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PubMed1995

Carotid endarterectomy based on preoperative duplex ultrasound.

Recent studies have suggested that carotid endarterectomy can be performed safely based solely on the noninvasive duplex ultrasound evaluation in selected patients. We have prospectively evaluated 60 consecutive patients who underwent 65 carotid endarterectomies, 48 patients without preoperative angiography and 12 with angiography. Forty-two patients were operated on for symptomatic disease, and 23 procedures were done for critical, asymptomatic stenoses. Long term followup consisted of physical examination and serial duplex scans every 3-6 months postoperatively over a mean followup period of 2.4 years. Clinical management indicated by duplex ultrasound was altered in only one of the 12 patients who had preoperative angiography, a change in the timing of the endarterectomy in a symptomatic patient with an ulcerated lesion seen at angiography. At operation the severity of disease predicted by duplex ultrasound was confirmed in all cases (100 per cent sensitivity), including one > 80% diameter stenosis interpreted by angiography as occluded; no unsuspected anatomic anomalies were found at surgery. The duplex scan also correlated well with intraoperative findings of surface ulceration and gross intraplaque hemorrhage. There was one intraoperative stroke with good recovery in a patient with preoperative angiography; and there were no deaths, for a combined morbidity and mortality of 1.6 per cent. During long term followup, 97 per cent of patients have remained symptom-free. We conclude that clinical assessment with a preoperative duplex ultrasound scan of good technical quality and interpreted in collaboration with the vascular surgeon provides appropriate information on which to base carotid endarterectomy and allows a safe alternative to the routine use of preoperative angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

Carotid endarterectomy for non-hemispheric ischaemia: long-term follow-up.

Earlier results reported by the authors suggest that carotid endarterectomy can relieve symptoms of non-hemispheric ischemia in patients who present with hemodynamically significant carotid stenosis. Long-term follow-up of a subgroup of these patients is described. Some 61 patients with non-hemispheric ischemia who underwent carotid endarterectomy were reviewed. Indications for surgery and postoperative results (stroke, death, symptom relief) were determined by office visit or phone interview. Results in these patients were compared with those of an entire patient population who underwent endarterectomy performed by the authors. Mean (s.d.) follow-up was available for 42.3 (31.7) months. Perioperative stroke rate (4.9%), survival (85.3 and 64.9% at 3 and 5 years respectively) and stroke-free survival (77.1 and 63.4% at 3 and 5 years respectively) were not different from that entire cohort of 553 patients. During follow-up, 11 patients (18%) developed recurrent symptoms of non-hemispheric ischemia. Carotid endarterectomy is successful in providing long-term relief of symptoms of non-hemispheric ischemia in most patients with significant carotid bifurcation stenosis. Results in such patients are similar to those seen in patients with symptoms of anterior cerebral ischemia or with symptom-free stenoses.

Aged↗
PubMed1995

Carotid endarterectomy in a vascular fellowship training program: good results with a consistent technique.

OBJECTIVE: To find out whether carotid endarterectomy performed by senior residents or vascular fellows in a vascular fellowship program with a uniform technical approach can give results equal to or better than the acceptable standard. DESIGN: A case study with follow-up ranging from 121 to 1369 days. SETTING: A university teaching hospital. PATIENTS: Two hundred and one consecutive patients operated on between May 1989 and June 1993. INTERVENTIONS: Isolated carotid endarterectomy. MAIN OUTCOME MEASURES: Neurologic findings, cardiovascular complications and local wound problems after carotid endarterectomy. RESULTS: There were no deaths, one permanent stroke and two significant deficits from which the patients fully recovered. CONCLUSIONS: Carotid endarterectomy can be performed by senior surgical residents and vascular fellows within a vascular fellowship program, with a perioperative stroke and death rate of less than 1% when a uniform approach is used.

Aged↗
PubMed1994

Endarterectomy versus angioplasty in the treatment of localized stenosis of the abdominal aorta.

OBJECTIVE: To compare the outcome after aortoiliac endarterectomy and percutaneous transluminal angioplasty (PTA) of the aorta for localized stenosis of the lower abdominal aorta. DESIGN: Chart review of patients treated over a 5-year period. SETTING: A university centre. PATIENTS: Sixteen women, all of whom were smokers; 5 had hyperlipidemia, 4 had evidence of coronary artery disease, 3 were hypertensive, and 1 was diabetic. INTERVENTIONS: Aortoiliac endarterectomy (eight women) and PTA (eight women). MAIN OUTCOME MEASURES: Ankle-brachial pressure index (ABI), degree of claudication and clinical outcome. RESULTS: Angiography showed localized stenosis of the lower aorta in all patients, aortic hypoplasia in nine patients and associated common iliac disease in seven. None of the eight patients managed by aortoiliac endarterectomy had complications or died. All were free of claudication at a mean follow-up of 29 months and had durable improvement in their ABI: mean ABI preoperatively was 0.69 (standard deviation [SD] 0.1) and postoperatively was 1.06 (SD 0.07). Of the eight patients treated by PTA, only one had partial dilatation; another had a subintimal tear with worsening symptoms and a fall in ABI, requiring surgery within 18 months. The remaining six were symptom free after a mean follow-up of 13.4 months. Aortic PTA resulted in improvement of the ABI: mean ABI before PTA was 0.69 (SD 0.19) and after PTA was 1.06 (SD 0.15). CONCLUSIONS: Endarterectomy is a safe and effective method of treating occlusive disease limited to the distal aorta. PTA appears to be less reliable. However, it is recommended as the initial treatment of choice in patients with angiographically suitable lesions because it is less invasive.

Adult↗
PubMed1994

Early results of the advanced coronary endarterectomy combined with CABG in the treatment of coronary artery occlusive disease.

BACKGROUND: Coronary Endarterectomy is a controversial but effective procedure for diffuse coronary artherosclerosis. Between April 1991 and January 1993, 57 patients in VGH-Taipei who had their diffuse coronary artery disease treated with combined endarterectomy and coronary artery bypass grafting (CABG). METHODS: One hundred and thirty-eight endarterectomies were performed, including 6 on the left main coronary artery system, 77 on the left anterior descending coronary artery system, 15 on left circumflex coronary artery system and 40 on the right coronary artery system (an average of 2.42 endarterectomies/patient). For graft conduit, great saphenous vein was used in 149 anastomoses, left internal mammary artery in 21, right internal mammary artery in 6 and right gastroepiploic artery in 4. The mean number of distal graft anastomoses was 3.15 per patient. Additional procedures were performed in 8 patients (14%): two patients required aortic valve replacement, one patient had mitral valve replacement, one had mitral annuloplasty, one had VSD repair and three had left ventricle aneurysm plications. The mean aortic clamp time was 108.8 +/- 30.5 minutes. RESULTS: The early mortality rate was 5.3%. The late mortality rate was 3.5%. During follow-up of mean 17.5 months, 98% of survivors were asymptomatic or in improved condition. CONCLUSIONS: Although endarterectomy is still a debatable procedure, it is valuable especially for the diffusely diseased arteries.

Aged↗
PubMed1994

Ambulatory blood pressure profile after carotid endarterectomy in patients with ischaemic arterial disease.

OBJECTIVE: To assess the circadian blood pressure profile observed 3 months after endarterectomy. DESIGN: Twenty-five patients undergoing unilateral or bilateral carotid endarterectomy were compared with a control population of 20 patients, matched for age, sex, weight and drug therapy. Casual mean blood pressure measured by mercury sphygmomanometry was similar in both groups. RESULTS: Non-invasive ambulatory blood pressure monitoring showed that, whereas mean arterial pressure was identical in both groups, the group undergoing surgery had a significant increase in pulse pressure and its variability over 24 h. Such abnormalities predominated during the nocturnal period, in which the reduction in systolic blood pressure was less pronounced in the operated group than in controls. For all parameters there was no significant difference between subjects with unilateral or bilateral endarterectomy. CONCLUSION: This study provides evidence that patients with carotid endarterectomy were characterized in the long term by an increase in the pulsatile component of blood pressure and its variability, in association with a disturbance in the physiological circadian rhythm. Such findings were not identified using casual blood pressure measurements.

Aged↗
PubMed1994

Carotid endarterectomy at Wellington Hospital.

AIM: To evaluate the morbidity and mortality of carotid endarterectomy at Wellington Hospital. METHOD: A retrospective study of all patients undergoing carotid endarterectomy at Wellington Hospital in the four year period from June 1987 to June 1991 was performed. Data was collected from chart review. A general practitioner questionnaire was sent to assess posthospitalisation outcome. RESULTS: One hundred and one carotid endarterectomies were performed in 89 patients. The overall combined 30 day mortality and disabling stroke rate in symptomatic patients was 5.1%. CONCLUSIONS: Carotid endarterectomy is performed at Wellington Hospital with an acceptable 30 day mortality and disabling stroke rate.

Cerebrovascular Disorders↗
PubMed1993

Combined carotid endarterectomy and coronary artery bypass in a community hospital.

A study examining combined carotid endarterectomy and coronary artery bypass (CAB) outside the metropolitan or university hospital setting was performed. Over a 5-year period, 52 patients underwent carotid endarterectomy and CAB under a single anesthetic. Twenty-two patients (42%) had unstable angina and 23 (44%) had previous neurologic symptoms. There were two postoperative strokes (4%), one ipsilateral and one contralateral to the endarterectomy site. No ipsilateral neurologic events occurred after discharge (mean follow-up 25 months). There were four deaths (8%), all of which were cardiac related. Three of the four deaths were in patients with a recent history of congestive heart failure, a subgroup with a high mortality rate (three of seven; 43%). Over the same period, 2421 patients underwent CAB alone with stroke and mortality rates of 1.4 and 2.0% respectively, while 344 patients had carotid endarterectomy alone with stroke and mortality rates of 0.6 and 0.6% respectively. It is concluded that the combined procedure can be performed in a community setting with morbidity and mortality rates similar to those for major centers. Although stroke and mortality rates for the combined procedure were higher than those for the isolated operations, this group has a high incidence of cardiac symptoms, including unstable angina and congestive heart failure. Patients with recent congestive heart failure had the highest mortality rate of any subgroup and these patients should be carefully examined with regard to selection for the combined procedure.

Adult↗
PubMed1993

Carotid endarterectomy for prevention of stroke.

Carotid endarterectomy, a frequently performed operation, has been used as a strategy for preventing stroke in patients with carotid bifurcation disease. The safety and efficacy of the operation were recently challenged by a number of sources. Three major responses to this challenge were to retrospectively review the natural history of carotid bifurcation disease compared with the immediate and long-term results of carotid endarterectomy, to initiate 6 prospective randomized trials to determine the efficacy of carotid endarterectomy for a variety of indications, and to develop appropriateness initiatives and guidelines for using this surgical procedure by organizations concerned with health care policy. I review the current status of these 3 areas of endeavor. In those areas where studies are complete, carotid endarterectomy has been shown to be highly effective in reducing stroke risk. Risk reduction has ranged from 66% to 80% compared with medical management. Based on these sources and findings, I present a list of indications for the operation for surgeons who are able to do the operation safely and within the guidelines established by the Stroke Council of the American Heart Association.

Carotid Artery Diseases↗
PubMed1993

[Middle cerebral artery endarterectomy: a case report].

This is a report of an endarterectomy performed upon the horizontal portion of the middle cerebral artery of a 45 year-old male patient. He had been suffering from TIAs (left hemiparesis) since 8 days prior to admission. Since the frequency of TIA episodes had increased from 2 times to 5 or 6 times a day and the episodes lasted from approximately 10 minutes to over 20 minutes on the day before admission, the TIA was considered to be of the crescendo type. On admission, neurological examination and CT scans showed no abnormalities. An angiography revealed a severe stenosis of the horizontal portion (M1) of the right middle cerebral artery. An endarterectomy was performed using a pterional approach on the day of admission because of the crescendo TIA. Heparin was not used during the surgery. The patient showed left hemiplegia after the endarterectomy. Angiography was performed immediately after the surgery, and severe stenosis caused by mural thrombus was found at the operative site. An emergency STA-MCA anastomosis was carried out to prevent cerebral infarction. However, left hemiplegia did not abate, and a CT scan taken a few days after the surgery revealed a low density area which included the right, basal ganglia and internal capsule. Two weeks after the surgery, angiography was again performed to determine the patency of the anastomosis, which showed normal configuration of the M1, indicating that the stenosis had disappeared. It was considered that if heparin had been used during the endarterectomy, the acute mural thrombus formation at the M1 would have been prevented, and neurological deficit would not have appeared.

Cerebral Arterial Diseases↗
PubMed1993

The role of duplex scanning and arteriography before carotid endarterectomy: a prospective study.

PURPOSE: This study examines the current role of diagnostic tests done before carotid endarterectomy and the need for routine arteriography. METHODS: We prospectively studied vascular surgeons' decision-making over a 29-month period during which 111 carotid arteries in 103 patients were considered for endarterectomy. For each case the surgeon's management plan was recorded after clinical evaluation and review of the duplex scan findings, but before arteriography. This plan was later compared with the patient's ultimate clinical management. RESULTS: Of 111 total cases in this period, 17 were excluded from analysis because arteriography was not done or it was performed before the surgeon's evaluation. Carotid duplex scans were diagnostic in 87 (93%) of the remaining 94 cases. The carotid lesion was incompletely assessed by duplex scanning in seven patients because the disease was not limited to the distal common or proximal internal carotid artery (n = 4); anatomic or pathologic features of the carotid artery interfered with imaging or accurate Doppler assessment (n = 1); or an internal carotid artery occlusion could not be distinguished from a high-grade stenosis (n = 2). When a technically adequate duplex scan showed significant disease of the carotid bifurcation, arteriography contributed information that affected clinical management in only a single case (1%). This patient had a middle cerebral artery occlusion distal to a high-grade carotid bifurcation stenosis. CONCLUSIONS: Clinical assessment and duplex scanning were sufficient for the preoperative evaluation of 93% of the candidates for carotid endarterectomy. Clinical circumstances or atypical duplex scan findings can be used to identify the minority of patients for whom arteriography is necessary. On the basis of this experience, we have developed practical guidelines for the selective use of arteriography before carotid endarterectomy.

Adult↗
PubMed1993

Lasting safe interruption of endarterectomy thrombosis by transiently infused antithrombin peptide D-Phe-Pro-ArgCH2Cl in baboons.

To evaluate the relative antithrombotic efficacy and hemostatic safety of antithrombin therapy for vascular thrombus formation at sites of mechanical vascular injury, we administered the potent and specific irreversible synthetic antithrombin D-PHE-PRO-ARG chloromethyl ketone (D-FPRCH2Cl) after performing carotid endarterectomies in baboons. The continuous intravenous infusion of D-FPRCH2Cl, 100 nmol/kg per minute for 1 hour, abolished acute carotid endarterectomy thrombosis for at least 48 hours. The plasma level of D-FPRCH2Cl during the infusion was maintained steady at 7.2 +/- 0.9 mumol/L, but decreased rapidly after discontinuing its infusion (T50 17 minutes). Platelet deposition, measured in real time using autologous 111In-platelet scintillation camera imaging, was 1.51 +/- 0.40 x 10(8) platelet/cm in the 14 treated animals 90 minutes postoperatively, compared with 11.7 +/- 1.16 x 10(8) platelet/cm in 14 heparin-treated controls (P < .002). The antithrombotic benefit was equivalent for treatment begun either 5 minutes before (nine animals) or 15 minutes after (five animals) reestablishing flow in the operated vessel, ie, 1.59 +/- 0.36 x 10(8) platelet/cm versus 1.35 +/- 0.51 x 10(8) platelet/min, respectively; P > .5. Endarterectomy thrombosis remained decreased for at least 48 hours postoperatively, as determined by the ratio between net 111In-platelet radioactivity at the endarterectomized site versus whole blood (ratio 0.82 +/- 0.25 in the treatment group v 3.03 +/- 0.51 in heparin controls at 90 minutes, P < .005; and 0.85 +/- 0.23 v 3.25 +/- 0.48 at 48 hours, P < .002). The marked reduction in endarterectomy thrombosis in treated animals at 48 hours was confirmed by scanning electron microscopy. Thrombin activity formed rapidly and became immediately bound to thrombus on thrombogenic segments in untreated control studies; treatment with D-FPRCH2Cl irreversibly inactivated the thrombus-bound thrombin. Hemostatic function, as measured by bleeding time (BT), activated partial thromboplastin time (APTT), and prothrombin time (PT) was impaired throughout the intravenous administration of D-FPRCH2Cl (BT > 30 minutes, APTT > 150 seconds, PT > 50 seconds); BT, APTT, and PT values were normal 30 minutes after discontinuing the infusions. As expected, blood loss into the surgical wound was substantial in nine animals receiving therapy initiated before restoring flow in the operated vessel (mean 95 mL, range 45 to 130 mL). By contrast, beginning D-FPRCH2Cl therapy in five animals 15 minutes after restoring arterial flow, a time when surgical hemostasis had been achieved, prevented excessive blood loss (mean 15 mL, range 10 to 35 mL; P < .01 compared with earlier treatment) without compromising the antithrombotic effects.(ABSTRACT TRUNCATED AT 400 WORDS)

Amino Acid Chloromethyl Ketones↗
PubMed1993

Symptomatic recurrent carotid stenosis and aneurysmal degeneration after endarterectomy.

BACKGROUND: Aneurysmal degeneration of a carotid reconstruction was not recognized until the patient, who was known to have recurrent carotid artery stenosis, had a thromboembolic stroke. This sequelae of carotid endarterectomy is a serious complication, associated with a high morbidity and mortality rate. This review was conducted to establish the risk of transient ischemic attack and stroke for patients found to have recurrent carotid stenosis associated with aneurysmal degeneration of the carotid artery after endarterectomy. METHODS: A case is reported, and 100 literature references of aneurysmal degeneration of the carotid artery after endarterectomy were reviewed. RESULTS: False aneurysm from anastomotic disruption was the most common presentation identified in the cases reviewed. Nineteen of the patients had a significant neurologic event; however, three (50%) of six patients with aneurysm and recurrent carotid artery stenosis had a transient ischemic attack or stroke. CONCLUSIONS: The incidence of neurologic symptoms is markedly increased when recurrent carotid artery stenosis is associated with carotid aneurysm. During postoperative surveillance after endarterectomy, the identification of recurrent carotid artery stenosis requires evaluation for aneurysmal degeneration of the carotid artery with duplex scanning. These patients are at significant risk for transient ischemic attack and stroke. This rare complication merits operative repair.

Aneurysm↗
PubMed1995

Carotid endarterectomy and patch angioplasty, utilizing a segment of autogenous endarterectomized superficial femoral artery. A case report.

A case of a male patient, who had undergone a left internal carotid endarterectomy and arterial patch angioplasty is presented. After endarterectomy, arteriotomy was completed with a patch taken from the initial segment of a completely occluded superficial femoral artery, which was properly endarterectomized. The technique of arterial patch endarterectomy preservation is described and special emphasis is given to the advantages of deep endarterectomy on the possible beneficial long-term patency, as well as the availability of this autogenous material, in cases where the SFA artery is completely occluded.

Aged↗
PubMed1996

Using physician claims to identify postoperative complications of carotid endarterectomy.

OBJECTIVE: This study develops a methodology for identifying complications following carotid endarterectomy, using physician claims data. DATA SOURCES/STUDY SETTING: We selected a random 20 percent sample of Medicare patients undergoing carotid endarterectomy in 1991 (n = 8,345) and extracted all of their claims. STUDY DESIGN: Project neurologists identified the following services as indicative of complications following carotid endarterectomy if they were provided within 30 days of surgery: head CT, head MRI, and surgical exploration of the neck for hemorrhage, thrombosis, or infection. DATA COLLECTION/EXTRACTION METHODS: Total costs were calculated from all claims associated with the hospitalization and the 30-day postoperative period. Outcomes included mortality (obtained from Medicare eligibility files), length of stay, discharge to an institution, and readmission to an acute care hospital (the latter obtained from claims data). PRINCIPAL FINDINGS: Surgical complications were identified in one out of every ten endarterectomy patients (10.3 percent). Patients with complications were significantly more likely to die within 30 days of surgery (8.9 percent, compared with 1.1 percent of those not experiencing complications). They also were significantly more likely to be discharged to an institutional setting (24.9 percent versus 2.9 percent), and more likely to be readmitted to acute care hospitals (26.8 percent versus 8.2 percent). Patients with postoperative complications also were significantly more expensive: $22,187 versus $10,892. CONCLUSION: Our findings suggest that physician claims could be used by PROs or similar entities as a screening tool to identify potential problem hospitals or problem surgeons. First, however, the methodology would need to be clinically validated.

Aged↗
PubMed1996

Our first experience applying simultaneous bilateral carotid endarterectomy.

Simultaneous bilateral carotid endarterectomy (SBCE) has been very rarely cited in the international literature. Twelve patients underwent 24 SBCE's (Group A). They were compared with 22 bilateral staged endarterectomies in 11 (Group B) and 155 cases with unilateral endarterectomies (Group C). The indications and surgical management were similar and the accompanying risk factors were comparable in the 3 groups. Shunt or patch was not used and occlusion time was 13 +/- 2'. Total occlusion time in the SBCE was 25 +/- 3'. The results are comparable in the 3 groups. In the SBCE group one case of TIA was particularly noted together with another case with transient vocal cord paresis; however no death, myocardial infarct, respiratory problems or permanent damage of the central nerves were observed in this group. Despite the small number of our patients together with that of the international literature, it seems that a better preoperative assessment of the function of the circle of Willis in association with meticulous surgical technique and proper patient selection, encourages the tactics of simultaneous bilateral carotid endarterectomy.

Carotid Stenosis↗
PubMed1996

[Carotid endarterectomy based on preoperative duplex ultrasound].

Carotid endarterectomy is the most common vascular procedure. Recent studies have suggested that carotid endarterectomy can be performed safely, based solely on ultrasound duplex evaluation in selected patients. We evaluated 12 men and 8 women who underwent carotid endarterectomy, 12 for significant symptomatic disease and 8 for tight, asymptomatic stenosis of the carotid artery. All had duplex ultrasound scans without angiography before operation. They all survived. 2 had hoarseness due to vocal cord paralysis which resolved 5 months later in 1, while in the other it still persisted 2 months after operation. There were no other neurologic complications. During follow-up all have remained symptom-free. We conclude that clinical assessment of carotid artery stenosis with duplex ultrasound scan of good technical quality provides appropriate information on which to base carotid endarterectomy, and is a safe alternative to preoperative angiography.

Aged↗
PubMed1996

The technique of eversion carotid endarterectomy.

Eversion endarterectomy of the Internal Carotid Artery (ICA) has been employed as a good alternative method to classical carotid endarterectomy. The details of this technique are presented. The main operative steps are: complete transection of the ICA from the carotid bifurcation, eversion endarterectomy of the ICA, endarterectomy of the External Carotid Artery, reimplantation of a the ICA to its normal position and reconstruction of a new bifurcation. The major advantages of this attractive technique are optimum correction of an elongated ICA in combination with stenosis, avoidance of patch material for arteriotomy closure and low restenosis rate.

Arteriosclerosis↗