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PubMed1994

Safety and durability of redo carotid endarterectomy for recurrent carotid artery stenosis.

We retrospectively reviewed the records of patients who underwent redo carotid endarterectomies during a 5-year period. Patients were followed by duplex ultrasound to assess late patency of the carotid artery. Reoperations for recurrent carotid stenosis were performed in 46 of 973 patients who had carotid endarterectomies (5%). Indications for surgery were hemispheric transient ischemic attacks (TIA) in 33 (72%) and asymptomatic greater than 80% stenosis in 13 (28%). Pathologic findings revealed that the cause of recurrence was myointimal hyperplasia in 11 patients (24%), with a mean recurrence interval of 12.8 postoperative months, and atherosclerosis in 35 (76%), with a mean recurrence interval of 84 postoperative months (P = 0.0002). Redo endarterectomy with patch angioplasty was used for reconstruction in 32 cases (70%), patch angioplasty alone in 11 (24%), and endarterectomy with primary closure in 3. There were 3 perioperative strokes (7%). Late follow-up (mean 30.9 months) revealed no strokes and 1 TIA. Of 40 patients, 34 (85%) were alive and stroke free. Although six late deaths occurred, none were stroke related. One patient (2%) had late significant second recurrent carotid stenosis. Redo carotid endarterectomy for symptomatic patients and asymptomatic high-grade stenosis is safe and durable.

Adult↗
PubMed1995

Cerebral microembolism during carotid endarterectomy.

BACKGROUND: This study was designed to assess the intraoperative risk of cerebral microembolism, as detected by transcranial Doppler ultrasonography, during carotid endarterectomy. PATIENTS AND METHODS: Thirty-six patients (37 procedures) with symptomatic (n = 35) or asymptomatic (n = 2) internal carotid artery origin stenosis(> 50%) were monitored continuously during carotid endarterectomy. Special instrumentation was used to detect high-intensity transient signals (HITS) in the middle cerebral artery on the carotid endarterectomy side. All HITS satisfied a priori established criteria. RESULTS: The incidence of carotid endarterectomies with formed-element HITS increased at clamp release (23/37, P < 0.001) and shunt opening (7/11, P = 0.014), and during wound closure (13/22, P< 0.005) and shunting (5/11, P = 0.046). HITS with air microbubble characteristics were detected at clamp release (22/37, P < 0.001) and shunt opening (5/11, P = 0.025). CONCLUSIONS: HITS do not occur randomly during carotid endarterectomy. Shunting, unclamping, and wound closure are high-risk periods.

Aged↗
PubMed1997

Management strategy for simultaneous carotid endarterectomy and coronary revascularization.

BACKGROUND: The occurrence of significant carotid artery disease in patients requiring coronary artery bypass grafting (CABG) results in a dilemma regarding the best surgical management. Our philosophy has been to perform simultaneous carotid endarterectomy and CABG. We reviewed the efficacy of this therapy in patients treated at a large community-based hospital. METHODS: During a 6-year period, from 1990 to 1996, 88 patients underwent simultaneous carotid endarterectomy and CABG. All patients underwent preoperative four-vessel arch arteriography and standard coronary angiography. The principal indications for combined procedures were the need for CABG and (1) symptomatic carotid artery disease; (2) internal carotid artery stenosis of 80% or more, with or without contralateral disease; or (3) an ulcerated, unstable internal carotid artery lesion, regardless of degree of stenosis. The average patient age was 68 years, and there was a 3:1 male-to-female predominance. All procedures were performed with the patients under general anesthesia. The carotid endarterectomy was performed first, and an intraluminal shunt was used in all patients. RESULTS: The average degree of stenosis on the operated side was 86.2%. An average of 3.6 coronary bypasses per patient were performed. Morbidity included four strokes (4.5%). There were no perioperative myocardial infarctions. There were three hospital deaths (3.4%). The combined permanent stroke and mortality rate was 6.8%. Univariate predictors of stroke were an elevated serum creatinine level, a pulmonary complication, and left main coronary artery disease. Univariate predictors of hospital death were stroke, an elevated serum creatinine level, peripheral vascular disease, and left main coronary artery disease. Multivariate predictors of a prolonged hospitalization were stroke, an elevated serum creatinine level, and a pulmonary complication. Eighty-five patients (96.6%) were discharged and alive at 30 days. CONCLUSIONS: In the context of the indications we used to select patients for simultaneous carotid endarterectomy and CABG, the combined permanent stroke and mortality rate was less than 7%. Our management strategy identified patients that were at increased surgical risk as a result of advanced carotid and coronary artery disease. In our practice, simultaneous carotid endarterectomy and CABG is the preferred surgical approach for these high-risk patients and results in a low in-hospital morbidity and mortality using a single anesthetic and hospitalization.

Aged↗
PubMed2000

Long-term results of simultaneous carotid endarterectomy and myocardial revascularization with cardiopulmonary bypass used for both procedures.

OBJECTIVE: Controversy continues about the treatment of patients with a concomitant occlusive disease of the coronary and carotid arteries. Our operative strategy in these patients is to do simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass with mild hypothermia. We report our experience with this kind of one-stage procedure and its retrospective long-term results. METHODS: From February 1985 to September 1998, 340 patients underwent simultaneous carotid endarterectomy and myocardial revascularization. The average age of the patients was 65.3 years; 45.6% were neurologically symptomatic, and 44.4% had bilateral carotid stenosis. The indication for carotid endarterectomy was lumen diameter reduction of more than 75%, angiographic signs of thrombogenic endovascular morphology, or both. Carotid endarterectomy was performed in conjunction with cardiopulmonary bypass with mild hypothermia, hemodilution, systemic heparinization, and controlled hemodynamics under pulsatile perfusion for additional cerebral protection. RESULTS: There were 16 perioperative neurologic complications (4.7%), 11 permanent deficits (3.2%), and 9 cardiac complications (2.6%). Early mortality was 2.6% (SE 0.8%): 2 patients had a stroke and 2 had a myocardial infarction. The 5-year survival was 78.9% (SE 2.6%), and freedom from ipsilateral stroke and cardiac event were 93.2% (SE 1.5%) and 87.5% (SE 2.1%), respectively. The predictor for early death was age over 70 years, and predictors for late death were age over 70 years, previous myocardial infarction, previous stroke, and bilateral carotid stenosis of greater than 90%. CONCLUSION: On the basis of our long-term results, we believe that simultaneous carotid endarterectomy and myocardial revascularization in conjunction with cardiopulmonary bypass is a method safe enough to prefer its routine use with acceptable low operative risk and satisfactory long-term morbidity.

Aged↗
PubMed1996

Acute platelet deposition after carotid endarterectomy in sheep: vein patch compared with gelatin-sealed Dacron and polytetrafluoroethylene patch closure.

PURPOSE: Patch angioplasty is commonly used to close the arteriotomy after carotid endarterectomy is performed. The purpose of this study was to determine whether any significant variations were present in platelet deposition for different patch sizes and materials. METHOD: The study measured 111-indium-labeled uptake in the sheep to compare thrombus deposition for three different patch materials: autologous vein, gelatin-sealed Dacron, and polytetrafluoroethylene and for 6- and 12-mm patch widths. Platelet uptake was measured on the patch itself and on the artery wall that was opposite to the patch and that had undergone endarterectomy. Scanning electron microscopy was used to confirm the localization of the labeled platelets on the patch and on the surface that had undergone endarterectomy. RESULTS: Although considerable variation was seen among animals, platelet accumulation was lowest in the vein patches compared with the prosthetic patches (p < 0.01), but the deposition on the gelatine-sealed Dacron was not significantly different from that on polytetrafluoroethylene patches. Platelet deposition on the artery wall that had undergone endarterectomy was considerably less than on the patch but was higher when a synthetic patch was used rather than a vein patch (p < 0.05). CONCLUSIONS: Acute thrombus deposition after carotid endarterectomy was considerably less for vein patch closure than for synthetic patches. A 6-mm patch width caused less thrombus deposition both on the patch itself and on the artery wall compared with a 12-mm patch, but the difference was proportional to the patch width.

Animals↗
PubMed1997

Diabetes mellitus: a risk factor for carotid endarterectomy?

PURPOSE: Symptomatic cerebrovascular disease is more common in patients who have diabetes mellitus than in the nondiabetic population, even when matched for associated risk factors. Although the safety and efficacy of carotid endarterectomy has been established by NASCET and ACAS, several small studies have noted an increased rate of perioperative neurologic morbidity in patients with diabetes. METHODS: Data for all patients who underwent carotid endarterectomy at a single institution from Jan. 1990 to Dec. 1995 were prospectively entered into a computerized vascular registry and form the basis of this report. RESULTS: Of 732 carotid endarterectomy procedures performed, 284 (39%) were performed in patients who had diabetes mellitus. Patients with diabetes and without diabetes were matched for clinical presentation (diabetic patients, 45% asymptomatic; nondiabetic patients, 43%) and internal carotid artery percent stenosis (86.6% +/- 10.6% vs 86.4% +/- 10.6%). Patients with diabetes were younger at presentation than patients without (68.8 +/- 8.5 years vs 70.9 +/- 8.5 years; p < 0.005) and were more likely to have a history of coronary artery disease (53% vs 45%; p = 0.04). The mean total length of stay was 6.1 days for patients with diabetes and 4.8 days among patients without (p = 0.01). An adverse postoperative cardiac event (myocardial infarction, congestive heart failure, or arrhythmia) occurred in nine patients with diabetes (3.2%) and in five nondiabetic patients (1.1%; p < 0.05). By logistic regression analysis, however, diabetes was not an independent risk factor for a postoperative cardiac event (p = 0.28). There were 11 perioperative neurologic events (eight cerebrovascular accidents, three transient ischemic attacks) during the entire period (1.5%), of which six were among diabetic patients (2.1%) and five among nondiabetic patients (1.1%; p = NS). Of the eight cerebrovascular accidents, three occurred in diabetic patients (1.0%) and five in nondiabetic patients (1.1%; p = NS). The total operative mortality rate was 0.3% (diabetic patients, 1 of 284, 0.35%; nondiabetic, 1 of 447, 0.2%). CONCLUSIONS: Patients with diabetes who undergo carotid endarterectomy are more likely to have coexisting cardiac disease, which may contribute to a higher incidence of postoperative cardiac morbidity. Diabetes mellitus alone, however, is not a risk factor for postoperative cardiac morbidity in patients who undergo carotid surgery. In addition, carotid endarterectomy may be safely performed in patients with diabetes with neurologic morbidity and mortality rates that are comparable with those of the nondiabetic population

Aged↗
PubMed1997

Carotid endarterectomy in women versus men: patient characteristics and outcomes.

PURPOSE: To examine and compare the results of carotid endarterectomy in women and men in a single-group experience. METHODS: A review of a consecutive series of 426 carotid endarterectomy procedures performed over an 11-year period. RESULTS: Women and men who underwent carotid endarterectomy were remarkably similar in nearly all characteristics except that women were less likely to have clinically overt coronary artery disease. Women were more likely than men to undergo patch closure of the carotid artery, but details of surgery and hospital stay were otherwise similar. A trend toward higher perioperative stroke risk in women was not significant, and late ipsilateral stroke risk was comparable in women and men. Women enjoyed a better late survival rate, presumably related to their lower prevalence of coronary artery disease. CONCLUSIONS: Women enjoyed similarly low risks of perioperative and late stroke and a better long-term survival rate when compared with men who underwent carotid endarterectomy. Further experience and longer follow-up in prospective randomized trials may provide more definitive information regarding the comparative efficacy of carotid endarterectomy in women and men, but our results suggest that absolute results are similar and excellent in both women and men.

Adult↗
PubMed1999

Refining the indications for carotid endarterectomy in patients with symptomatic carotid stenosis: A systematic review.

OBJECTIVE: The purpose of this study was to summarize the existing literature on the efficacy of carotid endarterectomy in patients with ipsilateral symptomatic carotid stenosis. METHODS: Database searching, relevance assessment, methodologic quality assessments, and data extraction were all performed in duplicate with prespecified criteria. RESULTS: Twenty-three publications were identified from the North American Symptomatic Carotid Endarterectomy Trial, the European Carotid Surgery Trial, and the Veterans Affairs Cooperative Studies Program. Stenosis was reported as measured in the North American Symptomatic Carotid Endarterectomy Trial. In patients with >70% stenosis, carotid endarterectomy was associated with a pooled relative risk reduction of 48% (95% confidence interval [CI], 27% to 73%) and an absolute risk reduction of 6.7% (95% CI, 3.2% to 10%) for the outcome of death or major disability from stroke. This translates into a number needed to treat of 15 (95% CI, 10 to 31). For patients with 50% to 69% stenosis, the benefit of surgery was less and the confidence intervals were wider. A relative risk reduction of 27% (95% CI, 5% to 44%), an absolute risk reduction of 4.7% (95% CI, 0.8% to 8.7%), and a number needed to treat of 21 (95% CI, 11 to 125) were observed in this group. The patients with the lowest degrees of stenosis (<50%) were harmed by the intervention (number needed to harm, 45). Increasing degree of stenosis, increasing age, male sex, the presence of other medical risk factors, and the presence of hemispheric rather than retinal antecedent events were factors that increased the benefits from surgery. CONCLUSION: Carotid endarterectomy reduced death or major disability from stroke in patients with >50% symptomatic stenosis. To maximize the benefits of surgery, careful preoperative risk assessment and the maintenance of low rates of major perioperative complications are mandatory.

Aged↗
PubMed2004

Carotid endarterectomy in patients with contralateral carotid occlusion.

Total occlusion of the contralateral internal carotid artery has often been considered to be a predictor of adverse neurologic outcomes following carotid endarterectomy of an ipsilateral carotid stenosis. Results from both the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study have suggested this to be true. However, each of these trials had relatively few patients with contralateral occlusion in the surgical arms of the studies. In contrast to these studies, there are multiple surgical series in the literature demonstrating excellent results of carotid endarterectomy in patients with contralateral total occlusion. Recently, advocates of carotid angioplasty and stenting have suggested that this technique may be preferable in patients with a contralateral occlusion because of the perceived poor outcomes with surgery. As carotid angioplasty and stenting becomes more popular, it is becoming even more crucial to better define those patients who are truly at increased risk following carotid endarterectomy; ultimately, this will help clinicians decide which patients may derive the most benefits from endovascular therapies. With these issues in mind, the purpose of this review is to examine results of carotid endarterectomy in patients with total occlusion of the contralateral carotid artery.

Aged↗
PubMed2003

Eversion carotid endarterectomy: a technical alternative that may obviate patch closure in women.

PURPOSE: Recurrent carotid stenosis following standard longitudinal carotid endarterectomy (s- CEA), with and without patch angioplasty, effects the durability of the procedure and can lead to reintervention. The purpose of this study is to evaluate the incidence of restenosis following eversion carotid endarterectomy (e-CEA) in women. METHODS: The records of all patients undergoing elective carotid endarterectomy (CEA) for symptomatic and asymptomatic high-grade carotid stenosis over a 5-year period from July 1994 to June 1999 were reviewed. Eversion endarterectomy was performed preferentially under regional anesthesia in awake patients. Postoperatively, patients were routinely evaluated by duplex scans at 3 months, 6 months, 12 months, and yearly thereafter. Hemodynamically significant restenosis (>70%) via duplex scans was confirmed by standard or magnetic resonance angiography. Student's t-test and Chi square analysis were used to assess statistical significance and assumed for P<0.05. RESULTS: Over this 5-year period, 3429 eversion carotid endarterectomies were done for symptomatic (female: 375, male: 573) and asymptomatic (female: 1091, male: 1390) high grade carotid stenosis. In the postoperative period 18 (0.9%) male and 12 (0.8%) female patients developed a permanent stroke (P = NS). Operative mortality was 0.6% (n = 12) in males and 0.5% (n = 8) in females (P = NS). Cranial nerve injuries, wound infections, and neck hematoma occurred in 7 (0.4%), 2 (0.1%), and 26 (1.3%) male and in 3 (0.2%), 3 (0.2%), and 15 (1.0%) female patients, respectively. Recurrent carotid stenosis greater than 70% via duplex scan (PSV >125 cm/s and EDV >100 cm/s) developed in 12 (1.0%) males and 15 (1.5%) females (P = NS). CONCLUSION: The eversion technique for CEA requires both the transection and anastomosis of the internal carotid artery at the carotid bulb, and appears to result in a low incidence of restenosis in women. This is a straightforward technique and obviates the need for primary closure of distal smaller caliber internal carotid artery that can lead to narrowing, and the use of patch closure that has its attendant risks.

Adult↗
PubMed1996

Bilateral carotid endarterectomy during the same hospital admission.

The efficacy of carotid endarterectomy for the prevention of strokes has been well demonstrated in recent multicenter randomized trials. However, patients presenting with bilateral significant disease pose a difficult problem to the vascular surgeon. Currently, bilateral carotid endarterectomies are staged at varying intervals between operations, with surgeon and patient weighing the risks of waiting for surgery versus the risks of having both procedures done within a shortened interval. There are few data and no consensus on the optimal time interval between these operations. In order to evaluate the timing of carotid endarterectomies in patients with severe bilateral disease, the authors reviewed their experience with patients who had bilateral procedures performed during one hospitalization. Over the past 5 years, they have performed 204 such carotid endarterectomies in 102 patients. Cervical block anesthesia was used in 99% (201/204) of these procedures. All patients either had symptomatic disease, > 60% stenosis or severe ulcerative plaque as defined by duplex scan and/or preoperative angiography. Symptomatic stenoses were the operative indications in 39% (80/204) of the patients; the remaining 61% (124/204) were symptom-free. The majority of patients (80%; 164/204) had their second procedure performed within 2 days of their first operation. There was no operative mortality and only one permanent neurologic defect in this group for a combined stroke mortality rate of 1%. Three patients (1.5%) had transient neurologic deficits postoperatively which completely resolved by discharge. These data show that bilateral carotid endarterectomies can be performed safely and effectively during one hospital admission with a short interprocedural interval and without an increase in mortality or morbidity.

Aged↗
PubMed1995

Culture of human adult endothelial cells on endarterectomy surfaces.

OBJECTIVES: Endothelial cell seeding of prosthetic grafts has not been as successful as initially hoped and the application of seeding technology to alternative reconstructive procedures such as endarterectomy and angioplasty has been increasingly considered. The success of such seeding depends on the ability of the seeded cells to attach to, and form a monolayer on the endarterectomised vessel wall which was the aim of this study. METHODS: Using a seeding chamber model, heterologous human adult endothelial cells were seeded onto fresh human endarterectomy specimens and cultured. Studies of endothelial call adherence to endarterectomy specimens were performed using 111-Indium oxine labelled cells using methodology analogous to graft seeding. RESULTS: Mean endothelial cell adherence of 70% (S.D. 10%) after 1 h incubation was achieved and the successful development of a monolayer of human adult venous endothelial cells on endarterectomised arteries was demonstrated in vitro. CONCLUSIONS: These results indicate that closed endarterectomy appears to offer a surface with cell attachment that is superior to prosthetic grafts. Where femoral endarterectomy is appropriate, endothelial seeding potentially offers a method of reducing thrombogenicity and intimal hyperplasia, improving patency and avoiding a prosthetic graft whilst preserving collateral circulation and autologous vein.

Adult↗
PubMed2000

Risk factors for peri-operative stroke complicating carotid endarterectomy: selective analysis of a prospective audit of 1000 consecutive operations.

BACKGROUND: The aim of the present study was to investigate the role of potential clinical risk factors in the causation of peri-operative stroke associated with carotid endarterectomy. With the change in carotid endarterectomy practice from the use of a shunt to high-dose thiopental for cerebral protection (a previously undocumented method), it was essential to identify accurately the causes of all perioperative strokes. METHODS: A prospective audit was undertaken of 1000 carotid endarterectomies in which the causes and pathology of all peri-operative strokes were documented. The roles of advanced age, female gender, hypertension, previous stroke, contralateral carotid stenosis >70%, and contralateral carotid occlusion as potential causes of peri-operative stroke were defined. Results were statistically analysed using odds ratio and Fisher's exact test. RESULTS: None of the potential risk factors was statistically significant for peri-operative stroke. Female gender was associated with a significant risk of peri-operative stroke due to operative site thrombosis. Complications at the endarterectomy site were the commonest cause of stroke. CONCLUSIONS: Prospective audit is a useful tool for identifying causes of peri-operative stroke and indicating the need for modifications to surgical clinical management which might improve outcomes for carotid endarterectomy.

Age Factors↗
PubMed1993

Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group.

BACKGROUND: The efficacy of carotid endarterectomy in patients with asymptomatic carotid stenosis has not been confirmed in randomized clinical trials, despite the widespread use of operative intervention in such patients. METHODS: We conducted a multicenter clinical trial at 11 Veterans Affairs medical centers to determine the effect of carotid endarterectomy on the combined incidence of transient ischemic attack, transient monocular blindness, and stroke. We studied 444 men with asymptomatic carotid stenosis shown arteriographically to reduce the diameter of the arterial lumen by 50 percent or more. The patients were randomly assigned to optimal medical treatment including antiplatelet medication (aspirin) plus carotid endarterectomy (the surgical group; 211 patients) or optimal medical treatment alone (the medical group; 233 patients). All the patients at each center were followed independently by a vascular surgeon and a neurologist for a mean of 47.9 months. RESULTS: The combined incidence of ipsilateral neurologic events was 8.0 percent in the surgical group and 20.6 percent in the medical group (P < 0.001), giving a relative risk (for the surgical group vs. the medical group) of 0.38 (95 percent confidence interval, 0.22 to 0.67). The incidence of ipsilateral stroke alone was 4.7 percent in the surgical group and 9.4 percent in the medical group. An analysis of stroke and death combined within the first 30 postoperative days showed no significant differences. Nor were there significant differences between groups in an analysis of all strokes and deaths (surgical, 41.2 percent; medical, 44.2 percent; relative risk, 0.92; 95 percent confidence interval, 0.69 to 1.22). Overall mortality, including postoperative deaths, was primarily due to coronary atherosclerosis. CONCLUSIONS: Carotid endarterectomy reduced the overall incidence of ipsilateral neurologic events in a selected group of male patients with asymptomatic carotid stenosis. We did not find a significant influence of carotid endarterectomy on the combined incidence of stroke and death, but because of the size of our sample, a modest effect could not be excluded.

Adult↗
PubMed1988

Turbulence occurring after carotid bifurcation endarterectomy: a harbinger of residual and recurrent carotid stenosis.

The goal of carotid endarterectomy is to remove an obstructing or embologenic lesion and reconstruct a durable arterial segment free of flow abnormality. The technical adequacy of 250 endarterectomy sites in 235 patients was assessed at operation by pulsed Doppler spectral analysis and arteriography and was correlated with postoperative patency, the incidence of residual and recurrent stenosis, and clinical outcome. Duplex scanning was used after operation to categorize disease severity. At operation, 10 patients (4%) had angiographic and Doppler flow abnormalities identified in the internal carotid artery. Vessel exploration identified intimal flaps, platelet aggregation, or stricture. Residual flow disturbances at the endarterectomy site correlated with perioperative thrombosis and stroke, angiographic abnormalities, primary closure of the arteriotomy, and a postoperative duplex scan consistent with stenosis. In 175 patients (182 sites) with normal arterial flow after carotid bifurcation endarterectomy, no thrombotic events occurred and the incidence of recurrent stenosis (life-table analysis) was zero at 3 months, 5% at 1 year, and 9% at 2 years. The incidence of occlusion and recurrent stenosis was increased (8% at 3 months, 18% at 1 year, and 21% at 2 years) in 68 arteries with residual flow disturbance identified at operation. Assessment of endarterectomy sites for turbulence identifies anatomic lesions that threaten patency and increase the incidence of residual and recurrent stenosis.

Aged↗
PubMed1990

Fate of the carotid artery contralateral to endarterectomy.

The management of internal carotid artery disease contralateral to endarterectomy is highly controversial. At our institution we have adopted an approach by which patients are followed with serial duplex scanning after unilateral carotid endarterectomy. Surgery on the contralateral carotid artery is recommended for patients who exhibit ischemic neurologic symptoms or develop an 80% to 99% carotid stenosis. This strategy is based on previous reports that have documented an increased incidence of strokes in these two groups of patients. As a result, 40 patients among a study population of 200 underwent carotid endarterectomy on the originally unoperated side. The current study reviews the natural history of the patients who were followed without or before operation of the contralateral carotid artery in an attempt to identify other cohorts at increased risk for stroke. Patients were followed for up to 126 months after unilateral carotid endarterectomy (mean, 54 months). Six patients were lost to follow-up (3.0%). By life-table analysis the estimated mean annual rate of progression to greater than or equal to 50% diameter reduction was 3.9% and 1.2% for progression to greater than or equal to 80% stenosis. Only two patients went on to occlusion during follow-up. Neurologic events referable to the contralateral carotid distribution were infrequent. The estimated mean annual rate was 2.9% for transient ischemic attacks and less than 0.8% for strokes. Case history review of the six patients who had strokes during follow-up suggested that only one patient may have benefited from carotid endarterectomy. Conservative management with serial duplex scanning of the unoperated, contralateral carotid artery appears appropriate.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Use of shunts with eversion carotid endarterectomy.

PURPOSE: The purpose of this study was to examine the utility of carotid shunting in the context of eversion endarterectomy. A comparison of patients who underwent carotid endarterectomy by eversion with and without shunts was performed. METHODS: Over a 5-year period, 2724 eversion carotid endarterectomies were performed. In most of these operations patients were under cervical block anesthesia. A shunt was used in 112 eversion endarterectomies (4.1%). Cervical block anesthesia was used in 103 patients (92.0%), general anesthesia was used in 5 patients (4.5%), and 4 patients (3.6%) were converted from cervical block to general anesthesia intraoperatively. The indications for shunting were neurologic deterioration in 99 patients (88.4%) who were under cervical block anesthesia, procedures performed in neurologically unstable or otherwise compromised patients who were under general anesthesia, and the operator's discretion in the remaining eight patients. RESULTS: There was a combined stroke/death rate of 2.7% in the shunt group. These three cases included one death from myocardial infarction and one delayed death due to intracerebral hemorrhage after discharge. Shunt insertion was unrelated to the negative outcome in these two cases. One perioperative major stroke in the shunt group was identified. Follow-up averaged 12.3 months (range, 1-53 months). CONCLUSION: Carotid shunts can be used effectively in the context of eversion endarterectomy. Shunt insertion is not associated with an increased stroke/death rate in these patients.

Aged↗
PubMed2000

Eversion endarterectomy of the carotid artery: technical considerations and recurrent stenoses.

PURPOSE: The purpose of this study was to examine the characteristics of residual and recurrent lesions after eversion endarterectomy of the carotid artery (E-CE) and compare these results with those following endarterectomy and patch closure (CE-P). METHODS: We reviewed 274 patients who underwent carotid endarterectomy in 1998 with electroencephalographic monitoring, general anesthesia, completion duplex scan, and 1-year follow-up. CE-P was preferred for patients who required temporary shunting. In the E-CE group an additional proximal 2-cm arteriotomy was made in the common carotid artery (CCA) in 79 patients, a longer arteriotomy was made for extensive involvement of the CCA in 14 patients, and the internal carotid artery was advanced proximally as a patch for the CCA arteriotomy closure in 14 patients. Stenoses of > 50% that were present at 1 month were considered residual, and those of > 50% that were present at 1 year but not at 1 month were considered recurrent. RESULTS: There were five (1.8%) postoperative strokes (four after CE-P and one after E-CE, P = not significant). At 30 days there were 28 patients (10.2%) with residual stenoses > 50% (11 patients [10.2%] in the E-CE group and 17 patients [10.1%] in the CE-P group; P = not significant). The incidence of recurrent lesions of more than 50% was similar (4.6% for E-CE vs 4.7% for CE-P). CONCLUSION: The pattern of residual lesions and recurrent stenoses differs with each technique of endarterectomy. Proximal stenoses are more common after E-CE, and distal stenoses are more common after CE-P at both 1 month and 1 year. The frequency of proximal lesions is reduced in E-CE when either the internal carotid artery is advanced proximally onto the CCA or a long CCA arteriotomy is made. Distal recurrences do not seem to be a problem after eversion endarterectomy.

Angiography↗