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PubMed1997

Recurrent laryngeal nerve dysfunction following carotid endarterectomy.

Recurrent laryngeal nerve dysfunction is a significant complication of carotid endarterectomy and vocal cord paralysis is a major source of morbidity. This study prospectively assessed patients undergoing carotid endarterectomy to determine the nature and frequency of vocal cord damage and attempt to identify avoidable factors. Fifty consecutive patients undergoing carotid endarterectomy for symptomatic disease were studied. A standardized surgical technique was used emphasizing identification of the vagus nerve and minimal disturbance of the surrounding tissues. All patients underwent pre-operative and post-operative (day 2) indirect laryngoscopy and videostroboscopy. Pre-operative assessment found asymptomatic compensated vocal cord paralysis in one patient who had previously had a stroke. Post-operative laryngoscopy revealed asymptomatic impaired vocal cord mobility in three patients (6%) all of whom recovered completely. In addition six patients (12%) developed post-operative hoarseness of whom five have fully recovered. The remaining patient (2%) developed vocal cord paralysis which is permanent to date. This prospective study demonstrates that recurrent laryngeal nerve dysfunction is a common but often transient complication of carotid endarterectomy. The incidence of vocal cord paralysis in this group was less than many of the reported series. This could be due to the technique of minimal dissection which may prevent disturbance of the vagal segmental blood supply. Pre-operative vocal cord assessment is essential in all patients undergoing carotid endarterectomy.

Aged↗
PubMed1996

Contribution to technique of endarterectomy of the right coronary artery.

We present our technique of performing endarterectomy of coronary arteries by means of injecting cardioplegic solution into the plane of dissection of the endarterium. This simple and gentle technique in combination with manual endarterectomy helps in separation of the core far into the periphery of the diseased vessel and thus helps to perform revascularization in patients with diffuse atherosclerotic changes. During the last 6 years (1991-1996) endarterectomy in coronary revascularization was used in 116 cases (it was 5.7 % (116/2031) of all myocardial revascularization procedures). On right coronary artery endarterectomy was used in 82 patients. Mortality rate in our group of patients was 4.88 % (4/82) and perioperative myocardial infarction developed in 4.88 % (4/82). According to our own experience with this technique of endarterectomy on right coronary artery we are convinced that in desperate patients with diffuse coronary artery disease our method can bring better and wider application of surgical treatment.

Adult↗
PubMed1997

[Carotid endarterectomy by eversion and reimplantation. Techniques and results].

Endarterectomy of the carotid bifurcation through a longitudinal arteriotomy of the common and internal carotid arteries followed by a direct closure is still accepted as the main surgical technique for carotid stenoses. However, this technique is complicated in about 10% of the cases by a restenosis. Mechanisms of myointimal hyperplasia leading to restenosis are not completely explained. The technique of eversion endarterectomy of the internal carotid artery has been said to be an alternate technique which could decrease the incidence of restenosis. We described the three main techniques of eversion endarterectomy and their results. The technique of eversion endarterectomy after proximal section of the internal carotid artery is the most frequently used. It allows to treat easily length excess of the internal carotid artery. Its results are good in terms of neurologic morbidity and mortality. However, randomized comparative studies are still required in order to determine its role on the incidence of restenosis despite the first encouraging results of first non comparative studies. The technique of eversion endarterectomy after distal section of the internal carotid artery has been proposed by Chevalier who reported also good short term results and no delayed restenosis.

Carotid Artery, Internal↗
PubMed2005

Review of developments in anesthesia for carotid endarterectomy.

PURPOSE OF REVIEW: Analysis of recent data indicates a clear benefit of carotid endarterectomy for symptomatic patients with high-grade carotid artery stenosis, and a marginal benefit for asymptomatic patients. Despite myriad challenges presented by patients undergoing carotid endarterectomy, excellent outcomes have been achieved and many centers have shown the technique to be safe as an outpatient procedure for specific populations. Greater attention to comorbidities and their management in the perioperative period is increasingly important as older and more complex patients present for invasive treatment of carotid disease. Scientific study aimed at defining which characteristics merit our attention will only lead to improved outcomes and greater understanding of carotid disease, endarterectomy and anesthesia. While controversial, the efficacy, safety, and durability of stenting and angioplasty have improved in recent years. Potential advantages of stenting and angioplasty of the carotid artery include avoiding cranial nerve damage, wound hematoma, and general anesthesia. Staying abreast of the science regarding such endovascular therapies will be increasingly important. RECENT FINDINGS: The major areas of investigative interest include patient selection, anesthetic technique, and monitoring for carotid endarterectomy, and durability of stenting and angioplasty of the carotid artery. SUMMARY: Patients with significant comorbidities may be managed safely by a variety of anesthetic techniques. Maintaining hemodynamic stability and monitoring cerebral oxygen delivery remain important goals of perioperative management. Recent data regarding the durability and safety of stenting and angioplasty of the carotid artery suggest that outcomes may approach those of carotid endarterectomy.

Journal Article↗
PubMed1999

Carotid endarterectomy for carotid stenosis: audit at a tertiary referral centre.

Prospective randomised controlled trials performed in North America and Europe have demonstrated that the risk of future stroke or death is substantially reduced by performing carotid endarterectomy in symptomatic patients who have severe carotid stenosis. An audit was conducted to analyse the results of carotid endarterectomy performed during a 3-year period, at a tertiary referral vascular centre in Hong Kong. A total of 35 patients who had significant carotid stenosis underwent 36 carotid endarterectomies from October 1994 to September 1997. All patients recovered uneventfully without neurological complications or mortality. The audit showed that the current results of carotid endarterectomy at this institution fulfilled the criteria advised by the Stroke Council of the American Heart Association in 1995. Therefore, carotid endarterectomy is a validated therapeutic option for carotid stenosis in Hong Kong.

Journal Article↗
PubMed2002

The appropriate use of carotid endarterectomy.

For the first 30 years after carotid endarterectomy was first developed, anecdotal evidence was used to identify patients with internal carotid artery disease for whom this procedure would be appropriate. More recently, the appropriateness of carotid endarterectomy for symptomatic patients and asymptomatic subjects has emerged from 7 randomized trials. Risk of stroke and benefit from the procedure are greatest for symptomatic patients with at least 70% stenosis of the internal carotid artery. Within this group, carotid endarterectomy is most beneficial for the following patients: otherwise healthy elderly patients, those with hemispheric transient ischemic attack, those with tandem extracranial and intracranial lesions and those without evidence of collateral vessels. Risk of perioperative stroke and death is higher in the following groups, although they still benefit: patients with widespread leukoaraiosis, those with occlusion of the contralateral internal carotid artery and those with intraluminal thrombus. Patients with 50% to 69% stenosis experience lesser benefit, and some other groups may even be harmed by carotid endarterectomy, including women and patients with transient monocular blindness only. The procedure is indicated for patients presenting with lacunar stroke and for those with a nearly occluded internal carotid artery, but the benefit is muted. Patients with less than 50% stenosis do not benefit. In the largest randomized trial of asymptomatic subjects, the perioperative risk of stroke and death was very low (1.5%), but the results indicated that a prohibitively high number of subjects (83) must be treated to prevent one stroke in 2 years. The subsequent literature reported higher perioperative risks (2.8% to 5.6%). In asymptomatic individuals nearly half of the strokes that occur may be due to heart and small-vessel disease. These limitations counter any potential benefit. Another trial is in progress and may identify subgroups of asymptomatic subjects who would benefit. Meanwhile, most individuals without symptoms fare better with medical care.

Adult↗
PubMed2000

Institutional peer review can reduce the risk and cost of carotid endarterectomy.

HYPOTHESIS: Surgeon-directed institutional peer review, associated with positive physician feedback, can decrease the morbidity and mortality rates associated with carotid endarterectomy. DESIGN: Case series. SETTING: Tertiary care university teaching hospital. PATIENTS/INTERVENTIONS: All patients undergoing carotid endarterectomy at our institution during a 5-year period ending August 1998. RESULTS: Stroke rate decreased from 3.8% (1993-1994) to 0% (1997-1998). The mortality rate decreased from 2.8% (1993-1994) to 0% (1997-1998). Length of stay decreased from 4.7 days (1993-1994) to 2.6 days (1997-1998). The total cost decreased from $13,344 (1993-1994) to $9548 (1997-1998). CONCLUSIONS: An objective, confidential peer review process that provides ongoing feedback of performance to surgeons and documents that performance in relationship with that of peers seems to be effective in reducing the morbidity and mortality rate associated with carotid endarterectomy. In addition, the review process lowered the hospital cost of performing carotid endarterectomy.

Aged↗
PubMed2002

Bovine pericardium vs dacron for patch angioplasty after carotid endarterectomy: a prospective randomized study.

HYPOTHESIS: Bovine pericardium (BP) demonstrates improved intraoperative hemostasis and equivalent perioperative morbidity compared with Dacron when used as patch material for angioplasty following carotid endarterectomy. OBJECTIVE: To prospectively compare BP and Dacron patch angioplasty after carotid endarterectomy in a randomized fashion. METHODS: Ninety-five consecutive primary carotid endarterectomies were performed in a prospective randomized fashion in 92 patients. Fifty-one procedures were performed using BP and 44 using Dacron. Intraoperative suture line bleeding was subjectively evaluated by observing bleeding at 3 and 4 minutes following carotid cross-clamp removal and then objectively weighing the sponge used to tamponade bleeding during these time intervals. Perioperative morbidity, including cervical wound hematoma, transient ischemic attack, and stroke, and perioperative mortality were recorded. Statistical analysis was performed using paired t tests, chi(2) analysis, Fisher exact test, or multiple linear regression as appropriate. RESULTS: Suture line bleeding at 3 minutes was present in 7 (14%) of 51 patients in the BP group and 24 (55%) of 44 patients in the Dacron group (P<.001). Suture line bleeding evaluated at 4 minutes was present in 2 (4%) of 51 patients in the BP group and 13 (30%) of 44 patients in the Dacron group (P =.001). Net +/- SEM sponge weight (total intraoperative suture line bleeding) was 6.25 +/- 0.55 g in the BP group and 16.34 +/- 1.85 g in the Dacron group (P<.001). Total suture line bleeding was significantly affected by activated clotting time; however, multivariate analysis demonstrated that bleeding was significantly less with BP (P<.001) even after adjusting for differences in activated clotting time. CONCLUSIONS: Bovine pericardium demonstrated a statistically significant decrease in intraoperative suture line bleeding compared with Dacron. Handling characteristics were judged by the surgeons to be superior for BP. Therefore, we believe BP may be an alternative to Dacron when performing patch angioplasty of the carotid artery after endarterectomy.

Aged↗
PubMed2005

Carotid endarterectomy in nonagenarians.

HYPOTHESIS: The North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial demonstrated that a greater benefit from carotid endarterectomy (CEA) was seen in elderly compared with younger patients. However, no patients older than 89 years were included in either study. We hypothesized that CEA is safe and effective in patients 89 years and older. DESIGN AND SETTING: This is a retrospective review of 3 neurosurgeons' CEA experience with nonagenarian patients. PARTICIPANTS AND INTERVENTIONS: Of our 1800 patients who underwent CEA, 26 were 89 years or older. Twenty-three patients had had cerebral ischemic symptoms (unilateral hemispheric symptoms in 21 and 2 dizzy spells associated with bilateral high-grade stenosis). Cerebral angiography was performed in 3 patients. Twenty-three patients underwent noninvasive imaging. Four patients had bilateral high-grade stenosis and underwent staged bilateral CEA. All procedures were performed after the induction of general anesthesia with electroencephalographic (and, more recently, transcranial Doppler) monitoring and etomidate-induced burst suppression for cerebral protection during cross-clamping. RESULTS: Unusual technical difficulties were frequently noted, including high bifurcations, looping rotated internal carotid arteries, and marked adherence of surrounding soft tissues. In 3 of the 30 procedures, a shunt was used. There were no perioperative cerebral ischemic or cardiac events. The mean hospital stay was 2 days. One patient had a transient vocal cord paresis. Twenty-two patients were alive and well 24 months following the procedure. Four patients died of non-stroke-related causes. CONCLUSIONS: Carotid endarterectomy was successfully performed without perioperative cerebral or cardiac complications in our series of 26 patients 89 years and older undergoing 30 CEAs. Extrapolating from reported results from the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial, we believe CEA should be considered in nonagenarian patients with high-grade symptomatic carotid stenosis who are otherwise well medically. Our recommendations are less certain in the case of asymptomatic disease.

Age Factors↗
PubMed1975

Evaluation of endarterectomy for aortoiliac and aortoiliofemoral occlusive disease.

During the past 11 years, 180 patients with aortoiliac and aortoiliofemoral occlusive disease were treated exclusively by endarterectomy. There were 59 patients in the former group and 121 patients in the latter group. A standard method of aortoiliac endarterectomy was applied to all patients. However, when disease extended to the external iliac and common femoral arteries, the eversion endarterectomy proved to be an invaluable technical aid. Cumulative patency rates to 11 years for the aortoiliac group was 85.7%, and for the aortoiliofemoral group it was 90.6%. Our results suggest that endarterectomy is the procedure of choice for the management of obilterative disease in the aorta, iliac, and femoral arteries.

Adult↗
PubMed1979

Failure of carotid stump pressures. Its incidence as a predictor for a temporary shunt during carotid endarterectomy.

A total of 289 carotid endarterectomies were performed in 204 patients. A decision to place a temporary shunt during carotid endarterectomy in this series was made entirely on the basis of intraoperative EEG monitoring. Retrospectively, the correlation between stump pressures and the results of intraoperative EEG monitoring in each case was determined. Evidence of ischemia developed in 6% of the total series on intraoperative EEG monitoring despite a stump pressure of greater than 50 mm Hg. The degree of disagreement between stump pressure and EEG varied according to clinical category in this series. In those endarterectomies performed for completed stroke, all cases requiring shunting had stump pressures less than 50 mm Hg. In those cases performed for symptoms of vertebral basilar insufficiency, however, 77% of the cases requiring an intraoperative shunt had stump pressures greater than 50 mm Hg. A review of the complication rate in the various study groups indicates that the use of intraoperative EEG is a safe indicator of cerebral ischemia during carotid endarterectomy regardless of stump pressure.

Blood Pressure↗
PubMed1981

Postoperative stroke and late neurologic complications after carotid endarterectomy.

From 1969 through 1973, 335 consecutive patients (mean age, 60 years) underwent 390 carotid endarterectomies using hypercarbic general anesthesia and no carotid shunting. Early neurologic complications were most common among patients with previous neurologic symptoms and among those with subtotal stenosis or occlusion of the contralateral internal carotid artery. The introduction of routine carotid shunting without hypercarbia during a subsequent series of 626 procedures from 1974 through 1978 has been associated with significantly fewer operative strokes in comparable groups of patients. Complete follow-up information during a mean interval of 8.6 years is available for 95% of 325 operative survivors. Late completed strokes have occurred in 17% of patients but have involved the cerebral hemisphere on the side of previous carotid endarterectomy in only 7%. Of 93 operative survivors who had subtotal stenosis of the contralateral internal carotid artery, 45 underwent contralateral endarterectomy as an elective procedure and 48 did not. The late contralateral stroke rates for these two groups of patients were 4% and 16%, respectively, although these differences did not attain statistical significance. Forty-nine (78%) of 63 patients with contralateral internal carotid occlusion have had no late neurologic symptoms following unilateral carotid endarterectomy.

Adult↗
PubMed1984

Stenosis following carotid endarterectomy. Its implication in management of asymptomatic carotid stenosis.

Carotid endarterectomy is established in the treatment of atherosclerosis of the carotid bifurcation, but the incidence of restenosis and the role of endarterectomy in the management of asymptomatic carotid stenosis are variable. During a four-year period, we performed 80 endarterectomies of the internal carotid artery in 73 patients. Patients were prospectively studied by means of Doppler ultrasonography in combination with real-time spectral analysis to determine the incidence of restenosis postoperatively. A concomitant study of 116 patients with 79 asymptomatic carotid stenoses was undertaken. We found a 12.5% incidence of stenosis following carotid endarterectomy and a 3% risk of transient neurologic deficit in the patients with asymptomatic carotid stenoses.

Aged↗
PubMed1987

Incidence and mechanism of post-carotid endarterectomy hypertension.

Hypertension following carotid endarterectomy occurs frequently but is poorly understood. Its occurrence has been correlated with an increased incidence of neurologic complication. We identified those factors that correlate with an increased incidence of post-carotid endarterectomy hypertension. The records of 100 patients who underwent carotid endarterectomy at UCLA Medical Center from November 1981 to September 1983 were examined. One hundred fifty variables were surveyed to determine those factors associated with this problem. Fifty-eight percent of the study patients developed post-carotid endarterectomy hypertension (an increase in systolic blood pressure greater than 35 mm Hg over baseline, and/or blood pressure requiring treatment with sodium nitroprusside). Of patients who developed this problem, 93% had diabetes mellitus, 75% received isoflurane anesthesia, 71% had peripheral vascular occlusive disease, 71% underwent ipsilateral transient ischemic attacks, and 65% had high-grade ipsilateral carotid stenosis. These variables have in common the loss of or interference with cerebral autoregulation. Central dysautoregulation may set the stage for a positive feedback mechanism that results in increased blood pressure. Anesthetic agents that do not interfere with cerebral autoregulation may reduce the incidence of this complication, and an aggressive treatment program may prevent neurologic complications.

Adult↗
PubMed1992

Results of staged bilateral carotid endarterectomy.

To determine differences in outcome between unilateral and staged bilateral carotid endarterectomies, we reviewed 850 carotid endarterectomies done by 14 surgeons in a community hospital. Results of 528 unilateral procedures were compared with those of 161 bilateral procedures. Data were abstracted from records for an 11-year period. Twelve of the patients in the unilateral group had nonfatal strokes, and 14 died within 30 days of surgery (stroke + death rate, 4.9%). There were no nonfatal strokes among patients in the bilateral group, and nine died (stroke + death rate, 5.6%). Seven of 14 deaths in the unilateral group and six of nine deaths in the bilateral group were due to neurologic events. In the bilateral group, death was associated with postoperative hypertension and a short intersurgical interval. The stroke + death rate was not significantly different between unilateral and bilateral procedures and compared favorably with North American Symptomatic Carotid Endarterectomy Trial guidelines and other published reports. Staged bilateral carotid endarterectomy can be safely performed in a community hospital.

Carotid Artery Diseases↗
PubMed1994

Do neck incisions influence nerve deficits after carotid endarterectomy?

OBJECTIVES: To determine whether transverse neck incisions for carotid endarterectomy were associated with a similar or greater incidence of cranial nerve complications when compared with vertical skin incisions, and to assess the patient's perception of the appearance of the incision. DESIGN: Prospective, but not randomized. SETTING: A university-affiliated tertiary care hospital. PATIENTS/INTERVENTIONS: Eighty-five consecutive carotid endarterectomy procedures were evaluated prospectively in 80 patients. Although patients were not randomly assigned, consideration was given to having approximately the same number of patients who had carotid endarterectomy performed through transverse neck incision as through vertical neck incision. Forty-four carotid endarterectomies were performed with a vertical incision and 41 procedures were performed with a transverse incision. MAIN OUTCOME MEASURE: To determine the incidence of cranial nerve dysfunction (primarily nerves VII and XII) after operation. RESULTS: The incidence of palsies of cranial nerves VII and XII in the two groups was similar; there was no statistical significance (the seventh nerve palsy, 32% transverse vs 25% vertical; the 12th nerve palsy, 15% transverse vs 20% vertical). Seventy-two percent of the deficits had disappeared by the 3- to 6-month follow-up. Patients expressed a clear preference for the transverse incision (P = .04). CONCLUSIONS: Although surgical exposure was simpler with the vertical incision, adequate exposure with the transverse incision was always possible. The incidence of mostly temporary deficits of cranial nerves VII and XII was similar. Patients favored the transverse incision.

Aged↗
PubMed1996

Mechanisms of neurologic deficits and mortality with carotid endarterectomy.

OBJECTIVE: To evaluate the incidence and etiology of perioperative complications of carotid endarterectomy. DESIGN: Retrospective review of carotid endarterectomies performed over 13 years. Risk factors, indications, results of electroencephalographic (EEG) monitoring, and outcomes were evaluated. SETTING: University medical center. PATIENTS: Three hundred sixty-seven consecutive primary carotid endarterectomies were performed on 336 patients. Indications for operation included transient ischemic attack (48.5%), asymptomatic stenosis (24%), stroke (17%), nonlateralizing ischemia (9.5%), and stroke-in-evolution (1%). MAIN OUTCOME MEASURES: Postoperative neurologic deficits (permanent and transient) and deaths were correlated with preoperative symptoms, probable mechanism of the neurologic event, intraoperative EEG changes, and the use of intraoperative shunts. RESULTS: Four new permanent neurologic deficits (1.1%) and one transient postoperative deficit were noted. Of the five deficits, three were related to undiagnosed intraoperative cerebral ischemia and two were related to perioperative emboli. Three perioperative deaths (0.8%) occurred: two of myocardial infarction and one of an intracerebral hemorrhage from a ruptured arteriovenous malformation. Intraoperative EEG tracings for the most recent consecutive 175 procedures were analyzed. Shunts were used in 45 patients (26%), 38 of whom demonstrated significant EEG changes with carotid clamping. CONCLUSIONS: Carotid endarterectomy can be performed with a low risk of stroke (1.1%) and death (0.8%). Stroke was due to cerebral ischemia or embolization. With meticulous surgical technique, death is due to myocardial ischemia and not neurologic events.

Adult↗
PubMed2000

Local versus general anaesthesia for carotid endarterectomy.

BACKGROUND: Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic. OBJECTIVES: The objective of this review was to assess the effect of endarterectomy under local compared with general anaesthetic. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register, Medline (1966 to 1995), Embase (1980 to 1995), and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched Annals of Surgery (1981 to 1995), British Journal of Surgery (1985 to 1995), European Journal of Vascular Surgery (1988 to 1995) and World Journal of Surgery (1978 to 1995). Reference lists of articles were searched. SELECTION CRITERIA: Randomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic. DATA COLLECTION AND ANALYSIS: One reviewer selected studies for inclusion and another independently checked the decisions. Two reviewers assessed trial quality and independently extracted the data. MAIN RESULTS: Three randomised trials involving 143 patients, and 17 non-randomised studies involving about 5970 patients were included. The methodological quality of the randomised trials was questionable. Two of the non-randomised studies were prospective and 12 reported on a consecutive series of patients. In nine non-randomised studies the number of patients, as opposed to the number of arteries, was unclear. There were insufficient data to enable conclusions to be drawn from the randomised trials. In 15 non-randomised studies, no significant difference was shown between local and general anaesthetic in deaths within 30 days of operation (odds ratio 0.61, 95% confidence interval 0.32 to 1.16). Non-randomised studies showed that local anaesthetic was associated with a significant reduction in the odds of stroke (15 studies), stroke or death (14 studies), myocardial infarction (12 studies), and pulmonary complications (five studies), within 30 days of the operation. Patient and surgeon satisfaction were not reported in any study. REVIEWER'S CONCLUSIONS: There is not enough evidence from randomised trials comparing carotid endarterectomy performed under local as opposed to general anaesthetic. Non-randomised studies suggest potential benefits with local anaesthetic. However these studies are likely to be significantly biased.

Anesthesia, General↗