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PubMed1995

Value of angioscopy for intraoperative assessment of carotid endarterectomy.

From March 1992 to November 1993 we used angioscopy and arteriography for intraoperative assessment of 103 carotid endarterectomies in 96 patients. The indication for surgery was asymptomatic stenosis in 55 cases and neurologic and/or ocular symptoms in 48. Intraoperative angioscopy and arteriography were performed to allow comparison of findings. Intraoperative angioscopic images were normal in 67 cases and abnormal in 36. The defect was an intimal flap in 26 cases, detachment of the distal plaque in seven cases, and an intimal wedge in five cases. In two cases both detachment and a wedge were observed. The defect was not considered severe enough to warrant revision in 31 cases and was corrected in five cases by either vein bypass (n = 1) or revision of the endarterectomy (n = 4). In the latter four cases repeat angioscopy showed normal findings. Arteriographic and angioscopic findings were compared in 102 cases. In the 71 cases in which angioscopic findings were normal, arteriography revealed a major abnormality in three cases: kinking in one and stenosis > 40% in two. Kinking was treated by attachment of the common carotid artery and stenosis by venous bypass. In the 31 cases in which angioscopy revealed defects not considered to warrant revision, arteriography revealed stenosis > 40% in three cases treated by either prosthetic bypass (n = 2) or revision of the endarterectomy (n = 1). The false negative rate for angioscopy was 5.9% and concordance between the two methods was 94.1%. The combined mortality-morbidity rate was 1.9% (one stroke and one death). Postoperative evaluation of anatomic findings by arteriography or Doppler ultrasonography revealed asymptomatic internal carotid occlusion in one and internal carotid stenosis < 30% in four cases. Angioscopy is a simple, low-cost method in intraoperative control that can be used either as an adjunct to arteriography or as an alternative if arteriography cannot be performed.

Adult↗
PubMed1991

Duplex scanning alone before carotid endarterectomy: a 5-year experience.

The role of duplex scanning and arteriography as a means of assessing patients for carotid endarterectomy has been reviewed for the period 1984 to 1988 when 98 carotid endarterectomies were performed. Of these 44 were selected for surgery on the basis of duplex assessment alone, 48 after carotid angiography and duplex scanning and six after angiography alone. No difference between the groups of patients was observed for either perioperative or follow-up complication rates, although all late deaths occurred in patients who had been examined by angiography. By the end of the study period angiography was requested for less than 30% of all patients undergoing carotid endarterectomy. It is argued that the change in our practice is safe provided that certain criteria are met. These include angiography in cases of suspected aortic arch or proximal vessel disease and in those symptomatic patients with a duplex diagnosis of complete occlusion.

Adult↗
PubMed1993

Defective cerebrovascular autoregulation after carotid endarterectomy.

Correction of high grade carotid artery stenosis may result in cerebral hyperperfusion because of defective vascular autoregulation. Thus, transcranial Doppler was used to determine mean arterial flow velocity (Vmean) of the middle cerebral artery in 95 patients before and after carotid endarterectomy. Attention was focused on postoperative episodes of ipsilateral headache and hypertension. Symptoms of cerebral hyperperfusion lasted for 3 (1.5-5) h (median and range) in nine patients, and for 12 (8-14) days in nine other patients. Of these later patients, two developed seizures on the 5th and 6th postoperative day, respectively. The mean pressure difference across the stenosis was 31 (0-63) mmHg in the symptomatic group (n = 18) as opposed to only 10 (0-60) mmHg in the asymptomatic group (n = 77) (p < 0.01). In the 18 patients with headache after surgery, ipsilateral Vmean increased to 177 (130-332)% of the preoperative value (p < 0.0001), while the contralateral Vmean remained unchanged. After blood pressure was reduced in symptomatic patients with labetalol, ipsilateral Vmean decreased from 92 (69-124) to 56 (32-93) cm s-1 (p < 0.0001) as systemic arterial pressure decreased from 101 (80-128) to 88 (60-103) mmHg, with no change in contralateral Vmean. Normalisation of Vmean via reduction of arterial pressure ended episodes of headache and seizure in symptomatic patients. Thus, in patients who developed post-endarterectomy hyperperfusion, these findings clearly demonstrated that ipsilateral middle cerebral artery mean flow velocity was pressure dependent. This substantiates the hypothesis of defective autoregulation in the ipsilateral hemisphere after carotid endarterectomy, and in turn demonstrates an immediate cessation of symptoms with reduction of arterial pressure even in normotensive patients.

Adult↗
PubMed1993

The influence of smoking and lipids on restenosis after carotid endarterectomy.

Factors associated with restenosis were investigated in 107 patients undergoing carotid endarterectomy for symptomatic disease. The patients, 71 men and 36 women with mean age 68 +/- 8 years, were followed up for 1 year by serial Duplex scanning. Carotid restenosis of > or = 50% developed in 18 patients (17%), 11 men and seven women. Restenosis was not influenced by age, sex, diabetes or hypertension. Continuing smokers, serum cotinine > 200 nmol/l, had a significantly higher incidence of > or = 50% restenosis after 1 year (39%), compared with only 16% of non-smokers, p = 0.023. Restenosis > or = 50% also was associated significantly with below median body mass index (p = 0.027). Women undergoing carotid endarterectomy had higher levels of cholesterol (median 7.4 mmol/l) and apolipoprotein B (median 0.81 g/l) than men (median cholesterol 6.4 mmol/l, median apolipoprotein B 0.69 g/l), p < 0.01. For men only, restenosis of > or = 50% was associated with low levels of serum cholesterol (median 5.7 mmol/l), p = 0.002. For women cholesterol levels were higher (median 8.1 mmol/l) in those with > or = 50% restenosis. Smoking adversely influences early restenosis (1 year) after carotid endarterectomy. Hyperlipidaemia is not a risk factor for restenosis in men, but may be associated with restenosis in women.

Adult↗
PubMed1991

Redo endarterectomy for recurrent carotid artery stenosis.

From a registry of 2406 carotid endarterectomies performed on 1818 patients over a 19-year period, 29 patients (1.6%) underwent reoperations for recurrent stenosis. Reoperations were performed for symptomatic stenosis for 23 and asymptomatic greater than 80% stenosis for six patients. Compared to the entire series, there was no difference in the incidence of restenosis for men and women. The pathologic findings were myointimal hyperplasia in 27%, atherosclerosis in 53%, thrombus with vessel dilatation in 17% and extrinsic scar in 3%. Redo endarterectomy with patch angioplasty was used for reconstruction in 27 patients and patch angioplasty alone in two. There were no operative deaths or strokes. Late follow-up (mean 50 months) revealed only one stroke and six other deaths. Although 21 (75%) were alive and stroke-free, follow-up studies suggest a high incidence (21%) of tertiary lesions among patients who have undergone redo endarterectomy for recurrent stenosis.

Aged↗
PubMed1987

Carotid endarterectomy in patients with occlusion of the contralateral carotid artery. Perioperative risk and late results.

Recent reports on the outcome of carotid endarterectomy in patients with contralateral occlusion have been conflicting. Therefore, we reviewed 51 cases identified, among 675 consecutive carotid endarterectomies. A perioperative mortality of 2% and a permanent morbidity rate of 16% was observed. Compared with a complication rate of about 5% previously reported from this institution, this clearly indicates contralateral carotid occlusion as a major risk factor in carotid surgery. Though not statistically significant, patients with severely reduced cerebral perfusion pressure (CPP) had suffered more severe strokes when compared to patients with only minor reduction in CPP. In addition, the internal carotid artery blood flow following endarterectomy was significantly higher in the low pressure group (P less than 0.02). No patients were lost during follow-up, for a mean of 34 months. The cumulative five-year survival rate was 74%, not significantly different from the expected survival of an age and sex matched population. During the period of follow-up 16 patients experienced new neurologic symptoms, in six (2 strokes and 4 TIA's) referable to the hemisphere ipsilateral to operation and in 10 (2 strokes and 8 TIA's) referable to the contralateral hemisphere. The five-year stroke rate was 16%. This together with the observed survival rate indicated a better-than-expected course in this group of patients with severe cerebrovascular atherosclerosis.

Carotid Artery Diseases↗
PubMed1988

Platelet kinetics following carotid endarterectomy: the effect of aspirin and patch angioplasty.

Platelet deposition on the subintimal surface of the arterial wall following endarterectomy has been implicated in the development of postoperative thrombosis, intimal hyperplasia and may be important in recurrent stenosis. Autologous radiolabelled platelet deposition has been measured in 51 patients following carotid endarterectomy. The effect of platelet inhibitory drugs and patch angioplasty on early postoperative platelet accumulation at the site of endarterectomy has been investigated. In patients undergoing direct suture of the arteriotomy, platelet deposition measured as the Carotid Uptake Ratio was significantly reduced from 1.44 +/- 0.03 to 1.11 +/- 0.35 in those receiving aspirin and dipyridamole (P less than 0.002). Carotid Uptake Ratio was greater following patch angioplasty at 1.41 +/- 0.07 when compared to 1.14 +/- 0.07 with direct suture of the arteriotomy (P less than 0.002).

Aspirin↗
PubMed1998

Cardiovascular stability during carotid endarterectomy: endotracheal intubation versus laryngeal mask airway.

STUDY OBJECTIVE: To compare cardiovascular stability during carotid endarterectomy in groups managed either with laryngeal mask airway (LMA) or endotracheal intubation. DESIGN: Randomized, retrospective, blinded study. SETTING: Teaching hospital. PATIENTS: 61 ASA physical status II, III, and IV unpremedicated adult males scheduled for carotid endarterectomy. INTERVENTIONS: Following standardized anesthetic technique, including intravenous (i.v.) induction with thiopental sodium 3 to 4 mg/kg, fentanyl 2 to 3 microg/kg), and isoflurane, standard intraoperative cardiovascular monitoring plus direct arterial blood pressure measurements were instituted. Patients were randomly assigned to an endotracheal intubation or LMA group. MEASUREMENTS AND MAIN RESULTS: Distinct intraoperative episodes of +/- 25% increase or decrease of mean arterial blood pressure (MABP) and heart rate (HR) when compared with preinduction baseline values, and the number of such episodes requiring interventional therapy were recorded from a blinded anesthesia record retrospectively. Mean end-tidal isoflurane determination and total case duration enabled calculation of minimum alveolar concentration (MAC) hours of isoflurane administered. The LMA group had a significantly (p < 0.05) lower incidence of increased MABP and HR episodes and such episodes requiring drug therapy than did the endotracheal intubation group. No difference was found in the length of surgery, mean end-tidal isoflurane concentration, or the total number of MAC hours of isoflurane administered. CONCLUSIONS: During carotid endarterectomy, a reduced incidence of hypertensive and tachycardic episodes, as well as such episodes requiring interventional drug therapy, was found in the group whose airway is managed by LMA when compared with endotracheal intubation.

Aged↗
PubMed2001

Posterior transverse plication technique for treatment of redundant internal carotid artery during endarterectomy.

PURPOSE: Posterior transverse plication (PTP) has gained popularity as a technique to correct redundancy of the internal carotid artery during endarterectomy. The safety of this technique in large series of patients has not been extensively studied. We investigated 876 primary carotid endarterectomies (CEAs) performed at our institution over the last six years to determine the safety of this technique. METHODS: Indication for surgery was carotid stenosis >/=70% in 341 (39%) symptomatic and 535 (61%) asymptomatic cases. Preoperative imaging consisted of duplex ultrasound alone or combined with magnetic resonance angiography. Patients were divided into four groups related to surgical technique: CEA+PTP+8mm patch (group Ia), CEA+PTP+10mm patch (group Ib), CEA+patch (group II) and CEA+primary closure (group III). There were 43, 39, 581 and 213 patients in groups Ia, Ib, II and III, respectively. No statistical differences in age, sex or risk factors for atherosclerotic disease were noted among the groups. Postoperative duplex ultrasonography was used at 2weeks and every 6months thereafter to evaluate the adequacy of the repair and presence of complications such as pseudoaneurysm formation and extrinsic compression by the excluded carotid segment. RESULTS: The 30-day mortality was 1.2%, 0.6% and 0.3% for groups I, II and III, respectively. Stroke rates for the same period were 0%, 0.6% and 0.8% for groups I, II and III, respectively. Duplex ultrasonography demonstrated significant stenosis (>/=50%) in two (5%) patients in group Ia at 12months. No restenosis was observed in group Ib. For groups II and III the rates of restenosis were 1.5% and 0.8%. One patient in group II developed a pseudoaneurysm after 7months. CONCLUSION: Posterior transverse plication safely corrects redundancy of the internal carotid artery during endarterectomy without causing early significant restenosis. Continued follow-up in a larger group of patients to determine long-term efficacy and correlation between patch size and restenosis rate is warranted.

Aged↗
PubMed2001

Carotid endarterectomy with bovine patch angioplasty: a preliminary report.

Carotid endarterectomy with patch angioplasty is a durable procedure for prevention of recurrent neurological symptoms and stroke. However, no definitive study has demonstrated a clear benefit of one class of the patch material over another. The aim of this study was to evaluate the clinical outcome of carotid endarterectomy with bovine pericardium patch in comparison with autologous vein patch. One hundred and twenty-two carotid endarterectomies were performed using patch closure of the arteriotomy with bovine pericardium (61 cases) and autologous vein (61 cases) between September 1995 and June 1999. Though this is not a double-blind type randomized comparative study, effort was made to achieve a 1:1 ratio in sequence with a few exceptions such as non-available veins at time of surgery or for future use. In bovine pericardium patch closure group, the mean total operating time was significantly shorter than autologous vein closure group (P<0.01), but the mean carotid clamping time was similar in both groups, regardless of the use of shunt. The incidence of postoperative local complications including groin wound was less in bovine pericardium patch closure group. The patients were followed with duplex scans in one month post-CEA and 6 months interval thereafter. During the follow-up period, three patients developed non-critical stenosis (two in bovine and one in vein patch), and one aneurysmal dilation occurred in vein patch group. The incidence of restenosis was similar in both groups. Although this is a preliminary report, it is concluded that the results of carotid angioplasty using bovine pericardium compare favorably with autologous vein.

Aged↗
PubMed2001

Six hundred consecutive carotid endarterectomies with temporary shunt and vein patch angioplasty: early and long-term results.

PURPOSE: This retrospective study evaluates the long-term clinical outcome and the survival of 600 consecutive carotid endarterectomies performed with a temporary shunt. All arteriotomies were closed by vein patch angioplasty. MATERIALS AND METHODS: Between November 1989 and November 1998, 600 isolated carotid endarterectomies (CEA) were performed in 540 patients by a uniform surgical technique at the University Clinic of Mont-Godinne. An intraluminal shunt and patch closure were systematically used. The mean age was 68 yr (ranging from 41 to 91 yr), 400 patients were men. The risk factors included hypertension in 73%, smoking history in 60%, coronary artery disease in 51% and hyperlipidemia in 35%. The indications were asymptomatic stenosis in 47%, transient ischemic attack in 40%, vertebrobasilar symptoms in 7% and stroke in 6%. EARLY RESULTS: The combined 30-day stroke and death rate was 0.9%. There were four deaths. The stroke and TIAs rates were 0.2% and 1.5% respectively. The incidence of early carotid occlusion was 0.5%. Cranial or cervical nerve dysfunction was identified in 6.3%. LATE RESULTS: The median follow-up was 49 months with a range of 2-124 months. Cumulative survival rates at 5 and 10 yr were 92+/-1% and 89+/-2% respectively. Thirty-two patients died during long-term follow-up; the death was stroke-related in only three patients. CONCLUSION: Carotid endarterectomy using an intraluminal shunt and vein patch closure is a safe and effective procedure associated with low morbidity and mortality rates at short and long-term follow-up.

Adult↗
PubMed1998

Combined carotid endarterectomy and coronary artery bypass grafting does not increase the risk of perioperative stroke.

Patients who present for coronary artery bypass grafting with hemodynamically significant carotid artery lesions pose a difficult problem for both the cardiac and vascular surgeons. There is no consensus as to the proper management of these patients despite numerous studies. Prospective collection of data was performed in patients undergoing combined carotid endarterectomy and coronary artery bypass grafting's from April 1980 to November 1996. A total of 470 simultaneous carotid endarterectomy's and coronary artery bypass grafting's were performed in 420 patients. The average age of the patient was 69 years, with 62% being male, 15% being diabetic and 38% being smokers. Sixty (13%) presented with Transient ischemic attacks, 22 (5%) presented with amaurosis fugax, 16 (3.4%) presented with a prior history of stroke and 372 (70%) were asymptomatic. Operative mortality was 2.4% or 10 patients; 90% of those patients died from cardiac complications postoperatively and one patient died of a stroke. Permanent neurological deficits occurred in five (1%) of the patients, and six (1.7%) of the patients had a transient neurological deficit that improved prior to discharge. In conclusion, in our experience simultaneous carotid endarterectomy with coronary artery bypass grafting can be performed with an acceptable mortality and morbidity and does not appear to put the patient at a higher risk than when either procedure is performed alone.

Aged↗
PubMed1999

The results of routine primary closure in carotid endarterectomy.

PURPOSE OF STUDY: The aims of this study were to determine the incidence of restenosis following carotid endarterectomy with primary closure of the arteriotomy and to observe the natural history of disease progression in the 1st postoperative year. METHODS: The study group consisted of a consecutive series of 126 patients undergoing carotid endarterectomy. Duplex imaging was performed preoperatively and at 8 weeks, 6 months and 1 year postoperatively. RESULTS: Five patients (4%) had a residual stenosis. At 12 months, the overall restenosis rate was 15%: 8.5% for males and 28.9% for females. None of these restenoses were symptomatic. There was no significant difference in the diameter of the internal carotid artery between male and female patients (U = 896, P = 0.60) and no significant difference in the diameter of the arteries that had restenosed at 12 months and those that had remained patent (U = 391, P = 0.33). CONCLUSIONS: Carotid endarterectomy with primary closure is associated with a low incidence of restenosis in men, but not in women. Criteria for selective patching should consider both gender and vessel calibre.

Aged↗
PubMed1999

Decreasing carotid endarterectomy length of stay at a university hospital.

In 1995, a clinical pathway for carotid endarterectomy patients was instituted at the authors' institution. The effect of this program on length of stay and patient outcomes was investigated. Records of 152 consecutive carotid endarterectomies performed by a single surgeon over a 45-month period with identical technique (general anesthesia, routine shunting, closure with a dacron patch) were reviewed. Comparison of patients treated under the pathway (n = 119) and those prior to that policy (n = 33) revealed no significant differences (P>0.05) in age, sex, co-morbid conditions, or surgical indication. No difference (P>0.05) was found for occurrence of complications, which included two fatal perioperative strokes (1.3%) and two myocardial infarctions (1.3%) (one fatal). No complications occurred after discharge and no patients required readmission to the hospital. Average length of stay was reduced from 6.0 to 3.3 days, with 78% of patients discharged within 48 h. Preoperative hospitalization decreased from 100 to 21%. A decrease in the use of preoperative arteriography from 100 to 10% was noted. The cost of vascular studies decreased from $2451 to $1228. Cost-saving measures, including early discharge of stable patients, elimination of preoperative hospitalization and decreased use of arteriography, can be accomplished while maintaining acceptable complication rates following carotid endarterectomy in a university hospital setting.

Adult↗
PubMed2000

Simultaneous carotid endarterectomy and coronary artery bypass grafting in 313 patients.

The coincidence of coronary and carotid artery disease (uni- or bilateral, with or without involvement of the supra-aortic branch) is still a problem with regards to surgical strategy. Since the opening of the Heart Centre Duisburg in 1989 the authors have favoured a simultaneous approach to lesions in both arterial systems in order to avoid myocardial infarction or stroke. The aim of this retrospective study was to review the early and late results of the combined procedures for the endpoints of death, myocardial infarction and stroke. During a 7-year period (1990-1997) a total of 18,050 patients underwent cardiac surgery and extracorporeal circulation. Simultaneous intervention in both arterial systems was performed in 313 patients (1.73%). All patients underwent preoperative ultrasonic diagnostics, digital subtraction angiography, neurological examination and cardiac catheterization. The principal indication was the need for myocardial revascularization, and symptomatic or asymptomatic carotid stenosis of 80% diameter reduction or more (with or without contralateral disease). The mean age was 66.4 +/- 6.9 years; 240 patients (76.7%) were male, 73 patients (23.3%) female; 243 patients (77.6%) had triple-vessel disease, 82 patients (26.2%) had left main stenosis and 94 patients (43.5%) had a reduced ejection fraction. A total of 171 patients (54.6%) had a previous myocardial infarction, 54 patients (17.3%) presented with unstable angina and nine patients (2.9%) had prior coronary artery bypass grafts. Eighty-seven patients (27.8%) had an internal carotid artery stenosis on the right side, 75 patients (24%) on the left side and 151 patients (48.2%) lesions in both carotid arteries. Prior carotid endarterectomy was performed in 14 patients (4.5%), and the contralateral carotid was occluded in 24 patients (7.7%). Fifty patients had a previous stroke (16%) and 185 patients (59.1%) were asymptomatic. During surgery, the the carotid artery was first exposed, followed by median sternotomy, systemic heparinization, cannulation and cardiopulmonary bypass. After achieving mild hypothermia (30 degrees C), endarterectomy was performed with a venous patch closure. An occluded contralateral carotid artery was always an indication for shunting. Coronary artery bypass grafting was carried out with intermittent cross-clamping under moderate hypothermia (22-27 degrees C). Ten patients suffered a myocardial infarction (3.2%), seven patients (2.2%) had an apoplectic insult perioperatively ( < 30 days) and one patient (0.3%) had an event during long-term follow-up. Early overall mortality was 28 (8.9%), of which 13 were cardiac related (4.2%). Overall late mortality was eight (2.6%), of which six were cardiac related (1.9%). Mean survival time was 6.18 years. Simultaneous carotid endarterectomy and myocardial revascularization can be justified as a routine surgical management of severe lesions in both arterial systems. The risk of myocardial infarction, apoplectic stroke or mortality was not significantly different than isolated procedures.

Aged↗
PubMed2000

Subtle brain damage cannot be detected by measuring neuron-specific enolase and S-100beta protein after carotid endarterectomy.

OBJECTIVE: To assess whether subtle brain damage after carotid endarterectomy could be detected using serum levels of neuron-specific enolase (NSE) or S-100beta protein. DESIGN: Prospective noninterventional study. SETTING: University hospital. PARTICIPANTS: Twenty-two patients undergoing carotid endarterectomy and 16 patients undergoing repair of abdominal aortic aneurysm. INTERVENTIONS: Serum levels of NSE and S-100beta protein were measured in all patients before surgery and postoperatively at 12, 24, 36, and 48 hours. In patients undergoing carotid endarterectomy, neuropsychologic testing was performed before surgery and postoperatively at discharge from the hospital and after 3 months using a neuropsychologic test battery. MEASUREMENTS AND MAIN RESULTS: Compared with abdominal aortic surgery patients, the preoperative serum concentration of NSE was significantly higher in carotid artery surgery patients. Postoperatively, the NSE serum level decreased significantly after uncomplicated carotid artery surgery, and the level was then similar to that in the aortic surgery patients. Before operation, the S-100beta protein levels were similar in the two groups, but a significant increase was seen in aortic surgery patients postoperatively. Neuropsychologic testing after uncomplicated carotid artery surgery revealed cognitive dysfunction in 2 of 20 (10%) of the patients after 5 days and 3 of 16 (19%) of the patients after 3 months. There was no correlation between the change in cognitive function and the changes in blood levels of either NSE or S-100 protein. CONCLUSIONS: Subtle brain damage after carotid artery surgery could not be detected by measuring blood levels of NSE and S-100beta protein. The NSE level was significantly higher before carotid artery surgery and decreased postoperatively to the level observed in aortic surgery.

Aged↗
PubMed1995

Re-establishment of cerebral metabolism after carotid endarterectomy.

OBJECTIVES: The purpose of this study was to evaluate the metabolic changes that occur in the human brain in patients with a symptomatic carotid artery stenosis. MATERIALS AND METHODS: N-acetyl-aspartate (NAA), choline, creatine and lactate were measured both before, and 4 days after, carotid endarterectomy, by magnetic resonance spectroscopic imaging (MRSI). Eight controls and 16 patients were examined. MRI and MRSI studies were performed on a Philips Gyroscan S15 whole body system operating at 1.5 Tesla. 1H spectra were selected from regions in the centrum semi-ovale outside areas showing white matter hyper intensities on MRI. RESULTS: All patients showed a decrease of the NAA/choline and NAA/creatine ratio in the symptomatic hemisphere compared to the contralateral hemisphere and also compared to the controls. Lactate was present in some patients (5/16). After endarterectomy, the NAA/choline and NAA/creatine ratios increased significantly compared to the ratios preoperative. Lactate was absent or more than 50% reduced after the operation. MRSI showed metabolic changes in areas of the brain that did not show any abnormalities on MRI. CONCLUSIONS: There are marked changes in brain metabolism in the symptomatic hemisphere of patients with a severe carotid artery stenosis. These metabolic changes normalise four days after endarterectomy.

Aged↗
PubMed1998

Retrograde balloon angioplasty of brachiocephalic or common carotid artery stenoses at the time of carotid endarterectomy.

OBJECTIVES: This study was performed to demonstrate the value and durability of intraoperative retrograde angioplasty for stenotic lesions of the aortic arch branches at the time of carotid endarterectomy for the treatment of tandem proximal and bifurcation carotid lesions. DESIGN: Retrospective analysis of the clinical data. METHODS: Forty-four patients were included in this study when they presented with symptomatic extracranial vascular disease due to stenosis of both a proximal aortic arch branch and carotid bifurcation disease. Tandem disease was detected in the vascular laboratory and confirmed by angiography. Each patient was subjected to conventional carotid endarterectomy, and at the time of operation, the proximal lesion was subjected to transluminal angioplasty through the endarterectomy arteriotomy (brachiocephalic 24; left common carotid 15; right common carotid artery five). Patients were then followed up clinically and by non-invasive tests at 6-monthly intervals. RESULTS: Forty-three successful dilatations were achieved. The single initial technical failure was due to heavy calcification of a brachiocephalic artery. In the follow-up period restenosis was noted in four patients. All restenosis occurred within 24 months. No restenosis at the angioplasty site was noted on subsequent follow-up of the remaining 39 patients. No perioperative stroke or death was encountered. A surprisingly high mortality rate was noted on follow-up in this group of patients, suggesting the presence of more aggressive and advanced diffuse vascular disease. CONCLUSION: Retrograde intraoperative angioplasty of the proximal component of a tandem extracranial lesion has in this series proven to be a safe and durable therapeutic option. This technique has an acceptable restenosis rate in a subset of patients who have been demonstrated to have a shortened life expectancy and a high mortality rate in the follow-up period.

Angiography↗