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PubMed1986

Microsurgical endarterectomy under barbiturate protection: a prospective study.

Carotid endarterectomy has the potential to improve on the natural history of untreated carotid artery disease with respect to subsequent infarction in symptomatic patients with causative angiographic lesions. This benefit of a reduced risk of stroke can be realized only if the perioperative morbidity and mortality rates are kept low. An approach to symptomatic carotid artery bifurcation disease is outlined, with a defined protocol of microsurgical endarterectomy utilizing barbiturate protection during the period of potential focal temporary cerebral ischemia. This protocol includes preoperative antiplatelet therapy, barbiturate anesthesia, the avoidance of an internal shunt, the use of the operating microscope, and strict control of postoperative hypertension. A series of 200 consecutive endarterectomies performed within this protocol in 180 patients and the resultant combined permanent morbidity and mortality rate of 1.5% are reported.

Adult↗
PubMed1987

Intravenous digital subtraction angiography and duplex ultrasonography in postoperative assessment of carotid endarterectomy.

Seventy-four consecutive patients who had undergone carotid endarterectomy procedures were examined with intravenous digital subtraction angiography (IV-DSA) and duplex ultrasonography (DUS) at intervals ranging from 1 to 14 months postoperatively. Ninety-one percent of the DUS and 74% of the DSA images were of diagnostic quality. The two modalities agreed in the assessment of the endarterectomy appearance in 84% of the arteries, with 85% showing no evidence of significant residual disease. There were no arteries with severe restenosis or complete occlusion. In the 10 vessels in which the two modalities disagreed in disease assessment, the IV-DSA images were often degraded by artifact or vessel overlap leading to underestimation of disease. The authors conclude that DUS is the examination of choice for routine follow-up studies of carotid endarterectomy.

Arteriosclerosis↗
PubMed1993

Computer-derived density spectral array in detection of mild analog electroencephalographic ischemic pattern changes during carotid endarterectomy.

The purpose of this prospective study was twofold: 1) to determine the sensitivity and specificity of computer-derived density spectral array in detecting analog electroencephalographic (EEG) ischemic pattern changes during carotid artery cross-clamping in patients undergoing carotid endarterectomy; and 2) to assess the ability of density spectral array to identify such changes in comparison with the degree and type of change seen in the analog EEG ischemic pattern. Sixteen channels of anteroposterior bipolar and two to four channels of referential electroencephalography with four channels of density spectral array were monitored simultaneously during carotid endarterectomy in 103 patients under general anesthesia. Two "observers" interpreted the density spectral array and the analog electroencephalograms, one during and immediately after the operations and the other 6 months after completion of all surgery. Analyses were conducted to establish both the number of patients with analog EEG ischemic changes and the number of ischemia events during carotid artery cross-clamping. Observer A indicated that the density spectral array identified analog EEG ischemic changes in 21 of 29 patients, for a sensitivity of 72% (specificity 99%), whereas Observer B's results showed that the density spectral array identified analog EEG ischemic changes in 16 of 27 patients, for a sensitivity of 59% (specificity 96%). Density spectral array detection of analog EEG ischemic changes based on severity classifications were 61% and 18% in the mild group, 70% and 71% in the moderate group, and 95% in the severe group, indicating a relationship between density spectral array sensitivity and severity of analog EEG ischemic change, with p = 0.02 and p = 0.004 for the two observers. The kappa statistics for observer reproducibility were highly significant, with k = 0.95 for analog EEG ischemic changes and 0.85 for density spectral array changes. It is concluded that density spectral array does not reliably detect mild analog EEG pattern changes of cerebral ischemia and is not a reliable substitute for 16-channel analog EEG monitoring of cerebral ischemia during carotid endarterectomy.

Adult↗
PubMed1995

An observational study of near-infrared spectroscopy during carotid endarterectomy.

Near-infrared spectroscopy was used to monitor changes in the cerebral oxygenation state in 13 patients during carotid endarterectomy. Variations in the levels of the chromophores (oxygenated hemoglobin (HbO2), deoxygenated hemoglobin (Hb), and oxidized cytochrome (CytO2)), and the total hemoglobin content (tHb) were compared with changes in middle cerebral artery flow velocity measured using transcranial Doppler ultrasonography. Of eight patients who showed a fall in flow velocity on application of the internal carotid artery cross-clamp, seven demonstrated a rapid and closely correlated fall in HbO2 signal, and an increase in Hb. Levels of CytO2 and tHb remained unchanged. During endarterectomy, recovery of the HbO2 and Hb levels toward preclamp baseline values occurred in three of these patients. Intraoperative shunts accelerated recovery of HbO2 and Hb signals in two of three individuals. Release of the internal carotid cross-clamp resulted in a rapid increase in HbO2 and decrease in Hb signal in those patients in whom spontaneous recovery had not occurred; in five instances, a hyperemia evolved with raised flow velocity and HbO2 to above baseline values. Cross-clamping and subsequent reperfusion of the external carotid artery had no effect on any parameter measured. The authors conclude that near-infrared spectroscopy can register changes in cerebral oxygenation during carotid endarterectomy without significant contamination from extracranial tissues.

Adult↗
PubMed1995

Mandibular subluxation as an adjunct to exposure of the distal internal carotid artery in endarterectomy surgery. Technical note.

The location of the carotid artery bifurcation and the distance atherosclerotic disease extends distally in the internal carotid artery (ICA) are two factors that contribute to the technical difficulty of carotid endarterectomy. When the bifurcation is high (above C-3) or the disease extends distally, standard approaches may not provide adequate exposure for dissection of plaque or for arteriotomy repair. A simple method of mandibular subluxation is described for added exposure of the distal carotid artery. The criteria for use of this method include: a carotid bifurcation at or above C-2; disease extending to within 2 cm of the skull base; and a small-caliber distal ICA lumen with the expectation of a patch graft extending close to the skull base. In dentulous patients, the mandible is subluxed by attaching an intradental wire from the ipsilateral mandibular bicuspid to an intradental wire around the contralateral maxillary bicuspid. In edentulous patients, a wire is placed around the ipsilateral mandible and secured to a wire placed through the anterior nasal spine. The entire preoperative subluxation requires 10 to 15 minutes under anesthesia and an additional 1 to 2 minutes postoperatively to remove the wires. A single skin suture and an absorbable intraoral suture were placed in some edentulous patients. This technique has been evaluated over a 15-month reference period during which 115 carotid endarterectomies were performed. The criteria stated above were met in seven cases (six patients, 6%) and jaw subluxation was performed preoperatively. An additional 1 to 2 cm of distal exposure was obtained by using this technique and endarterectomy proceeded without complication. A slight "shift" of the standard anatomical landmarks occurred due to the movement of the mandible, which was easily recognized. There were no significant postoperative complaints related to the subluxation; specifically, no temporomandibular joint pain, no other postoperative pain, and no tooth damage were encountered. It is concluded that this relatively simple approach to mandibular subluxation provided significant added exposure to the distal ICA without notably increasing operative time. In addition, there was no morbidity and little additional care was needed when compared with other more radical approaches to high carotid artery exposure.

Aged↗
PubMed1998

Repair of carotid endarterectomy with a collagen-impregnated fabric graft.

UNLABELLED: Saphenous vein patch closure of carotid endarterectomies may decrease the risk of acute postoperative occlusion and recurrent stenosis. However, the disadvantages of a vein patch include postoperative rupture and pseudoaneurysm formation. OBJECT: The authors sought to assess the effectiveness of collagen-impregnated fabric grafts as substitutes for saphenous vein grafts. METHODS: In this report the authors prospectively analyzed 290 consecutive carotid endarterectomies in which a secondary closure was accomplished using a knitted double-velour graft. The 30-day major neurological morbidity and mortality rate was 1.7%. There were no postoperative occlusions or wound hematomas. The rate of recurrent carotid artery stenosis was less than 1%, and the graft site in one patient became infected. CONCLUSIONS: For surgeons who prefer a secondary closure of carotid endarterectomies, the synthetic graft may prove to be a viable alternative to a saphenous vein.

Blood Vessel Prosthesis↗
PubMed2004

Cost of treating high-risk symptomatic carotid artery stenosis: stent insertion and angioplasty compared with endarterectomy.

OBJECT: Definitive data characterizing the safety and efficacy of carotid angioplasty with stent placement (CAS) for symptomatic, occlusive carotid artery (CA) disease require further refinements and standardization of techniques as well as large prospective studies on a par with the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Despite the absence of such data, many surgeons have performed angioplasty and stent placement in patients with clinical or anatomical features known to add significant perioperative risk and capable of disqualifying the patients from participation in NASCET: There exists no cost analysis comparing high-risk endarterectomy with percutaneous angioplasty and stent insertion. METHODS: Forty-five patients (29 men and 16 women) with high-risk, symptomatic CA stenosis have been treated with CAS at the authors' institution since 1996. Indications for this procedure included symptomatic recurrent stenosis following CA endarterectomy (CEA), active coronary disease, high CA bifurcation, and severe medical comorbidities. A longstanding CEA computer database was screened for control patients with similar risk factors; 391 patients (276 men and 115 women) were identified. Actual cost data, duration of hospital stay, and relevant clinical data from the time of treatment until hospital discharge were collected in each patient. The median total cost of CAS was dollar 10,628, whereas that for CEA was dollar 10,148 (p = 0.495). CONCLUSIONS: In patients with high-risk, NASCET-ineligible CA stenosis there was no overall statistically significant cost difference between CEA and CAS. Given that there may not be a cost advantage for either procedure, procedural risk, efficacy, and durability should be key factors in determining the optimal treatment strategy.

Aged↗
PubMed2000

[Advances in carotid endarterectomy--review].

Atherosclerosis of carotid artery, resulting in stenosis is a common cause of cerebral ischaemia. Ischaemic stroke is cause of death in 10% of patients and the leading cause of disability in adults. The risk of stroke increases with the degree of stenosis. The diagnosis of the degree of stenosis is performed by duplex sonography, MR-angiography, CT-angiography and conventional angiography. Carotid endarterectomy is a method of choice in the treatment in the case of high-grade carotid stenosis. The operation was introduced in 1953. Either regional or general anaesthesia is used for the operation. The different monitoring techniques are used for assessment of the need for shunting. Microsurgical technique enables perfect endarterectomy and fine arterial repair without need for patch grafting. Other techniques of the treatment for carotid stenosis, including carotid angioplasty with or without stenting are subject to the evaluation. Carotid endarterectomy is now the method of choice in the treatment of high-grade carotid stenosis.

Carotid Artery Diseases↗
PubMed1976

Aortocoronary bypass made possible by coronary endarterectomy.

Thirty bypass grafts to coronary arteries were made possible by manual core endarterectomy. The overall patency rate of the grafts was 57%, which is less than the patency rate of bypass grafts to nonendarterectomized vessels (75 to 80%). In the perioperative period and during follow-up to 29 months there was no increase in mortality or morbidity even when the endarterectomized vessel subsequently became occluded. These results represent early technical experience. Routine anticoagulant therapy in the postoperative period, to prevent early occlusion, was not used. The results of this and other studies suggest that coronary endarterectomy with bypass grafting is a useful procedure in situations where the coronary artery is so severely obstructed that standard saphenous vein bypass grafting cannot be performed; the procedure is superior to coronary endarterectomy alone.

Arterial Occlusive Diseases↗
PubMed2000

Carotid endarterectomy versus carotid angioplasty: comparison of current results.

Carotid endarterectomy is the standard treatment for carotid artery occlusive disease, with proven low morbidity and mortality and acceptable long-term durability. Recently, enthusiasm for carotid angioplasty and stenting has led to increasingly widespread clinical application of this endovascular technique. Because no prospective randomized trial has yet been published comparing carotid endarterectomy with carotid angioplasty and stenting, we must use data from statewide, population-based, and single-center reports to compare the procedures. Although carotid stenting has already earned a significant role in treating selected patients with carotid disease, current evidence does not indicate the use of carotid stenting as a routine alternative to carotid endarterectomy.

Angioplasty↗
PubMed2001

The effect of changing transfusion practice on rates of perioperative stroke and myocardial infarction in patients undergoing carotid endarterectomy: a retrospective analysis of 1114 Mayo Clinic patients. Mayo Perioperative Outcomes Group.

OBJECTIVE: To evaluate changes in the institution's red blood cell (RBC) transfusion practice during the past 15 years and the influence of these changes on neurologic or cardiac morbidity after carotid endarterectomy. PATIENTS AND METHODS: Based on a retrospective analysis of the Mayo Clinic database, 1,114 patients who underwent carotid endarterectomy were stratified into 1 of 2 groups: (1) 1980 to 1985 (ie, pre-human immunodeficiency virus screening, early-practice group [n=552]) and (2) 1990 to 1995 (ie, recent-practice group [n=562]). Data were compared between time periods using the chi2 test for categorical variables and the rank sum test for continuous variables. Logistic regression was used to assess the association between perioperative transfusion practice and the occurrence of stroke or myocardial infarction. Two-tailed P values < or = 05 were considered statistically significant. RESULTS: Patients in the recent-practice group were significantly older (mean +/- SD age, 69.6 +/- 8.7 years) vs 65.9 +/- 8.3 years in the early-practice group (P<.001). The proportion of patients receiving perioperative RBC transfusion decreased dramatically from 72.9% in 1980-1985 to 8.7% in 1990-1995 (P<.001). Additionally, the mean +/- SD number of RBC units transfused decreased from 1.10 +/- 1.30 U in 1980-1985 to 0.27 +/- 1.22 U in 1990-1995 (P<.001). Mean +/- SD discharge hemoglobin concentration decreased from 13.7 +/- 1.4 g/dL in 1980-1985 to 11.8 +/- 1.5 g/dL in 1990-1995 (P<.001). Rates of perioperative stroke and myocardial infarction did not differ between the 2 time periods (early-practice group vs recent-practice group: stroke, 5.1% vs 3.6% [P=.22]; myocardial infarction, 1.5% vs 2.3% [P=.29]). CONCLUSIONS: Our results suggest that elderly patients undergoing carotid endarterectomy (ie, individuals known to be at high risk for cerebral and cardiac ischemia) can tolerate modest perioperative anemia despite a considerable change in the institution's transfusion practice (lower "transfusion trigger," the hemoglobin concentration or hematocrit value below which RBC transfusion is indicated).

Academic Medical Centers↗
PubMed2001

Management of carotid coils during routine carotid endarterectomy.

BACKGROUND: A coil in the internal carotid artery (ICA), defined as a circular configuration or exaggerated S shape of the ICA, is occasionally encountered during endarterectomy for carotid bifurcation lesions. The significance of coils as an etiology for symptoms is difficult to determine. It is thought, however, that the failure to correct coils and kinks during routine carotid endarterectomy (CE) may lead to turbulence and failure of the CE. Various techniques have been discussed to repair coils. METHODS: Our technique consisted of complete dissection of the coil, routine use of a Javid shunt, standard endarterectomy, resection of the redundant ICA, re-approximation of the posterior wall of the ICA and patch angioplasty of the anterior wall. Three hundred and fifteen patients underwent CE between August, 1998 and February, 2000. Fifteen patients (4.7%) had a carotid coil that was repaired. There were ten men and five women. Mean age was 72.6+/-6.1 years. Ten patients had an asymptomatic stenosis. Four patients had lateralizing symptoms and one patient had dizziness. Fifteen patients underwent preoperative duplex scanning and 14 of these patients had MRA scans performed. All patients had a preoperative stenosis of 80-99% by duplex on the operated side. The right carotid artery was repaired in 12 patients. The left in three patients. The length of resected artery varied from 1.2-2.8 cm (1.93+/-0.49 cm). RESULTS: All patients survived surgery. One patient developed a cerebellar stroke on the third postoperative day. A postoperative carotid duplex scan demonstrated a widely patent repair. There were no cranial nerve injuries in this series. One patient died seven months after surgery from cardiac events with no follow-up duplex exam. There have been no long term strokes or anastomotic complications. Follow-up duplex scans demonstrated widely patent repairs (1-15% stenosis) in seven patients and low end 15-49% stenosis in five patients. CONCLUSIONS: Resection of redundant ICA with re-anastomosis of the posterior wall and patch reconstruction of the anterior wall gives acceptable perioperative and long term results.

Aged↗
PubMedDate not supplied

[Endarterectomy in asymptomatic carotid stenosis: a controversial procedure for primary prevention of stroke].

Stroke is the second cause of death and one of the main determinant of disability worldwide. Prevention remains the most important measure for reducing its incidence and mortality. Carotid endarterectomy is one of the possible means for reducing stroke incidence, at least in a subgroup of patients at risk of ischemic stroke. The benefit of carotid endarterectomy has been demonstrated consistently by two large international randomised controlled trials (North American Symptomatic Carotid Endarterectomy Trial, and European Carotid Surgery Trial) in patients with severe symptomatic carotid stenosis. In subjects with asymptomatic carotid stenosis the benefit has been shown by the only available trial (Asymptomatic Carotid Atherosclerosis Study), but proved to be quantitatively less relevant. The benefit is marginal if one considers that only part of stroke events occurring in the territory of an asymptomatic carotid stenosis is preventable by the intervention, since a consistent proportion (almost 50%) of these events are due to other causes (cardioembolism, lacunar infarction). Based on these observations, to obtain a beneficial effect, the perioperative risk should be minimized. Every surgical group should monitor carefully this risk, not omitting minor strokes, that in some cases are functionally relevant. Estimating prevalence and natural history of asymptomatic carotid stenosis in a definite population, the population impact number is expected to be very high, not justifying a widespread screening of the population aimed to identify subjects with asymptomatic carotid stenosis.

Age Factors↗
PubMed1975

Operative assessment of carotid endarterectomy: Internal carotid arterial back pressure, carotid arterial blood flow, and carotid arteriography.

Determination of ICA back pressure, electromagnetic measurement of internal carotid arterial blood flow, and performance of operative carotid arteriography have been assessed in a series of elective carotid endarterectomies. If ICA back pressure is used to determine the need for an internal shunt, our data suggest that a minimal pressure of 60-70 mmHg is required to insure adequacy of collateral cerebral blood flow in all patients. Internal carotid arterial blood flow was not significantly increased after endarterectomy. Although flow measurements are of some interest, their routine measurement does not appear to have significant clinical usefulness. Operative carotid arteriography is a valuable technique in identifying unsuspected technical errors at the site of endarterectomy and should be used routinely.

Aged↗
PubMed2001

Propofol EEG burst suppression in carotid endarterectomy.

BACKGROUND: The results of randomized trials indicate that carotid endarterectomy, performed with a low morbidity-mortality perioperative risk, is the best therapeutic option both for patients with high-grade symptomatic and asymptomatic stenosis. Since the main operative risk is represented by embolic or hemodynamic cerebral ischemia, it appears necessary to maintain an adequate intraoperative cerebral blood flow and to carry out a meticulous endarterectomy. METHODS: On the basis of these considerations we prospectively studied a series of 100 consecutive patients operated on for high-grade carotid stenosis, by using a protocol based on: 1) an accurate selection of patients for surgery; 2) meticulous surgical technique without any shunt; 3) perioperative cerebral protection by barbiturate or propofol; 4) pre- and postoperative medical treatment of risk factors. All patients of our series performed preoperatively brain CT scan, transcranial Doppler, carotid duplex scanning, four vessel angiography, brain 99mTc-HMPAO SPECT. Eighty-two patients had symptomatic carotid stenosis ranged between 70 and 90%, 18 had carotid stenosis higher than 90%. RESULTS: In this series there have been one postoperative death due to myocardial infarction and one major stroke. CONCLUSIONS: We think that this protocol can significantly minimize risks of endarterectomy and probably maximize the benefits of surgery, also in patients with asymptomatic high-grade carotid stenosis.

Aged↗
PubMed2002

Duplex sonographic predictors of restenosis, vascular and neurological events after carotid endarterectomy.

BACKGROUND: Although excellent short- and long-term results have been achieved with surgery in extracranial internal carotid artery stenosis, recurrent stenosis continues to play an important role in post-endarterectomy. Therefore, a close follow-up of patients is warranted. The value of postoperative duplex sonographic evaluations in postoperative follow-up is highly disputed. The study evaluates duplex sonographic parameters as predictors of carotid restenosis, general vascular events and ipsilateral neurological symptoms, in order to assess the role of duplex sonography in follow-up after carotid endarterectomy. METHODS: A retrospective cohort study with a follow-up period ranging from 7 months to 7.5 years was performed in 150 patients who underwent carotid endarterectomy. Pre- and postoperative duplex sonographic and clinical data were analyzed by life-table analysis and multivariate Cox regression with respect to carotid restenosis, vascular and ipsilateral neurological events. MAIN FINDINGS: Duplex sonographic predictors of carotid restenosis include the postoperative degree of stenosis (residual stenosis > or = 30% or more: relative risk (RR) = 1.56; 1.05-2.32), pre- to postoperative reduction of stenosis (higher than 50%: RR = 0.61; 0.45-0.83), and residual plaques in the operated carotid artery (RR = 1.96; 1.31-2.93). Some of these morphological parameters such as reduction of stenosis are also predictive of vascular events (RR = 1.25; 1.01-1.56) and ipsilateral neurological events (RR = 1.52; 1.05-2.19). In 12 cases restenosis was discovered by duplex sonography and in 3 cases by evaluation of clinical symptoms. In 5 cases restenosis was treated by repeat surgery. Contralaterally, progressive or newly developed carotid stenoses were observed in 17 cases, and only 5 were discovered on the basis of clinical symptoms. Fourteen contralateral stenoses required surgery. Overall, 12 patients underwent treatment for stroke prevention on the basis of duplex follow-up findings (8% of the study population). CONCLUSIONS: Postoperative duplex sonography allows for the identification of patients at risk for carotid restenosis as well as those at risk for other vascular events. As expected, regular examinations permit early detection of restenosis requiring surgical treatment. However, a large number of contralateral stenoses requiring surgical treatment were detected by routine duplex sonographic examinations. The timing of follow-up intervals may be oriented towards the perioperative outcome of duplex sonography.

Adult↗
PubMed2002

Closure of carotid bifurcation endarterectomy using a polyurethane patch. A multicentre prospective study with 252 patients.

BACKGROUND: In order to evaluate the results of carotid endarterectomy with closure using a polyurethane patch, a multicentre prospective study of 252 patients (263 interventions) undergoing this operation was performed between November 1996 and August 2001. METHODS: One hundred and seventy-one men and 81 women with a mean age of 70 years were studied. Fifty-five percent of the patients had neurological symptoms. The degree of carotid stenosis evaluated using the European carotid surgery trialist's collaborative group (ECST) criteria was greater than or equal to 70% in 95% of cases. RESULTS: The combined mortality-morbidity operation rate (CMMR) was 2% (1 death from cerebrovascular haemorrhage on Day 3, 1 non-regressive cerebrovascular accident (CVA), 3 regressive CVAs). The patients had follow-up clinical examinations and Doppler ultrasound scans for 2 years. Fifteen patients died during follow-up, 8 of these patients died from heart-related causes and 2 patients died from CVA. Four patients presented with CVAs ipsilateral or contralateral to the endarterectomy. Two false aseptic aneurysms and 1 false septic aneurysm required further surgery. Three asymptomatic carotid occlusions occurred during follow-up. The rate of restenosis greater than 50% was 1.2% at 6 months, 2.3% at 1 year and 5.3% at 2 years. CONCLUSIONS: These results confirm the value of po-lyurethane patch closure of carotid endarterectomy.

Aged↗
PubMed1976

Clinical review of 106 consecutive carotid endarterectomies.

We have reviewed 106 consecutive carotid endarterectomies performed from 1966 through 1973. During this period, 99 elective procedures and seven emergency procedures were done on 84 patients, 22 of whom had bilateral endarterectomies. Indications for elective procedures included transient ischemic attacks, emboli from ulcerative plaques, high grade stenotic plaques on the same or opposite side in patients with old cerebrovascular accidents and asymptomatic bruits. Seven patients had emergency endarterectomies performed for acute strokes and these demonstrated a higher risk. They were grouped together as emergency procedures for comparison with the 99 elective procedures. Previous histories, risk factors, complications and outcome in the two groups are presented and discussed. Mortality in the elective cases was 2%, compared to 30% in the emergency cases with acute stroke. Surgical indications, operative technic and immediate and late results are discussed.

Aged↗