHg evoking a reflex increase in systemic pressure of 12 mmHg. After endarterectomy the corresponding values were 34 mmHg and 19 mmHg. The closed loop gain of the carotid sinus reflex, calculated as the ratio of change in arterial pressure to change in carotid sinus pressure was therefore increased from 0,27 before endarterectomy to 0,56 after endarterectomy. It is concluded that carotid endarterectomy improves carotid sinus baroreflex sensitivity ant that the carotid sinus nerve should therefore be preserved whenever possible.

Blood Pressure↗
PubMed1982

The effect of carotid siphon stenosis on stroke rate, death, and relief of symptoms following elective carotid endarterectomy.

It has been suggested that carotid endarterectomy for carotid bifurcation disease may be contraindicated in the presence of carotid siphon lesions. This study was undertaken to assess any difference in stroke rate, mortality, or relief of symptoms in patients with and without such "tandem" lesions following elective carotid endarterectomy. Ninety-one bifurcation endarterectomies were performed in 79 patients. The patients were divided into two groups. Group I (44 patients, 47 endarterectomies) had carotid bifurcation stenosis only; group I (35 patients, 44 endarterectomies) had siphon stenosis plus bifurcation stenosis. All patients in both groups who were symptomatic before operation were relieved of their symptoms. In group I there were no intraoperative or perioperative strokes, four late strokes (8.7%), one operate death (2.1%), and no late deaths. Group II patients had two intraoperative strokes (4.5%), three perioperative strokes (6.8%), two late strokes (5.1%), four operative deaths (9.1%), and three late deaths (7.5%). Eighteen of the 35 patients in group II had a greater degree of carotid siphon stenosis than bifurcation stenosis. In this subgroup, there was one operative stroke (5.6%), only perioperative stroke (5.6%), one late stroke (5.9%), one postoperative death (5.6%), and one late death (5.6%). None of these differences were statistically significant. Relief of symptoms was the same in patients with and without tandem carotid lesions, and there was no significantly increased risk of stroke or death following bifurcation endarterectomy in patients with tandem carotid lesions.

Adult↗
PubMed1994

Division-endarterectomy-anastomosis of the internal carotid artery: a prospective randomized comparative study.

Saphenous vein patch angioplasty is reported to yield superior results for carotid endarterectomy. In order to evaluate an alternative technique, which leaves the saphenous vein intact for other possible graft purposes, 200 carotid endarterectomies were included in a prospective randomized comparative study. Patients were randomized to two statistically equivalent groups: one group underwent classical carotid endarterectomy through a longitudinal incision with saphenous vein patch angioplasty; the other had endarterectomy through an oblique division of the internal carotid followed by in situ anastomosis. Cross-clamping time was approximately 5min shorter with the division-endarterectomy-anastomosis technique. The overall perioperative (< 30 days) mortality rate was 2.5% and cumulative mortality-morbidity rate 8% in the patch group compared with 4% in the other (P > 0.05). There were significantly more cranial nerve injuries in the patch group, most of which were transient (P < 0.01). The mean follow-up was 365 days. The late mortality rate was 5.5%. There were no late permanent or fatal strokes, but 3% of patients sustained mild transient neurological events. Only three significant (> 60%) stenoses developed during follow-up, all within 9 months. Dilatation and disturbed flow were more pronounced in the patch group (P < 0.05). There were no statistically significant differences between both techniques on mortality, disabling neurological morbidity and recurrent stenosis. In conclusion, the results of the division-endarterectomy-anastomosis technique are equivalent to those with patch angioplasty, leaving the patient's venous capital intact.

Adult↗
PubMed1996

Technical results from the eversion technique of carotid endarterectomy.

A total of 167 carotid endarterectomies by the eversion technique were completed in 158 patients at a teaching hospital during the 6-year period ending July 1995. The average patient age was 66 years with a range of 39 to 89 years, and 99 (63%) were male. General anesthesia was employed routinely, and temporary indwelling shunts, were not used. Indications for endarterectomy included hemispheric transient ischemic attack (43), amaurosis fugax (20), stroke (41), and asymptomatic stenosis (63). Associated patient risk factors were not significantly different for men and women, and included diabetes mellitus (22%), tobacco abuse (72%), hypertension (69%), hypercholesterolemia (76%), cardiac disease (54%), and renal disease (21%). One (0.6%) permanent operative stroke and two (1%) 30-day hospital deaths occurred. Vascular laboratory follow-up was accomplished by duplex scanning with a documented sensitivity of 98 per cent in detecting a > or = 40 per cent stenosis. Eighty-nine per cent (148) of the 167 endarterectomies were tested at least once postoperatively. Overall laboratory follow-up averaged 17 months and ranged from one to 69 months. Residual stenosis, included perioperative thrombosis, occurred in 8 (5%) arteries. Recurrent stenosis was detected in four (2%) cases at 9, 24, 54, and 66 months after endarterectomy. Statistical analyses failed to implicate any specific patient risk factor, age, sex, or operative indication relevant to recurrent stenosis. Residual stenosis was correlated with younger patient age (P = 0.002), female gender (P = 0.12), and endarterectomy on the right side (P = 0.008). Carotid eversion endarterectomy appears to be a universally applicable, safe, and durable operative technique.

Adult↗
PubMed1996

Carotid endarterectomy in Oklahoma Medicare beneficiaries: patient characteristics and outcomes.

BACKGROUND AND OBJECTIVES: Ischemic stroke represents the third leading cause of death and the most common cause of permanent disability in the United States. Carotid endarterectomy has been widely utilized as a procedure to reduce the risk of stroke and represents the most commonly performed peripheral arterial surgery. This cooperative project was initiated to assess the appropriateness of carotid endarterectomies performed on Medicare beneficiaries and the postoperative outcomes (mortality and stroke) in these patients. METHODS: Retrospective review was performed on the inpatient medical records of 774 patients who underwent 813 carotid endarterectomy procedures in eight hospitals during calendar years 1993 and 1994. Medicare claims data were also analyzed for all carotid endarterectomies performed in Oklahoma during calendar years 1992 through 1995. RESULTS: A history of transient ischemic attack or stroke in the distribution of the operated carotid artery was documented in 57% of the cases. The majority of patients had preoperative ultrasound imaging of the carotid arteries and a preoperative angiogram was performed before 96% of the procedures. Accepted indications for the surgery were documented for 98% of the procedures. Stroke or death within 30 days of the date of the carotid endarterectomy occurred after 4.9% (0-8.8% by hospital) of the procedures. CONCLUSIONS: This project demonstrated considerable variation between hospitals in the outcomes of patients undergoing carotid endarterectomy and the potential for improved care of patients with regard to discharge planning, education, and use of anticoagulant or antiplatelet medications postoperatively.

Adult↗
PubMedDate not supplied

[Carotid endarterectomy using the classical technique and by eversion].

After a brief introduction on the history of the surgical treatment of carotid stenosis the authors illustrate both the classical endarterectomy and the eversion endarterectomy. The constant search for a technique which could be of easy execution and also reduce the risk of complication (especially late ones, such as restenosis), brought the authors to adopt the eversion endarterectomy with reimplantation of internal carotid artery. From 1990 through 1995, 1034 carotid endarterectomies were performed, of which 611 with eversion technique and 423 with others techniques. The average follow-up was 38 months. The eversion endarterectomy group had lower neurological morbidity and mortality rates, both early and late. Even more important, they had a lower incidence rate of hemodynamically relevant restenosis (0.37% in the eversion endarterectomy group vs 1.97% in the other group).

Adult↗
PubMed1998

Which asymptomatic patients should have carotid endarterectomy?

Carotid endarterectomy for asymptomatic very-high-grade stenosis has been shown to be of clear benefit when compared with best medical treatment in recent prospective randomized studies. However, the benefit of carotid endarterectomy in these trials has been less than most vascular surgeons predicted based on prior nonrandomized studies. Furthermore, vascular surgeons often see patients who do not fit the inclusion criteria for any of the prospective randomized trials and whose potential benefit from endarterectomy may be different from that observed in those trials. Medical comorbidities or other patient characteristics that suggest even small increases in risk for carotid endarterectomy may negate the marginal benefit of the procedure in asymptomatic patients. Potential benefit is also highly dependent on surgeon-specific and hospital-specific perioperative morbidity and mortality. This article addresses some of the factors that may alter the potential benefit of carotid endarterectomy and the implications with respect to recommendations for or against carotid endarterectomy in the individual patient.

Age Factors↗
PubMed1995

Neodymium:yttrium-aluminum-garnet laser fusion of endarterectomy flaps.

PURPOSE: This study evaluated the efficacy of neodymium:yttrium-aluminum-garnet laser welding of flaps in canine arteries and in securing the distal flap during human carotid endarterectomy. METHODS: Endarterectomy flaps were created in both common carotid and both common femoral arteries in 12 dogs. The flaps were repaired with either the neodymium:yttrium-aluminum-garnet laser or with 6-0 polypropylene sutures. The arteries were removed after duplex scanning at either 7 or 28 days. Eighteen high carotid endarterectomy flaps in 16 patients have been subsequently secured with the laser welding technique. RESULTS: Laser repairs (125 +/- 19 joule) of the canine arteries were completed more quickly than suture repairs (mean 25 seconds vs 135 seconds, respectively; p < 0.04). Duplex ultrasonography revealed no discernable differences between the two groups of arteries. Arteries studied at 7 days revealed three microscopic flaps (two suture, one laser), more subintimal fibroblastic proliferation in suture than laser-repaired carotid arteries (3: 1, p = 0.0530), and similar amounts of inflammation in suture- and laser-repaired arteries. Arteries studied at 28 days revealed one microscopic intimal flap (suture-repaired); equal fibroblastic and inflammatory responses in suture- and laser-repaired vessels; and no evidence of laser thermal injury. Eighteen carotid endarterectomy flaps have been successfully fused with no immediate or long-term complications in 16 patients (follow-up of 0 to 24 months). CONCLUSION: Laser fusion appears to be a safe and effective method for securing distal carotid endarterectomy flaps.

Animals↗
PubMed1991

Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.

BACKGROUND: Without strong evidence of benefit, the use of carotid endarterectomy for prophylaxis against stroke rose dramatically until the mid-1980s, then declined. Our investigation sought to determine whether carotid endarterectomy reduces the risk of stroke among patients with a recent adverse cerebrovascular event and ipsilateral carotid stenosis. METHODS: We conducted a randomized trial at 50 clinical centers throughout the United States and Canada, in patients in two predetermined strata based on the severity of carotid stenosis--30 to 69 percent and 70 to 99 percent. We report here the results in the 659 patients in the latter stratum, who had had a hemispheric or retinal transient ischemic attack or a nondisabling stroke within the 120 days before entry and had stenosis of 70 to 99 percent in the symptomatic carotid artery. All patients received optimal medical care, including antiplatelet therapy. Those assigned to surgical treatment underwent carotid endarterectomy performed by neurosurgeons or vascular surgeons. All patients were examined by neurologists 1, 3, 6, 9, and 12 months after entry and then every 4 months. End points were assessed by blinded, independent case review. No patient was lost to follow-up. RESULTS: Life-table estimates of the cumulative risk of any ipsilateral stroke at two years were 26 percent in the 331 medical patients and 9 percent in the 328 surgical patients--an absolute risk reduction (+/- SE) 17 +/- 3.5 percent (P less than 0.001). For a major or fatal ipsilateral stroke, the corresponding estimates were 13.1 percent and 2.5 percent--an absolute risk reduction of 10.6 +/- 2.6 percent (P less than 0.001). Carotid endarterectomy was still found to be beneficial when all strokes and deaths were included in the analysis (P less than 0.001). CONCLUSIONS: Carotid endarterectomy is highly beneficial to patients with recent hemispheric and retinal transient ischemic attacks or nondisabling strokes and ipsilateral high-grade stenosis (70 to 99 percent) of the internal carotid artery.

Aged↗
PubMed1980

Carotid artery disease, carotid endarterectomy, and behavior.

Thirty-five carotid endarterectomy patients and 17 peripheral vascular surgery controls were evaluated psychologically preoperatively and postoperatively. The endarterectomy sample was restricted to patients with transient ischemic attacks. Neuropsychological tests included measures of language, attention, memory, problem solving, and sensory and motor skills. Personality tests included measures of general psychopathology, with specific evaluation of anxiety and depression. Mean scores of the endarterectomy and control groups were not statistically significantly different preoperatively for any test. Postoperatively, only the endarterectomy group showed mean improvement on measures of memory and verbal fluency. Both groups showed improvement on several other neuropsychological measures, and in reduction in state anxiety and on another indicator of psychopathology. Endarterectomy patients whose cognition improved postoperatively were younger, better educated, and had lower admitting systolic blood pressure; they also tended to have a lesser incidence of generalized vascular disease.

Anxiety↗
PubMed1999

Perioperative strokes after 1001 consecutive carotid endarterectomy procedures without an electroencephalogram: incidence, mechanism, and recovery.

HYPOTHESIS: That alternative methods of cerebral protection, especially routine shunting of all patients undergoing general anesthesia or shunting on the basis of neurologic assessment with the patient awake under cervical plexus block, result in outcomes of carotid endarterectomy comparable with those reported using electroencephalographic monitoring. DESIGN: Retrospective review of cases from a vascular registry established in 1990. SETTING: Tertiary care center. PATIENTS: Consecutive sample of 1001 patients who underwent carotid endarterectomy. INTERVENTIONS: Carotid endarterectomy procedures were performed without electroencephalographic monitoring, using general anesthesia with routine shunting or using regional anesthesia. MAIN OUTCOME MEASURES: Overall stroke and mortality rates and cause and consequence of the postoperative strokes. RESULTS: There were 14 nonfatal strokes (1.4%) and 2 deaths (0.2%), for a combined stroke and death rate of 1.6%. Nine (64%) of the 14 strokes appeared to result from a technical error during the endarterectomy. Mild deficits were noted after 7 strokes (50%), with the remainder resulting in deficits that required inpatient rehabilitation. Twelve patients with strokes (86%) eventually returned home without need for assistance. CONCLUSIONS: Most postoperative strokes in this series were due to technical errors. Overall, even in patients with strokes initially requiring inpatient rehabilitation, there was good recovery of function. Low stroke and mortality rates can be achieved in carotid endarterectomy without the use of electroencephalographic monitoring.

Adult↗
PubMedDate not supplied

Indications, outcomes, and provider volumes for carotid endarterectomy.

CONTEXT: While trials have demonstrated that carotid endarterectomy is superior to best medical therapy, most recently among asymptomatic patients, uses and outcomes of the procedure in more representative settings have not been established. OBJECTIVES: To profile the use and outcomes of carotid endarterectomy in a representative sample of Ohio's Medicare beneficiaries and to examine the relationships between provider-specific procedural volumes and patient outcomes. DESIGN: Retrospective cohort using Medicare Provider Analysis and Review files supplemented by detailed reviews of medical records on a random sample of patients. SETTING: Ohio hospitals performing carotid endarterectomy. PATIENTS: A random sample of 678 charts of the 4120 non-health maintenance organization Medicare beneficiaries who underwent carotid endarterectomy between July 1, 1993, and June 30, 1994. MAIN OUTCOME MEASURES: Nonfatal stroke or death within 30 days of surgery. RESULTS: The reviewed patients were similar to all eligible patients in sociodemographic characteristics and 30-day mortality rates. Among the 678 patients, indications for surgery were asymptomatic carotid stenosis in 167 (24.6%), transient ischemic attack in 294 (43.4%), completed stroke in 62 (9.1%), and nonspecific symptoms in 155 (22.9%). Thirty-two patients (4.7%) died or suffered nonfatal strokes by 30 days postoperatively. In univariate analyses, rates varied by hospital volume (P=.004) but not surgeons' volume (P=.47), although power to detect this difference was limited. Patients at higher- and lower-volume hospitals had similar indications and distributions of comorbidities. In analyses controlling for indications, comorbid conditions, and surgeon's volume, being operated on in a higher-volume hospital conferred a 71% reduction in risk for 30-day stroke or death (odds ratio, 0.29; 95% confidence interval, 0.12-0.69; P=.006). CONCLUSIONS: Almost half (47.5%) of the carotid endarterectomies among Ohio's Medicare population are performed on persons who are asymptomatic or who have nonspecific symptoms. These results highlight the importance of identifying patients and providers having the most favorable outcome profiles. The higher rate of adverse outcomes observed in lower-volume hospitals deserves further investigation, as it does not appear to be due to differences in patient selection.

Aged↗
PubMed2000

Carotid endarterectomy for symptomatic carotid stenosis.

BACKGROUND: Severe narrowing (or stenosis) of the carotid artery is an important cause of stroke. Surgical removal of the atheromatous material from the inside of the carotid artery (endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. OBJECTIVES: This review seeks to summarize the evidence from randomized trials on the balance of risks and benefits of carotid endarterectomy in adults with symptomatic carotid stenosis. SEARCH STRATEGY: We searched the Cochrane Stroke Group's Specialized Register of trials (date last searched: March 1999), supplemented by electronic searches of several databases. SELECTION CRITERIA: Randomized controlled trials comparing 'best medical treatment plus carotid endarterectomy' with 'best medical therapy' in patients with carotid stenosis and a recent transient ischaemic attack or nondisabling ischaemic stroke in the territory of that artery. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected the studies and extracted the data. An intention to treat analysis was performed. MAIN RESULTS: Data on death or disabling stroke were available from two trials, which included 5950 patients: the North American Symptomatic Carotid Endarterectomy Trial (NASCET), and the European Carotid Surgery Trial (ECST). The two trials used different methods to measure stenosis, but a simple formula can be used to convert between the two methods. For patients with severe stenosis (ECST > 80% = NASCET > 70%), surgery reduced the relative risk of disabling stroke or death by 48% (95% confidence interval [CI] 27 - 73%). The number of patients needed to be operated on (number needed to treat [NNT]) to prevent one disabling stroke or death over 2 to 6 years follow-up was 15 (95% CI 10 - 31). For patients with less severe stenosis (ECST 70 - 79% = NASCET 50 - 69%), surgery reduced the relative risk of disabling stroke or death by 27% (95% CI 15 - 44%). The number of patients needed to be operated on to prevent one disabling stroke or death was 21 (95% CI 11 - 125). Patients with lesser degrees of stenosis were harmed by surgery. Surgery increased the risk of disabling stroke or death by 20% (95% CI 0 - 44%). The number of patients needed to be operated on to cause one disabling stroke or death was 45 (95% CI 22 - infinity). REVIEWER'S CONCLUSIONS: Carotid endarterectomy reduced the risk of disabling stroke or death for patients with stenosis exceeding ECST-measured 70% or NASCET-measured 50%. This result is generalizable only to surgically-fit patients operated on by surgeons with low complication rates (less than 6%).

Adult↗
PubMed1991

Carotid endarterectomy in Great Britain and Ireland: trends and current practice.

Of 309 questionnaires on carotid endarterectomy sent to all surgeons in Great Britain and Ireland who might use this technique, 298 (96 per cent) were returned. In all, 110 (37 per cent) of 298 surgeons performed at least one carotid endarterectomy in 1989; 67 performed less than 10 and 43 greater than 10. In total, these 110 surgeons performed 1417 operations in 1989, a situation that has changed little over 5 years since the previous survey. Transient ischaemic attack and minor stroke remain the main indications for carotid endarterectomy; the operation was hardly ever performed for asymptomatic stenosis. By 1989 almost all surgeons initially assessed prospective patients using a technique less invasive than conventional angiography; duplex scanning was used 'always' or 'sometimes' by 70 per cent of surgeons. While 72 per cent of surgeons in 1984 'always' required conventional angiograms before operation, by 1989 only 21 per cent did so, most now relying on less invasive techniques. During operation there was an increasing use of shunts, carotid sinus nerve blockade and patch closure of the arteriotomy. The overall number of carotid endarterectomies performed annually in Great Britain and Ireland has remained steady over the past 5 years and is relatively low for a population of 60 millions. An increase in the number of surgeons performing the operation is almost entirely accounted for by an increase in those performing less than 10 carotid endarterectomies per year.

Angiography, Digital Subtraction↗
PubMed1997

Late stroke in patients after carotid endarterectomy.

BACKGROUND: Some patients may be more predisposed to develop an ulceration of atherosclerotic plaque in the carotid artery, and emboli. These patients should be more at risk for a late stroke even after carotid endarterectomy than patients who are not. MATERIALS AND METHODS: Six-hundred thirty-eight patients had 750 carotid endarterectomies. Excised plaque specimens were examined for gross ulceration. The degree of stenosis was determined by duplex scan and/or angiography, and at operation. The median follow-up time was 3.6 years. The risk of a stroke occurring >30 days after carotid endarterectomy was calculated. Within 1 year, an endarterectomy of the contralateral artery was done in 77 patients (Subgroup) at a median time of 60 days. RESULTS: Late stroke occurred in 48 patients. Patients who had had ulcerated plaque had a stroke at a median time of 2.0 years, and patients who had had no ulcers had a stroke at a median time of 5.2 years (P < 0.025). The 14-year stroke-free curve was lower (P < 0.05) if there was plaque ulceration. In the Subgroup, plaque ulcers were found in 55 patients (71%) at the first endarterectomy and later in 46 of the 55 patients (84%) in the contralateral artery. No ulcers were found in 22 patients (29%) initially, but later 50% had ulcers in the contralateral artery. The risk of an ulcer in the contralateral artery was increased (P < 0. 005) in those patients who had ipsilateral carotid ulcers. CONCLUSIONS: Some patients appear to be predisposed for plaque ulceration and late stroke.

Aged↗