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PubMed1995

Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty.

PURPOSE: The purpose of this study was to explore the feasibility of iliofemoral endarterectomy performed through a single groin incision. METHODS: Thirty-two patients aged 34 to 75 years (mean age 63.4 years) with a male/female ratio of 20:12 underwent 36 lower extremity inflow reconstructions from July 1989 to September 1994. Surgical indications were for limb-threatening ischemia in 24 patients and for claudication in eight patients. The procedures were done for occlusive disease of the external iliac artery and common femoral artery with patients under either spinal (n = 24) or local (n = 12) anesthesia. Intraoperative balloon angioplasty with fluoroscopic guidance preceded open retrograde iliofemoral endarterectomy. Adjunctive procedures included 18 profundaplasties, eight femorofemoral, nine femoropopliteal, and one femorotibial bypasses. RESULTS: Thirty-three of the 36 cases were initially successful. The three failures were in patients with extensive calcification. The mean follow-up has been 36.4 months, and the patency rate was 80.5% at 3 and 4 years. The four failures noted on follow-up were caused by three common iliac artery stenoses and one iliac system occlusion. The former group was successfully treated with balloon angioplasty/stent, and the latter patient required an aortofemoral bypass. No operative deaths or limb loss occurred in this series. CONCLUSIONS: Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty is a safe, easy-to-perform, and viable option for patients with combined external iliac artery and common femoral artery occlusive disease. Midterm results (36.4 months) are favorable, and most hemodynamic failures are easy to correct with standard endovascular techniques.

Adult↗
PubMed1995

Contralateral intracerebral hemorrhage after carotid endarterectomy.

Postoperative intracerebral hemorrhage is a rare but devastating complication of carotid endarterectomy. Intracerebral hemorrhage on the side contralateral to the carotid endarterectomy has been reported only twice before in the literature. We present a case of fatal postoperative right intracerebral hemorrhage after left carotid endarterectomy in an 81-year-old patient. A review of the literature and a discussion of the pathophysiology of this condition is presented.

Aged↗
PubMed1995

Inhibition of platelet deposition by combined hirulog and aspirin in a rat carotid endarterectomy model.

PURPOSE: Hirulog, a thrombin-specific inhibitor, has shown efficacy in reducing arterial thrombosis in patients treated with aspirin who require angioplasty or have unstable angina. In this study, the effect of hirulog on reducing deposition of indium 111-labeled platelets was assessed in a surgical model of aspirin-treated rats undergoing carotid endarterectomy. METHODS: Animals were randomly assigned to one of five groups: control (no aspirin or hirulog); aspirin alone (10 mg/kg); aspirin plus low-dose hirulog (0.2 mg/kg bolus followed by 0.5 mg/kg/hr); aspirin plus medium-dose hirulog (0.4 mg/kg bolus followed by 1.0 mg/kg/hr); or aspirin plus high-dose hirulog (0.6 mg/kg bolus followed by 1.5 mg/kg/hr). Hirulog was infused before surgery and continued until termination of the experiment 30 minutes after endarterectomy. RESULTS: Platelet deposition in rats receiving aspirin alone was reduced by 19% +/- 23% SE (p = 0.26) compared with controls. Deposition in aspirin-treated groups receiving low-, medium-, and high-dose hirulog decreased in a dose-dependent manner by 37% +/- 20% (p = 0.048), 44% +/- 19% (p = 0.061), and 56% +/- 13% (p = 0.022), respectively. As the dose of hirulog was increased, the plasma hirulog levels and activated partial thromboplastin time ratios (final:initial) also increased in a dose-dependent manner. The mean plasma hirulog levels ranged from 0.74 +/- 0.08 micrograms/ml in the low-dose hirulog group to 2.55 +/- 0.08 micrograms/ml in the high-dose hirulog group, and the corresponding activated partial thromboplastin time ratios were 1.5 +/- 0.12 (p = 0.001) and 3.3 +/- 0.63 (p = 0.001). Bleeding was easily controlled by local hemostatic measures for all experimental groups. CONCLUSION: Hirulog causes significant decrease in 111In-labeled platelet deposition in aspirin-treated rats subjected to microsurgical endarterectomy at doses that allow surgical hemostasis to be easily established.

Animals↗
PubMed1996

A comparison of regional and general anesthesia in patients undergoing carotid endarterectomy.

PURPOSE: The optimal anesthetic for use during carotid endarterectomy is controversial. Advocates of regional anesthesia suggest that it may reduce the incidence of perioperative complications in addition to decreasing operative time and hospital costs. To determine whether the anesthetic method correlated with the outcome of the operation, a retrospective review of 3975 carotid operations performed over a 32-year period was performed. METHODS: The records of all patients who underwent carotid endarterectomy at our institution from 1962 to 1994 were retrospectively reviewed. Operations performed with the patient under regional anesthesia were compared with those performed with the patient under general anesthesia with respect to preoperative risk factors and perioperative complications. RESULTS: Regional anesthesia was used in 3382 operations (85.1%). There were no significant differences in the age, gender ratio, or the rates of concomitant medical illness between the two patient populations. The frequency of perioperative stroke in the series was 2.2%; that of myocardial infarction, 1.7%; and that of perioperative death, 1.5%. There were no statistically significant differences in the frequency of perioperative stroke, myocardial infarction, or death on the basis of anesthetic technique. A trend toward higher frequencies of perioperative stroke (3.2% vs 2.0%) and perioperative death (2.0% vs 1.4%) in the general anesthesia group was noted. In examining operative indications, however, there was a significant increase in the percentage of patients receiving general anesthesia who had sustained preoperative strokes when compared with the regional anesthesia patients (36.1% vs 26.4%; p < 0.01). There was also a statistically significant higher frequency of contralateral total occlusion in the general anesthesia group (21.8% vs 15.4%; p = 0.001). The trend toward increased perioperative strokes in the general anesthesia group may be explicable either by the above differences in the patient populations or by actual differences based on anesthetic technique that favor regional anesthesia. CONCLUSIONS: In a retrospective review of a large series of carotid operations, regional anesthesia was shown to be applicable to the vast majority of patients with good clinical outcome. Although the advantages over general anesthesia are perhaps small, the versatility and safety of the technique is sufficient reason for vascular surgeons to include it in their armamentarium of surgical skills. Considering that carotid endarterectomy is a procedure in which complication rates are exceedingly low, a rigidly controlled, prospective randomized trial may be required to accurately assess these differences.

Aged↗
PubMed1996

Intraoperative high-dose regional urokinase infusion for cerebrovascular occlusion after carotid endarterectomy.

Operative stroke complicating carotid endarterectomy is traditionally treated by reexploration of the operative site to correct a potentially causative lesion; however, attempts are not made to diagnose or treat the intracranial arterial occlusion. A 65-year-old man had a right hemiplegia during a left carotid endarterectomy that was caused by premature reversal of heparin, which resulted in thrombosis of his left anterior cerebral artery. On reexploration, the patient was treated with a 1-hour infusion of 1 million U urokinase through an indwelling carotid shunt. A repeat arteriogram demonstrated patency of the left anterior cerebral artery, with complete clot dissolution and resolution of the right hemiplegia on awakening. Natural history studies of stroke and prospective, angiographically controlled clinical trials of intraarterial thrombolytic therapy for acute stroke support the use of intraoperative intraarterial infusion of urokinase as part of a therapeutic approach to patients who have an ischemic stroke during carotid endarterectomy.

Aged↗
PubMed1996

Carotid endarterectomy with homologous vein patch angioplasty: a review of 1006 cases.

PURPOSE: Because homologous vein is rarely used in vascular reconstructions, we evaluated the homologous vein as a patch for the reconstruction of the carotid bifurcation after endarterectomy. METHODS: Excess vein harvested during open heart operations was either refrigerated in saline solution or cryopreserved in a solution of 10% dimethyl sulfoxide. Donors were tested for transmissible infections, and the veins were cultured for common pathogens. Data were analyzed from 837 consecutive patients (1006 cases) who underwent carotid endarterectomy with homologous vein patch angioplasty between 1981 and 1993. RESULTS: The perioperative mortality rate was 0.8% (eight patients). Two deaths (0.2%) were attributed to ipsilateral strokes. Ischemic strokes occurred in 12 patients (1.2%; 10 ipsilateral), and ipsilateral transient ischemic attacks occurred in three patients (0.3%). Follow-up data were obtained for 482 patients (56%; mean follow-up time, 61 months; range, 1 to 132 months). Ipsilateral recurrent symptoms occurred in eight patients (1.7%; seven strokes, one transient ischemic attack). Of the 63 late deaths (13%), the majority (25 patients; 40%) were caused by complications of coronary artery disease. The 10-year overall survival rate was 76% +/- 3.2%, and the 10-year rate of freedom from late ipsilateral morbidity was 96% +/- 1.4%. The 10-year rate of freedom from late stenosis (a reduction in diameter of > or = 20%) in the 220 arteries (22%) that were studied by duplex scan was 84% +/- 2.3%. CONCLUSIONS: The postoperative mortality and neurologic morbidity rates of carotid endarterectomy with homologous vein patch angioplasty are similar to those in the best series with all types of closure. The existing long-term follow-up data indicate that the homologous vein is a durable patch that behaves like other patches used in the same location.

Aged↗
PubMed1996

Influence of patient-related variables on the outcome of carotid endarterectomy.

PURPOSE: Variability in outcome after carotid endarterectomy is well recognized. This study examines the importance of patient-related factors in determining outcome. METHODS: Four hundred and sixty consecutive patients undergoing carotid endarterectomy for symptomatic severe (60% to 99%) internal carotid stenosis performed by one vascular surgeon have been studied prospectively. Patients were followed-up at 3, 6, 9, and 12 months and then yearly. Pre-, intra-, and perioperative details and follow-up information were entered on a database. RESULTS: Multiple logistic regression identified a number of factors significantly associated with death and stroke. A history of crescendo transient ischemic attacks (TIAs) (p = 0.003, p = 0.0002) and being female (p = 0.03, p = 0.0001) were associated with both perioperative death and stroke within 30 days of operation, respectively. Deaths between 1 and 36 months were associated with ischemic heart disease (p = 0.03) and diabetes (p = 0.04), whereas stroke was associated with small internal carotid diameter (p = 0.02). The importance of symptoms at presentation on outcome was further emphasized by life-table analysis. In 98% of patients with amaurosis fugax, only 67% of those with crescendo TIAs were alive at 18 months (p < 0.01). The survival of patients with amaurosis was significantly better than those with TIAs (p < 0.01), transient stroke (p < 0.01), and progressive, stroke (p < 0.05). Similarly, postoperative stroke was significantly more common for patients with crescendo TIAs than those with amaurosis (p < 0.01), established stroke (p < 0.05), and TIA (p < 0.05). Transient stroke was associated with a poor outcome, with only 66% of patients being alive in 36 months and 14% having suffered a stroke (p < 0.05 compared with established stroke). CONCLUSION: Presenting symptoms significantly predict outcome after carotid endarterectomy. This should be considered both in patient selection and comparison of patient series.

Carotid Artery, Internal↗
PubMed1996

Carotid endarterectomy without a shunt for symptomatic lesions associated with contralateral severe stenosis or occlusion.

PURPOSE: The purpose of this study was to assess the adequacy of thiopental protection against ischemic cerebral damage in patients undergoing carotid endarterectomy for symptomatic stenosis greater than 70% in association with contralateral stenosis greater than 70% or contralateral occlusion. METHODS: All patients (n=259) with severe bilateral carotid disease who underwent carotid endarterectomy for symptomatic stenosis greater than 70% were extracted from the database of an ongoing prospective carotid surgery study. Large-dose thiopental sodium without shunting was used for cerebral protection during endarterectomy. Asymmetric electroencephalogram changes during the operation, carotid occlusion time, stroke onset, and neuropathologic outcomes were analyzed. RESULTS: Three contralateral strokes occurred in the series, producing a cerebral morbidity/mortality rate of 1.2% (major 0.4%, minor 0.8%). Transient morbidity was 1.9% made of two reversible ischemic neurologic deficits and three transient ischemic attacks. New asymmetric electroencephalography changes were seen in 49 (19% patients, one of whom had transient deficit. Average occlusion time was 35 minutes. All strokes occurred within 24 hours of the procedure. Patients with previous stroke and and systemic hypertension seemed at greatest risk, and the contralateral hemisphere was the area at greatest risk. All transient deficits were ipsilateral and related to technical complications rather failed protection. CONCLUSIONS: Thiopental cerebral protection eliminates strokes caused by complications of shunting, prevents ischemic stroke during carotid occlusion for periods up to 67 minutes (average 35 minutes), allows meticulous management of the operative site, may modify or minimize clinical neurologic deficit, and in our experience has rendered intraluminal shunting obsolete.

Acute Disease↗
PubMed1997

Transcranial Doppler monitoring during carotid endarterectomy: is it appropriate for selecting patients in need of a shunt?

PURPOSE: This report summarizes our experience in evaluating a series of 168 patients who underwent a total of 175 carotid endarterectomy procedures under local anesthesia. Patients were monitored by stump pressure (SP) measurement and transcranial Doppler scanning (TCD). The need for shunting was compared between SP/TCD flow velocity reduction and the awake response (gold standard). METHODS: The study cohort represented 56% of all the carotid patients treated during the study period. Clamping ischemia was defined as the appearance of focal deficit (focal ischemia) or unconsciousness (global deficit) on carotid clamping. In the case of clamping ischemia, a shunt was inserted. To define the optimal value of SP and TCD flow velocity that is able to discriminate patients with clamping ischemia, a receiver operator characteristic (ROC) curve was constructed. Sensitivity and specificity tests, together with negative and positive predictive values (NPV and PPV), were calculated. Cutoff values were defined as the ROC curve values that correlated the highest sensitivity with the highest specificity for both SP and TCD. RESULTS: Clamping ischemia was present in 18 procedures (10%) in which a shunt was used. No perioperative deaths were recorded. Major perioperative morbidity occurred in one patient (0.6%). Two nondisabling strokes were also recorded (1.8% overall rate of neurologic morbidity). Cutoff values for both SP and TCD, using the ROC curve, were < or = 50 mm Hg and > or = 70% flow velocity reduction from baseline, respectively. SP values of < or = 50 mm Hg or less showed a sensitivity of 100%, a specificity of 83%, a PPV of 40%, and an NPV of 100%. TCD flow monitoring (> or = 70% flow reduction) revealed a lower sensitivity (83%) but a greater ability to avoid false positive results (96% specificity), resulting in increased PPV (71%) and NPV (98%). Combining SP and TCD failed to provide better results in terms of specificity (81%) and PPV (38%). CONCLUSIONS: SP measurement using a 50 mm Hg cutoff appears to be a reliable predictor of clamping ischemia but requires the use of a shunt in 17% of the patients who would otherwise not require this procedure. In contrast, TCD has greater specificity but is associated with a lower sensitivity, with 17% false negative results. In our experience, both SP and TCD show limitations, as they overestimate or underestimate carotid endarterectomy procedures in need of a shunt. We believe that sensitivity is more important than specificity in carotid endarterectomy, and thus conclude that TCD flow velocity measurement is not an optimal method for detecting clamping ischemia.

Aged↗
PubMed1997

Carotid endarterectomy for recurrent stenosis.

PURPOSE: The purpose of this study was to report our results in the surgical management of recurrent carotid stenosis (RCS) after carotid endarterectomy (CEA). METHODS: In a 20-year period, we performed 1209 CEAs; 82 operations (6.8%) were for RCS. There were 33 men and 36 women, with an average age of 66.3 years. Nine patients underwent two redo CEAs and two patients underwent three redo CEAs for either bilateral recurrence or a second recurrence on the same side. Overall, 10 patients were identified with a second recurrence. RESULTS: The average time to presentation with RCS was 65 months (range, 3 to 361 months). The majority of patients (66%) were symptomatic, 34% had transient ischemic attacks, 17% had amaurosis fugax, 9% had strokes, and 6% had nonhemispheric symptoms. Before repair, angiograms were obtained. Patch repair was performed in 61 procedures (74%), 41 with vein, 11 with Dacron, and nine with polytetrafluoroethylene. Autogenous or synthetic bypass grafts were used in 20 procedures (24%), vein in eight, Dacron in two, and polytetrafluoroethylene in 10. In one patient, an occluded internal carotid artery was ligated and an endarterectomy of the external carotid artery was performed without a patch. The operative stroke rate was 4.8%. Minor complications included transient or permanent cranial nerve deficits in 7.3% and wound hematomas in 2.4%. CONCLUSION: Although repeat endarterectomy to treat RCS is technically more demanding, it can be performed safely. Long-term follow-up examination shows that a second recurrence may develop, and we recommend serial noninvasive testing.

Aged↗
PubMed1997

Cranial/cervical nerve dysfunction after carotid endarterectomy.

PURPOSE: The purpose of this article is to review the results of patients who had cranial and cervical nerve dysfunction after undergoing carotid endarterectomy. METHODS: The prospective study reviewed 183 consecutive carotid endarterectomies. Preoperative and postoperative cranial nerve assessments were accomplished on all patients. Neurologic evaluation included direct fiberoptic laryngoscopy. Patients found to be neurologically intact had no further follow-up. Patients with postoperative neuropraxia were entered into regular long-term follow-up to assess delayed recovery. RESULTS: Twenty-six (14.2%) nerve injuries were identified in 21 patients. There were 14 recurrent laryngeal, 8 hypoglossal, 2 marginal mandibular, and 2 greater auricular nerve dysfunctions. Two patients were lost to follow-up. Eighteen (9.8%) nerve injuries were transient, whereas two (1.1%) were permanent. Four patients are currently undergoing extended follow-up to assess delayed recovery. Two patients with recurrent laryngeal nerve dysfunction were found to have prolonged full recovery intervals: 20 months and 50 months, respectively. CONCLUSIONS: The incidence of focal neuropraxia after carotid endarterectomy is presented. Most injuries are transient. However, permanent injuries can lead to significant disability. Extended follow-up will identify the small subset of patients with delayed complete nerve recovery.

Adult↗
PubMed1997

Geometric dimension changes with carotid endarterectomy reconstruction.

PURPOSE: The geometry of carotid endarterectomy (CEA) reconstruction is a major determinant of carotid bifurcation hemodynamics that, in turn, may play a significant role in the likelihood of early postoperative thrombosis and early and late restenosis. The purpose of this study was to measure the geometry of various types of CEA reconstructions. METHODS: Six carotid artery diameters and lengths were measured during surgery, before and after CEA. Three reconstruction methods were used in 562 CEA procedures: a greater saphenous vein patch in 389, a synthetic patch in 157, and primary closure in 16. Veins 6 mm or more in distended diameter were trimmed before use as a patch. Synthetic patches were 8 to 11 mm in width. Patch reconstruction was used when the length of the arteriotomy required to obtain a complete distal endarterectomy end point extended beyond the internal carotid artery bulb. Saphenous vein patches were used when it was available and adequate. Neither gender nor internal carotid artery diameter was used as a criteria for the selection of the reconstruction method. RESULTS: Before endarterectomy, the 302 male carotid arteries had 7% to 15% greater linear dimensions than the 260 female arteries (p < 0.001). Both vein and synthetic patch reconstruction produced up to 16% changes in linear dimensions except for almost doubling of the length of the internal carotid bulb. Patching made the elliptical common carotid bulb significantly more round, but the maximum diameter of curvature of the carotid bulb remained unchanged. Primary closure slightly decreased the diameter of the internal carotid bulb. CONCLUSIONS: CEA patch reconstruction has two major effects on carotid geometry: an increase in internal carotid bulb length and a more round common carotid bulb. The former allows for a gradual transition from the terminal common carotid bulb to the uniform diameter more distal internal carotid artery. It also separates the two major causes of disturbed flow: the bifurcation and the step-down in internal carotid artery diameter. Primary closure has minimal effect on preoperative geometry.

Carotid Artery, Common↗
PubMed1997

Continuous electroencephalographic monitoring and selective shunting reduces neurologic morbidity rates in carotid endarterectomy.

PURPOSE: The role of continuous electroencephalographic (EEG) monitoring during carotid endarterectomy was evaluated in this retrospective review. METHODS: We analyzed data from 902 consecutive carotid endarterectomy procedures performed with vein patch angioplasty. In 591 operations from 1980 to 1988 we did not use intraoperative EEG monitoring or shunting (non-EEG group). Continuous intraoperative EEG monitoring and selective shunting were used in 311 procedures from 1988 to 1994 (EEG group). The patients' mean age was higher in the EEG group (68.8 years; range, 41 to 87 years) than in the non-EEG group (66.2 years; range, 34 to 90 years; p < 0.001). There was also a significantly higher incidence of hypertension (56.2% vs 41.9%) and redo operations (5.4% vs 2.54%) in the EEG group than in the non-EEG group (p < 0.05). The operative technique was identical in both groups. We defined a significant EEG change as a greater than 50% reduction of the amplitude of the faster frequencies, a persistent increase of delta activity, or both. RESULTS: In the EEG group, acute EEG changes occurred in 40 patients (12.8%); 31 (77.5%) unilateral and ipsilateral to the operated carotid artery, and nine (22.5%) bilateral. In five patients (12.5%) the changes correlated with an intraoperative episode of hypotension, and after normal blood pressure was restored the EEG returned to normal. In 35 procedures (87.5%) a carotid shunt was inserted. In 33 of those patients the EEG returned to baseline, in one patient there was a significant improvement, and in one patient the EEG changes persisted. Postoperative hospital strokes occurred in one patient (0.32%) in the EEG group and in 13 patients (2.19%) in the non-EEG group (p < 0.05). All strokes (n = 14) were ipsilateral to the operated carotid artery. Of the 13 strokes in the non-EEG group nine were major and four were minor. The one stroke in the EEG group was embolic in origin and occurred before carotid cross-clamping; it was associated with profound EEG changes that did not reverse after placement of a shunt. In the total group (n = 902), intraoperative EEG monitoring was inversely associated with postoperative stroke (p < 0.05). CONCLUSION: The overall neurologic morbidity rate was significantly lower in the EEG group than in the non-EEG group, therapy demonstrating the value of intraoperative EEG monitoring in carotid endarterectomy.

Adult↗
PubMed1997

Use of muscle flap to cover infections of the carotid artery after carotid endarterectomy.

Wound infection after carotid endarterectomy is an extremely uncommon complication. This complication occurred in two of our patients in a series of 170 consecutive carotid endarterectomies over the last 3 years. There has been an increased use of prosthetic patch grafts to close carotid endarterectomy sites. However, the presence of infection in the setting of prosthetic graft material poses difficulties in management and may lead to life-threatening complications. Recent strategies for the management of wound infections (in cases where the artery/graft interface is intact) include the use of appropriate antibiotics, repeated wound debridement, and covering the tissue defect or the perigraft area with well-vascularized muscle flap. In this case report the use of sternocleidomastoid muscle flap as a coverage for the infected area is described. The use of sternocleidomastoid muscle flap helped control the infective process and secured the viability of the patched carotid arteries.

Anti-Bacterial Agents↗
PubMed1999

Incidence, time-of-onset, and anatomical distribution of recurrent stenoses after remote endarterectomy in superficial femoral artery occlusive disease.

PURPOSE: The incidence, time-of-onset, and anatomical distribution of recurrent stenoses after remote endarterectomy in superficial femoral artery (SFA) occlusive disease were studied. METHODS: Patients undergoing SFA remote endarterectomy procedures were examined with duplex surveillance. Patients were examined at 6 weeks, 3, 6, 9, and 12 months, and then annually. Recurrent stenosis was defined as a peak systolic velocity ratio of 2.5 or higher. Duplex results were also compared with clinical and hemodynamic changes. RESULTS: Restenoses were identified in 46 of 101 (46%) limbs treated after a mean interval of 5.8 months (range, 1 to 18 months). These 46 limbs formed the base of this study. The median follow-up period was 25 months. Thirty-eight (83%) of all restenoses were detected within 1 year. The lesions were located within the entire SFA and were not specifically related to the adductor canal or distal stented region only. Multiple stenoses were found in 21 limbs. Only 10 (22%) restenoses were correlated with worsening of clinical symptoms, change of ankle-brachial index, or both. Ten of 23 cases (43%) of nonrevised restenoses progressed to occlusion. These 10 occlusions occurred in all patients with restenosis that developed within the first year. Nonrevised late restenoses (more than 1 year) were not associated with any reocclusion. CONCLUSION: Recurrent stenoses after SFA remote endarterectomy were noticed in 46 of 101 (46%) limbs. Most restenoses (83%) developed within the first year. In the nonrevised group, time-of-onset restenosis (less than 1 year) was correlated with a higher risk for occlusion ( P =.02). The location of restenoses were found without any anatomical site of preference along the entire endarterectomized SFA segment.

Aged↗
PubMed1999

Selection of patients for carotid endarterectomy.

OBJECTIVE: The aim of this study was the definition of the duplex scan parameters that best select patients for carotid endarterectomy. METHODS: This study was set in a regional vascular unit. Duplex scanning and angiography were performed prospectively on 50 patients who were symptomatic (100 carotid bifurcation) to identify the most accurate and sensitive duplex scan criteria to identify an 80% to 99% stenosis according to the European Carotid Symptomatic Trial. With data from the European Carotid Symptomatic Trial, we estimated the effect of three different approaches used to select patients for carotid endarterectomy. The first approach was the selection of patients for carotid surgery on the basis of duplex scanning alone with the most accurate duplex scan criteria (approach I). The second approach was the selection of patients for carotid surgery on the basis of duplex scanning alone with a 100% sensitive duplex scan criteria (approach II). The third approach was the selection of patients for angiography with duplex scanning (100% sensitive criteria) and then the use of angiography to define which patients should undergo surgery (approach III). RESULTS: All three approaches appeared to have a similar potential in stroke reduction. However, approach I, which minimized the number of patients who underwent surgery (19% less than approach II) or invasive imaging (65% less than approach III), appeared to be the most appropriate. CONCLUSION: These data support the selection of patients for carotid endarterectomy on the basis of duplex scanning alone. The duplex scan criteria should be validated against angiography.

Aged↗
PubMed1989

Carotid endarterectomy in community practice: surgeon-specific versus institutional results.

The efficacy of carotid endarterectomy in preventing stroke is clearly related to appropriate patient selection and low surgical morbidity and mortality. It has been suggested that since results at some centers are better than nationwide statistics, perhaps the operation should be limited to those institutions. In this paper we present an experience with carotid endarterectomy over the past twelve years. These 566 consecutive cases were performed by two vascular surgeons in a large metropolitan area using thirteen different hospitals ranging from 150 to 500 beds. Our mortality of 0.5% and permanent stroke incidence of 1.6% did not vary significantly from hospital to hospital. Where the results of surgical audits were available from the individual hospitals, the overall complication rates were significantly higher. We conclude that individual surgeons, not institutions, determine the efficacy of carotid endarterectomy in community practice.

Adult↗
PubMed1989

Carotid endarterectomy in patients with contralateral carotid occlusion: is the risk increased?

Many vascular surgeons believe the risk of carotid endarterectomy is greater if the patient has a contralateral carotid occlusion, and thus believe intraoperative shunting is mandatory. Five hundred and eleven carotid endarterectomies were performed over the last 11 years by two of us (JEM and RAL). Of these, 370 had charts available for detailed analysis. Twenty-seven of these patients had complete occlusion of the contralateral carotid artery. Eight of these 27 patients were asymptomatic and 16 patients had transient ischemic attacks prior to surgery. Two patients had strokes which were stable at the time of surgery. One patient with a previous stroke was operated upon emergently with a new stroke in evolution. All were operated upon under general anesthesia and only three had intraoperative shunting. Occlusion time averaged 17.1 minutes varying from 11 to 34 minutes. There were two deaths, one cardiac and one pulmonary, and no postoperative strokes either temporary or permanent. Of the 343 patients without contralateral occlusion, three patients (.87%) died, and there were 19 (5.5%) neurologic complications of which seven (2%) were present at the time of hospital discharge. It appears that contralateral carotid occlusion does not increase the risk of stroke after carotid endarterectomy even when intraoperative shunting is not used.

Aged↗