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PubMed2002

[Complications of carotid endarterectomy].

BACKGROUND AND PURPOSE: Carotid endarterectomy has been shown to be beneficial in patients with high-grade carotid stenosis. This benefit will be realized only if the operation is performed safely. We determined the ratio of operative complications and sought to identify the risk factors for operative stroke and death from carotid endarterectomy. METHODS: Two hundred fifty seven patients underwent carotid endarterectomy during 1995-1999 years in Vilnius emergency hospital. Nineteen potential risk factors for operative complications were examined. RESULTS: Mortality of endarterectomy was 2.7%, the overall risk of stroke and/or death was 4.3%. In multivariate logistic-regression models a symptom status (recent history of stroke) and angiographic features (contralateral stenosis 70% and more) were as independent risk factors for operative stroke and death. CONCLUSIONS: The risk of stroke and death from carotid endarterectomy is related to clinical and angiographic characteristics. These observations may help clinicians to estimate operative risks for individual patients.

Adult↗
PubMedDate not supplied

Effect of anesthetic management on resource utilization and outcome in carotid endarterectomy patients.

Several well-controlled randomized trials have demonstrated the efficacy of carotid endarterectomy for prevention of stroke in patients with symptomatic, severe (> 70%) internal carotid artery stenosis. This benefit has resulted in a significant increase in the number of carotid endarterectomies performed annually. However, the benefit of carotid endarterectomy depends on low perioperative stroke, death and complication rates. This fact has drawn the attention of third party payers and there is considerable emphasis on further decreasing complications and medical expenditures. Implementations of clinical pathways and preventive strategies to obviate complications that increase length of stay and hospital costs have been critical. Although the incidence of perioperative stroke has decreased considerably over the recent years, cardiac and other systemic complications have remained relatively stable. Even though there is no unequivocal evidence of one anesthesia technique over another, several trials have suggested suggested improved clinical outcomes and economic benefit for carotid endarterectomies performed under regional anesthesia. This article describes a study at West Virginia University to assess the role of anesthetic management upon resource utilization and outcome in patients undergoing carotid endarterectomy.

Aged↗
PubMed2005

Carotid endarterectomy in heart transplant patients.

AIM: The aim of this study was to determine the clinical outcome of carotid endarterectomy in heart transplant recipients and morphologic features of atherosclerotic plaques removed during operation. METHODS: Between April 1993 and October 2001 5 heart transplant patients with symptomatic carotid stenosis >70% underwent carotid endarterectomy with regional anesthesia, including a staged bilateral procedure in one patient. Cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol were evaluated in each patient. The plaques ( n=6) underwent histologic analysis after carotid endarterectomy. Carotid artery duplex imaging was added to the routine postoperative evaluation. RESULTS: Carotid plaques resulted to be echolucent on B-mode ultrasound examination. Cholesterol, triglycerides and LDL-cholesterol levels were found to be increased, while HDL-cholesterol were decreased. All patients underwent successful carotid endarterectomy; there were no perioperative deaths, major neurologic or cardiac events. The mean length of stay was 2.2 days. The mean follow-up was 44 months. In 1 case, an asymptomatic restenosis >50% occurred 9 months later and, in 2 other cases, a contralateral mild stenosis was found 12 and 36 months later. One patient had a progressive contralateral stenosis, requiring operation 18 months later. High lipid content and heterogeneous cellular infiltration were observed, including macrophages, T-lymphocytes, neutrophils, and also eosinophils in the rapidly progressing plaque. CONCLUSIONS: Heart transplant patients receiving immunosuppression may successfully undergo carotid endarterectomy, without increased risk, but progression of atherosclerotic disease in the carotid arteries seems to continue, despite lipid-lowering regimen and antiplatelet therapy.

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PubMed2006

[Off-pump coronary artery bypass with endarterectomy].

The diffusely diseased left anterior descending coronary artery (LAD) remains a challenge for both interventional cardiologists and cardiac surgeons. We assessed the surgical outcomes obtained from off-pump coronary artery reconstruction, with or without endarterectomy, for a diffusely diseased LAD. One hundred and eighteen patients were treated with an extended LAD reconstruction, with or without endarterectomy. The left internal thoracic artery (LITA) was used to reconstruct the LAD in all patients. Coronary artery reconstruction was performed without endarterectomy in 63 patients and with endarterectomy in 55 patients. The operative mortality was 0.8%. Perioperative myocardial infarction was observed in 14.4% of the patients. The mean LAD incision length was 5.6 +/- 1.4 cm. The patency rate of the LITA to LAD was 96.2% by early angiographic examination. Coronary artery reconstruction, with or without endarterectomy, using the LITA for a diffusely diseased LAD can be performed with acceptable results.

Coronary Artery Bypass, Off-Pump↗
PubMedDate not supplied

Is cerebral arteriography necessary for decision making in carotid endarterectomy?

The development of ultrasonic diagnostic imaging technics has recently been a competitive diagnostic method in cerebral arteriography. Many vascular surgeons, based on the high specificity and sensitivity of the ultrasonic imaging technics in carotid artery disease, have been performing carotid endarterectomy without arteriography with satisfactory results. In the last four years we have performed in our Department 62 carotid endarterectomies on 57 patients without using cerebral arteriography. In this paper diagnostic ultrasonic imaging and transcranial Doppler technics are presented and the immediate results of carotid endarterectomy in the above series of patients are reported. From our and other authors' experience it is concluded that carotid endarterectomy in patients with carotid artery disease is a safe procedure. Larger series of patients are needed with a longer follow-up in order that carotid endarterectomy without arteriography be accepted by the medical profession as a safe procedure.

Adult↗
PubMed1991

[Cervical carotid endarterectomy. Evaluation of a 12 years' experience (260 operations)].

From 1978 to 1989, 235 patients were operated upon with 260 procedures for cervical carotid endarterectomy. The patients were classified according to the presence or absence of ischemic symptomatology, and for symptomatic patients, according to the reversibility or persistence of ischemic symptoms. So the selection of patients was: reversible ischemia 46%, stroke 29%, asymptomatic patients 25%. In the stroke group, no patient was operated on in emergency, the endarterectomy was performed after stabilization of the patients. Three subgroups were included in patients operated on for asymptomatic carotid stenosis: casual discovery 40%, treatment of the second carotid artery (previous endarterectomy for symptomatic controlateral carotid artery) 34%, and treatment of the second carotid artery (previous ECIC Bypass for controlateral occluded artery) 26%. All patients were operated upon after angiographic exploration (femoral catheterism in most cases), and after cerebral CT Scan. The surgical technique included general anesthesia, systematic shunting, endarterectomy after longitudinal arteriotomy, closure without patch. The operative microscope has been used since 1985. The operatives results were studied in terms of uneventful post-operative course (87.3%), reversible complications (8.1%) and long lasting complications (4.6%). The long lasting complications were of local origin (1.1%), of neurological origin (2.3%), of general origin (1.2%). Overall the operative results at 6 months were: return to previous clinical state 95.4%, neurological sequellae 1.5%, deaths 3.1%. In patients operated on for asymptomatic carotid stenosis the overall results were: previous clinical state 97%, death 3%. The legitimy of carotid endarterectomy procedure is discussed in view of some recent pertinent literature.

Adult↗
PubMed1990

Carotid endarterectomy.

Carotid endarterectomy is a surgical procedure to remove atherosclerotic occlusions from the carotid artery. The surgery is usually performed in patients with transient ischemic attacks (TIAs), asymptomatic stenosis, or stroke in order to reduce stroke risk and increase cerebral blood flow. Complication rates vary widely among surgeons and hospitals, and numerous studies testing the efficacy of carotid endarterectomy and documenting its associated morbidity and mortality have produced conflicting or inconclusive results. No properly designed prospective clinical trial has convincingly demonstrated this surgery to be superior or inferior to nonoperative management for any subset of patients with carotid artery disease. There has been no definitive study concluding that patients with TIA benefit from carotid endarterectomy. The benefits for asymptomatic patients are even less clear. Among the alternative surgical and medical treatments advocated for occlusive carotid disease, none has clearly demonstrated superior therapeutic results. It is generally agreed that current ongoing prospective, randomized, controlled clinical trials are likely to provide the data required for determination of optimal therapy and better identify subsets of patients who are most likely to benefit from carotid endarterectomy. Until the results of these clinical trials become available, the proposed benefits of carotid endarterectomy must be regarded as indeterminate.

Arteriosclerosis↗
PubMed1990

Is routine duplex examination after carotid endarterectomy justified?

Routine follow-up of patients after carotid endarterectomy with duplex scanning is commonly practiced, yet the clinical significance of identifying those with asymptomatic restenosis is unclear. To address this issue we reviewed 120 consecutive patients who underwent 143 carotid endarterectomies from August 1983 to December 1988. One hundred one patients (118 operations) were available for clinical follow-up, and the overall incidence of recurrent symptoms was 6% (6/101). Sixty-three of these patients (78 carotid endarterectomies) had postoperative duplex examination. Two had evidence of residual disease from the time of surgery and were not included in further analysis. Significant recurrent stenosis (greater than 50% diameter reduction) developed in 14 of the remaining 76 arteries (18.2%). Twelve of 14 stenoses remained asymptomatic during follow-up from 18 to 72 months (mean 47.0 months) and did not undergo reoperation. Recurrent ipsilateral hemispheric symptoms developed in two patients with restenosis (14.3%). Four of the 62 arteries without significant recurrent stenosis developed ipsilateral symptoms (6.5%), but none required reoperation during follow-up from 1 to 71 months (mean 31.6 months). Life-table analysis showed no increased risk of transient ischemic attack, stroke, or death in patients with restenosis. This study supports regular clinical follow-up after carotid endarterectomy with emphasis on patient education in the recognition of symptoms. Although duplex scanning may be useful to follow known contralateral asymptomatic disease or evaluate those with recurrent symptoms, its routine use to identify patients with asymptomatic restenosis after carotid endarterectomy may be unnecessary.

Aged↗
PubMed1987

Late results after carotid endarterectomy for amaurosis fugax.

Amaurosis fugax is considered an ocular transient ischemic attack with an ominous prognosis. One hundred twenty-eight patients with amaurosis fugax as the presenting symptom underwent carotid endarterectomy at the University of California, San Diego (UCSD) and Scripps Clinic between 1970 and 1985 with one death (0.8%) and one postoperative permanent stroke (0.8%). Subsequently, these patients were followed up for 6 to 160 months (mean 45.3 months). Only two subsequent late strokes were documented (at 2 and 5 years after operation). These results were significantly better (p less than 0.01) by life-table analysis than the late stroke rate after carotid endarterectomy performed to treat anterior motor transient ischemic attacks at both UCSD and Scripps Clinic, as well as the reported late follow-up for all transient ischemic attacks after carotid endarterectomy in the literature (1.8% per year, 17 publications, 1980 operations). Thus amaurosis fugax appears to be a particularly favorable indication for carotid endarterectomy. Left untreated, this event carries a high risk of stroke; after carotid endarterectomy, which has a low operative risk, there is a very low postoperative stroke rate (two strokes in 448 patient-years of follow-up).

Actuarial Analysis↗
PubMed1986

Changing patterns in the practice of carotid endarterectomy in a large metropolitan area.

Changes in the practice of carotid endarterectomy were studied by review of all endarterectomies performed in the greater Cincinnati area during 1980 and from July 1983 through June 1984. The number of operations rose from 431 to 750 (74% increase). The perioperative stroke rate fell from 8.6% in 1980 to 5.1% in 1983-1984; operative mortality declined from 2.8% to 2.3%; and the combined stroke or death rate declined from 9.5% to 6.5%. Asymptomatic carotid artery disease was the indication for 50% of the endarterectomies during both time periods. The combined stroke or death rate for asymptomatic patients declined from 6.9% to 5.3%, but both rates were higher than the 3% suggested as acceptable for prophylactic carotid endarterectomy. We conclude that carotid endarterectomy is becoming an increasingly common procedure, that morbidity continues to decline, and that mortality continues to be significant. Citywide surgical morbidity and mortality remain excessive for patients with asymptomatic carotid disease.

Aged↗
PubMed1984

Hypertension following carotid endarterectomy: the role of cerebral renin production.

The cause of hypertension in the immediate postoperative period after carotid endarterectomy is unknown. In order to elucidate the etiology of hypertension following carotid endarterectomy, blood samples were drawn intraoperatively from internal jugular vein and external carotid artery prior to and subsequent to carotid endarterectomy in 20 patients. Renin measurement in these samples produced a ratio of internal jugular vein (cerebral) to external carotid artery (systemic). In pre-endarterectomy samples, this cerebral-to-systemic ratio was 1.0 +/- 0.17. However, in the six patients hypertensive postoperatively, this ratio was significantly (p less than 0.02) higher at 1.39 +/- 0.4 than in 14 patients not hypertensive, 0.99 +/- 0.28. Although this ratio in hypertensive patients reverted to 1.12 +/- 0.24 in the postoperative period, the present study suggests a relation between hypertension after carotid endarterectomy and renin production by the brain.

Aged↗
PubMed1983

The role of real-time B-mode ultrasonography and ocular pneumoplethysmography following carotid endarterectomy.

Real-time B-mode ultrasonography and ocular pneumoplethysmography (OPG-G) were used to evaluate 41 patients (54 arteries) following carotid endarterectomy. Thirteen patients had bilateral procedures. Recurrent stenosis was observed in three (6%), and postoperative occlusion in three (6%). In one symptomatic patient, the origin of an occluded external carotid artery was the source of atheroemboli. Only two of the seven patients were symptomatic and three of the seven had hemodynamically insignificant stenoses. Of the three patients with recurrent stenosis, two had a normal OPG-G and demonstrated the value of combinate noninvasive evaluation. The noninvasive diagnosis in these two cases was based on B-mode ultrasonography. Of the three postoperative occlusions, one had a normal OPG-G. Since the OPG-G cannot distinguish stenosis from occlusion, B-mode ultrasonography was necessary to demonstrate the presence of an occluded internal carotid artery and the absence of internal carotid flow in each case. B-mode ultrasonography also permitted the identification of several characteristic postoperative findings. An intimal shelf was often observed, corresponding to the proximal limit of the endarterectomy. Seventy-four per cent demonstrated thickening of the arterial wall and 45 per cent were observed to have calcification in the area of the endarterectomy. The true incidence of recurrent disease following carotid endarterectomy is uncertain, but it probably exceeds those estimates based on symptomatic recurrence. Because of the incidence of asymptomatic and/or hemodynamically insignificant disease, we recommend the routine use of noninvasive studies following carotid endarterectomy.

Arterial Occlusive Diseases↗
PubMed1983

[Comparative characteristics of gas and mechanical endarterectomy based on light and scanning electron microscopy].

A portion of a coronary artery removed at mechanical or gas endarterectomy shows the intima, internal elastic membrane and part of the media. After gas endarterectomy, the vascular "mould" is cone-shaped and pointed, resembling the main arterial trunk with lateral branches, whereas its surface is smooth. After mechanical endarterectomy, the main trunk "mould" may have no lateral branches, while its surface is rough. Electron microscopic scanning shows collagen and elastic fibres of the vascular wall to remain intact following gas endarterectomy, while after mechanical procedure they are torn and "stick out" on the surface, this observation providing anatomical evidence for the advantage of the gas technique over the mechanical one. Following endarterectomy, the vessel retains part of the media, outer elastic membrane and adventitia, whereas the vascular lumen closes due to dystonia of folding vascular wall.

Aged↗
PubMed1978

Role of staging in bilateral carotid endarterectomy.

Staging of bilateral carotid endarterectomies 1 to 6 weeks apart has been recommended because of presumed excessive morbidity chiefly related to respiratory problems, hypertension, and neurological deficits. Since data regarding the timing of the second procedure are lacking, an analysis of 79 consecutive patients undergoing bilateral endarterectomies staged from 6 days to 34 months apart (median interval, 52 days) was performed. In addition to postoperative neurological deficits, however, transient perioperative mean systolic and diastolic blood pressures (SBP and DBP) were compared after each side and were correlated with the time interval between the two procedures. No significant difference existed between the two sides in terms of preoperative hypertension, administration of steroids prior to clamping, intraoperative clamp time, the use of shunts, and the duration of operation (P greater than 0.05). Seven temporary neurological deficits occurred after operation, six after the first and one after the second endarterectomy. One permanent deficit following operation on the second side led to the only death (0.6%) in this series. Both neurological deficits (one temporary and one permanent) following the second endarterectomy occurred after procedures staged more than 60 days apart. No differences in mean SBP and DBP existed between patients with and without neurological deficits. Statistical analysis of SBP and DBP recordings during and 6, 12, 24, and 36 hours after operation when the two were staged 7 days (nine patients), 8 to 14 days (five patients), 15 to 30 days (10 patients), 30 to 60 days (17 patients), and more than 60 days (38 patients) apart revealed significantly higher readings after the second procedure, only in patients staged greater than 60 days (P less than 0.05). Therefore, in our experience, neurological deficits were less common after the second endarterectomy, and, although postoperative blood pressures were higher after the second side, these were significant only in patients staged more than 60 days apart. We find no evidence to suggest that increasing the waiting period between bilateral procedures will lower the incidence of undesirable neurological sequelae.

Arterial Occlusive Diseases↗
PubMed1993

Carotid endarterectomy in Durban--the first 10 years.

This study was a prospective evaluation of the Durban experience with carotid endarterectomy over the past decade. Since 1981, 478 carotid endarterectomies have been performed in 411 patients. The majority of these patients were white men, with an average age of 60.6 years. The indication for surgery was a lateralising transient ischaemic attack or amaurosis fugax in 65.5%, lateralising stroke (< 1 year before surgery) in 14.4%, non-lateralising global cerebral ischaemia in 9.4% and asymptomatic carotid stenosis in 10.7%. Carotid endarterectomy was performed under general anaesthesia and with invasive monitoring; 25% of patients underwent selective shunting. After open carotid bifurcation endarterectomy, all but 6 underwent primary closure (99.4%). The combined major stroke/mortality rate was 6%. This audit identified a group of patients who presented with a history of stroke within the year preceding surgery and who had a significantly higher postoperative stroke/mortality rate of 20.2%. Long-term follow-up, ranging from 1 month to 96 months, showed 80.7% to be stroke-free after 8 years. This audit demonstrates a postoperative stroke/mortality rate comparable to that of other series and additionally confirmed the durability of carotid endarterectomy in the long term.

Adult↗
PubMed1993

Coronary artery endarterectomy: a method of myocardial preservation.

The lack of acceptable coronary arteries for grafting often causes the cardiac surgeon considerable problems in treating patients with severe coronary artery disease. By combining the standard approach of coronary bypass surgery with coronary endarterectomy and with retrograde coronary sinus cardioplegia perfusion, we can achieve a longer ischemic period and can flush the debris from the coronary arteries in a retrograde fashion. Using this approach, we managed 72 patients with near inoperable coronary artery disease. One third of these patients required endarterectomy of more than one vessel. A higher than expected number of patients had diabetes mellitus. The left coronary artery system required endarterectomy in almost 60% of patients, much higher than percentages reported in other series of patients. The mortality rate in our patients who underwent the left system endarterectomy was 5.7%. Endarterectomy must be considered an adjunct in the management of high-risk patients with severe coronary artery disease.

Aged↗
PubMedDate not supplied

[Importance of the evaluation of cerebral vasoreactive capacity in the indication for carotid endarterectomy].

In order to evaluate the outcome of endarterectomy, we estimated the cerebral vasoreactive capacity in 3 main patient groups with carotid artery disease: A. occlusion, B. high-grade, and C. low-grade carotid stenosis. The results showed that certain proportion of patients with reduced CVC can be distinguished in the each investigated groups, indicating thus, those patients in whom endarterectomy can benefit. Our study provides evidence that acetazolamide test with TCD measuring may be used to assess the CVC before and after endarterectomy. Carotid endarterectomy improves CVC in patients who had compromised cerebral perfusion reserve before operation. We suggest that the endarterectomy can also benefit in the patients with carotid occlusion and low grade stenosis if CVC is estimated.

Acetazolamide↗
PubMed1996

Indications for intensive care unit care after carotid endarterectomy.

OBJECTIVES: To describe the complications of carotid endarterectomy and the interventions performed in the intensive care unit (ICU) after carotid endarterectomy. To identify preoperative and recovery room (RR) risk markers for these complications and interventions. DESIGN: A retrospective case study. SETTING: The ICU of a university hospital. PATIENTS: One hundred and one patients who required carotid endarterectomy over a 15-month period. INTERVENTION: Carotid endarterectomy (bilateral procedures in 11 patients). OUTCOME MEASURES: Demographic data including Goldman's cardiac risk index and the therapeutic intervention scoring system (TISS) score to measure the risk of complications. RESULTS: Most of interventions conducted in the RR and ICU were to control high blood pressure. In the RR, three patients experienced a neurologic event, one patient was reintubated for vocal cord paralysis and one had electrocardiographic abnormalities. Overall, 5 of the 101 patients had neurologic complications and 2 suffered a myocardial infarction. Two patients died, one as a result of a massive stroke and the other of myocardial infarction with cardiogenic shock. The mean (and standard deviation) TISS. score in the ICU was 12.6 (3.8). Analysis of all events in the RR was not predictive of events in the ICU. However, the absence of major complications in the RR had a negative predictive value of 97%. CONCLUSIONS: The decision to admit patients to the ICU after carotid endarterectomy should be based on major complications occurring in the RR. A low TISS score and low incidence of complications does not warrant routine admission.

Aged↗