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PubMed1997

[Cerebral hemorrhage after carotid endarterectomy in a young adult].

INTRODUCTION: Cerebral haemorrhage after carotid endarterectomy is a rare complication. It follows 0.5% to 20% of all endarterectomies, but should be borne in mind because of the morbidity and mortality seen in most cases. CLINICAL CASE: We describe the case of a 42 year old man in whom carotid endarterectomy had been done 7 days before to treat a stenosis of 80%. He complained of a sudden onset of weakness of the right half of his body and changes in his speech. Physical examination showed right inferior facial paresia, right hemiparesia and right extensor cutaneous plantar reflex. On admission to the Emergency Department, before treatment, blood pressure was 80/60. Carotid auscultation and palpation were normal. Cerebral TRC showed a left lenticular haematoma. The patient progressed satisfactorily. DISCUSSION/CONCLUSIONS: We review the literature on the subject as well as the factors which should be considered as possibly predisposing to bleeding after carotid endarterectomy, such as arterial hypertension and occlusion or severe stenosis of the contralateral carotid artery. The detection of patients with the risk of postendarterectomy bleeding by simple noninvasive investigations, such as the transcranial doppler and the acetazolamide test, and early diagnosis of a clinical picture compatible with a hyperperfusion syndrome may contribute to the relief and prevention of sequelae in these patients.

Carotid Stenosis↗

PubMed1997

[Carotid endarterectomy].

Carotid endarterectomy has been a controversial matter since its introduction more than 40 years ago. In the last decade several clinical trials were performed to determine the efficacy of this operation in patients with carotid estenosis and hemispheric or ocular ischemic symptoms. In 1991 the interim results of the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial were reported, both trials demonstrating the beneficial effects of surgery in symptomatic patients with stenosis of greater than 70%. In 1994 the Asymptomatic Carotid Atherosclerosis Study reported their interim results in patients who have stenosis of greater than 60% in favor of endarterectomy, in centers with documented perioperative mortality and morbidity of less than 3%. The Asymptomatic Carotid Surgery Trial is still in progress. All this trials have restored the confidence on carotid endarterectomy.

Angioplasty, Balloon, Coronary↗

PubMed1997

Influence of projected complication rates on estimated appropriate use rates for carotid endarterectomy. Appropriateness Project Investigators. Academic Medical Center Consortium.

OBJECTIVE: To examine specifically the influence of estimated perioperative mortality and stroke rate on the assessment of appropriateness of carotid endarterectomy. DATA SOURCES/STUDY SETTING: An expert panel convened to rate the appropriateness of a variety of potential indications for carotid endarterectomy based on various rates of perioperative complications. We then applied these ratings to the charts of 1,160 randomly selected patients who had carotid endarterectomy in one of the 12 participating academic medical centers. STUDY DESIGN: An expert panel evaluated indications for carotid endarterectomy using the modified Delphi approach. Charts of patients who received surgery were abstracted, and clinical indications for the procedure as well as perioperative complications were recorded. To examine the impact of surgical risk assessment on the rates of appropriateness, three different definitions of risk strata for combined perioperative death or stroke were used: Definition A, low risk < 3 percent; Definition B, low risk < 5 percent; and Definition C, low risk < 7 percent. PRINCIPAL FINDINGS: Overall hospital-specific mortality ranged from 0 percent to 4.0 percent and major complications, defined as death, stroke, intracranial hemorrhage, or myocardial infarction, varied from 2.0 percent to 11.1 percent. Most patients (72 percent) had surgery for transient ischemic attack or stroke; 24 percent of patients were asymptomatic. Most patients (82 percent) had surgery on the side of a high-grade stenosis (70-99 percent). When the thresholds for operative risk were placed at the values defined by the expert panel (Definition A), only 33.5 percent of 1,160 procedures were classified as "appropriate." When the definition of low risk was shifted upward, the proportion of cases categorized as appropriate increased to 58 percent and 81.5 percent for Definitions B and C, respectively. CONCLUSIONS: Despite the high proportion of procedures performed for symptomatic patients with a high degree of ipsilateral extracranial carotid artery stenosis and generally low rates of surgical complications at the participating institutions, the overall rate of "appropriateness" using a perioperative complication rate of < 3 percent was low. However, the rate of "appropriateness" was extremely sensitive to judgments about a single clinical feature, surgical risk. These data show that before applying such "appropriateness" ratings, it is crucial to perform sensitivity analyses in order to assess the stability of the results. Results that are robust to moderate in variation in surgical risk provide a much sounder basis for policy making than those that are not.

Academic Medical Centers↗

PubMed1997

Early effect of carotid endarterectomy on arterial blood pressure measured with an ambulatory monitor.

BACKGROUND: Carotid artery disease and hypertension are associated, and carotid endarterectomy is often followed by acute changes in blood pressure. As the carotid sinus is responsible for short-term blood pressure control, occlusive carotid disease may contribute to the mechanism of preoperative hypertension. METHODS: Ten patients undergoing carotid endarterectomy and eight having a peripheral bypass procedure were studied 2 weeks before and 2 weeks after operation, using home ambulatory blood pressure measurement. RESULTS: A significant fall in both mean systolic (-14.4 mmHg) and mean diastolic (-12.7 mmHg) pressure was observed after carotid endarterectomy (P < 0.006), whereas no change was seen in controls. CONCLUSION: These results suggest that there is an increase in carotid sinus activity in patients following carotid endarterectomy and supports the hypothesis that carotid sinus dysfunction contributes to hypertension in patients with carotid artery disease.

Aged↗

PubMed1998

Understanding racial variation in the use of carotid endarterectomy: the role of aversion to surgery.

Previous studies indicate that African-American patients undergo carotid endarterectomy at one fourth the rate of white patients. This study was undertaken to determine if differences in aversion to carotid endarterectomy might account for some of the racial difference in utilization of this procedure. A sample of 185 African-American and white patients was selected from a cohort of patients hospitalized for stroke or transient ischemic attack at four Veterans Affairs medical centers. Of these patients, 115 (62%) were able to be contacted by telephone and 95 (83%) agreed to be interviewed. The interview included assessments of functional status, patient preferences for their current health status, and risk aversion to a hypothetical carotid endarterectomy. Patients from both racial groups were similar in age, marital status, level of education, and comorbid medical illnesses. All respondents were male. Functional status for both groups was high and not statistically different. There were no significant racial differences in patients' perceptions of their current health state. However, African-American patients expressed more aversion to the hypothetical surgery than whites. The median excess risk of death accepted to avoid surgery was 20% for African Americans versus 2.5% for whites. These results indicate that racial differences in the utilization of carotid endarterectomy may be due in part to differences in patients' levels of aversion to this surgery.

Black or African American↗

PubMedDate not supplied

[Carotid endarterectomy under locoregional anesthesia].

The purpose of carotid surgery is to prevent the incidence of stroke in patients with cerebrovascular disease. It's important, therefore, to find the most useful methods of cerebral protection and flow monitorization during carotid endarterectomy. It is well known that patient's clamping tolerance changes according to his anatomical and physiopathological conditions (contralateral carotid patency, stenosis, occlusion), and compensative circles efficiency (Willis). General anaesthesia reduces cerebral metabolic requests and allows a better pressure control, but requires difficult, expensive and complex monitoring techniques. On the contrary loco-regional anaesthesia alone can't assure cerebral protection, but allows to test in real-time patient's reaction at clamping. If an ischaemia occurs, carotid shunting allows to perform endarterectomy, but this method might produce any complication: distal plaque dissection, embolizations. Authors show their 10 years (1986-1996) experience of 624 carotid endarterectomies performed on 580 patients evaluated by: -symptomatic or asymptomatic lesions -mono-bilateral stenosis -general or loco-regional anaesthesia -clamping tolerance -carotid shunting -intra-postoperative complications (temporary or persistent). According to results, authors propose loco-regional anaesthesia in carotid endarterectomy as a simply available and at low costs method to monitorize cerebral functions. In addition it has low rate complications, few contra-indications and may be selected like first-choice anaesthesiological method.

Anesthesia, Conduction↗

PubMed1998

[Coronary endarterectomy].

The technique of coronary endarterectomy, in coronary artery surgery, has been controversial and alternatively indicated or contraindicated by different authors. In this paper coronary endarterectomy is reviewed, including its definition, history and development of different techniques. Early and late results of the main papers in the literature are commented on as well as our results. The surgical technique of endarterectomy in the different coronary artery territories is described with the primary indications and contraindications. Coronary endarterectomy is a valid and well established technique that can provide possibilities of revascularization in patients with extended and diffused coronary artery obstructions, which are unable to be treated with conventional coronary artery bypass grafts. Operative mortality and morbidity are slightly higher, but long-term results, as far as survival and functional class are concerned, are similar to standard coronary artery surgical procedures.

Contraindications↗

PubMedDate not supplied

[Transcranial Doppler sonography in the pre- intra- and post-operative evaluation of 85 patients undergoing carotid endarterectomy].

PURPOSE: To evaluate the usefulness of transcranial Doppler sonography during carotid endarterectomy. PATIENTS AND METHODS: Pre-, intra-, and postoperative transcranial Doppler was performed in 85 patients who underwent carotid endarterectomy. Intracranial collateral pathways were evaluated preoperatively and continuous monitoring of middle cerebral artery flow velocity was performed during carotid surgery. Transcranial Doppler was repeated in each patient 1 and 7 days thereafter. RESULTS: Values of residual middle cerebral artery flow velocity during preoperative digital compression of the common carotid artery were significantly correlated (r = 0.56; P < 0.001) with those obtained during cross-clamping. Middle cerebral artery flow velocity was significantly lower during cross-clamping with respect to pre-clamping (P = 0.006), in patients with neurologic symptoms (P = 0.001), EEG alterations (P = 0.001), or defective collateral blood supply through the anterior communicating artery (P = 0.01). Postoperative flow velocity values of the MCA were significantly higher at day-1 examinations (P < 0.0001) with respect to preoperative values, and were no more significantly different at day-7. CONCLUSIONS: Transcranial Doppler is a useful method to evaluate the risk of cerebral ischemia during carotid endarterectomy cross-clamping, to identify those patients in which shunt insertion is mandatory, and to evaluate the postoperative effect of carotid endarterectomy on cerebral hemodynamics.

Blood Flow Velocity↗

PubMed2004

The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease.

BACKGROUND AND PURPOSE: Perioperative risk and long-term benefit of carotid endarterectomy (CE) are not detailed in women with symptomatic internal carotid artery (ICA) stenosis. Our aim was to compare the efficacy of CE versus medical therapy in women and men with symptomatic ICA stenosis. METHODS: Data were taken from the North American Symptomatic Carotid Endarterectomy Trial (873 women, 2012 men) and the ASA and Carotid Endarterectomy trial (335 women, 813 men). RESULTS: The 30-day perioperative risk of death was higher in women than in men (2.3% versus 0.8%, P=0.002). Higher perioperative risk of stroke and death was also observed (7.6% versus 5.9%) but not statistically significant. With > or =70% stenosis, the 5-year absolute risk reduction (ARR) in stroke from CE was similar between women (15.1%) and men (17.3%). With 50% to 69% stenosis, CE was not beneficial in women (ARR=3.0%, P=0.94), contrary to men (ARR=10.0%, P=0.02). Medically treated women had low risk for stroke. A stroke prognosis instrument (SPI-II) assigned points to 7 factors that identified higher risk for medically treated women: 3 points for hemispheric (not retinal) event, history of diabetes, previous stroke; 2 for age older than 70 years, stroke (not transient ischemic attack); 1 for severe hypertension, history of myocardial infarction. CE was beneficial only for 29.0% of women with 50% to 69% stenosis who had the highest total score of 8 to 15 (ARR=8.9%). CONCLUSIONS: Women and men with > or =70% symptomatic stenosis had similar long-term benefit from CE, although the perioperative risks were higher for women. CE was not beneficial for women with 50% to 69% stenosis without other risk factors for stroke.

Aged↗

PubMed1999

Extrathoracic arterial grafts performed for carotid artery occlusive disease not amenable to endarterectomy.

HYPOTHESIS: Extrathoracic cervical grafts are safe and provide long-lasting stroke prevention in patients with disease not amenable to standard carotid bifurcation endarterectomy. DESIGN: Review of a prospectively maintained vascular surgical registry. SETTING: Combined university and Department of Veterans Affairs vascular surgical service. PARTICIPANTS: Patients requiring surgery for carotid atherosclerotic occlusive disease not amenable to endarterectomy from January 1988 to March 1998. INTERVENTIONS: Carotid interposition grafting, subclavian-carotid bypass, or carotid-carotid bypass. MAIN OUTCOME MEASURES: Perioperative stroke and death, and life-table determination of freedom from stroke, stroke-free survival, and graft patency. RESULTS: Sixty patients (mean age, 65.8 years; range, 36-83) underwent cervically based carotid grafting. All had greater than 70% stenosis or occlusion of the innominate, common carotid, or internal carotid arteries, and 30 (50%) had undergone at least 1 previous ipsilateral carotid endarterectomy. Indication for operation was stroke or transient ischemic attack in 46 (77%) and asymptomatic high-grade stenosis in 14 (23%). Operative procedures included 31 (52%) carotid interposition grafts, 18 (30%) subclavian-carotid grafts, and 11 (18%) carotid-carotid grafts. Mean follow-up was 29 months (range, 1-117 months). Perioperative stroke rate was 5% (3/60) all in symptomatic patients, and there were no perioperative deaths. By life-table analysis, freedom from stroke was 92% at 1 and 5 years. Stroke-free survival was 90% at 1 year and 61% at 5 years. Primary graft patency was 94% at 1 year and 84% at 5 years, with assisted primary patency of 90% at 5 years. CONCLUSION: Cervical carotid artery grafts for complicated or recurrent carotid atherosclerosis not amenable to endarterectomy are durable and provide excellent freedom from stroke with low perioperative morbidity and mortality.

Adult↗

PubMed2005

Anaesthesia management for pulmonary endarterectomy.

PURPOSE OF REVIEW: Options for the surgical treatment of chronic thromboembolic pulmonary hypertension are either lung transplantation or pulmonary endarterectomy. Pulmonary endarterectomy is considered permanently curative and the treatment of choice. The procedure dramatically improves functional status and provides an excellent immediate and long-term survival, much better than transplantation. Pulmonary endarterectomy, until recently performed in only a few highly specialized centres, is now spreading worldwide with good results. This review will focus on the understanding of the pathophysiology of the disease and on recent advances in assessment and treatment strategies. RECENT FINDINGS: Recent data reinforce the thromboembolic nature of chronic thromboembolic pulmonary hypertension, and have shown that the disorder is more common than was thought and remains underdiagnosed. There has recently been a remarkable surge in the understanding of the mechanisms involved in the pathogenesis of pulmonary hypertension. Advances in diagnosis, surgical techniques, preoperative treatment, and perioperative management have improved the prognosis of this debilitating disease. New information about pretreatment and medical treatment with prostanoids and endothelin receptor antagonists is now available. SUMMARY: Pulmonary endarterectomy can be successfully performed in selected centres using a multidisciplinary approach involving the specialities of surgery, pulmonary medicine, cardiology, radiology, anaesthesiology and critical care medicine. The largest risk factor remains the degree of operability related to a high pulmonary vascular resistance caused by permanent changes in the pulmonary vascular bed. Early operation is now recommended to prevent these irreversible changes. Further investigations are warranted to establish the role of new drugs in surgical patients with chronic thromboembolic pulmonary hypertension.

Journal Article↗

PubMed1989

Nerve-sparing dissection as alternative to anesthesia of carotid sinus nerve in preparation for carotid endarterectomy.

This prospective randomized study was undertaken to determine intraoperatively the hemodynamic effects of local anesthesia of the carotid sinus nerve during carotid dissection in preparation for endarterectomy. Twenty carotid endarterectomy patients were divided into 2 groups: a control group of 10 patients, in whom ordinary saline solution was infiltrated into the carotid bifurcation; and a study group of 10 patients, in whom 5 mL of 2% lidocaine hydrochloride was infiltrated. To determine whether a nerve-sparing dissection might in itself be adequate to prevent the perioperative hemodynamic instability associated with carotid endarterectomy, we took scrupulous care in all patients to avoid injuring the carotid sinus nerve. After we had established baseline values for heart rate and blood pressure in each patient, we recorded heart rate and blood pressure again intraoperatively, every 2 minutes during a 10-minute period. Because the series was small, an analysis of variance showed no statistically significant changes in these values during carotid dissection in either group. However, intraoperative increases in systolic pressure (p < 0.0064) and mean pressure (p < 0.0028) were greater in the lidocaine group. Neither group experienced any deaths, or any neurologic or hemodynamic sequelae during 48 hours of postoperative observation. We conclude that local anesthetic injection of the carotid sinus nerve before carotid dissection and endarterectomy is unnecessary when nerve-sparing dissection is performed; and we conclude further that such injection might actually be deleterious to intraoperative systolic and mean blood pressures.

Journal Article↗

PubMed1987

Coronary endarterectomy combined with vein patch reconstruction and internal mammary artery grafting: experience with 18 patients.

Over a 19-month period (from November 1985 to June 1987), 18 patients underwent open coronary endarterectomy combined with vein patch reconstruction and internal mammary artery (IMA) grafting. All 18 patients had disabling angina and severe, diffuse coronary atherosclerosis that prevented revascularization by conventional means. Thirteen underwent open endarterectomy of the left anterior descending coronary artery, and the remaining five had open endarterectomy of the right coronary artery. All patients received additional bypass grafts to other coronary arteries (2.6 grafts per patient). There was no operative mortality, but one patient had a perioperative myocardial infarction that was unrelated to the open endarterectomy. Postoperative angiography in 16 cases showed that only one of the grafts to the endarterectomized artery was occluded. After a mean follow-up of 8.7 months, all the patients but one were angina-free. No late deaths occurred. Although the long-term clinical results and graft patency have yet to be evaluated, the early results of this series encourage us to continue using this technique in patients whose diffuse coronary artery disease is untreatable by conventional means.

Journal Article↗

PubMed2004

Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery.

BACKGROUND: Carotid endarterectomy reduces the risk of stroke in patients with recently symptomatic stenosis. Benefit depends on the degree of stenosis, and we aimed to see whether it might also depend on other clinical and angiographic characteristics, and on the timing of surgery. METHODS: We analysed pooled data from the European Carotid Surgery Trial and North American Symptomatic Carotid Endarterectomy Trial. The risk of ipsilateral ischaemic stroke for patients on medical treatment, the perioperative risk of stroke and death, and the overall benefit from surgery were determined in relation to seven predefined and seven post hoc subgroups. RESULTS: 5893 patients with 33000 patient-years of follow-up were analysed. Sex (p=0.003), age (p=0.03), and time from the last symptomatic event to randomisation (p=0.009) modified the effectiveness of surgery. Benefit from surgery was greatest in men, patients aged 75 years or older, and those randomised within 2 weeks after their last ischaemic event, and fell rapidly with increasing delay. For patients with 50% or higher stenosis, the number of patients needed to undergo surgery (ie, number needed to treat) to prevent one ipsilateral stroke in 5 years was nine for men versus 36 for women, five for age 75 years or older versus 18 for younger than 65 years, and five for those randomised within 2 weeks after their last ischaemic event, versus 125 for patients randomised after more than 12 weeks. These results were consistent across the individual trials. INTERPRETATION: Benefit from endarterectomy depends not only on the degree of carotid stenosis, but also on several other clinical characteristics such as delay to surgery after the presenting event. Ideally, the procedure should be done within 2 weeks of the patient's last symptoms.

Age Factors↗

PubMed1997

Consensus against both endarterectomy and routine screening for asymptomatic carotid artery stenosis. Canadian Stroke Consortium.

BACKGROUND: Despite several randomized controlled trials, the role of carotid endarterectomy for asymptomatic patients is controversial. Validated evidence-based guidelines are needed. METHODS: Thirty-five members of the Canadian Stroke Consortium, an independent body of cerebrovascular disease experts, reviewed evidence-based guidelines developed by the Canadian Task Force on the Periodic Health Examination. We held 3 rounds of Delphi consensus to solicit opinion and agreement. RESULTS: We found a high level of interrater agreement for all guidelines using multiple statistical measures. Members agreed that evidence is insufficient to endorse carotid endarterectomy for asymptomatic patients with angiographically proven stenosis of more than 60% (kappa = 0.70, P < .01). Reasons cited included concern over the reproducibility of low surgical morbidity rates in the community at large, the questionable clinical benefit conferred by surgery, and the lack of proven reduction in the risk of major disabling stroke. Screening the general population for asymptomatic stenosis was unanimously rejected. Also, screening even patients with risk factors or proven atherosclerosis at other sites was not endorsed (kappa = 0.91 and kappa = 0.79, respectively, both P < .01). CONCLUSIONS: There is insufficient evidence to recommend carotid endarterectomy for asymptomatic patients. Evidence is also insufficient to endorse a screening strategy even for patients with risk factors for carotid disease. While stroke prevention remains a critical goal, we do not recommend that it be accomplished by screening or by performing carotid surgery in asymptomatic patients.

Canada↗

PubMed1997

Comparison of carotid endarterectomy outcomes from randomized controlled trials and Medicare administrative databases.

OBJECTIVE: To compare the characteristics and outcomes demonstrated for participants in randomized controlled trials of carotid endarterectomy with those of the Medicare patient population who received the procedure in 1989. DESIGN: Historical cohort study using Medicare claims data. SETTING: Medicare beneficiary population aged 65 years and older. PATIENTS: Medicare patients 65 years and older who received carotid endarterectomy during 1989. MAIN OUTCOME MEASURES: Perioperative mortality rate and occurrence of transient ischemic attack, stroke, and death within 2 years of surgery. RESULTS: The risk for death within 2 years of the procedure was substantially higher among Medicare patients who received surgery in hospitals with perioperative mortality rates greater than rates demonstrated in the trials (odds ratio, 1.36; 95% confidence interval, 1.29-1.44) and among those with comorbidity that exceeded trial participation criteria (odds ratio, 1.72; 95% confidence interval, 1.64-1.84). CONCLUSIONS: Although carotid endarterectomy trials demonstrate the efficacy of the procedure, this evidence only applies to patients and hospitals with characteristics comparable to those of the trial participants. The importance of this consideration is demonstrated by the substantially higher odds of death experienced among Medicare patients receiving the procedure who had a level of comorbidity that exceeded that of the trial participants or who received their surgery in a hospital with a perioperative mortality rate that exceeded the experience of the hospitals in the trials.

Aged↗

PubMed2004

Does carotid stenting measure up to endarterectomy? A vascular surgeon's experience.

HYPOTHESIS: Carotid angioplasty and stenting seems to have equal or better outcomes in high-risk patients than carotid endarterectomy. DESIGN: Single-center case-control study. SETTING: University hospital tertiary referral center. PATIENTS: Individuals (n = 53) undergoing elective carotid angioplasty and stenting for cervical carotid stenosis (n = 57) between April 2001 and October 2003. All patients were referred to and treated by the primary author (M.K.E.). RESULTS: Mean +/- SD age was 68.8 +/- 1.2 years (64% men [34] and 36% women [19]), and overall mean +/- SD rate of stenosis was 79% +/- 10%. Preprocedural neurologic symptoms were present in 42% of the group. Indications for treatment included prior neck surgery with irradiation (4), recurrent stenosis (19), and severe comorbidities (34). Duplex scanning 24 hours after stenting showed immediate mean percentage reductions in peaksystolic velocity and end diastolic velocity of 74% and 76%, respectively. After a 30-day follow-up period, there were no deaths and no major or minor strokes. One patient (1.7%) developed transient amaurosis fugax 12 hours after the procedure. Four patients (7.0%) experienced access-related complications. Intraoperative complications included 1 seizure (1.7%) and 1 asystolic arrest (1.7%), both treated successfully. During follow-up, 3 cases of re-stenosis (5.0%) occurred. One asymptomatic occlusion (1.7%) was detected at the 6-month follow-up visit. There have been no late carotid-related complications or deaths. CONCLUSIONS: Vascular surgeons possessing advanced catheter-based skills can safely perform carotid angioplasty and stenting and can achieve perioperative results comparable with carotid endarterectomy. Determination of the true efficacy and durability of carotid angioplasty and stenting as compared with endarterectomy awaits ongoing randomized national trials.

Aged↗

PubMed1982

Prevention of neurologic complications of carotid endarterectomy.

We studied the neurologic complications after carotid endarterectomy to develop recommendations for prevention. From 1973 through June 1981, 195 carotid endarterectomies were performed on 184 patients. Carotid endarterectomy was performed using general anesthesia with routine use of a Javid shunt. There were no postoperative deaths. Three major, disabling strokes (1.5%) and four (2%) minor, permanent neurologic deficits occurred. The neurologic deficits were analyzed according to cause: (1) inadequate cranial inflow in four patients, (2) fluctuation in blood pressure requiring treatment in one third (61) of our patients, and (3) embolic complications, usually a single, transient ischemic episode, in 17 patients during the first postoperative week. This was not observed in patients receiving postoperative antiplatelet therapy. Inadequate collateral cerebral inflow accounts for most permanent postoperative neurologic deficits. Postoperative hypotension is now more dangerous than hypertension. Postoperative embolization is largely preventable with antiplatelet agents.

Aged↗