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PubMed1988

Is duplex follow-up cost-effective in the first year after carotid endarterectomy?

Recent reports have suggested that duplex scanning is an ideal method to noninvasively assess the incidence of recurrent carotid stenosis. However, the timing and frequency of the follow-up studies are controversial. In the present study, 150 patients underwent 173 carotid endarterectomy procedures over a 2 year period. In the postoperative period, a total of 210 duplex studies were carried out on 117 carotid arteries. 21.4 percent of the 117 arteries studied had recurrent stenosis of 16 percent or greater at a mean postoperative follow-up of 15.2 +/- 3 months. Recurrent stenoses were detected early after operation; 96 percent were detected at or before 15 months postoperatively. Patients with recurrent stenoses remained stable and had infrequent symptoms. Several risk factors placed the patient at increased risk for recurrent carotid stenosis: presence of contralateral disease (defined as stenosis of 50 percent or greater), use of tacking sutures, and continued smoking in the postoperative period. Although it remains important for researchers to thoroughly investigate the natural history of atherosclerosis of the extracranial carotid artery, including those changes that occur after carotid endarterectomy, our results indicate that frequent duplex scanning in the first postoperative year is unnecessary and is not cost-effective. Duplex follow-up studies 1 and 12 months after carotid endarterectomy are sufficient for assessing the problem of recurrent stenosis in the first postoperative year.

Adult↗
PubMed1995

Are one-day admissions for carotid endarterectomy feasible?

BACKGROUND: In 1990, a clinical pathway for streamlining the care of patients undergoing elective carotid endarterectomy was developed and tested at our institution. This consisted of extensive preoperative patient education in the surgeon's office, outpatient arteriography (now performed only on select patients), same-day admission, regional anesthesia when possible, selective use of the intensive care unit (ICU), and early discharge in the first postoperative day when feasible. PATIENTS AND METHODS: Between January 1, 1991 and June 30, 1994, 186 patients were entered into the protocol. Twenty-six percent of the patients were asymptomatic, while 74% had either transient symptoms or a prior stroke; 13% were operated on under general anesthesia. RESULTS: Three (1.6%) patients developed neurologic complications: 1 minor stroke, 1 transient ischemic attack, and 1 intracerebral hematoma; and 18 (10%) patients required the ICU postoperatively. On the first postoperative day, 157 patients were discharged. Average operative time was 48 minutes (range 39 to 61). Average length of stay (LOS) was 1.27 days. One death occurred on the 28th postoperative day from cardiac causes, and there were no hospital readmissions. Cost savings were over $3,000/patient when compared to the diagnosis-related group reimbursement. Because of the distribution of the data, statistical analysis was not feasible; however, several trends were clear. Neurologic complications, admission to the ICU, and increasing LOS all diminished the cost efficiency of carotid endarterectomy. Type of anesthesia and the use of a shunt or patching did not affect cost. Clearly, increasing the length of operation would also decrease cost efficiency. CONCLUSIONS: Adoption of the clinical pathway presented here is feasible in any institution. One-day admission for patients undergoing carotid endarterectomy has been shown to be safe, highly cost-effective, and results in more efficient use of scarce resources, such as the ICU.

Adult↗
PubMed2001

Is tranexamic acid safe in patients undergoing coronary endarterectomy?

BACKGROUND: Patients undergoing coronary endarterectomy during coronary artery bypass grafting (CABG) are at increased risk of perioperative myocardial infarction due to coronary intimal disruption. Data assessing the safety of the antifibrinolytic drug tranexamic acid (TA) in patients undergoing this procedure are lacking. METHODS: From September 1997 to December 1999, 221 patients underwent nonemergency primary CABG with endarterectomy of the right coronary artery alone in 149, the left anterior descending in 35, or both right and left anterior descending in 27. TA was administered intraoperatively to 87 patients (TA group: average total dose 62 +/- 4.4 mg/kg; range 20 to 109 mg/kg), and was not administered to 134 patients (No TA group). RESULTS: The patient characteristics of the 2 groups were similar. In-hospital mortality consisted of 2 patients in the TA group and 4 patients in the No TA group. Perioperative myocardial infarction rates were 2% and 5% in the TA and No TA groups, respectively (p = 0.49). The relative risk for any type of perioperative cardiac ischemic event in the TA group versus the No TA group was 0.77 (95% CI; 0.4, 1.2). Patients in the TA group had a significant reduction in postoperative chest tube drainage (685 versus 894 mL in the TA versus No TA groups, respectively) and in the use of fresh-frozen plasma (p = 0.03). CONCLUSIONS: These results suggest that the clinical effectiveness of tranexamic acid in reducing postoperative blood loss in patients undergoing coronary endarterectomy is not associated with a higher incidence of myocardial ischemia-related complications.

Aged↗
PubMed2000

Simultaneous carotid endarterectomy and coronary revascularization.

BACKGROUND: Combined cardiac operation and carotid endarterectomy using our technique is an acceptable approach to simultaneous correction of both carotid and cardiac disease. METHODS: From August 1989 to March 1998, 121 consecutive patients underwent combined operations. Of these patients, 112 had coronary artery bypass grafting and carotid endarterectomy, and 9 had coronary artery bypass grafting, carotid endarterectomy, and valve repair or replacement. All patients had a critical stenosis of 85% or more of the carotid artery. Mean age of the patients was 69.2 years; 80 patients were 65 years old or older. There were 88 men and 33 women. Notable risk factors included chronic obstructive pulmonary disease (19.8%), congestive heart failure (28%), preoperative myocardial infarction and unstable angina (66.9%). Of the patients, 20.7% had a stenosis of greater than 50% of the left main coronary artery. The technique used was correction of both the carotid and coronary lesions during a single aortic cross-clamp period using retrograde continuous blood cardioplegia for myocardial protection. Systemic hypothermia to 25 degrees C was used for cerebral protection. RESULTS: Mean cross-clamp time was 118 minutes. Seven patients (5.8%) sustained perioperative cerebrovascular accidents. Two patients had transient ischemic attacks. The procedure-related mortality rate was 5.8%. CONCLUSIONS: The described technique is a good method for simultaneous repair of coronary and carotid lesions in a high-risk group of patients with concomitant disease. We will continue to use it.

Aged↗
PubMed2003

Carotid endarterectomy then and now: outcome and cost-effectiveness of modern practice.

BACKGROUND: During the past decade, our practice of performing carotid endarterectomy (CEA) has changed dramatically, most notably by an abrupt shift from routine to selective preoperative angiography, reliance on defined care plans with full-time nurse practitioner oversight, and increasing reliance on eversion endarterectomy and cervical block anesthesia. This study was designed to determine whether these shifts in policy have been associated with lower costs without sacrificing clinical outcome. METHODS: All patients undergoing CEA from July 1993 to December 2000 were identified, and inpatient and outpatient charts were reviewed. Cost data were obtained from the central hospital accounting system and converted to 2001 dollars. Thirty-day outcomes and costs were quantified each year and compared between each of 2 temporally well-defined groups: those undergoing "routine" versus "selective" angiography and those cared for before and after defined patient care protocols were instituted. RESULTS: A total of 1168 CEAs were analyzed. Thirty-day combined stroke and death rate was 3.1%, and no trends or significant differences over time were seen. From 1993 to 2000 the cost of CEA fell from $9302 to $6216 (P<.0002), and length of stay was reduced 1 full day (P=.005). Institution of "selective" angiography was associated with an immediate cost savings of approximately $2000 per case (P<.0001), and nurse practitioner oversight along with institution of defined clinical protocols with a $530 (P<.05) decline in nonoperating room-related costs. CONCLUSIONS: Changes in policy from routine to selective angiography, reliance on defined postoperative care pathways, eversion endarterectomy, and cervical block anesthesia have been associated with significant cost savings, with no compromise in clinical outcome at our institution.

Anesthesia↗
PubMed1997

Transaortic mesenteric endarterectomy.

Although a number of methods for mesenteric artery reconstruction have been suggested, we believe that patients with atherosclerotic stenosis and occlusion of mesenteric vessels presenting with either acute or chronic visceral ischemia are best managed by either antegrade aortomesenteric bypass or transaortic mesenteric endarterectomy. Antegrade bypass is the most versatile technique and is therefore best adapted to extensive mesenteric disease. Transaortic mesenteric endarterectomy lends itself well to simultaneous renal artery endarterectomy when clinically significant osteal atherosclerosis is present at both sites. With any method of reconstruction, the technical adequacy of repair should be defined intraoperatively. In this regard, intraoperative duplex sonography provides both anatomic and hemodynamic data necessary to ensure technical success and late patency.

Arterial Occlusive Diseases↗
PubMed1986

Carotid endarterectomy for cerebrovascular insufficiency: long-term results in 592 patients followed up to thirteen years.

Seven hundred forty-eight carotid endarterectomies were performed on 592 patients with cerebrovascular insufficiency during a 13-year period. Overall operative procedure mortality was 2.7%. In the last 6 years, using a shunt routinely and avoiding operation on acute strokes, mortality was 1.47%. In frank strokes it was 3.7%; in transient ischemia, 0.77%; and zero for chronic ischemia and asymptomatic bruits. Incidence of operation-related deficits among transient ischemia and asymptomatic bruit patients was 0.9% for transient weakness and 2% for permanent deficits. Of 172 long-term deaths, 23 were due to cerebral causes, or 3.9% of the entire series. Among frank stroke survivors, 30.2% are normal and 58.7% improved. In transient ischemia survivors 81% are normal and 15.7% improved. In 65 asymptomatic bruit patients operated upon electively, two had strokes during follow-up, one mild and one severe. Among 37 asymptomatic bruit control patients, 24 or 65% developed symptoms of transient ischemia or frank strokes. Of 118 totally occluded carotid arteries explored, flow was restored in 48 (40.7%) but could not be restored in 70 (59.3%). For cerebral protection during carotid endarterectomy the routine use of a temporary inlying bypass shunt with general anesthesia is advocated for all partial occlusions. Endarterectomy is most useful for transient ischemia and selected patients with mild frank strokes and asymptomatic bruits. Acute profound and rapidly progressing strokes should not be operated upon as an emergency, but allowed to stabilize for several weeks and then be considered for possible operation.

Acute Disease↗
PubMed1988

Coronary endarterectomy. An adjunct to coronary artery bypass grafting.

There is a wide variation in the reported results of endarterectomy in conjunction with coronary artery bypass grafting. Operative mortality ranges from 0 to 10 per cent, perioperative infarction ranges from 5 to 30 per cent, and patency rates range from 38 to 100 per cent, with 74 to 95 per cent being asymptomatic or improved. This wide discrepancy in clinical outcome occurs for a number of reasons. First, there is nonhomogeneity of patient populations resulting from a lack of standardized patient selection criteria. Second, the operative experience of most published reports spans a decade throughout which major advances in cardiac surgery have occurred. Finally, endarterectomy is a technically challenging procedure with its own learning curve. Differences in technique and expertise almost certainly contribute to the variability of results. Patients with diffuse coronary artery disease pose a challenge to the cardiac surgeon. Endarterectomy entails the risks of increased morbidity and mortality and therefore should be done only if conventional bypass grafting is precluded. However, the risks of these complications must always be weighed against the possible benefits. At the present time carefully selected patients can benefit from this procedure. Unfortunately, until such time as controlled randomized studies are carried out on a prospective basis, statistical support for this procedure will not be available. Given that such a study is questionable from an ethical point of view, clinical decisions for this select group of patients must be done on a case-by-case basis. The best that can currently be done is to carefully follow these patients and scrutinize existing data to ensure optimal clinical management.

Coronary Artery Bypass↗
PubMed1999

Cerebrovascular reactivity before and after carotid endarterectomy.

BACKGROUND: The hemodynamic relevance of internal carotid artery (ICA) stenosis often does not correlate with anatomic features, as angiographically defined. The cerebrovascular reactivity (CVR) has been advocated as a means of defining the cerebral hemodynamic impairment. METHODS: We assessed the results of pre- and postoperative CVR evaluation, using the CO2 transcranial doppler method, in 25 patients with high-grade ICA stenosis. The patients with history of stroke, evidence of cerebral CT infarction or symptoms from the contralateral circulation or the brain stem were excluded to avoid the effects of cerebral infarction on the hemodynamic studies. Statistical analysis was used to evaluate the CVR changes after carotid endarterectomy. RESULTS: Preoperative evaluation showed that CVR was generally well correlated with the degree of ICA stenosis and concomitant contralateral carotid steno-occlusion. Before endarterectomy the mean CVR value was 66.5% (moderately reduced). After surgery the overall mean value of CVR was 84.1% (normal), with a statistically significant improvement. CONCLUSION: The results of this study suggest that the CVR evaluation allows one to obtain hemodynamic information of clinical interest in the patients with ICA stenosis and that carotid endarterectomy is effective to restore the CVR in patients with cerebral hemodynamic impairment.

Aged↗
PubMed1997

The effect of carotid endarterectomy on ocular blood velocity.

PURPOSE: The authors studied the effect of carotid endarterectomy on blood velocity in the ophthalmic artery and in the central retinal artery (CRA) and central retinal vein. METHODS: Pre- and postoperative ultrasonographic and preoperative angiographic determination of the internal carotid artery occlusion rate and orbital color Doppler imaging measurements were performed on 18 consecutive cases of carotid endarterectomy (17 patients). RESULTS: Most of the blood velocity values in the CRA improved and corresponded to the contralateral values postoperatively. The peak systolic (vp) and end diastolic velocity (edv) in the CRA and ophthalmic artery (OA) increased significantly postoperatively (vpCRA: P = 0.027; edvCRA: P = 0.023; vpOA: P = 0.034; edv OA: P = 0.047). Systolic acceleration in the OA also increased (P = 0.018). However, the individual response was variable. In 81%, the ratio of vpCRA of the operation side and the contralateral side was higher postoperatively than preoperatively. The flow increased also in the OA. The flow was reversed in the OA in two cases and in both the direction of flow changed postoperatively. There was no increase in the peak velocity in the central retinal vein. CONCLUSIONS: Carotid endarterectomy resulted in significantly increased flow in the CRA and OA, but no effect was observed on the central retinal vein.

Aged↗
PubMed2003

[Coronary endarterectomy and bypass grafting without cardiopulmonary bypass].

We prospectively analyzed patients who underwent simultaneous off-pump coronary artery bypass grafting and endarterectomy between March 1, 1997 and February 28, 2002. The incidence of perioperative myocardial infarction, need for inotropic support, morbidity, long-time functional class, and mortality were evaluated. Nine endarterectomies were performed in eight patients, more frequently in the right coronary artery. Dopamine was used in four patients. One perioperative myocardial infarction (12.5%) occurred. No deaths occurred and all patients are now functional class I. Tests for ischemia have been negative in all patients.Coronary endarterectomy is an alternative procedure that has little morbidity and enables complete myocardial revascularization without cardiopulmonary bypass.

Adult↗
PubMed1975

Facial thermography in the diagnosis of cerebrovascular disease and in evaluation of carotid endarterectomy.

Some 60% of strokes are due to extracranial occlusive arterial lesions, most frequently at the bifurcation of the common carotid artery. Since these lesions are accessible to endarterectomy, their prestroke diagnosis is very important. Facial thermography quickly supplies reliqble information on the circulatory area in which these lesions occur, and this information can be atraumatically obtained in an out-patient setting. The success rate of facial thermography versus aortic arch angiography was 83% and 80%, respectively, in our case material, and this rate corresponds with data in the literature. In a series of 23 patients with facial thermograms and angiograms obtained before and after endarterectomy, facial thermography proved to be a useful diagnostic and prognostic aid in neurological out-patient guidance after carotid endarterectomy. By virtue of its rapidity and atraumatic character, because it can be carried out by technicians and because the findings are suitable for computer data processing, facial thermography would seem to be suitable for potential stroke screening of a high-risk asymptomatic population.

Adult↗
PubMed1998

Remote endarterectomy in SFA occlusive disease.

The authors present a new modified endarterectomy technique for the treatment of artherosclerotic occlusive disease of the superficial femoral artery (SFA). The SFA remote endarterectomy procedure can be performed through a single groin incision using a ring strip cutter and stenting the distal endpoint. Complete disobliteration of lengthy occlusions was accomplished in more than 100 cases with a cumulative 2-year primary and assisted primary patency rate of 71 and 86%. The mean length of the removed intima core was 33 (10-45) cm. The endovascular remote endarterectomy technique is explained and depicted in detail and some important questions and controversies are discussed.

Arteriosclerosis↗
PubMed1988

Rotational endarterectomy in normal canine coronary arteries: preliminary report.

Endarterectomy was performed in vivo using a high speed rotating abrasive-tipped catheter device in 11 normal canine coronary arteries. The device is designed to remove atheromatous material from diseased arteries by the abrasive action of its rotating tip. It was operated percutaneously from a femoral approach using conventional angioplasty guiding equipment. The rotating device was advanced over a guide wire from just beyond the tip of the guide catheter into the distal vessel. Six arteries were harvested immediately after endarterectomy and five were left in place for 7 +/- 2.8 days; in the latter group, the animals were maintained on a regimen of aspirin, 325 mg/day. Angiography before and after treatment demonstrated vessel patency in all cases. Caliper-measured luminal diameters were not significantly changed after endarterectomy. Histologic examination of pressure-fixed vessels showed extensive intimal loss and 20 to 30% loss of the internal elastic lamina. Medial damage was superficial and never exceeded 40% of the total medial thickness. There were no vessel perforations. Results of histologic study of the myocardium supplied by the treated vessels were normal without evidence of distal embolization or infarction. It is concluded that a high speed rotating abrasive device can be safely operated percutaneously in normal coronary arteries and results in minimal vessel damage and continued patency at 7 +/- 2.8 days.

Angioplasty, Balloon↗
PubMed2003

Prospective, randomized study of external jugular vein patch versus polytetrafluoroethylene patch during carotid endarterectomy: perioperative and long-term results.

OBJECTIVES: The purpose of this study was to evaluate the relative risks and advantages of using external jugular vein (EJV) patch, compared with polytetrafluoroethylene (PTFE) patch, during carotid endarterectomy. The primary end point was the relevant neurologic complication rate (RNCR; fatal or disabling stroke) at any time during follow-up. Secondary end points included stroke-free survival, 30-day and long-term mortality, recurrent stenosis rate (> or =50%), occlusion, patch infection, aneurysm formation, and other local complications. METHODS: The study, a prospective randomized clinical trial carried out at a single center, was divided into two 3-year phases: December 1996 to March 1999, when patients were enrolled, and March 1999 to March 2002, which was the follow-up period. Inclusion criteria included an external jugular vein suitable for patching, defined as vein diameter 3 mm or larger and absence of collateral vessels noted on preoperative color duplex ultrasound scans. Patients were prospectively randomized 1:1 to receive either the EJV (n = 80; group A) or synthetic (n = 80; group B) patch. RESULTS: Carotid endarterectomy and patching was performed by one surgeon. At 30 months the RNCR-free rate, analyzed with the Kaplan-Meier method, was 98.7% for group A (1 ipsilateral lethal stroke) and 94.6% for group B (4 ipsilateral disabling strokes), and remained stable to 60 months. No statistical difference was observed with the log-rank test. Stroke-free survival rate was 100% for group A and 98.7% for group B at 1 year, 98.7% for group A and 93.6% for group B (1 ipsilateral minor stroke) at 30 months, and was unchanged at 60 months. Life table analysis demonstrated freedom from significant recurrent stenosis (> or =50%) of 97.5% for both groups at 6 months, 93.6% for group A and 92.2% for group B at 30 months, and 90.2% for group A and 86.7% for group B at 60 months. No statistical difference was observed with the log-rank test. In no patients was recurrent stenosis greater than 70%. No aneurysm formation was noted during follow-up. CONCLUSIONS: We can conclude, with the power limitation of the study, that carotid endarterectomy can be safely performed with either the EJV or PTFE patch. Advantages of the EJV for carotid angioplasty include no cost for material, low risk for graft infection, and preservation of the saphenous vein.

Aged↗
PubMed2003

Remote iliac artery endarterectomy: seven-year results of a less invasive technique for iliac artery occlusive disease.

OBJECTIVE: Remote endarterectomy of external and common iliac artery occlusions through a single, groin incision under fluoroscopic guidance is a relative unknown surgical procedure. This prospective single center cohort study describes this less invasive endovascular technique with the ring strip cutter and its early complications. The results at midterm follow-up are presented. PATIENTS AND METHODS: From April 1994 to July 2001, 49 remote-endarterectomies of the external or common iliac artery were performed in a retrograde manner from a single, groin incision in 48 patients (30 men, 31 procedures). The median age was 66 years (39 to 82 years). Indications for operation were as follows: severe claudication in 28 (57%), rest pain in 13 (27%), and gangrene in 8 (16%) procedures. Follow-up included clinical evaluation, ankle-brachial index, and duplex scanning at 6 weeks, 3 months, and yearly thereafter. RESULTS: Intraoperative technical success was achieved in 43 (88%) procedures. A retroperitoneal incision was necessary in three patients for an additional arteriotomy in the iliac artery and in three others for a bypass procedure. The mean follow-up was 20 months (2 to 77 months). Three-year cumulative primary patency rate by means of life table analysis was 60.2% +/- 12.0 (SE). During follow-up, percutaneous transluminal balloon angioplasty with and without stenting was performed in six and two patients, respectively, resulting in a 3-year primary-assisted patency rate of 85.7% +/- 9.56. Three-year secondary patency was 94.2% +/- 5.50. CONCLUSIONS: Remote endarterectomy in external and common iliac arterial occlusive disease is a feasible endovascular procedure with a low complication rate. The midterm primary-assisted patency rate is good.

Adult↗
PubMed1994

The influence of anesthetic technique on perioperative complications after carotid endarterectomy.

PURPOSE: This study evaluated the influence of anesthetic techniques on perioperative complications after carotid endarterectomy. METHODS: Perioperative complications, the use of a carotid artery shunt, the duration of the operative procedure and postoperative hospital course were retrospectively compared in 584 consecutive patients undergoing 679 carotid endarterectomies with use of either general anesthesia (n = 361) or cervical block regional anesthesia (n = 318). There was no significant difference in the preoperative medical characteristics between the two anesthetic groups. Symptomatic carotid artery disease was the indication for surgery in 247 (68.4%) patients receiving general anesthetics, whereas 180 (56.6%) patients treated with a cervical block anesthetic had a symptomatic carotid artery stenosis (p = 0.02). RESULTS: The perioperative stroke rate and stroke-death rate for the entire series was 2.4% and 3.2%, respectively, and was not significantly different between the anesthetic groups or between patients with symptomatic or asymptomatic disease. A carotid artery shunt was used in 61 (19.2%) patients receiving a cervical block anesthetic and 152 (42.1%) patients treated with a general anesthetic (p < 0.0001). Use of cervical block anesthesia was associated with a significantly shorter operative time, fewer perioperative cardiopulmonary complications, and a shorter postoperative hospitalization when compared with general anesthesia. Multivariate risk factor analysis indicated that age greater than 75 years, operative time greater than 3 hours, and the use of a carotid artery shunt were all independent risk factors for perioperative cardiopulmonary complications. When a carotid artery shunt was not analyzed as a multivariate risk factor, then general anesthesia became a significant risk factor for perioperative cardiopulmonary complications (risk ratio 2.08; p = 0.04). CONCLUSIONS: We conclude that cervical block anesthesia is safer and results in a more efficient use of hospital resources than general anesthesia in the treatment of patients undergoing carotid endarterectomy.

Aged↗
PubMed1994

The cause of perioperative stroke after carotid endarterectomy.

PURPOSE: The purpose of this study was to examine the cause of perioperative stroke after carotid endarterectomy. METHODS: The records of 2365 patients undergoing 3062 carotid endarterectomies from 1965 through 1991 were reviewed. Sixty-six (2.2%) operations were associated with a perioperative stroke. The mechanism of stroke was determined in 63 of 66 cases. Patient risk factors and surgeon-dependent factors were analyzed. RESULTS: More than 20 different mechanisms of perioperative stroke were identified, but most could be grouped into broad categories of ischemia during carotid artery clamping (n = 10), postoperative thrombosis and embolism (n = 25), intracerebral hemorrhage (n = 12), strokes from other mechanisms associated with the surgery (n = 8), and stroke unrelated to the reconstructed artery (n = 8). Dividing the operative experience approximately into thirds, during the years 1965 to 1979, 1980 to 1985, and 1986 to 1991 the perioperative stroke rates were 2.7%, 2.2%, and 1.5%, respectively. This, in part, is associated with a better selection of patients (more symptom free, fewer with neurologic deficits). There has been a notable decrease in perioperative stroke caused by ischemia during clamping and intracerebral hemorrhage, but postoperative thrombosis and embolism remain the major cause of neurologic complications. CONCLUSIONS: Although patient selection seems to play a role, most perioperative strokes were due to technical errors made during carotid endarterectomy or reconstruction and were preventable.

Aged↗