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PubMed2002

The anatomy of the circle of Willis as a predictive factor for intra-operative cerebral ischemia (shunt need) during carotid endarterectomy.

The collateral flow to the cerebral hemisphere after carotid cross clamping during carotid endarterectomy is mainly through the circle of Willis, and the circle is incomplete in the majority of cases. A correlation between the status of the circle of Willis and the necessity of shunting was evaluated in 67 carotid endarterectomies with pre-operative four-vessel cerebral angiogram. All carotid endarterectomies were performed with selective shunting, based on the change of consciousness and motor function after carotid test clamping under regional anesthesia. Of the 55 patients with either an anterior or a posterior communicating artery, only four (7.3%) required shunting. Twelve patients had neither anterior nor posterior communicating artery, and 10 (83.3%) showed signs of cerebral ischemia necessitating shunting. Mandatory shunt was significantly higher in patients with absence of collaterals (p = 0.00). The rate of intraoperative cerebral ischemia was significantly higher in patients with poor collateral circulation defined by the anatomy of the circle of Willis.

Adult↗
PubMed2004

Factors influencing the decision to perform carotid endarterectomy.

Various interpretations of the indications for carotid endarterectomy exist. Physician knowledge as it relates to the decision to proceed or recommend carotid endarterectomy was investigated, using disaggregate discrete choice analysis. Canadian neurologists, neurosurgeons, vascular surgeons, and internists were surveyed. The degree of stenosis was most important, followed by symptoms, comorbid illness, and arterial imaging modality. No differences existed by specialty. Canadian physicians in four specialties are knowledgeable about results of randomized clinical trials for carotid endarterectomy.

Canada↗
PubMed2004

Importance of the imaging modality in decision making about carotid endarterectomy.

OBJECTIVE: To determine the influence of all possible imaging strategies on the appropriateness ratings for carotid endarterectomy, because less accurate noninvasive techniques are replacing contrast angiography, which was used in the major efficacy trials. METHODS: An expert panel, using appropriateness methodology, rated 203 scenarios where endarterectomy might be performed. Each scenario was rated where internal carotid artery stenosis was determined using five different imaging sources: 1) conventional angiography, 2) ultrasound carotid Doppler only, 3) CT (CTA) or MR (MRA) angiography only, 4) concordant results from two noninvasive carotid imaging studies, and 5) discordant results from two noninvasive studies. The scenarios deemed appropriate by conventional angiography were identified. The effect of the other imaging modalities on these results was examined. RESULTS: Thirty-three scenarios were identified as being appropriate. Concordant imaging results had no effect on appropriateness ratings in symptomatic carotid artery disease when compared with conventional angiography. Single noninvasive imaging techniques were deemed appropriate for investigation only in the presence of severe symptomatic stenosis. In all other scenarios, single noninvasive imaging and discordant results reduced the appropriateness rating of scenarios to either uncertain benefit or inappropriateness. The single appropriate scenario for asymptomatic carotid artery stenosis was where severe stenosis was determined by concordant noninvasive imaging or by CTA or MRA alone. CONCLUSION: It is important to take into account both the clinical scenario and the imaging modalities utilized to determine the degree of internal carotid artery stenosis in the clinical decision making surrounding carotid endarterectomy.

Angiography↗
PubMed1977

The value of carotid endarterectomy in treating transient cerebral ischemia of the posterior circulation.

The results of a retrospective study of patients undergoing carotid endarterectomy for hemispheric and/or nonhemispheric symptoms of transient ischemic attacks are presented. During an approximately 3-year period of follow-up observation, recurrent cerebral ischemia following carotid endarterectomy was two to three times more frequent among patients with nonhemispheric transient ischemia than among those with hemispheric transient ischemia. Patients with symptoms of both hemispheric and nonhemispheric transient ischemia had the highest frequency of transient ischemic attacks and stroke during the follow-up period and also had the greatest surgical morbidity and mortality. The results of this study suggest that carotid endarterectomy has little or no therapeutic value in treating patients with vertebral-basilar ischemia.

Adult↗
PubMed1984

Effect of different aspirin doses on arterial thrombosis after canine carotid endarterectomy: a scanning electron microscope and indium-111-labeled platelet study.

Although it is widely accepted that aspirin inhibits platelet aggregation in arterial thrombosis, the appropriate dosage of aspirin remains quite controversial. The purpose of this study was to determine the effect of different doses of aspirin (0.5 mg/kg vs. 10 mg/kg) on mural thrombus formation after carotid endarterectomy. Eighteen hours after oral aspirin administration, 20 endarterectomies were performed on mongrel dogs with the use of the operating microscope. Blood flow was then restored for 3 hours and the vessels were prepared for investigation with the scanning electron microscope. Ten endarterectomies were also performed on unmedicated dogs as controls. Five minutes before vessel unclamping, autologous indium-111-labeled platelets were administered intravenously, and the endarterectomized portions of the vessels were studied with a gamma counter system after harvesting. Group 1, the control group, revealed extensive mural thrombus consisting of platelet aggregates, fibrin, red blood cells, and white blood cells. Six of the 10 vessels in Group 2, premedicated with 0.5 mg of aspirin per kg, demonstrated varying amounts of mural thrombus. Group 3 (10 vessels), premedicated with 10 mg of aspirin per kg, revealed a platelet monolayer completely covering the exposed vessel wall media, with scattered white blood cells and infrequent fine fibrin strands overlying the platelet surface. The mean (+/- SD) radioactivity per group expressed as counts/minute/mm2 was: Group 1--2055.3 +/- 1905.5, log = 7.253 +/- 0.926; Group 2--1235.6 +/- 1234.3, log = 6.785 +/- 0.817; Group 3--526 +/- 433.06, log = 5.989 +/- 0.774.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1985

Time course of thrombotic changes after microsurgical carotid endarterectomy in the rat.

An experimental model of microsurgical carotid endarterectomy in rats developed recently in our laboratory was used in the present study. Our adult Sprague-Dawley rats were killed by in vivo perfusion-fixation at 5 minutes, 15 minutes, 30 minutes, 3 hours, 1 day, and 3 days after the completion of carotid endarterectomy, and vessels were studied by scanning electron microscopy, light microscopy, and transmission electron microscopy for evaluation of thrombotic changes at the level of arterial injury. Although no postoperative carotid occlusion was observed, thrombus formation was noted as early as 15 minutes after recirculation. Thrombus formation reached its peak at 3 hours and was no longer detected 3 days after the procedure. Microsurgical carotid endarterectomy in rats may be a useful experimental model for the evaluation of antithrombotic drugs.

Animals↗
PubMed1986

Carotid endarterectomy after recent stroke: preliminary observations in patients undergoing early operation.

Three patients with recent stroke underwent carotid endarterectomy 1, 4, and 8 days after the onset of maximal symptoms. In each case, computed tomography (CT) demonstrated recent cerebral infarction and cerebral arteriography showed high grade cervical carotid stenosis. No patient developed worsened neurological symptomatology, intracerebral hemorrhage, or vasomotor paralysis. These results suggest that carotid endarterectomy, if indicated, can be performed safely after acute stroke under certain conditions. These criteria include the following: normal level of consciousness, relatively small cerebral infarction without mass effect on CT, and meticulous control and monitoring of systemic blood pressure during the perioperative period. These initial observations suggest that a specific subgroup of patients with recent cerebral infarction may be able safely to undergo carotid endarterectomy shortly after diagnosis.

Carotid Artery Diseases↗
PubMed1988

Morbidity and mortality of carotid endarterectomy under local anesthesia: a retrospective study.

It has been shown that carotid endarterectomy reduces the incidence of stroke in patients with symptomatic extracranial occlusive vascular disease in the absence of major perioperative complications such as stroke or death. We present a retrospective study of 106 carotid endarterectomies performed under local anesthesia in 100 patients in whom transient ischemic attack (TIA) or minor stroke had occurred. Nonfatal stroke occurred in 2%, and TIA occurred in 1%. There was no perioperative mortality. Our study suggests that, under local anesthesia, even high risk patients can be operated safely and the majority of carotid endarterectomies can be performed without the use of an indwelling shunt. Meticulous surgical technique is of great importance for achieving low perioperative complications.

Adult↗
PubMed2004

Delayed cerebral hyperperfusion syndrome caused by prolonged impairment of cerebrovascular autoregulation after carotid endarterectomy: case report.

OBJECTIVE AND IMPORTANCE: Cerebral hyperperfusion syndrome is a rare but potentially devastating complication that typically occurs within several days after carotid endarterectomy. CLINICAL PRESENTATION: A 66-year-old man experienced asymptomatic cerebral hyperperfusion as demonstrated by single-photon emission computed tomography (SPECT) during a 2-week period after undergoing right carotid endarterectomy. This phenomenon occurred despite intensive pharmacological control of blood pressure. On the 28th postoperative day, repeat SPECT demonstrated resolution of hyperperfusion, and intensive blood pressure control was discontinued. INTERVENTION: Twelve hours later, the patient experienced left motor seizures with secondary generation. SPECT performed 36 hours after the onset of seizures demonstrated the reappearance of hyperperfusion. Intensive blood pressure control was reinstituted and maintained until the 36th postoperative day. On the next day, SPECT demonstrated resolution of hyperperfusion. CONCLUSION: The present case suggests that cerebral hyperperfusion syndrome may occur at later time points (e.g., 1 mo) after carotid endarterectomy. This delayed hyperperfusion syndrome may be related to prolonged impairment of cerebrovascular autoregulation.

Aged↗
PubMed2006

A randomized trial of synthetic patch versus direct primary closure in carotid endarterectomy.

OBJECTIVE: To define whether or not direct microscopic closure with or without the use of a vascular patch is advantageous in terms of clinical outcome and late vessel occlusion rates after microsurgical carotid endarterectomy. METHODS: Three hundred thirty-eight elective carotid endarterectomies in 315 patients were randomized to direct arteriotomy or closure with a polyester collagen-coated vascular patch. Ten procedures did not follow the randomization process because of technical difficulties and were excluded. Vessel patency (duplex ultrasound) and outcome were assessed during and immediately after surgery and at 4 and 12 months after surgery. RESULTS: Four-month ultrasound assessment (n = 321) identified five occluded vessels: two in the patch group (n = 149) and three in the direct closure group (n = 172). Six patients in the patch group had died or were significantly disabled at 4 months, compared with five in the direct closure group. At the 12-month assessment (n = 313), eight vessels had occluded: five from the patched group (n = 146) and three from the direct closure group (n = 167). Eight patients in the patch group had died or were significantly disabled, compared with four in the direct closure group. No statistically significant difference between the two groups in terms of vessel occlusion, morbidity, or mortality was seen (P > 0.1). CONCLUSION: No difference in vessel patency and clinical outcome has been identified after microscopic patch angioplasty and direct arteriotomy repair. The authors conclude that there is no benefit from the routine use of patch angioplasty in microscopic carotid endarterectomy.

Aged↗
PubMed2004

[Carotid endarterectomy under regional anesthesia: follow-up of 104 patients].

Cervical carotid stenosis is one of the main causes of ischemic stroke. Carotid endarterectomy is a safe procedure for treatment of moderate and severe symptomatic and asymptomatic carotid stenosis. Regional anesthesia allows neurological evaluation of the patient during the surgery. We reviewed the results of 104 patients operated on at our institution under regional anesthesia during the period of April 1996 and May 2002. 64 patients were symptomatic (61.54%) and 40 asymptomatic (38.46%). All patients had carotid stenosis over 70%. The patients were followed from one to 72 months (Mean: 29.5). Three patients had cervical hematoma, that required surgical drainage. Two patients had minor stroke at the same side of the endarterectomy at the post-operative period and another two during the follow-up (1.92%). Two patients died due to complications related to the surgery (1.92%). Our results, compared with the literature, show that endarterectomy is a safe procedure to treat moderate or severe carotid artery stenosis.

Aged↗
PubMed1989

Effect of flunarizine on arterial thrombosis after endarterectomy in rats.

Unilateral carotid endarterectomy was performed microsurgically in 60 rats. The effects of perioperative administration of aspirin and flunarizine, a Ca2+ entry blocker, on thrombus formation were examined 24 hours after endarterectomy. An untreated group of endarterectomized rats served as controls. Platelet adhesion, blood cells, and fibrin cords were observed at the cut edge of the intima as well as in the endarterectomized area in all three groups. However, these findings were significantly more extensive in the control group than in the drug-treated groups. Flunarizine was as effective as aspirin in inhibiting platelet adhesion and fibrin cord formation. Both drugs significantly increased the patency rate after carotid endarterectomy.

Animals↗
PubMed1991

Endarterectomy for persistent primitive hypoglossal artery--case report.

Persistent primitive hypoglossal artery, an anastomosis between the carotid artery and the vertebrobasilar system, is found in about 0.05% of cerebral angiograms. Though usually asymptomatic, it may occasionally cause ischemic disease. A 62-year-old male presented with left hemiparesis. Right carotid angiograms demonstrated a primitive hypoglossal artery originating from the internal carotid artery at the 2nd cervical spine. This artery supplied almost all blood to the basilar artery system. A marked stenosis extended from the origin of the internal carotid artery to the primitive hypoglossal artery. An endarterectomy of the internal carotid and primitive hypoglossal arteries was performed using a special internal shunt 46 days after the onset. Sudden arterial bleeding from the incised part of the internal carotid artery occurred 12 days after the operation. The carotid artery was resutured. The rupture of the carotid artery appeared to be caused by an infection of Pseudomonas aeruginosa, which was detected by culture of the chronic ear discharge. Rupture of the vessel wall due to infection is an important complication after endarterectomy. This is the second reported endarterectomy of the primitive hypoglossal artery.

Arterial Occlusive Diseases↗
PubMed1992

The value of cerebral angiography in predicting cerebral ischemia during carotid endarterectomy.

OBJECTIVE: Temporary occlusion of the carotid artery during endarterectomy can result in ipsilateral cerebral ischemia if collateral blood flow is insufficient. This requires placement of a shunt across the carotid bifurcation, which is associated with increased operative risk. We retrospectively analyzed preoperative cerebral angiograms and intraoperative electroencephalographic recordings to determine if ischemia during carotid endarterectomy could be predicted from angiographic data. MATERIALS AND METHODS: The cerebral angiograms of 30 patients were examined. Collateral blood flow to the hemisphere on the side of surgery was determined to be present if both proximal segments of the anterior cerebral artery and the anterior communicating artery were visualized, or if filling and washout of the ipsilateral posterior cerebral artery could be seen. Collateral flow was determined to be inadequate if the anterior collateral system was incomplete, and if either the ipsilateral posterior communicating artery was absent or the posterior cerebral artery filled without washout. This information was compared with intraoperative electroencephalographic and shunting data. RESULTS: Of 15 patients who had demonstrable collateral blood flow, 14 had stable electroencephalograms and did not require a shunt during surgery. In all 15 patients in whom no collateral flow to the ipsilateral hemisphere could be shown, electroencephalographic changes prompted placement of an intraluminal shunt. CONCLUSION: We found that the angiographic determination of inadequate collateral cerebral circulation correlated strongly with the development of intraoperative ischemia. This implies that routine preoperative cerebral angiograms can be used to alert the surgeon to the potential need for shunt placement during carotid endarterectomy.

Aged↗
PubMed1991

Neurosurgical experience with carotid endarterectomy: a 12-year study.

In the 13-year period from 1975 to 1988, 91 carotid endarterectomies were performed on 83 patients in a neurosurgical unit. Sixty-seven of these patients had continued to have symptoms after the best medical treatment. Seventy-one presented with transient ischaemic attacks (TIAs), nine with TIA and minor completed stroke (MCS), and three with MCS alone. Follow-up ranged from 8 months to 12 years with a mean of 5.5 years. Within the follow-up period, including operative complications, four deaths of cerebral origin (4.8%) and three major cerebral events (3.6%) occurred--an annual stroke morbidity and mortality rate of less than 1.5%, which compares favourably with a minimum stroke risk of 5% per annum for the first 3 years following a TIA and 3% for subsequent years. The annual stroke and/or vascular death rate including myocardial infarction was 3.5% compared to an expected stroke and/or vascular death rate of 7.4%. It appears that carotid endarterectomy is a useful adjunct to medical therapy. Myocardial ischaemia is the major cause of death in the follow-up period in this group of patients. It is suggested that patients with TIAs and MCS should be investigated, and those who do not respond to medical therapy should be identified for carotid endarterectomy.

Adult↗
PubMed1987

Endarterectomy of the LAD and internal mammary artery grafting. A reliable association.

Endarterectomy of the left anterior descending (LAD) coronary artery and concomitant myocardial revascularization with the internal mammary artery (IMA) were performed in five men aged 52-62 years. There was no perioperative myocardial infarction and no hospital mortality. Early postoperative angiography was performed in four cases and showed patent IMA grafts. The infrequent association of LAD endarterectomy and IMA grafting in the literature is commented on. The authors recommended myocardial revascularization with the IMA in all cases of LAD atherosclerosis, even though the condition is severe and diffuse, requiring endarterectomy.

Coronary Artery Disease↗
PubMed1983

Early versus delayed heparin reversal after carotid endarterectomy in the dog. A scanning electron microscopy study.

The present study investigates the hematological reaction to arterial injury during the first 10 minutes after endarterectomy in dogs to determine if heparin reversal during this early period predisposes to thrombus formation. Known platelet physiology would predict that heparinization during this early period would be useful to allow a fibrin-free platelet monolayer to form. After systemic heparinization (145 mu/kg) of the experimental animals, 42 endarterectomies were performed. Blood flow was then resumed for specific periods of time, and the vessels were prepared for scanning electron microscopy. Group 1 vessels (from the unheparinized control group) revealed mural thrombus formation after 10 minutes of blood flow. Group 2 vessels revealed the progressive formation of a fibrin-free platelet monolayer after 2, 5, or 10 minutes of blood flow resumption under systemic heparinization. Group 3 arteries, harvested at 10 minutes, underwent immediate (within 1 to 2 minutes after resumption of flow) heparin reversal with protamine sulfate, and demonstrated numerous patches of fibrin covering the platelet monolayer. Group 4 arteries, studied after 3 hours of blood flow, also underwent immediate heparin reversal. Two of these seven specimens had clumps of fibrin overlying the platelet monolayer. The Group 5 vessels had heparin reversal at 10 minutes, and demonstrated no fibrin overlying the platelet monolayer after 3 hours of blood flow. This study demonstrates the formation of a fibrin-free platelet monolayer over the endarterectomized vessel wall within 10 minutes of resumption of flow under systemic heparinization. These findings suggest that heparin may safely be reversed following a carotid endarterectomy if one awaits the initial critical 10 minutes of blood flow.

Animals↗
PubMed1985

Effect of perioperative platelet inhibition on postcarotid endarterectomy mural thrombus formation. Results of a prospective randomized controlled trial using aspirin and dipyridamole in humans.

A prospective randomized double-blind trial was conducted to study the effect of platelet-inhibiting drugs on mural thrombus formation after carotid endarterectomy. Twenty-two patients undergoing carotid endarterectomy were randomly assigned to perioperative administration of an aspirin/dipyridamole combination or a placebo, and the postoperative results were compared. Autologous indium-111-labeled platelets were injected postoperatively, and platelet deposition was measured at the endarterectomy site. It was found that the treated group had a significant reduction in platelet accumulation compared with the placebo group. The results suggest that the perioperative use of aspirin/dipyridamole may reduce the risk of operative stroke and the long-term risk of repeat carotid stenosis.

Aged↗