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At least 595 records · Page 33Linked to original sources
PubMed1979

Asymptomatic carotid stenosis. Immediate and long-term results after prophylactic endarterectomy.

1. A review of the immediate and long-term results of prophylactic carotid endarterectomy for asymptomatic lesions of 78 carotid arteries in 72 patients between 1961 and 1976 is presented. 2. The inhospital operative mortality was zero. Two patients experienced postoperative transient neurologic deficit with complete recovery (2.6 per cent). There were no postoperative strokes. 3. Late follow-up data demonstrated that in only one patient did a stroke subsequently develop appropriate to the operative side, and it occurred 4 years after operation. Life table analysis for neurologic events carried out for up to 15 years indicated a 96 per cent stroke-free status of the surviving patients. 4. A 42 month survival rate of 83 per cent in patients treated by prophylactic carotid endarterectomy represented a statistically significant improvement over the 67 per cent survival of a comparable group of patients reported on in the literature. 5. Prophylactic carotid endarterectomy in the experience of vascular surgeons who can offer a low operative morbidity and mortality appears to be reasonable therapy in preventing stroke and prolonging survival until a randomized controlled study comparing surgery with the natural history of untreated patients shows evidence to the contrary.

Adult↗
PubMed1984

Incidence of recurrent stenosis after carotid endarterectomy determined by digital subtraction angiography.

The results of recent reports of nonselected patients studied by noninvasive techniques suggest there is a 10 to 36 percent rate of restenosis within the first 1 to 2 years after carotid endarterectomy. In the present study of nonselected patients examined by intravenous digital subtraction angiography, only 6.7 percent of operated vessels had recurrent stenosis with a 50 percent or greater decrease in vessel diameter at a mean of 28.5 months postoperatively. These data, when compared with the results of most noninvasive studies, suggest that many of the early lesions regress after 1 to 2 years, as suggested by Zierler et al [8] or that there is a true difference in the rates of restenosis between centers, possibly due to subtle differences in surgical technique or patient risk factors, or both. A symptomatic recurrence rate of only 2.7 percent and a 6.7 percent overall rate of hemodynamically significant recurrent stenosis support the conclusions from earlier and larger series that carotid endarterectomy is a highly effective and durable operation. Although it is important that research centers continue to study the natural history of carotid artherosclerosis and serial changes after carotid endarterectomy, these results suggest that for routine clinical follow-up, frequent and expensive periodic tests to detect recurrent stenosis may not be warranted.

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PubMed1986

Carotid endarterectomy after Doppler ultrasonographic examination without angiography.

We prospectively reviewed our experience with 32 carotid endarterectomies in 30 patients performed without angiography in a 7 year period. Although this represents 6.7 percent of our total experience with carotid endarterectomy in this period, carotid endarterectomy without angiography is increasing and comprises 17 percent of the last 2 years' total. We have adhered to strict criteria for patient selection that identifies circumstances for a safe operative experience in seven broad categories. Evidence is also presented to reduce an overriding concern for intracranial aneurysms and siphon stenosis if either one exists unrecognized. We are hopeful that in the future, the latter will be identified by intracranial Doppler studies currently being performed. Our experience in this small series has been favorable, with intraoperatively measured lesions equal to the preoperative noninvasive predictions. We suggest that Doppler ultrasonography in its current form can be effectively used in place of conventional angiography or digital subtraction angiography in selected patients.

Aged↗
PubMed1989

External carotid endarterectomy under direct vision.

At the conclusion of standard carotid endarterectomy in 50 consecutive patients, we examined flow in the external carotid artery using a continuous-wave Doppler probe. In two patients (4 percent), flow was absent in the distal external carotid artery. In both patients, opening the external carotid artery through a separate incision revealed an obstructing intimal flap that was removed easily under direct vision, and external carotid endarterectomy was accomplished without interrupting flow through the internal carotid artery. This simple manuever allows for salvage of external carotid arteries that are occluded during standard blinded external carotid endarterectomy.

Carotid Artery, External↗
PubMed1989

Carotid endarterectomy for high plaques.

Seventeen instances of high plaque (plaque extending up to the level of the second cervical vertebra) were encountered out of a total of 454 carotid endarterectomies (3.7 percent). With careful dissection and knowledge of anatomy superior to hypoglossal nerve, carotid endarterectomy was accomplished without resorting to mandibular subluxation or dislocation. There was no operative mortality or perioperative strokes. One patient had perioperative myocardial infarction and another sustained temporary glossopharyngeal nerve dysfunction. High carotid plaques were more common in male patients with bilateral stenoses or contralateral internal carotid occlusion and could be suspected by findings of preoperative carotid arteriography in some instances. In the majority of cases, extension of high plaque in a tongue-shaped manner on the posterior wall of the internal carotid artery was an unexpected finding at the time of carotid endarterectomy.

Aged↗
PubMed1989

Endarterectomy as the procedure of choice for atherosclerotic occlusive lesions of the common femoral artery.

Isolated atherosclerotic lesions of the common femoral artery, though uncommon, are frequently associated with disabling peripheral ischemic symptoms when compared with similar lesions in the superficial femoral artery since claudication involves the thigh and calf and usually limits walking distance to less than one block. From 1969 to 1987, 29 patients underwent common femoral endarterectomy with vein patch angioplasty for symptoms of disabling claudication in 17, rest pain in 6 and ischemic ulceration in 6 patients. Endarterectomy was confined to the common femoral artery in 10 patients whereas endarterectomy was carried into either or both the deep or superficial femoral arteries in 19 patients. There was one immediate failure, secondary to residual disease in the outflow tract. All patients were discharged with patent reconstructions. Amputations were avoided in the 12 patients with advanced ischemic symptoms. Patients were followed long-term. Three patients were lost to follow-up with patent repairs to that time. There was one late occlusion. The cumulative patency rate 5 years postoperatively was 94 percent. The only complication was aneurysmal dilatation of the end-arterectomy site in one patient.

Aged↗
PubMed1995

Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. National Institute of Neurological Disorders and Stroke.

On September 28, 1994, the investigators of the Asymptomatic Carotid Atherosclerosis Study (ACAS) reported the interim results of a randomized controlled clinical trial of carotid endarterectomy in patients who have asymptomatic carotid stenosis of greater than 60% reduction in diameter. In addition to aspirin and aggressive management of modifiable risk factors, one-half of the patients were randomly assigned to receive surgery after angiographic confirmation of the lesion. Carotid endarterectomy is beneficial with a statistically significant absolute reduction of 5.8% in the risk of the primary end point of stroke within 5 years and a relative risk reduction of 55%. As a consequence of the trial reaching statistical significance in favor of endarterectomy, and on the recommendation of the study's data monitoring committee, physicians participating in the study were immediately notified and advised to reevaluate patients who did not receive surgery. It is important to note that the success of the operation is dependent on medical centers and surgeons who have a documented perioperative morbidity and mortality of less than 3%, careful selection of patients, and postoperative management of modifiable risk factors.

Adult↗
PubMed1996

Collateral flow changes through the anterior communicating artery during carotid endarterectomy.

To evaluate early changes in collateral flow through the anterior communicating artery, 11 patients undergoing carotid endarterectomy were monitored. All had angiographically demonstrated collateral flow towards the hemisphere on the side of surgery. The middle cerebral artery ipsilateral to the operated side and the contralateral anterior cerebral artery were simultaneously insonated with a transcranial Doppler instrument equipped with dual transducers, and flow velocity values were obtained at specific surgical stages. Mean flow velocity in the contralateral anterior cerebral artery's A1 segment increased at clamp placement (p = 0.036), did not change during clamping, and decreased at clamp release (p = 0.004). The rise in velocity occurred within seconds of clamp placement in all patients with an increase, reaching the 10 cm/s threshold within 1 min. No consistent increase was detected after 5 min. A decrease in pulsatility index, indicating a drop in resistance, was detected at clamp placement in the middle cerebral artery on the side of surgery (p = 0.012). The index did not change during clamping, but increased at clamp release (p = 0.002). Our findings indicate that significant changes in anterior communicating artery collateral flow occur during carotid endarterectomy, starting within seconds of carotid artery clamping. These changes are associated with arterial resistance alterations in the territory of the middle cerebral artery on the endarterectomy side. Our observations should be useful to assess intracranial early collateral flow changes in surgical and non-surgical settings.

Aged↗
PubMedDate not supplied

Intraoperative pulsed Doppler assessment of carotid endarterectomy.

A 20 MHz pulsed Doppler velocimeter and fast Fourier transform spectrum analyzer were used at operation to assess the velocity patterns just prior to and immediately following carotid endarterectomy (TEA). In all 45 sides studied, the status of the endarterectomized segment was verified by operative arteriography. Corresponding Pre-TEA and Post-TEA internal carotid artery spectra were compared to each other and classified according to criteria developed using the ultrasonic Duplex scanner. Of 39 arteries with significant Pre-TEA flow disturbances, improvement in Post-TEA spectral characteristics was observed in 35, and 4 were not changed. Six arteries had only minimal flow disturbances both before and after endarterectomy. In one case the initial Post-TEA spectrum showed a worsening of the flow disturbance which was found on operative arteriography to be due to a stenosis secondary to a technical error. After vein patch angioplasty, the spectrum and repeat arteriogram were both improved. No other significant technical problems were encountered. Although the velocity patterns were improved by endarterectomy in most cases, some residual flow disturbance often remained. Technical factors were not a major cause of the Post-TEA flow disturbances. Lack of improvement or deterioration in the spectra after closure of the arteriotomy may be useful in selecting patients for operative arteriography. Intraoperative spectra also provide important baseline data for long term followup studies.

Blood Flow Velocity↗
PubMed1994

Carotid endarterectomy--is intensive care unit care necessary?

PURPOSE: The purpose of this study was to determine whether postoperative intensive care unit care is necessary for all patients undergoing carotid endarterectomy and whether a subgroup of patients at low-risk not requiring treatment in the intensive care unit could be identified. METHODS: Case control analysis of random numbers sample over the last decade of 50% of patients undergoing isolated carotid endarterectomy at a tertiary care hospital. One hundred twenty-nine patients undergoing carotid endarterectomy were identified. Preoperative risk factors, intraoperative course, intensive case unit interventions including vasoactive agents, myocardial ischemia/infarction, arrhythmias, bronchospasm, reintubation, neurologic events, and need for reoperation, were recorded. Timing of interventions, length of stay in intensive care unit, and postoperative course were all recorded. Financial impact was assessed. RESULTS: Among 129 patients only 31 patients did not require intensive care unit interventions. A multivariate linear regression analysis demonstrated a model in which a preoperative history of hypertension, myocardial infarction, arrhythmia, and chronic renal failure were 83% predictive of the need for an intensive care unit bed. Specifically, patients could be stratified into a low-risk group before the operation by less than four risk factors. Additionally, all patients requiring interventions or with adverse outcomes were identified by the eight postoperative hour. CONCLUSIONS: In preoperative scheduling of intensive care unit beds, patients with less than four risk factors can be stratified to monitoring beds and those with greater than or equal to four can be stratified to intervention beds. After 8 hours, if no interventions are necessary or adverse outcomes occur, then floor recovery is safe. Patients who satisfy this algorithm would save 50% of current intensive care unit charges.

Adult↗
PubMed1995

Effects of completion angiography on the outcome of carotid endarterectomy.

The carotid endarterectomy results of a single surgeon were analyzed over an 8-year period to determine how routine completion angiography affected endarterectomy outcome. Completion angiography was performed in 80% of cases. A total of 145 patients (86%) were symptomatic while 23 (14%) were symptom-free. Of 131 completion angiographies performed, 94 were interpreted as normal and 37 abnormal. The arteries were reopened in 23 patients with abnormal results. In the 14 patients with abnormal angiograms who were not reopened, two showed no flow into the internal carotid artery and the vessels were ligated. The remaining 12 patients had abnormalities in the external carotid artery or normal Doppler signals along the common carotid artery and internal carotid artery segments. Among the 37 patients with abnormal angiograms, arteries were re-explored in four; there were no neurologic complications. In the entire group, there were three mortalities, one stroke, one transient ischemic attack, two wound complications, four myocardial infarctions, two occurrences of cerebral edema, two pneumonias and nine transient local nerve injuries. Completion angiography has allowed an improved technique while also enhancing the ability to identify technical problems during surgery without increasing morbidity. These results support the use of intraoperative completion angiography to evaluate carotid endarterectomy sites.

Aged↗
PubMed1995

Carotid endarterectomy in the presence of a contralateral occlusion: a review of 315 cases over a 27-year experience.

Recent data from the North American Symptomatic Carotid Endarterectomy Trial revealed a 14.3% perioperative risk of stroke or death with carotid endarterectomy contralateral to a carotid artery occlusion. Since last reporting on this topic in the mid-1980s, the authors have reviewed 180 patients with occlusion of one internal carotid artery (ICA) and who underwent endarterectomy of the stenotic contralateral ICA operated from 1965 to 1984 (group A) compared with 135 operated on from 1985 to 1991. The two groups were similar with respect to age, sex, incidence of coronary artery disease, hypertension, diabetes and history of smoking, but group B had a significantly increased incidence of patients who were neurologically symptom-free before surgery (21.5% versus 7.8%, P < 0.001). The combined perioperative stroke or death rate for patients in group B was significantly lower than for those in group A (0.7% versus 6.7%, P < 0.01). Comparison of the operative techniques showed more frequent placement of intra-arterial shunt (52.6% versus 29.4%, P < 0.001) and increased use of general anesthesia (20.0% versus 9.4%, P < 0.01) in patients of group B. Analysis of the etiology of the complications, however, showed that shunting alone could not account for the improved results. Lower incidences of postoperative thrombosis, embolization and intracerebral hemorrhage were equally important.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Vessel Prosthesis↗
PubMed1996

Myocardial ischaemia, infarction and cardiac-related death following carotid endarterectomy: risk assessment by thallium myocardial perfusion scan compared with clinical examination.

Risk factors in 402 patients undergoing 447 carotid endarterectomies were reviewed to see whether the presence of coronary artery disease before operation influenced the likelihood of perioperative cardiac complications. A second aim of the study was to assess whether myocardial thallium scintigraphy was valuable for preoperative assessment. Fourteen patients developed postoperative cardiac complications, six (1.3%) of which were fatal. Four of these deaths occurred in 60 patients undergoing combined carotid-coronary revascularization (6.6%). In 387 carotid endarterectomies without simultaneous coronary revascularization, there were two deaths from myocardial infarcts (0.5%). These fatalities and other cardiac complications occurred in 204 patients with preoperative clinical or ECG evidence of coronary artery disease. In 198 patients with no preoperative evidence of coronary disease there were no fatalities and only one patient with reversible postoperative myocardial ischaemia (0.4%). It is concluded that carotid endarterectomy under general anaesthesia is unlikely to be followed by cardiac complications when there is no preoperative evidence of coronary artery disease. When coronary disease is detected before operation, postoperative cardiac complications occur after 5.6% of operations, including 0.9% fatalities. When coronary artery disease is severe enough to warrant combined carotid-coronary reconstruction, the perioperative mortality rate was 6.6%, all the deaths being cardiac-related. When myocardial thallium scintigraphy was normal, postoperative cardiac complications did not occur.

Carotid Stenosis↗
PubMed1995

External carotid endarterectomy with internal carotid artery transposition flap angioplasty for symptomatic internal carotid artery occlusion.

The external carotid artery is an important collateral pathway for cerebral perfusion when the internal carotid artery is occluded. After internal carotid artery occlusion, there is a definite risk of ipsilateral neurological events. The authors retrospectively examined their experience with endarterectomy of the external carotid artery for symptomatic internal carotid artery occlusion. Results based on the authors' experience and on historical data show external carotid endarterectomy to be a safe procedure. Obliteration of the cul-de-sac appears to be a very important factor in the prevention of reocclusion or recurrence of symptoms after external carotid endarterectomy. Use of the internal carotid artery stump for patching of the endarterectomized external carotid artery is both safe and effective in treating symptomatic internal carotid artery occlusion.

Aged↗
PubMed1996

Carotid endarterectomy in patients with contralateral carotid occlusion: review of a 10-year experience.

A total of 116 carotid endarterectomies were performed in patients with a totally occluded opposite internal carotid artery over a 10-year period from 1983 until 1992. The average age of patients was 66.4 years; 75% were men and 25% were women. The average degree of stenosis on the operated side was 76.7%. Twenty-one patients (18.1%) had had a documented previous stroke referrable to the side of the occlusion; 22 had a neurologic deficit attributable to the occluded vessel at the time of preoperative evaluation. Indications for surgery included transient ischemic attacks in 35 (30.2%), ipsilateral stroke in 10 (8.6%), amaurosis fugax in 11 (9.5%), and high-grade asymptomatic stenosis in 60 (51.7%). Forty-eight percent of the procedures were performed using local anesthesia, with intraluminal shunts inserted in all except one patient. The combined 30-day mortality and stroke morbidity in this population was 4.3%, which is comparable with a combined stroke and death rate of 4.0% among 956 patients without contralateral carotid occlusion undergoing endarterectomy during this period. This experience suggests that endarterectomy can be performed safely in the patient with internal carotid occlusion and is an important mechanism for the prevention of stroke.

Adult↗
PubMed2004

Cerebral protection during carotid endarterectomy.

BACKGROUND: Perioperative stroke rates with carotid endarterectomy are 3.4% for asymptomatic and 5.2% for symptomatic patients. Several methods are used to limit perioperative stroke. METHODS: A retrospective chart review of consecutive carotid endarterectomies from January 1, 2000 to February, 28, 2003, was performed. Data were collected on patient demographics, operative procedure, intraoperative monitoring, and outcome. Comparative analysis of intraoperative monitoring and outcome was performed. RESULTS: Two hundred twenty-nine patients underwent 251 carotid endarterectomies. In 196 procedures decision to shunt was based on intraoperative monitoring, 129 by electroencephalogram (EEG), and 67 by stump pressures. Sixteen neurologic events occurred perioperatively, one transient ischemic attack and 15 strokes. The EEG group had 12 strokes, with a 38% event rate in procedures with EEG changes without shunting. The stump pressure group had one stroke. Stroke rate for intraoperative EEG monitoring was elevated (P = 0.02). CONCLUSIONS: Intraoperative EEG based decision to shunt may not be as effective as other methods for prevention of perioperative neurologic events. When EEG changes occur, shunting is necessary.

Adult↗
PubMed2005

Coronary endarterectomy and stent removal in patients with in-stent restenosis.

BACKGROUND: In-stent restenosis (ISR) remains the major limitation of coronary stent implantation. Controversies exist regarding optional treatment for ISR. Recently, we developed aggressive surgical options, coronary endarterectomy and stent removal, in this complex setting. METHODS: Between April 2001 and March 2004, 11 consecutive patients who presented with angina and angiographically severe ISR were treated with coronary endarterectomy and stent removal with concomitant multivessel coronary bypass grafting. There were 10 men and 1 woman. The age ranged from 43 to 75 years old (mean 64.1 +/- 9.6 years). The mean number of target vessel interventions was 1.6 +/- 0.7. Data were analyzed retrospectively. RESULTS: The target vessel was the left anterior descending artery (LAD) in all patients. The mean interval from the last intervention was 4.8 +/- 1.9 months. The mean number of target vessel interventions was 1.6 +/- 0.7. The mean LAD incision length was 57.3 +/- 11.0 mm. The left internal mammary artery (LIMA) was grafted in situ, as an on-lay patch. Procedural success without in-hospital complications was achieved in all cases, except one patient with low output syndrome. Postprocedure angiography demonstrated that all LIMA patches and LAD arteries were patent and left ventricular functions were preserved. CONCLUSIONS: Coronary endarterectomy and stent removal with on-lay LIMA patch is a safe and effective technique used in patients with ISR involving diffuse target vessel disease.

Adult↗
PubMed2004

A brain symmetry index (BSI) for online EEG monitoring in carotid endarterectomy.

INTRODUCTION: Carotid endarterectomy is a common procedure as a secondary prevention of stroke, and one of the early controversies in carotid surgery is centered around whether a shunt should be used during this procedure. Although various EEG parameters have been proposed to determine if the brain is at risk during carotid artery clamping, the common procedure is still the visual assessment of the EEG. We propose a brain symmetry index (BSI), that has been implemented as an on-line quantitative EEG parameter, as an additional criterion for shunt need in carotid endarterectomy. METHODS: The BSI captures a particular asymmetry in spectral power between the two cerebral hemispheres, and is normalized between 0 (perfect symmetry) and 1 (maximal asymmetry). The index was evaluated retrospectively in a group of 57 operations in which the EEG and the transcranial Doppler were used as criteria for shunt insertion. In addition, after online implementation of the algorithm, several patients have been evaluated prospectively. RESULTS: If no visual EEG changes were detected, it was found that the change in BSI from baseline, DeltaBSI or=0.06. In this group, one patient suffered from intraoperative stroke and one patient died, most likely from a hyperperfusion syndrome. CONCLUSIONS: The BSI may assist in the visual EEG analysis during carotid endarterectomy and provides a quantitative measure for electroencephalographic asymmetry due to cerebral hypo-perfusion. In patients with a change in the BSI (DeltaBSI) smaller than 0.03 during test clamping, visual EEG analysis showed no changes, whereas if visual EEG analysis did warrant shunting, it was found that DeltaBSI>or=0.06.

Adult↗