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PubMed2002

Carotid stenting and endarterectomy: a clinical and cost comparison of revascularization strategies.

BACKGROUND AND PURPOSE: Investigational carotid stenting for extracranial carotid stenosis has demonstrated procedural results approaching those reported with endarterectomy, but with limited cost and long-term data. This study compared the in-hospital outcomes and costs of these 2 revascularization strategies at a single institution and the long-term effectiveness of carotid stenting. METHODS: Data for 136 endarterectomies and 136 carotid stent procedures at a tertiary-care community hospital were obtained. The primary clinical outcome measures were in-hospital major ipsilateral stroke and death. In-hospital direct variable costs and length of stay were the primary economic measures. Information on restenosis and late ipsilateral stroke for the stent group was available at 2-year follow-up. RESULTS: These nonrandomized groups were similar, but the endarterectomy group had more symptomatic patients (42% versus 31%; P=0.0004), and the stent group had more NASCET-excluded patients (68% versus 35%; P<0.0001). In-hospital major ipsilateral stroke and death occurred more frequently in the surgical group, but the difference was not significant (2.9% versus 0%; P=0.1). Minor ipsilateral strokes were similar (2.2% versus 2.9%; P=NS). Cost ($5409 versus $3417; P<0.0001) and length of stay (3.0 versus 1.4 days; P<0.0001) were significantly greater for the surgical group. In the stent group, 6-month angiographic restenosis was 3.1%, and 2-year ipsilateral major stroke rate was 0%. CONCLUSIONS: In-hospital outcomes with carotid stenting were similar to those with endarterectomy but were achieved in patients with significantly more comorbidities. Cost and resource utilization with stenting were substantially less than those with endarterectomy. At 2 years, carotid stenting appeared not only durable but also effective in stroke prevention.

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PubMedDate not supplied

Local versus general anesthesia for carotid endarterectomy: report of 329 cases.

Since stroke is an important cause of morbidity and mortality, carotid endarterectomies are used frequently to reduce the risk of stroke and death. Unfortunately, an inherent risk of the carotid endarterectomy procedure is that surgery itself may result in stroke. At this point the question is which method of anesthesia, local or general, is better to protect and monitorize the brain function during cross-clamp period in carotid endarterectomies? In the authors' center, 365 carotid endarterectomies were applied to 329 patients between 1990 and 2001; 165 operations were done under general anesthesia and the other 200 operations were done under local anesthesia. These 2 groups, general (group I) and local anesthesia (group II), were studied retrospectively according to preoperative and postoperative data. In group I, the rate of major stroke was 7.3%, but this rate was 1% in group II (p < 0.05). Intraoperative shunts were used in 50 (30.3%) operations of group I, but the usage of shunt was 8% (16 operations) in group II (p < 0.0001). The hospitalization period was also much shorter in group II than in group I. The time of hospitalization was 4.1 +/-1.9 days in group I and 2.4 +/-1.1 days in group II (p < 0.0001). In terms of cost analysis, the mean costs were 1007.14 dollars +/-135.71 dollars in group I and 885.71 dollars +/-78.57 dollars in group II (p < 0.0001). In short, the local procedure was more cost-effective. As a result, in carotid endarterectomy procedures, the authors prefer local anesthesia to achieve better brain function monitoring and to reduce hospitalization time and cost.

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PubMed2003

Brain diffusion changes in carotid occlusive disease treated with endarterectomy.

BACKGROUND: Patients with unilateral high-grade carotid stenosis or occlusion have been reported to have more leukoaraiosis and ischemic lesions in ipsilateral than in contralateral cerebral hemisphere. The lesions alter apparent diffusion coefficient (ADC) values in diffusion-weighted MRI (DWI). The overall effects of carotid endarterectomy on ADC values have not yet been explored. OBJECTIVE: S: To find out whether 1) average ADC (ADC(av)) values differed between hemispheres, 2) diffusion changes induced by carotid endarterectomy could be detected in brain tissue with serial DWI, and 3) patients with asymptomatic carotid stenosis differed from patients with a symptomatic stenosis. METHODS: Forty-five patients (22 with asymptomatic carotid stenosis and 23 with symptomatic carotid stenosis) with unilateral high-grade carotid stenosis underwent DWI before carotid endarterectomy and 3 and 100 days afterward, and 45 age- and sex-matched healthy control subjects were imaged once. We evaluated ADC(av) values in normal-appearing gray and white matter, watershed regions (WsR), and thalamus. RESULTS: ADC(av) values of ipsilateral white matter and WsR were higher than those of contralateral white matter and WsR, both being higher than in white matter and WsR of control subjects. After carotid endarterectomy, these differences were diminished, but the levels remained higher than in controls. ADC(av) values of gray matter and thalamus remained unaffected. Asymptomatic carotid stenosis and symptomatic carotid stenosis patient groups did not differ from each other. CONCLUSIONS: Carotid stenosis has an effect on diffusion in the white matter of the ipsilateral hemisphere, and it is partly reversible by carotid endarterectomy. The finding may be associated with leukoaraiotic development ("preleukoaraiosis").

Adult↗
PubMed1984

Microsurgical carotid endarterectomy in rats.

The purpose of this study was to develop an inexpensive experimental model of carotid endarterectomy. Unilateral common carotid endarterectomies 3 mm in length were performed on 25 rats using microsurgical techniques. The pattern of endothelial regrowth after endarterectomy, the pinocytosis of regenerated endothelial cells, and the effects of heparin and thromboxane A2 synthetase inhibitor on thrombus formation were examined 7 days after the resumption of flow. Pinocytotic vesicular transport in endothelial cells was evaluated using horseradish peroxidase. All endarterectomized vessels in both control and drug-treated groups were patent 7 days after operation without apparent mural thrombus formation. Regenerated endothelial cells had spindle-shaped nuclei and cell bodies with long axes oriented parallel to the direction of blood flow. There were several instances where the leading edge of the endothelium at the distal end was reflected back in the distal direction. The extent of the endothelial ingrowth was often greater from the proximal end of the endarterectomy than from the distal end. These observations suggest that hemodynamic force affects endothelial regeneration. Pinocytotic activity was less in the regenerated endothelium than in either the endothelium remaining at the periphery of the endarterectomy or the endothelium of the control animals.

Animals↗
PubMed1986

False aneurysm complicating carotid endarterectomy.

We present two cases of false aneurysm after carotid endarterectomy with primary arteriotomy closure. In both cases, infection appeared to be the precipitating cause. Both lesions were repaired with a saphenous vein patch graft, but infection in one patient persisted, and recurrence of a false aneurysm required ligation of the common carotid artery. There were no neurological sequelae in either patient. A review of the English language literature, our experience, and personal communications yielded 57 cases of false aneurysm. The overall incidence of false aneurysm after carotid endarterectomy was 0.30%. There was no significant difference in the incidence after endarterectomy alone and that after endarterectomy and patch grafting. A significant increase in neurological deficit occurred only when carotid ligation was used, with a morbidity/mortality of 50% in eight reported cases. Infection was the major cause of false aneurysm after endarterectomy; it occurred in 50% of cases closed primarily without patch grafting. Repair with a saphenous vein patch graft and monofilament synthetic suture, plus liberal use of antibiotics, should be considered in the treatment of this condition.

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PubMed2005

Simultaneous Carotid Endarterectomy and Coronary Revascularization is Safe Using Either On-Pump or Off-Pump Technique.

The appropriate surgical strategy for patients with combined carotid and coronary artery disease remains controversial. We retrospectively compared our surgical results for 2 types of approaches in this disorder. The records of 76 patients consecutively operated on for carotid and coronary artery disease between August 1993 and October 2004 were reviewed. There were 18 males (66.6%) and 9 females (33.3%) in group I. Group II consisted of 35 males (71.4%) and 14 females (28.5%). The patients were divided into two groups: patients with combined off-pump coronary artery bypass and carotid endarterectomy (group I, n = 27), and those with one-stage on-pump coronary artery bypass and carotid endarterectomy (group II, n = 49). Surgical mortality and morbidity and late outcome were compared among the two groups. The average number of grafts was 1.2 +/- 0.4, with the average operative time of 3.3 +/- 0.3 hours in group I, and 2.3 +/- 0.5 grafts with operative time of 4.6 +/- 0.4 hours in group II (P < 0.001 and P < 0.001, respectively). There was 1 death (3.7%) in group I and 2 deaths (4.8%) in group II (P = 0.937). No patient from either group I or group II had postoperative stroke. Mean hospital stay was 7.4 +/- 1.9 days in group I and 11.3 +/- 1.7 days in group II (P < 0.001). At a mean follow-up of 5.5 +/- 3.3 years in group I, 1 patient had contralateral carotid endarterectomy (3.7%). Group II had a mean follow-up of 5.2 +/- 3.0 years and contralateral carotid endarterectomy was performed in 1 patient (2.0%). There were no late strokes or deaths in either group. Combined coronary artery bypass grafting and carotid endarterectomy using 2 different types of technique is a safe and effective procedure in patients with significant concomitant monolateral carotid and coronary artery disease.

Cardiac Surgical Procedures↗
PubMed2001

Early and late results of carotid endarterectomy: retrospective study of 70 operations.

CONTEXT: Indications and results of carotid endarterectomy have been defined from clinical multicentric trials like the European Carotid Surgery Trialists, North-American Symptomatic Carotid Endarterectomy Trial and Asymptomatic Carotid Atherosclerosis Study. The patients included in these trials were highly selected, as were the surgeons performing the operations. Clinical practice is different but the same results should be achieved. OBJECTIVE: To study indications, technique, early and late results, and whether carotid endarterectomy has been performed in accordance with standards defined by multicentric trials. DESIGN: Retrospective case report study. SETTING: A tertiary care private hospital. PARTICIPANTS: 57 patients, on whom 70 carotid endarterectomies were performed over a 10-year period. The median age was 66.4 +/- 7.8 years; 43 (75.4%) were male, 41 (71.9%) hypertensive, 36 (63.1%) current smokers and 24 (21.0%) had diabetes. Bilateral carotid stenosis was present in 31 (54.3%) patients, peripheral arterial occlusions in 32 (56.1%) and ischemic cardiopathy in 25 (43.1%). All patients had had angiography and 41 (71.9%) had also had a duplex-scan of neck arteries. Cerebral imaging via computerized tomography scan or magnetic resonance imaging was obtained for 36 patients. Patients were followed up over a period of one to 122 months. MAIN MEASUREMENTS: early and late post-operative death, early and late post-operative stroke, and recurrence of atheroma plaque and symptoms relative to carotid stenosis. RESULTS: There was one post-operative death (1.4%) caused by myocardial infarction and two early strokes (2.8%): a total complication rate of 4.2%. After 3 and 5 years, 95.4% and 81.3% of patients respectively were stroke-free and 72.8% and 67.3% were alive. There were four recurrences and two of them related to stroke. Forty-nine (70%) stenoses operated on were symptomatic. Brain infarction was detected in 59.2% of patients who underwent computerized tomography scan or magnetic resonance imaging. CONCLUSIONS: Carotid endarterectomy was done in accordance with international standards. The most frequent cause of late death was myocardial infarction, and recurrences were related to stroke. Patients should be followed up closely.

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PubMed2005

Simultaneous carotid endarterectomy and myocardial revascularization by using cardiopulmonary bypass for both procedures.

OBJECTIVE: The optimal treatment of patients with co-existing occlusive coronary and carotid arterial disease is controversial. This study reports our experience with simultaneous carotid endarterectomy and coronary bypass in conjunction with cardiopulmonary bypass with mild hypothermia. METHODS AND RESULTS: From March 2001 to June 2004, 72 patients underwent simultaneous coronary bypass and carotid endarterectomy. Their mean age was 68.9 years and there were 56 men and 16 women. The indication for carotid endarterectomy was a lumen diameter reduction of more than 75% and/or the presence of ulcerated/unstable plaque. Carotid endarterectomy was done during cardiopulmonary bypass under mild hypothermia, haemodilution, systemic heparinization and controlled haemodynamics under pulsatile perfusion for additional cerebral protection. The mean cardiopulmonary bypass time was 64.7 minutes and aortic cross-clamp time 32.4 minutes, and the mean number of grafts per patient was 2.7. Four patients had perioperative neurological complications (5.5%) and two had permanent deficits (2.7%). The procedure-related mortality was 3 (4.1%). CONCLUSIONS: We suggest that combining coronary revascularization and carotid endarterectomy and performing both under cardiopulmonary bypass is safe, offering acceptable morbidity and mortality rates.

Adult↗
PubMed1991

Excimer laser radiation for endarterectomy of experimental atheromas.

Open laser endarterectomy produces a smooth arterial surface with welded distal end points. This report evaluates 308-nm excimer laser radiation for the laser endarterectomy operation. Arteriosclerotic New Zealand white rabbits (N = 15) were studied. A thoraco-abdominal exploration was performed, the aorta was isolated, heparin was administered, and multiple endarterectomies were performed in each rabbit. A line of laser craters was created at the proximal and distal ends of an atheroma. Laser radiation was used to connect the craters to form the proximal and distal end points. The atheromas were dissected from the aorta with laser light and the end points were fused. The aortas were removed for light and electron microscopy and the animals were sacrificed. Excimer radiation was delivered by a 600-microns fiber at 50 mJ/pulse, 120-ns pulses and either 15- or 20-Hz frequency. At 15 Hz excimer laser endarterectomies showed no perforations along the surface or at the end points. The surfaces were smooth but the end points were not welded in place. At 20 Hz, perforations were seen along 7/11 surfaces and at 5/11 end points. Excimer laser endarterectomy is best performed at 15 Hz. The end points, however, cannot be welded with excimer laser radiation.

Animals↗
PubMed1984

Local anaesthesia in carotid surgery. A prospective study of 111 endarterectomies in 100 patients.

A prospective study was carried out on 100 patients consecutively undergoing carotid endarterectomy in local anaesthesia, in order to evaluate the usefulness of clinical signs in awake patients for monitoring of cerebral function and to determine the need for internal shunt in carotid surgery. The indications for operations were transient ischemic attacks in 67 patients and major or minor stroke in 24 (16 with persistent neurologic deficit). In nine asymptomatic patients the endarterectomy was prophylactic, following detection of bruit and angiographic stenosis. Bilateral stenosis was present in 47 patients, including 13 with total occlusion of the contralateral vessel, and 60 patients had significant vertebral artery stenosis. The carotid artery was first tentatively occluded and, if this was well tolerated for 5 min, endarterectomy was done without an internal shunt. Neurologic deficit signs during the trial occlusion necessitated such shunt in 16 patients with pressure in the internal carotid stump ranging from 0 to 40 (mean 22.4) mmHg. On the other hand, 11 additional patients with stump pressure less than 35 mmHg tolerated the trial occlusion well, underwent carotid endarterectomy without internal shunt and had no deficit symptoms during or after operation. One patient died postoperatively. Hemiparesis appeared in two more patients, but resolved completely in one and gave only minor sequelae in the other. These complications were related to the preoperative condition (stroke) and the postoperative residual pressure gradient. It is concluded that trial occlusion of the carotid artery and observation of the awake patient provide reliable information on the need for an internal shunt during carotid endarterectomy.

Adult↗
PubMed1989

Coronary endarterectomy--angiographic and clinical results.

Of 75 patients who underwent coronary endarterectomy, 16% had left main stem stenosis, 4% one-vessel, 27% two-vessel and 53% three-vessel disease. On average 2.9 grafts per patient were inserted, in conjunction with 82 manual endarterectomies (38 right coronary, 35 left anterior descending, 9 circumflex branches). In 68/75 cases (91%) the endarterectomy was not preplanned and in 39 cases (52%) greater than or equal to 3 cm of the atherosclerotic core was removed. All four early deaths (5%) followed endarterectomy of LAD. Acute perioperative myocardial infarction was confirmed in 19% and probable in further 8%. At angiography 1-139 (median 25) months postoperatively, all three internal mammary artery grafts and 19/34 saphenous vein grafts (56%) to endarterectomized vessels were patent, though in 4 of the 19, the coronary artery was occluded distal to the anastomosis. In addition 17/18 conventional internal mammary artery (94%) and 48/59 conventional saphenous vein grafts (81%) were patent. The vein graft patency rate was not significantly influenced by postoperative anticoagulant therapy, but was significantly increased among patients with relief of angina: 44% reported freedom from angina and 92% at least some relief after a median of 3 years. The 5-year and 10-year survival rates were 85% and 68%. Despite the increased risk, endarterectomy can be recommended for severely diseased major coronary arteries.

Angina Pectoris↗
PubMedDate not supplied

Surgical outcome of carotid artery disease: analysis of 367 carotid endarterectomies.

Carotid endarterectomy is a method of prophylaxis. A total of 367 carotid endarterectomies in 335 patients were performed during the period of 1989-1997: 222 (66.3%) were symptomatic and 113 (33.7%) asymptomatic patients. In all, 262 (78.2%) had unilateral, 41 (12.2%) contralateral occlusion and 32 (9.6%) bilateral artery disease. All were operated on under general anesthesia without using shunt or patch. Of the patients with bilateral occlusive disease, 17 underwent simultaneous and 15 staged endarterectomy. The mortality rate of the first 30 postoperative days was 1.19% and the mortality/stroke rate 2.38%. Transient neurogenic dysfunction occurred in 3.68%, myocardial ischemia in 0.89%, and postoperative hypertension in 16.7%. Endarterectomy of symptomatic and asymptomatic patients with unilateral localisation, contralateral occlusion or bilateral occlusive disease remains a highly acceptable prophylactic method. The future will show whether other endovascular procedures affect the broad application of carotid endarterectomy.

Aged↗
PubMed1999

Carotid artery tandem lesions: frequency of angiographic detection and consequences for endarterectomy.

BACKGROUND AND PURPOSE: Several prospective trials have shown that ischemic stroke can be prevented by performing an endarterectomy in patients with high-grade carotid stenosis. Our purpose was to ascertain the frequency of carotid artery tandem lesions and to determine whether their presence alters the surgeon's decision to perform an endarterectomy. METHODS: We retrospectively reviewed the cerebral angiograms obtained between January 1994 and June 1996 in 853 patients with carotid occlusive disease. Studies were analyzed for the presence of internal carotid artery (ICA) stenosis as well as for tandem lesions (defined as > or = 50% diameter stenosis) within the common carotid artery, carotid siphon, or proximal intracranial arteries. The frequency of intracranial saccular aneurysms was determined. RESULTS: Six hundred seventy-two of the 853 patients had a carotid bifurcation stenosis of 70% or greater or underwent an endarterectomy. Of these, a carotid siphon stenosis of 50% or greater was noted in 65 patients (9.7%) and was ipsilateral to an ICA stenosis in 37 patients (5.5%). A common carotid stenosis was present in 29 patients (4.3%), ipsilateral to an ICA stenosis in 14 patients (2.1%). A stenosis of 50% or greater within the proximal intracranial circulation was present in 28 patients (4.2%), ipsilateral to an ICA stenosis in 15 patients (2.2 %). Four patients had tandem stenoses at more than one site. Tandem stenoses in the siphon or intracranial segments were noted in 13.5% with a bifurcation stenosis and in 8.8% of those with no bifurcation stenosis. Endarterectomy was performed in 48 of the 66 patients with tandem stenotic lesions. CONCLUSION: The presence of a tandem lesion infrequently alters the surgeon's decision to perform an endarterectomy. However, the importance of detecting tandem stenoses cannot be underestimated, since they may have important implications for long-term medical management in symptomatic patients.

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PubMed2000

[Carotid endarterectomy under regional anesthesia: initial experience].

BACKGROUND: Endarterectomy is the treatment of choice for internal carotid artery critical stenosis. Some authors have proposed that the use of regional anesthesia has advantages over general anesthesia. AIM: To report our initial experience with carotid endarterectomy under regional anesthesia. PATIENTS AND METHODS: Between 1998 and 1999, patients with critical carotid artery stenosis, asymptomatic or with transient and recovered symptoms, were selected. A C2, C3, C4 root deep cervical block and superficial block was performed, using a mixture of lidocaine and bupivacaine. A carotid endarterectomy with patch and without routine shunt insertion, with standard and neurological monitoring, was performed. RESULTS: During the study period, 94 carotid endarterectomies were done, 22 under regional anesthesia in 21 patients (12 male, age range 58-90 years old). Ninety five percent had hypertension, 52% smoked and 38% had renal dysfunction. One patient was converted to general anesthesia. Seventeen patients were discharged within 48 hours of the procedure and the rest, within 72 hours. There was no mortality or complications. CONCLUSIONS: Endarterectomy under regional anesthesia is less invasive, has excellent results and is well accepted by patients.

Aged↗
PubMed2000

Transesophageal atrial pacing reduces phenylephrine needed for blood pressure support during carotid endarterectomy.

OBJECTIVE: To determine whether transesophageal atrial pacing reduces phenylephrine requirement for blood pressure support during general anesthesia for carotid endarterectomy. DESIGN: Prospective randomized clinical study. SETTING: University hospital. PARTICIPANTS: Thirty-six patients undergoing elective carotid endarterectomy under general anesthesia. INTERVENTIONS: Adults of either sex (n = 36) received general anesthesia using a standardized anesthetic regimen for elective carotid endarterectomy. Phenylephrine requirements were measured in patients having carotid endarterectomy and randomized to phenylephrine infusion (group 1, 19 patients) or phenylephrine infusion plus transesophageal atrial pacing (group 2, 17 patients) to maintain systolic blood pressure within +/-20% of baseline systolic blood pressure. MEASUREMENTS AND MAIN RESULTS: Measurements included (1) the amount of phenylephrine required in each group, (2) the variance of systolic blood pressure outside the desired range, and (3) the occurrence of postoperative electrocardiogram or myocardial enzyme changes suggesting myocardial ischemia. The average requirement for phenylephrine was less for group 2 (0.28+/-0.16 microg/kg/min) than for group 1 patients (0.46+/-0.23 microg/kg/min) (p = 0.02 by t-test). CONCLUSIONS: Under controlled conditions of general anesthesia for carotid endarterectomy, transesophageal atrial pacing reduced by 40% the amount of phenylephrine needed for blood pressure support and helped in the treatment of disadvantageous sinus bradycardia.

Adrenergic alpha-Agonists↗
PubMed2000

The influence of anesthetic technique on perioperative blood pressure control after carotid endarterectomy.

The optimal anesthetic for use during carotid endarterectomy has been a matter of debate for three decades. The goal of this study is to evaluate the influence of anesthetic technique on perioperative hemodynamic instability after carotid endarterectomy. This study is a retrospective chart review and was performed in a community teaching hospital. All consecutive patients undergoing carotid endarterectomy over a 2-year period at Providence Hospital were reviewed. One hundred ninety-eight patients underwent 203 carotid endarterectomies. Two patients were excluded because of combined coronary artery bypass grafting. Patients underwent carotid endarterectomy and were divided into two groups on the basis of use of general or regional anesthesia. Blood pressure was recorded hourly for the subsequent 24 hours, and the doses of vasoactive medications received to maintain the blood pressure within 25 mm Hg of preoperative levels were recorded. Patients receiving general anesthesia were found to require significantly more sodium nitroprusside for control of hypertension compared with those receiving regional anesthesia (72.1 +/- 14.5 microg/kg vs 20.2 +/- 6.6 microg/kg; P = 0.001) in the first 8 postoperative hours. No significant differences were noted in the doses of any other vasoactive medications used. No differences were found in the subsequent 16-hour period in doses of vasoactive medications. Patients suffering myocardial infarctions were found to receive higher doses of nitroglycerine, but no differences were noted in any other vasoactive medication used based on complications. Length of stay was longer in the general anesthesia group compared with the regional anesthesia group for both the intensive care unit (1.59 +/- 0.13 days vs 1.08 +/- 0.03 days; P = 0.001) and total hospital stay (5.8 +/- 0.03 days vs 4.5 +/- 0.02 days; P = 0.003). Regional anesthesia required lower doses of antihypertensive medication in the early postoperative period when compared with general anesthesia. The doses of vasoactive medications used had no significant impact on the complication rate. Regional anesthesia allowed for shorter stay in both the intensive care unit and total hospital stay.

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PubMed2001

Carotid endarterectomy based on duplex ultrasound in patients with and without hemispheric symptoms.

Carotid endarterectomy is the most commonly performed vascular procedure. This retrospective study was conducted to determine the efficacy of duplex imaging as the sole diagnostic study for preoperative evaluation of symptomatic and asymptomatic patients who underwent carotid endarterectomy. We conducted a retrospective case series analysis in a community teaching hospital. From January 1994 to September 1998, 316 patients underwent carotid endarterectomy for carotid stenosis. A total of 177 patients were symptomatic and 139 patients were asymptomatic. Angiography was performed routinely in the beginning of the study but later was performed only in selected patients. Preoperative duplex ultrasound of carotid artery was performed by a laboratory accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories. Data were reviewed to obtain morbidity and mortality rates, and duplex imaging results were compared with operative findings. Cost and risk analysis of carotid angiography reviewed. This study reviewed variables of age, sex, race, diabetes, smoking, hypertension, hypercholesterolemia, coronary artery disease, and renal failure. Five patients had a lesion in the proximal portion of the carotid artery by duplex imaging criteria. Duplex ultrasound results were grossly confirmed intraoperatively in all patients except in one patient who was found to have complete occlusion of carotid artery whose duplex was read as high-grade stenosis. The duration of stay ranged from two to 30 days. This duration was influenced by patients' comorbid conditions, postoperative complications or simultaneous coronary artery bypass graft. Four patients had a stroke within 30 days of surgery making the stroke rate of 1.26 per cent. There has been considerable debate on the use of duplex ultrasound as the only method of preoperative evaluation of carotid stenosis before carotid endarterectomy. Our study demonstrates that it is safe to perform carotid endarterectomy based on neurologic history and duplex ultrasound with good technical quality performed in an accredited vascular laboratory. This approach eliminates the cost and risk associated with angiography. Proximal carotid and intrathoracic lesions are rare and can be predicted by the duplex study. We think that carotid angiography is required only when duplex imaging is suboptimal or equivocal in the presence of atypical symptoms or uncommon vascular abnormalities.

Adult↗
PubMed2002

[Carotid endarterectomy in chronic renal failure patients: report of two cases].

Chronic renal failure is one of the risk factors for carotid atherosclerosis. We report two cases of stenosis of the carotid bifurcation treated by carotid endarterectomy. A 66-year-old man with a 17-year history of hemodialysis experienced repeated episodes of right hemiparesis. Cerebral angiography showed severe stenosis of the cervical carotid bifurcation bilaterally. Left and right carotid endarterectomy operations were performed one month apart. The postoperative course was uneventful, and the patient returned home without neurological symptoms. The second case was in a 49-year-old woman with a 15-year history of hemodialysis had vertigo of one month duration. Cerebral angiography revealed occlusion of the left subclavian artery, and the distal left axillary artery was filled by retrograde flow from the left vertebral artery. Stenosis of the right carotid bifurcation was also noted. Right carotid endarterectomy was performed without any complications. Although a high incidence of intraoperative complications and of recurrent stroke after carotid endarterectomy (CEA) has been reported in chronic renal failure patients, the poor prognosis of the natural history of severe carotid stenosis in chronic renal failure should be taken into consideration. The cases reported indicate that carotid endarterectomy is safe and justified for carotid stenosis in chronic renal failure patients.

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