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At least 433 records · Page 24Linked to original sources
PubMed2001

Effect of carotid endarterectomy on chronic ocular ischemic syndrome due to internal carotid artery stenosis.

OBJECTIVE: We evaluated the effect of carotid endarterectomy on chronic ocular ischemic syndrome due to internal carotid artery stenosis by use of data obtained from ophthalmic artery color Doppler flow imaging. METHODS: We examined 11 patients with ocular ischemic syndrome due to internal carotid artery stenosis (>70% stenosis) who were being treated by carotid endarterectomy. Ophthalmic artery color Doppler flow imaging indicated ophthalmic artery flow direction and peak systolic flow velocity and was performed before and at 1 week, 1 month, and 3 months after surgery. RESULTS: We assessed the ophthalmic arteries of 11 patients via color Doppler flow imaging. Before undergoing carotid endarterectomy, five patients showed reversed ophthalmic artery flow. In the other six patients who experienced antegrade ophthalmic artery flow, the average peak systolic flow velocity was 0.09 +/- 0.05 m/s (mean +/- standard deviation). Preoperative reversed flow resolved in each patient 1 week after undergoing surgery. All patients showed antegrade ophthalmic artery flow. The average peak systolic flow velocity in the patients who had preoperative antegrade flow rose significantly, to 0.21 +/- 0.14 m/s (P < 0.05). There was no significant change as compared with findings at 1 week after surgery. During the follow-up period (mean, 32.4 mo), no patients complained of recurrent visual symptoms. At the end of the study period, visual acuity had improved in five patients and had not worsened in the other six patients. CONCLUSION: Carotid endarterectomy was effective for improving or preventing the progress of chronic ocular ischemia caused by internal carotid artery stenosis.

Angiography↗
PubMed1988

Complications of carotid endarterectomy: the influence of case load.

We reviewed the records of 508 consecutive carotid endarterectomies done by 19 surgeons during a five-year period in one medical center to evaluate postoperative complications (stroke and death). Each of 16 surgeons did 32 operations or fewer, with case loads ranging from one to 32. Three surgeons did 70, 98, and 172 respectively. The incidence of stroke among patients of the 16 surgeons combined who did 32 cases or fewer in five years (fewer than ten cases per year) was 7%, with a combined stroke and death rate of 8%; in contrast, patients of the combined surgeons who did more than 32 operations in five years (more than ten cases per year) had a stroke rate of 3%, with a combined stroke and death rate of 3%. When the carotid disease was examined separately, it was apparent that the adverse event rate among patients with asymptomatic or nonhemispheric disease accounted for the difference. Patients of surgeons with fewer cases had 18% adverse events, whereas those of more experienced surgeons had 2% adverse events. The adverse events were similar for both groups in patients with focal transient ischemic attacks or stroke. Seven of the 16 surgeons who did fewer than 32 cases had no patients who had stroke, despite the few carotid endarterectomies they had done. Thus, the stroke rate was somewhat lower in the hands of those surgeons who did endarterectomy more often, but the number of carotid endarterectomies done by a surgeon is not the only factor to decrease the stroke rate. Proper selection of patients and attention to risk factors and technique are essential.

Adult↗
PubMed1995

Magnetic resonance angiography findings in the early post-carotid endarterectomy period.

This preliminary study was designed to investigate the ability of multiple axial volume three-dimensional fourier transform (3DFT) time-of-flight (TOF) magnetic resonance angiography (MRA) to depict the carotid bifurcation in the early post-carotid endarterectomy period. Five patients underwent intra-operative digital subtraction angiography (DSA) and carotid MRA within 5 days of carotid endarterectomy. An axial volume fast imaging in steady-state precession (FISP) gradient-echo 3DFT TOF carotid MRA technique in this limited series appeared to display accurately the surgically significant abnormalities at the carotid bifurcation after endarterectomy. However, in normal or near-normal intra-operative DSA studies, overestimation of internal carotid artery stenoses was encountered. Postoperative MRA demonstrates potential as a useful non-invasive investigation after carotid endarterectomy but should be interpreted with caution until larger studies become available.

Aged↗
PubMed1977

Right coronary endarterectomy: a procedure with increased risk of perioperative infarction.

Although right coronary endarterectomy extends operability on this vessel, the procedure is associated with increased risk of perioperative infarction. Forty-nine patients at St Vincent's Hospital underwent endarterectomy and saphenous vein grafting to the distal right coronary artery, with a hospital mortality of 6.1% and a perioperative infarction rate of 20.4%, compared with rates of 4.2% and 10.9% respectively in a group of patients who did not require endarterectomy. These figures show a trend toward statistical significance which suggests that careful patient selection for endarterectomy is required to obviate an increased risk of complications with this procedure.

Coronary Artery Bypass↗
PubMedDate not supplied

Clinical results of endarterectomy of the right and left anterior descending coronary arteries.

In this study, we examined the clinical outcome of coronary endarterectomy. From 1990 to 1998, 4839 patients underwent surgical revascularization. Coronary artery bypass graft surgery (CABG) was performed alone on 4516 patients, was combined with right coronary artery endarterectomy (RCA-E) in 242 patients, and was combined with left anterior descending coronary artery endarterectomy (LAD-E) in 81 patients. An analysis of preoperative variables revealed a higher proportion of males (90.7% vs 80.2%, p < 0.001), of patients with low ejection fraction (< 35%; 4.6% vs 1.7%, p < 0.001), and of three-vessel disease (47.9% vs 36%, p < 0.001) in the RCA-E versus the CABG patients. There was a higher proportion of unstable angina (51.9% vs 40.3%, p = 0.04) in the LAD-E patients. The 30-day mortality rate for CABG was 2% versus 2.5% for RCA-E and 3.7% for LAD-E (p = NS). Perioperative myocardial infarction (MI) rate for CABG was 3.4% versus 7.0% for RCA-E (p < 0.001) and 4.9% for LAD-E patients (p = NS). Postoperative low cardiac output syndrome was recorded in 11.5% of CABG, 18.6% of RCA-E (p = 0.01), and 11.1% of LAD-E (p = NS) patients. Predictors of postoperative bad outcome (death, MI, low cardiac output, cerebrovascular accident) were preoperative intra-aortic balloon pump, repeat operation, ejection fraction of < 35%, renal insufficiency, female gender, RCA-E, and age over 70. Protective factors included the use of internal mammary artery, multiple arterial grafts, and warm cardioplegia. Actuarial analysis at 6, 12, and 24 months showed late mortality rates of 0.8%, 1.3%, and 2.1% for CABG; 1.2%, 3.7%, and 3.7% for RCA-E; and 2.9%, 2.9%, and 2.9% for LAD-E, respectively. Late MI occurrence was 0.4%, 0.4%, and 0.7% for CABG; 1.5%, 1.5%, and 2.7% for RCA-E; and 0% for LAD-E, respectively. Multivariate analysis found renal insufficiency, ejection fraction of < 35%, repeat operation, female gender, New York Heart Association functional class IV, and diabetes to be predictors for late adverse events (recurrence of angina, MI, and cardiac death), and RCA-E was found to be a predictor of late MI. We conclude that the use of coronary endarterectomy to achieve complete revascularization in patients with diffuse distal coronary artery disease is a reasonable option, associated with a minimal addition in complication rates.

Cause of Death↗
PubMed1982

Intellectual function in patients with transient ischaemic attacks (TIA) or minor stroke. Long-term improvement after carotid endarterectomy.

Psychological testing was performed in 25 patients (mean age 56 years) with transient ischaemic attacks and/or minor strokes and with angiographically verified internal carotid artery stenosis. The effects of carotid endarterectomy on intellectual functions were evaluated postoperatively at 2 weeks and 8 months respectively. Preoperatively the mean test values were below the normal level for all tests indicating a general intellectual impairment for the group as a whole. This may reflect multi-infarct dementia in statu nascendi. At the early postoperative test session some test results were statistically significantly worse than the preoperative. 8 months postoperatively the mean values for all tests had improved as compared with the preoperative values. This improvement reached a statistically significant level in 6 tests. When the side of operation was considered a pattern emerged: in the 12 patients with left-sided endarterectomies improvement was significant for tests mainly related to left-hemisphere function (Word Pairs Test, Story Recall, Trail Making B, Similarities) and in the 13 patients with right-sided endarterectomies significant improvement occurred in the functions mainly related to the right hemisphere (Visual Gestalts, Block Design, Digit Span backwards). This relationship between side of operation and improvement in lateralized functions cannot be explained by retest effects. It is concluded that TIA's and minor strokes per se may impair intellectual function, and that reversal of deterioration and even improved mental state may follow carotid endarterectomy.

Adult↗
PubMed1993

Carotid endarterectomy: preoperative evaluation of candidates with combined Doppler sonography and MR angiography. Work in progress.

Doppler sonography and magnetic resonance (MR) angiography were prospectively used in combination as a substitute for conventional angiography in 24 consecutive patients likely to undergo carotid endarterectomy. Of 19 patients (20 lesions) who underwent carotid endarterectomy, 18 had not undergone preoperative angiography. High-grade lesions (> 75%-diameter stenosis) were surgically confirmed in 16; a 60%-70% stenosis, in one; and subtotal occlusion of the internal carotid artery, in another. Angiography was performed in a case of suspected internal carotid artery dissection. In the five nonsurgical cases, no significant stenosis was noted with both techniques in two instances, total occlusion was seen in two cases, and an asymptomatic stenosis was seen in one. Follow-up (average, 4.5 months) showed one case of symptomatic occlusion of the internal carotid artery after endarterectomy. This preliminary study suggests that the combined use of Doppler sonography and MR angiography can, in up to 79% (15 of 19) of cases, replace angiography for the preoperative evaluation of patients likely to need carotid endarterectomy.

Aged↗
PubMed2004

International carotid stenting study: protocol for a randomised clinical trial comparing carotid stenting with endarterectomy in symptomatic carotid artery stenosis.

BACKGROUND: Carotid stenting avoids general anaesthesia, cranial nerve injury and the discomforts of surgical treatment of carotid stenosis. A systematic review of the randomised trials showed no overall difference in the major risks of endovascular treatment for carotid stenosis compared with surgery, but the confidence intervals were wide and both methods carried a significant risk of stroke. The use of protection devices appears to improve the safety of endovascular treatment, but there are little randomised data available about long-term outcomes. We have therefore set up an international, multicentre, randomised, controlled, open, prospective clinical trial, namely the International Carotid Stenting Study (ICSS), also known as CAVATAS-2. The objectives of the ICSS are to compare the risks, benefits and cost-effectiveness of a treatment policy of referral for carotid stenting compared with referral for carotid endarterectomy. METHODS: Centres are required to have a team with audited expertise in carotid endarterectomy and stenting procedures, including at least one neurologist or stroke physician, a surgeon and an interventionalist. Attendance at a carotid stenting training course is required. Centres with more limited experience can join the trial as probationary centres, but stenting must then be proctored by an experienced interventionalist. Symptomatic patients are included over the age of 40 years with atherosclerotic carotid stenosis, suitable for both stenting and surgery, and are randomised in equal proportions between carotid endarterectomy and stenting. Stents and other devices are chosen for use at the discretion of the interventionalists but must be approved by the devices committee. The protocol recommends that a cerebral protection system should be used whenever the operator thinks one can be safely deployed. The combination of aspirin and clopidogrel is recommended to cover stenting procedures. Standard or eversion endarterectomy is allowed using local or general anaesthesia, shunts or patches. All patients will receive best medical care. Patients will be followed up by neurologists at 30 days after treatment, 6 months after randomisation and then annually up to 5 years after randomisation. The primary outcome measure is the difference in the long-term rate of fatal or disabling stroke in any territory between patients randomised to stenting or surgery. Secondary outcome measures include any stroke, myocardial infarction or death within 30 days of treatment, treatment- related cranial nerve palsy or haematoma. Restenosis (>70%) on ultrasound follow-up, economic measures and quality of life will also be analysed. The sample size is estimated at 1,500 patients, which will provide 95% confidence intervals of +/- 3.0 percentage points for the outcome measure of 30-day disabling stroke and death rate and +/- 3.3 percentage points for the outcome measure of death or stroke during follow-up. The trial office monitors outcome events at individual centres and a rate of events above a given threshold triggers a blinded assessment of the events, submitted to the chairman of the data-monitoring committee. CONCLUSIONS: The ICSS protocol incorporates a number of novel features to ensure patient safety, including the concept of probationary centres, proctoring of inexperienced investigators and monitoring of individual centre results on an ongoing basis. The protocol is also designed to mirror routine clinical practice as far as possible, so that the results will be widely applicable and relevant to determining the place of carotid stenting in clinical practice in the future.

Carotid Stenosis↗
PubMed1999

Increased systemic oxidative stress after elective endarterectomy: relation to vascular healing and remodeling.

It has been reported that systemic and local redox state may have an important role in the functional and organic changes characterizing the process of vascular response to injury. Carotid endarterectomy to remove atherosclerotic plaque is followed by a long lasting healing and remodeling process that can be carefully followed over time with noninvasive ultrasonography. Plasma vitamin C concentration and native LDL (n-LDL) content in lipid peroxides, vitamin E, beta-carotene, and lycopene as well as LDL susceptibility to peroxidation were assessed in 45 patients undergoing elective endarterectomy for internal carotid stenosis, at baseline, 24 hours, 3 and 15 days, and 1 month after surgery. Serial duplex scans were performed in all patients postoperatively and 3, 6, and 12 months. The changes in far wall thickness (FW) and % renarrowing from postoperatively to 12 months were used as remodeling indices. Plasma antioxidant vitamins and lag-phase showed a sharp and significant decrease during the first 24-hours after surgery remaining unchanged until the third day, whereas, an opposite trend was evidenced for n-LDL content in lipid peroxides and serum ceruloplasmin. After the third day all the parameters returned progressively to baseline within one month from endarterectomy. Interestingly, the n-LDL lipid peroxide content, the serum ceruloplasmin and the plasma vitamin C concentration, measured at 24 and 3 days from surgery, were significantly associated to the change in % renarrowing from postoperatively to 12 months. The higher the LDL content in lipid peroxides, the higher the serum level of ceruloplasmin, the lower the plasma content in vitamin C and the higher the % of vessel renarrowing. In conclusion, carotid endarterectomy with atherosclerotic plaque removal is associated with an acute and prolonged increase in systemic oxidative stress that influences vascular healing and late luminal loss.

Aged↗
PubMed2002

Risk of stroke, transient ischemic attack, and vessel occlusion before endarterectomy in patients with symptomatic severe carotid stenosis.

BACKGROUND AND PURPOSE: We aimed to identify and determine the clinical relevance of parameters predictive of stroke recurrence and vessel occlusion before carotid endarterectomy. METHODS: One hundred forty-three consecutive patients (105 men; mean age, 66.1+/-8 years) with symptomatic severe carotid artery stenosis were prospectively followed up until carotid endarterectomy. Patients had suffered an ischemic vascular event in the ipsilateral anterior circulation 9.6 days (median; range, 0 to 92 days) before presentation and assessment of stenosis. Admission examination included medical history, neurological status, extracranial and transcranial Doppler/duplex sonography, CT/MRI, ECG, and routine laboratory examination. All patients were reevaluated in the same way the day before surgery (without CT/MRI) and at recurrence of an ischemic event (including CT/MRI). RESULTS: The end point of follow-up after 19.0 days (median; range, 0 to 118) was carotid endarterectomy in 120 patients, ipsilateral recurrent ischemia in 15 patients (7 transient events and 8 disabling strokes, with carotid occlusion in 4), and (asymptomatic) carotid occlusion in 8 patients. An exhausted cerebrovascular reactivity as determined by a Doppler CO2 test in the middle cerebral artery ipsilateral to the stenosis was the only independent predictive parameter for disabling stroke (odds ratio [OR], 9.7; 95% confidence interval [CI], 2.1 to 44.1; P=0.003). Stroke rate in patients with exhausted reactivity was 27% per month compared with 5.2% in those with normal reactivity. Progression of stenosis toward occlusion was observed in 12 patients and correlated with decreased poststenotic peak systolic velocity (OR, 0.75; 95% CI, 0.62 to 0.90; P=0.002), poststenotic arterial narrowing (OR, 22.7; 95% CI, 3.6 to 141.6; P=0.001), and very severe stenosis (OR, 13.6; 95% CI, 2.2 to 83.7; P=0.005). In patients without hemodynamic compromise, occlusion was not associated with increased stroke risk. CONCLUSIONS: Patients with recently symptomatic high-grade carotid artery stenosis and ipsilateral hemodynamic compromise are at high risk for early disabling stroke. Assessment of the hemodynamic status is recommended after diagnosis of severe carotid stenosis in symptomatic patients to further investigate and evaluate whether these patients may benefit from early endarterectomy.

Aged↗
PubMed2002

Chlamydia pneumoniae serology is associated with thrombosis-related but not with plaque-related microembolization during carotid endarterectomy.

BACKGROUND AND PURPOSE: Chlamydia pneumoniae has repeatedly been associated with atherosclerotic disease. Our study was designed to clarify whether this association is based on C pneumoniae-induced transformation of a stable into an unstable atherosclerotic plaque or on stimulation of hypercoagulability leading to increased thrombotic arterial occlusions by C pneumoniae infection. Transcranial Doppler ultrasonographic monitoring of the middle cerebral artery during carotid endarterectomy offers the opportunity to study, before removal of the plaque, atherothrombotic emboli dislodging from an unstable carotid plaque (plaque-related emboli) and emboli related to (excessive) thrombus formation at the endarterectomy site after removal of the plaque and restoration of flow (thrombosis-related emboli). METHODS: C pneumoniae IgA (> or =1/16) and IgG (> or =1/64) seropositivity was assessed in 53 patients with symptomatic carotid artery disease undergoing carotid endarterectomy. The removed carotid plaques were studied histologically to assess plaque instability. RESULTS: Plaque- and thrombosis-related emboli were registered in 43 patients with an adequate transtemporal window. IgA seropositivity (58%) was associated significantly with thrombosis-related embolization (P=0.030) but not with plaque-related embolization or with histological plaque instability. CONCLUSIONS: C pneumoniae serology is associated with microembolization after endarterectomy and restoration of flow. Since these microemboli represent platelet aggregations and are related to cerebrovascular complications, our data suggest that C pneumoniae infection contributes to cerebrovascular events in patients with carotid artery disease through stimulation of thrombosis.

Aged↗
PubMed2003

Revisiting the appropriateness of carotid endarterectomy.

BACKGROUND AND PURPOSE: In the 1980s, carotid endarterectomy was controversial because proof of efficacy was lacking, complication rates were high, and one third of cases were reported to be inappropriate. Since publication of several randomized controlled trials (RCTs), rates of carotid endarterectomy have doubled nationwide. This study assesses the appropriateness and use of carotid endarterectomy since publication of the RCTs. METHODS: Using the literature, we developed a list of 1557 mutually exclusive indications for carotid endarterectomy and asked a panel of national experts to rate the appropriateness of each indication using the RAND methodology. We used these ratings to assess appropriateness in a sample of 2124 patients who underwent the procedure in 1997 to 1998 in 6 hospitals. We also analyzed the reasons for the procedure and rates of death, stroke, and myocardial infarction within 30 days of surgery. RESULTS: Overall, 84.9% of operations were done for appropriate reasons, 4.5% for uncertain reasons, and 10.6% for inappropriate reasons. Among procedures considered inappropriate, the most common reasons were high comorbidity (46.6%) and minimal stenosis (27.1%). Overall, 72.5% were asymptomatic, 17.4% had a carotid transient ischemic attack, and 10.1% had a stroke. The 30-day rate of death or stroke was 5.47% for symptomatic patients and 2.26% for asymptomatic patients. Among patients having combined carotid and coronary artery bypass graft surgery, the rate was 10.32%. The complication rate in asymptomatic patients with high comorbidity was 5.56%. CONCLUSIONS: Since the RCTs, rates of overuse appear to have fallen considerably, although they are still significant. A major shift has occurred toward operating on asymptomatic patients. Although overall complication rates were low, rates among asymptomatic patients with high comorbidity exceeded recommended thresholds.

Aged↗
PubMed2004

Effect of carotid endarterectomy or stenting on impairment of dynamic cerebral autoregulation.

BACKGROUND AND PURPOSE: Analysis of dynamic cerebral autoregulation (DCA) from spontaneous blood pressure fluctuations might contribute to prognosis of severe internal carotid artery stenosis, but its response to carotid recanalization has not been investigated so far. This study investigates the effect of carotid endarterectomy or stenting on various DCA parameters. METHODS: In 58 patients with severe unilateral stenosis undergoing carotid endarterectomy (n=41) or stenting (n=17), cerebral blood flow velocity (CBFV, transcranial Doppler) and arterial blood pressure (ABP, Finapres method) were recorded over 10 minutes before and on average 3 days after carotid recanalization. Nineteen patients were additionally examined after 7 months. Correlations between diastolic and mean ABP and CBFV fluctuations were averaged to form the correlation coefficient indices (diastolic [Dx] and mean values [Mx]). Transfer function parameters (low-frequency phase and high-frequency gain between ABP and CBFV oscillations) were calculated over the same 10 minutes. CO2 reactivity was assessed via inhalation of 7% CO2. RESULTS: Before recanalization, all DCA parameters were clearly impaired ipsilaterally compared with contralateral sides. Phase, Dx, and Mx indicated early normalization of DCA after both endarterectomy and stenting. By multiple regression, the degree of DCA improvement was highly significantly related to the extent of impairment before recanalization. No significant change in DCA was found at follow-up. Ipsilateral gain and CO2 reactivity increased significantly less after endarterectomy than after stenting (P<0.05). CONCLUSIONS: Dynamic cerebral dysautoregulation in patients with severe carotid obstruction is readily and completely remedied by carotid recanalization.

Blood Flow Velocity↗
PubMed2005

High rate of early restenosis after carotid eversion endarterectomy in homozygous carriers of the normal mannose-binding lectin genotype.

BACKGROUND AND PURPOSE: Mannose-binding lectin (MBL) is thought to influence the pathophysiology of cardiovascular disease by decreasing the risk of advanced atherosclerosis and by contributing to enhanced ischemia reperfusion injury. Thus, we investigated the role of MBL in restenosis after eversion endarterectomy in patients with severe carotid atherosclerosis. METHODS: In a prospective study, 123 patients who underwent carotid endarterectomy were followed-up by carotid duplex scan (CDS) sonography for 14 months. In a retrospective study, we examined 17 patients and 29 patients, respectively, who had or had not at least 50% restenosis 29 months after carotid eversion endarterectomy. MBL genotypes were analyzed by a polymerase chain reaction-based method, and MBL serum concentrations were measured. RESULTS: In the prospective study in the patients homozygous for the normal MBL genotype, CDS values were significantly higher after 14 months of follow-up compared with the values measured 6 weeks after surgery (P<0.001). In contrast, only a slight increase was registered in patients carrying MBL variant alleles. The differences were much more pronounced in female than in male patients. Similar differences were observed when patients with high and low MBL serum concentrations were compared. In the retrospective study, a significant increase in the frequency of MBL variant genotypes was observed in patients not experiencing restenosis compared with the patients with restenosis (P=0.007). CONCLUSIONS: These results indicate that reoccurrence of stenosis after carotid endarterectomy is partially genetically determined and imply that MBL contributes significantly to the pathophysiology of this condition.

Aged↗
PubMedDate not supplied

Multicenter retrospective review of results and complications of carotid endarterectomy in 1981.

A multicenter retrospective audit of carotid endarterectomies performed during 1981 was completed with 46 institutions contributing 3,328 cases. Overall, there was a 2.5% risk of transient neurological dysfunction following surgery and a 6% risk of stroke or death. The intra-institutional combined major morbidity and mortality varied from 21% to 0. Those institutions with greater than 700 beds had a statistically lower incidence of stroke or death than did other institutions. The incidence of stroke or death postoperatively was significantly lower for patients who were operated on for amaurosis fugax or for unspecified reasons. Those patients who were operated on for a progressing stroke had a higher incidence of stroke but this group was at greatest risk for stroke without surgery. The incidence of postoperative stroke or death was related to the type of arterial repair; vein patch grafting was statistically better than both fabric patch grafting and primary closure. When all patients who were not monitored during surgery were compared to all patients who had electroencephalographic (EEG) monitoring, there was found to be a significant statistical difference in favor of the EEG group. Endarterectomy combined with coronary artery bypass or simultaneous bilateral endarterectomies had a statistically significant higher incidence of stroke or death than did unilateral carotid endarterectomy.

Canada↗
PubMed1989

Site and pathogenesis of infarcts associated with carotid endarterectomy.

We analyzed perioperative strokes in 658 carotid endarterectomies with the purpose of explaining the pathogenesis from the morphologic aspect of the infarct on cerebral computed tomograms. All endarterectomies were performed with continuous electroencephalographic monitoring. Of the 42 ischemic strokes (6.4% of all endarterectomies), 34 could be studied. Seven infarcts were hemodynamically induced (five watershed infarcts, two patients with bilateral ischemia); all seven occurred during surgery. Twenty-three of the remaining 27 infarcts were within the territory of the middle cerebral artery (20) or anterior cerebral artery (three) and were probably of thromboembolic origin; 13 of these 23 occurred during surgery (57%). If intraoperative stroke was heralded by permanent electroencephalographic changes, these were not related to the moment of cross-clamping. In four patients the computed tomogram was normal. We believe these facts favor the hypothesis that thromboembolism is the most important factor in the pathogenesis of perioperative stroke associated with carotid endarterectomy under conditions of optimal cerebral monitoring.

Brain↗
PubMed1989

Patch angioplasty in carotid endarterectomy. Advantages, concerns, and controversies.

There is much controversy in the literature regarding the precise role of patch angioplasty in carotid endarterectomy. Our report summarizes the theoretical and experimental considerations, including the hemodynamic effects and biologic behavior of the graft, associated with this technique. We present a detailed review of the literature regarding the clinical efficacy of patch angioplasty in carotid endarterectomy, including the early results, the late results, and the incidence and nature of carotid restenosis. We address concerns about the use of patch angioplasty, including the duration of cross-clamping, potential problems with the graft and suture-line disruption, and graft atherogenesis. We conclude that most recent literature indicates that patch angioplasty decreases acute complications (notably carotid occlusion) after carotid endarterectomy and prevents or delays carotid restenosis. As pressure increases to achieve a minimal rate of perioperative morbidity, many surgeons are expected to adopt patch angioplasty in more of their cases. However, in the absence of conclusive results from a prospective randomized study, opinion will continue to be divided regarding the routine versus the selective use of patch grafting in carotid endarterectomy. We present criteria for randomized trials of this technique.

Animals↗
PubMed1990

Cerebral vasoreactivity and blood flow before and 3 months after carotid endarterectomy.

We measured regional cerebral blood flow and cerebral vasoreactivity before and 3 months after carotid endarterectomy using xenon-133 inhalation with single-photon emission computed tomography and the acetazolamide test in 14 selected patients who had suffered cerebral transient ischemic attacks due to an ipsilateral internal carotid artery stenosis. The patients had neither clinical nor cerebral computed tomographic evidence of infarction. Baseline regional cerebral blood flow was symmetrical before and unchanged after endarterectomy. Before endarterectomy, vasoreactivity in the middle and anterior cerebral artery territories of the symptomatic side was significantly reduced (p less than 0.05); however, vasoreactivity was normalized 3 months after surgery. Our findings strongly suggest that the stenoses caused a reduction in perfusion reserve that was improved by carotid endarterectomy.

Acetazolamide↗