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PubMed1998

Cognitive testing in patients undergoing carotid endarterectomy.

OBJECTIVES: To determine by literature review the effect of carotid endarterectomy (CEA) as a modulator of cognitive function in patients with carotid arterial disease. Derive recommendations for standardising cognitive testing of patients with carotid arterial disease. DESIGN AND METHODS: The English language literature was interrogated using a CD-ROM driven medline search using carotid endarterectomy and cognitive function as keywords between 1986-1995. These subsets were scanned and papers of direct relevance or commonality were selected. Cited papers prior to 1986 from these references were then sought directly. RESULTS: There are few controlled studies reporting on the effect of CEA. There is no consensus in the literature for the effect of CEA on cognition or which tests should be used. Studies reporting a benefit for CEA lack a control group and fail to eliminate the effect of practice. Reports suggesting cognitive impairment following CEA performed follow-up tests early. CONCLUSIONS: There are many methodological problems with the study of cognitive function before and after carotid endarterectomy and wide disagreement in the interpretation of results. Further studies should contain control groups, use tests resistant to practice and be performed when the effects of surgery and anaesthesia are passed.

Cognition↗
PubMed1998

Minimally invasive superficial femoral artery endarterectomy: early experience with a modified technique.

OBJECTIVES: To describe our experience of a modified technique for carrying out remote endarterectomy for superficial femoral artery occlusive disease. METHODS: A 4-French arterial dilator is inserted using a Smart needle into the popliteal artery below the occlusion. A remote endarterectomy is carried out through an arteriotomy in the proximal superficial femoral artery. The atheroma is cut distal to the lower extent of disease using a Moll ring cutter. The lower flap of atheroma is secured with an intraluminal stent inserted from the arteriotomy in the superficial femoral artery. The arteriotomy is extended into the common femoral artery and closed with a vein patch. RESULTS: The procedure was completed in 21 of 26 limbs. In 18 cases the superficial femoral artery remained patent at 30 days. Of the 21 cases all but four stayed in hospital for one night. A successful femoropopliteal bypass was carried out in the five patients in whom the procedure was not completed. CONCLUSION: Insertion of the dilator into the popliteal artery distal to the occlusion before carrying out the remote endarterectomy has two advantages. Firstly, the stent insertion is carried out in the correct plane and prevents dissection of the distal cut atheroma when attempting to pass the guidewire from above. Secondly, the procedure can be carried out under simple image intensification without sophisticated radiological equipment. The early results are encouraging and further evaluation of the technique is justifiable.

Arteriosclerosis↗
PubMed1987

Carotid endarterectomy without indwelling shunts and intraoperative electrophysiologic monitoring.

Although carotid endarterectomy is a common surgical procedure in North America, controversies exist regarding the type of anesthesia, the use of indwelling shunts and the need for intraoperative cerebral monitoring. We present a prospective study of 100 carotid endarterectomies performed over a three year period by a single surgeon without the use of indwelling shunts, patch grafts, or EEG monitoring. The combined stroke and mortality rate was 1%. Our results confirm those of other authors; that indwelling shunts and EEG monitoring are not absolutely essential for a satisfactory outcome in carotid endarterectomies.

Aged↗
PubMed2000

Continuous contralateral jugular acid-base and blood gas monitoring during carotid endarterectomy.

BACKGROUND: The aim of this study is to evaluate the intravascular multiparameter sensor Paratrend 7 (P7) for continuous acid-base and blood gas monitoring after retrograde jugular catheterization during carotid endarterectomy. PATIENTS AND METHODS: We studied 11 patients with history of smoking (72.7%), coronary artery disease (72.7%), hypertension (100%), diabetes mellitus (55.5%) and TIA's and/or nondisabling stroke (90.9%). The contralateral internal jugular vein was punctured retrogradely and the calibrated P7 sensor was introduced. The sensor was removed after surgery. The P7 provides continuous graphical display of pH, pCO2, and pO2, while temperature, oxygen saturation, HCO3 concentration and base excess are displayed numerically. RESULTS: Mean duration of carotid cross-clamping was 17.0 +/- 6.2 min. Mean stump pressure was 50.2 +/- 12.9 mmHg. Intraluminal shunting was not used in any operation. All sensors were easily inserted. During clamping, pH became persistently more acidic (7.31 to 7.28; p < 0.05), pCO2 was elevated (44.7 to 49.8 mmHg; p < 0.05) while, in the majority of the patients, there was a non significant decrease in pjvO2/SjvO2. Declamping was followed by a short period of decrease of pH and elevation of pCO2 reminiscent of wash out phenomena. PjvO2 was significantly elevated (53.8 +/- 5.2 to 59.0 +/- 5.8 mmHg; p < 0.001) after the restoration of flow. In one case, P7 was diagnostic for unsuccessful endarterectomy. CONCLUSIONS: P7 is useful during carotid endarterectomy providing continuous and "on-line" information on brain metabolism. It is a simple and powerful technique, which should be further investigated.

Acid-Base Equilibrium↗
PubMed1998

Role of arteriography in the selection of patients for carotid endarterectomy.

BACKGROUND: Duplex ultrasonography is used increasingly to select patients for carotid endarterectomy. This study aims to clarify whether arteriography is still required. METHODS: A total of 272 patients in whom duplex imaging indicated significant disease of the internal carotid artery underwent arteriography and the results were compared. Regarding the arteriogram as the 'gold standard', three aspects were considered: the accuracy of duplex ultrasonography in detecting significant stenosis, the ability of duplex imaging to identify patients who should have arteriography and whether the arteriogram provided important additional information that might influence a decision to operate. RESULTS: Three patients (1 per cent) suffered a permanent neurological deficit as a result of arteriography. Of the 272 patients with significant stenosis identified by duplex ultrasonography, 241 (89 per cent) were confirmed as significant on arteriography. Duplex imaging was not able to predict accurately which arteriograms would provide useful additional information (sensitivity 59 per cent, specificity 65 per cent), whereas 89 arteriograms (33 per cent) contained information that might have influenced subsequent management. CONCLUSION: Duplex imaging is unable to detail the anatomy or determine the extent of carotid disease and may therefore lead to an inappropriate decision to perform carotid endarterectomy. Duplex imaging alone is not adequate before carotid endarterectomy.

Aged↗
PubMed2001

Eversion carotid endarterectomy.

BACKGROUND: Eversion carotid endarterectomy (ECEA) is a technique that obviates the need for traditional longitudinal arteriotomy and patch closure, with low stroke and restenosis rates. The aim of the present study was to report an Australian experience and technique of ECEA. METHODS: All patients who underwent ECEA by the investigating surgeons between October 1997 and July 2000 were followed up clinically and with duplex ultrasound. The technique of ECEA is described. RESULTS: One hundred and fifty-two ECEA were performed, 13 combined with coronary artery bypass grafting (CABG). The combined perioperative stroke and death rate was 2%; 0.65% excluding CABG combined cases. This compares with 2.9% for standard carotid endarterectomy throughout Victoria. Significant restenosis occurred in 2.6% after a mean follow up of 21.7 months. CONCLUSION: ECEA is a simple and safe alternative to standard carotid endarterectomy.

Aged↗
PubMed2001

Prevention of postoperative wound haematomas and hyperperfusion following carotid endarterectomy.

OBJECTIVE: To study the incidence of wound haematomas and hyperperfusion following carotid endarterectomy and the effect of changes in perioperative management. METHODS: We undertook a prospective audit of the postoperative outcome of 300 consecutive carotid endarterectomies performed for a symptomatic stenosis of the internal carotid artery, under the care of a single consultant. RESULTS: audit of the first 100 operations between 1990-93 resulted in 4 changes to clinical practice. These included the use of Dacron instead of vein because of 3 vein patch blowouts, invasive postoperative monitoring of blood pressure, and the use of intravenous beta-blockers to control hypertension, because of 4 hyperperfusion injuries. The use of 10F suction drains was discontinued, because they did not prevent 8 wound haematomas. The results of the second 100 cases between 1994-97 and the third 100 cases between 1998-2000 confirmed no further hyperperfusion injuries or patch blowouts (p =0.01 and 0.04 respectively). Larger 14F suction drains were reintroduced for the third series because of thirteen haematomas in the second series (p =0.09). Only 4 haematomas occurred in the third series ( p =0.05). The need for beta-blockers fell in the third series due to the introduction of local anaesthesia (p =0.0001). CONCLUSION: The use of Dacron patches and postoperative control of hypertension has reduced the incidence of haemorrhage and hyperperfusion after carotid endarterectomy. Larger suction drains may also help.

Adrenergic beta-Antagonists↗
PubMed2001

Cervical nerve injury after carotid endarterectomy.

OBJECTIVE: to determine the extent and direct significance of cervical nerve injury after carotid endarterectomy. MATERIAL AND METHODS: fifty-two patients (61 operations) were followed by means of patient history and neurological examination between 3 and 55 months following carotid endarterectomy. RESULTS: sixteen operated sites showed normal sensitivity. Patients assessed 3-6 months after surgery showed on average a neurological loss of 3.4 points (scale from 0-4). Patients assessed after 7-12 months had on average a deficit of 2.1 points. After 13-24 months the score was at 1.4 and after the second postoperative year the score yielded only 0.4 points. CONCLUSION: loss of cervical nerve sensation is always present after carotid endarterectomy but tends to improve with time. However, the timing and extent of this improvement is unpredictable. Patients are usually not disturbed by these changes.

Aged↗
PubMed2001

PTA and stenting after previous aortoiliac endarterectomy.

OBJECTIVES: to evaluate the feasibility and long-term results of angioplasty and stenting in the treatment of restenosis following aortoiliac endarterectomy. MATERIALS AND METHODS: between 1991 and 1999 19 patients underwent angioplasty with selective stenting for recurrent stenosis after previous aortoiliac endarterectomy. Aortic lesions were treated five times in four patients. At the iliac level 28 lesions (25 stenosis and three occlusions) were treated in 16 patients (one patient had a stenosis at the aortic as well as iliac level). All patients were followed clinically and by ultrasound. In the second half of 1999, an angiogram or spiral CT-angiography was performed in all patients to determine long-term outcome. RESULTS: technical success was obtained in all patients and clinical success was achieved in 18 of the 19 patients. Angiographic cumulative primary patency for aortoiliac lesions was 96% at 1 year and 76% at 3 years. CONCLUSIONS: angioplasty with selective stenting of recurrent aortoiliac disease after previous aortoiliac endarterectomy is feasible and safe. Long-term clinical and angiographic patency rates are in accordance with results of aortoiliac angioplasty in general.

Aged↗
PubMed2001

Remifentanil conscious sedation during regional anaesthesia for carotid endarterectomy: rationale and safety.

OBJECTIVES: to prospectively evaluate the safety and efficacy of remifentanil during regional anaesthesia for carotid endarterectomy. METHODS: twenty-eight consecutive patients underwent carotid endarterectomy with combined superficial and deep cervical plexus block supplemented with continuous intravenous 0.04 microg.kg(-1).min(-1)remifentanil infusion. Depth of sedation was monitored using the Observer's Assessment of Alertness/Sedation Scale (OAA/S). The degree of pain, discomfort and anxiety was self-assessed by the patients using a horizontal visual analogue scale. RESULTS: all patients experienced adequate comfort and analgesia. No local anaesthetic supplementation was necessary. No patient had a OAA/S score lower than 4 (with 5=awake/alert to 1=asleep). Respiratory depression did not occur. Selective shunting was required in four cases. No patient was converted to general anaesthesia. There were no permanent neurological deficits, cardiopulmonary complications or deaths. CONCLUSION: remifentanil as a supplement to regional anaesthesia for carotid endarterectomy, provides comfort and analgesia without hampering mental status evaluation.

Aged↗
PubMed2006

Technical advances of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

Pulmonary endarterectomy is the definitive treatment for chronic pulmonary hypertension as the result of thromboembolic disease. Although significant progress has been made over the last decade in recognition, diagnostic modalities, and treatment of this disease, chronic thromboembolic pulmonary hypertension (CTEPH) continues to be severely underdiagnosed and as a consequence pulmonary endarterectomy remains an uncommon procedure. Patients with CTEPH may present with a variety of debilitating cardiopulmonary symptoms. However, once diagnosed, there is no curative role for medical management, and surgery remains the only option. Medical management in these patients is only palliative, and surgery by means of transplantation for this type of pulmonary hypertension is an inappropriate use of resources with less than satisfactory results. In this article we describe the technical advances of pulmonary endarterectomy and the current procedure as it is performed at University of California-San Diego Medical Center.

Chronic Disease↗
PubMed2003

Association of sex with perioperative mortality and morbidity after carotid endarterectomy for asymptomatic carotid stenosis.

OBJECTIVE: To examine whether perioperative morbidity and mortality after carotid endarterectomy depend on the sex and the presence of symptoms on presentation. DESIGN: Retrospective review of quality assurance database prospectively collected. SETTING: A university teaching hospital. PARTICIPANTS: One thousand two hundred eighty-seven patients who had 1,503 carotid endarterectomies from 1990 to 1999 from a quality assurance database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The cases were divided into 4 groups by sex and symptoms on presentation: male-symptomatic (MS), male-asymptomatic (MA), female-symptomatic (FS), and female-asymptomatic (FA). The 4 groups were compared for preoperative demographic and comorbidity profiles, carotid plaque characteristics, and outcome. Outcome measures included in-hospital stroke, myocardial infarction (MI), congestive heart failure (CHF), and death. There were 496 cases in the MS group, 407 in the MA group, 315 in the FS group, and 285 in the FA group. Women were less likely to have a history of coronary artery disease, prior MI, or smoking, and their carotid plaques were less likely to be ulcerated or contain intraplaque hemorrhage. Even when controlling for the comorbidities and plaque characteristics, the incidence of each of the complications examined was low and not significantly different between the sexes in both the symptomatic and asymptomatic groups. The rate of stroke or death was 3.0% (MS) versus 1.9% (FS) (p = NS) and 1.2% (MA) versus 1.8% (FA) (p = NS). CONCLUSION: There is no significant sex difference in perioperative cardiac or cerebrovascular complications. Women with symptomatic or asymptomatic carotid stenosis can have acceptably low complication rates from carotid endarterectomy and may benefit from the surgery as much as men.

Aged↗
PubMed1992

Aortoiliac endarterectomy: a 9-year experience.

Thirty-two patients (median age: 51 years) underwent aortoiliac endarterectomy between 1982 and 1990, for disabling claudication (27), rest pain (3), and tissue loss (2). There was no post-operative death and morbidity affected 6 patients. Five patients showed insufficient or suboptimal vascularisation of a limb which justified early reoperation in four. Follow-up was obtained in 31 patients with a median time of 36 months (6 months to 8 years). Five patients experienced recurrence of claudication symptoms: two received an aortofemoral bypass at 6 and 36 months. In the other patients, distal arterial occlusive disease accounted for recurrence alone (2 patients) or in association with aortoiliac involvement (1). Technical problems or disputable indications were responsible for postoperative failure in 3 cases or early recurrence of symptoms in 2. Cumulative patency rates of aortoiliac endarterectomy were 94 and 90 per cent at 2 and 5 years, and actuarial rates of clinical improvement were 90 and 82 per cent at 2 and 5 years, respectively. Aortoiliac endarterectomy provides the advantages of avoiding foreign material. The success of this reconstruction depends on strict criteria of selection and surgical expertise. It is indicated for the relatively young patient with nonectasic disease where atherosclerosis has not attacked the external iliac arteries.

Adult↗
PubMed1990

Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography.

BACKGROUND AND METHODS: In a nationally representative population 65 years of age or older, we have demonstrated that about one quarter of coronary angiographies and upper gastrointestinal endoscopies and two thirds of carotid endarterectomies were performed for reasons that were less than medically appropriate. In this paper we examine whether specific characteristics of patients (age, sex, and race), physicians (age, board-certification status, and experience with the procedure), or hospitals (teaching status, profit-making status, and size) predict whether a procedure will be performed appropriately. RESULTS: In general, we found that little of the variability in the appropriateness of care (4 percent or less) could be explained on the basis of standard, easily obtainable data about the patient, the physician, or the hospital. For all three procedures, however, performance in a teaching hospital increased the likelihood that the reasons would be medically appropriate (P = 0.09 for angiography, P = 0.30 for endoscopy, and P less than 0.01 for endarterectomy). In addition, angiographies were more often performed for appropriate reasons in older or more affluent patients (P less than 0.01 for both). Being treated by a surgeon who performed a high rather than a low number of procedures decreased the likelihood of an appropriate endarterectomy by one third, from 40 to 28 percent (P less than 0.01). CONCLUSIONS: Appropriateness of care cannot be closely predicted from many easily determined characteristics of patients, physicians, or hospitals. Thus, for the present, if appropriateness is to be improved it will have to be assessed directly at the level of each patient, hospital, and physician.

Aged↗
PubMed2000

The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.

BACKGROUND: The causes of stroke in patients with asymptomatic carotid-artery stenosis have not been carefully studied. Information about causes might influence decisions about the use of carotid endarterectomy in such patients. METHODS: We studied patients with unilateral symptomatic carotid-artery stenosis and asymptomatic contralateral stenosis from 1988 to 1997. The causes, severity, risk, and predictors of stroke in the territory of the asymptomatic artery were examined and quantified. RESULTS: The risk of stroke at five years after study entry in a total of 1820 patients increased with the severity of stenosis. Among 1604 patients with stenosis of less than 60 percent of the luminal diameter, the risk of a first stroke was 8.0 percent (1.6 percent annually), as compared with 16.2 percent (3.2 percent annually) among 216 patients with 60 to 99 percent stenosis. In the group with 60 to 99 percent stenosis, the five-year risk of stroke in the territory of a large artery was 9.9 percent, that of lacunar stroke was 6.0 percent, and that of cardioembolic stroke 2.1 percent. Some patients had more than one stroke of more than one cause. In the territory of an asymptomatic occluded artery (as was identified in 86 patients), the annualized risk of stroke was 1.9 percent. Strokes with different causes had different risk factors. The risk factors for large-artery stroke were silent brain infarction, a history of diabetes, and a higher degree of stenosis; for cardioembolic stroke, a history of myocardial infarction or angina and hypertension; for lacunar stroke, age of 75 years or older, hypertension, diabetes, and a higher degree of stenosis. CONCLUSIONS: The risk of stroke among patients with asymptomatic carotid-artery stenosis is relatively low. Forty-five percent of strokes in patients with asymptomatic stenosis of 60 to 99 percent are attributable to lacunes or cardioembolism. These observations have implications for the use of endarterectomy in asymptomatic patients. Without analysis of the risk of stroke according to cause, the absolute benefit associated with endarterectomy may be overestimated.

Aged↗
PubMed1986

The influence of surgical specialty and caseload on the results of carotid endarterectomy.

Carotid endarterectomy is rapidly becoming one of the most commonly performed major surgical operations in the United States, in part because of the greater availability of noninvasive techniques to accurately diagnose extracranial carotid arterial disease and a low reported morbidity and mortality. We retrospectively reviewed the records for all carotid endarterectomies performed in the greater Cincinnati area for a recent 12-month period and examined the impact of surgical specialty and operative caseload on the results. Altogether, 750 operations were performed on 656 patients by 61 surgeons working in 16 general medical-surgical hospitals. Overall, strokes occurred in 5.1% of all patients; 2.3% of patients died. Symptomatic patients had a significantly higher risk of suffering a postoperative stroke compared with asymptomatic patients (6.5% vs. 3.7%), although the risk of death was virtually identical (2.4% vs. 2.1%). When the operating surgeons were classified into four types on the basis of their previous training, no statistically significant differences in either postoperative stroke or death could be identified. Furthermore, when the surgical caseloads of these physicians were grouped into three categories (i.e., less than 12 each year, more than 50 each year, and a group between these two extremes), no significant differences in outcome were seen. We concluded that our community-wide results for carotid endarterectomy were not comparable to those previously published from specialized centers and that these results did not appear to be influenced by the type of formal surgical specialty or operative caseload.

Aged↗
PubMed1986

The long-term results of carotid endarterectomy for transient ischemic attacks.

One hundred patients who underwent carotid endarterectomy for transient ischemic attacks (TIAs) have been followed up for 3 to 10 years (mean, 5.5 years). Seven patients have been lost to follow-up but none is recorded as dead (National Registry of Deaths) at least 5 years after operation. Fifteen patients (16.5%) have died, four from cerebral and eight from cardiac causes. Three patients had cerebral infarction with permanent deficits, one occurring immediately after operation, one at 3 months, and one at 9 years. Four patients had minor strokes but a full clinical recovery, three patients postoperatively and one patient at 4 years. Fourteen patients had ipsilateral TIAs, four occurred postoperatively and 10 occurred from 1 to 8 years later. Ten patients had contralateral TIAs and five patients then had a contralateral carotid endarterectomy. Another nine patients also had bilateral operations, three for bilateral TIAs, five as prophylactic procedures on the basis of arteriographic findings, and one for a contralateral cerebral event that occurred after arteriography. Thus, at the mean follow-up time (5.5 years) and including the operative complications, four deaths (4%) of cerebral origin and seven serious cerebral problems (7%) have occurred--an annual morbidity and mortality rate of less than 2%. This compares favorably with the commonly predicted rate of stroke occurring after TIAs of 5% per year. These figures support the argument that carotid endarterectomy reduces the incidence of stroke occurring after TIA and stops TIAs caused by emboli from the carotid bifurcation.

Adult↗
PubMed1987

A simple method for combined carotid endarterectomy and correction of internal carotid artery kinking.

Occasionally symptomatic kinking of the internal carotid artery will require correction. More frequently one must rectify a kink that occurs after bifurcation endarterectomy when associated with a redundant internal carotid artery. Most procedures described for shortening of the carotid artery are somewhat cumbersome when endarterectomy is also performed or require the use of patch closure. Herein we described a technique for combined endarterectomy of the bifurcation and straightening of a critically angulated internal carotid artery. The approach obviates many of the difficulties encountered with other methods.

Arteriosclerosis↗