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At least 883 records · Page 49Linked to original sources
PubMed1985

[Resection graft prosthesis (PTFE) of the carotid bifurcation (RGPCB). A new alternative to endarterectomy or to venous bypasses for the treatment of cervical carotid atheromatous stenoses. Technique and indications].

Carotid endarterectomy, possibly followed by an enlarging angioplasty using a venous patch or a prosthesis, is standard treatment for cervical atheromatous lesions. However, this technique may be impossible to apply and a bypass operation may be necessary. J.M. Cormier has proposed the use of a venous by-pass by autologous internal saphenous graft as an alternative to endarterectomy, and reported very favorable results. The usual procedure is lateral implantation into common carotid artery followed by end-to-end implantation into internal carotid artery. The object of this paper is to demonstrate the interest of total resection of the pathologic carotid artery bifurcation followed by total replacement with a prosthesis in PTFE (Goretex) with bifurcated thin walls (new bifurcation constructed by the surgeon) and 3 end-to-end anastomoses (common carotid proximally and internal and external carotids distally). This repair procedure is simple, orthoanatomic, and complete, ensuring permeability of the two axes, internal and external, and is logical. It avoids the thrombo-embolic risk related to the walls after endarterectomy which are often imperfectly smooth leaving a distal intimal projection difficult to prevent or to fix. This thrombotic in situ risk of the endarterectomized wall is shown by isotopic studies with Indium 111-labelled platelets, and most secondary neurologic accidents, definitive, sometimes fatal, or transient, are due to this phenomenon. The three anastomoses in healthy zones considerably reduces this risk. The use of PTFE in femorodistal bypass surgery has been shown to give a good level of long-term permeability even for poor distal beds, and to present a low septic risk compared with Dacron prosthesis. This material was therefore considered a good alternative to a venous graft for the carotid vessels. The technique was used 12 times in 11 patients, between 1984 and 1985, without occlusion, or mortality. One patient developed a transient ischemic accident related to a low output and with multiple pedicles lesions, but there were no sequelae. All shunts were seen to be permeable on follow up venous angiography. Wider experience and a longer review period are necessary before proposing this method, but initial results of its use have been encouraging.

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PubMed1979

Hypertension following carotid endarterectomy.

Seventy-nine patients undergoing staged bilateral carotid endarterectomy were studied to determine the relationship of perioperative hypertension to postoperative neurologic deficits. Six of the eight neurologic deficits following 158 endarterectomies (5%) occurred after the first operation, all being temporary. Comparison of the mean blood pressures in patients with and without postoperative strokes revealed no statistically significant differences. Patients on antihypertensive medications were at a significantly higher risk of developing postoperative strokes. A trend towards higher blood pressure was noted following the second endarterectomy, particularly when they were staged more than 60 days apart. Based on our findings, a cautious approach is warranted in the treatment of postendarterectomy hypertension.

Adult↗
PubMed1984

Minimizing the risks of carotid endarterectomy.

In 1971 this study was undertaken to determine optimal methods and guidelines for lowering the mortality and neurologic complication rates associated with carotid endarterectomy. Of 570 carotid endarterectomies, 481 (84%) were performed under local anesthesia to provide continuous neurologic monitoring and to permit operation on the very elderly and poor-risk patient. In 418 of these procedures carotid stump pressures (CSPs) were measured with patients awake to determine the level of back pressure sufficient for brain protection during operative occlusion. Selective shunting was necessary in 40 (8%) of these cases. Of 78 patients with a CSP of 0 to 25 mm Hg, only 39 (50%) required shunting. Only one patient with a pressure greater than 25 mm Hg (29 mm Hg) needed a shunt. The CSP/brachial blood pressure (BBP) index was calculated for 410 procedures. Of 97 patients with a CSP of 0 to 30 mm Hg, only 31 required a shunt (CSP/BBP index 0.01 to 0.18). No shunt was necessary for an index greater than 0.18. Patients with a contralateral occlusion or severe stenosis required a shunt six times more frequently than those with unilateral disease. For 570 procedures the overall mortality rate was 0.7% and the neurologic complication rate was 0.9%. When local anesthesia was used for 481 procedures, there was only one death (0.2%). For 74 asymptomatic lesions there were no deaths or stroke. Neurologic monitoring under local anesthesia and CSPs are reliable indicators for selective shunting. Multiple-risk factors influence the outcome of carotid endarterectomy, but most can be avoided.

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PubMed1984

The efficacy of routine completion operative angiography in reducing the incidence of perioperative stroke associated with carotid endarterectomy.

Routine operative angiography was performed during a 14 1/2-year period ending June 1982, during which 603 consecutive carotid endarterectomies were performed. For the purpose of standardization, a functional classification of stroke in terms of severity was established: class I--minimal, class II--moderate, class III--marked, class IV--severe, and class V--coma or death. Patients were analyzed to determine the cause of the stroke, the severity of the stroke, and the efficacy of routine operative angiography in reducing the incidence of perioperative stroke caused by technical error. Perioperative stroke occurred in 18 patients (2.9%), with only one having been caused by technical error. Fifteen patients underwent revision of the endarterectomy before wound closure because of unsatisfactory operative angiography results. None of the patients developed permanent neurologic deficits. Permanent perioperative neurologic deficits resulted from embolization (six patients), hypertensive episodes with cerebral hemorrhage (three patients), conversion of ischemic to hemorrhagic infarcts (two patients), spontaneous thrombosis (one patient), clamp ischemia (two patients), and other factors (three patients). Nine patients died, two of myocardial infarction and seven of stroke, for a combined mortality and morbidity rate of 3.3%. There were three class II, five class III, two class IV, and eight class V strokes that were determined to be related to the procedure. In this series stroke may have been prevented in 15 patients who underwent revision of the endarterectomy because of an unacceptable technical error demonstrated on operative angiography.

Arterial Occlusive Diseases↗
PubMed1983

Carotid endarterectomy for unilateral carotid system transient cerebral ischemia.

This study involved 151 consecutive patients who had transient focal cerebral ischemia (TIA) in one carotid arterial system and who had carotid endarterectomy on the side corresponding to the ischemic symptoms. Each patient was examined preoperatively by a neurologist, who also judged the postoperative morbidity and mortality. All patients were operated on by one surgeon. A major or minor ischemic stroke occurred in 3% of patients during operation or within 30 days thereafter. The mortality was less than 1% at 1 month. After the first month, ischemic stroke occurred at a rate of 2% per year, and two-thirds of the strokes were ipsilateral to the endarterectomy. Long-term mortality was 3% per year. Long-term stroke morbidity was less than would have been expected for a comparable group of patients with TIA, and the percentage of deaths due to a cardiac cause was greater than expected, owing to a relative shift from stroke mortality to cardiac mortality. No patient who had a cerebral blood flow of 40 ml or greater per 100 g of brain per minute during occlusion for endarterectomy had a stroke during operation or during 4 1/2 years of follow-up.

Carotid Artery, Internal↗
PubMed1980

Endarterectomy of the superficial femoral artery.

The long-term results of 63 consecutive femoro-popliteal endarterectomies are presented and discussed. The average period of follow-up was 52 months. There were no per- or postoperative deaths. The early failure rate was 30 % (10 out of 63) and five-year patency was 26 %. Extremities with compromised inflow and/or outflow had a five-year patency of only 10 %, whereas five-year patency was 40 % for the remainder. Endarterectomies of short occlusions and a five-year patency of 38 %, while five-year patency for long occlusions was only 8%. Since five-year patency for even the optimal operative candidate (with only moderate ischemic symptoms, with short occlusions of the femoral artery, as well as with both good inflow and outflow) was not above 40 %, the authors conclude that endarterectomy is not suited for the treatment of femoro-popliteal occlusions.

Adult↗
PubMed1982

Simultaneous myocardial revascularization and carotid endarterectomy.

Two methods for performing simultaneous carotid endarterectomy and coronary artery bypass grafting (CABG) were compared in 73 patients. A technique for performing carotid endarterectomy during cardiopulmonary bypass providing hypothermic cerebral protection was used in 37 patients (group 1). The 36 other patients (group 2) underwent carotid endarterectomy immediately before cardiopulmonary bypass was instituted. The mean age, New York Heart Association functional class, ventricular function and extent of carotid disease were similar in the two groups. The proportion of patients with previous myocardial infarction or stroke was higher in group 1 (p less than 0.05). One permanent neurologic deficit (technical error) and one transient neurologic deficit occurred in group 1 and none in group 2 (NS). Twenty-seven patients (37%) had left main disease, compared with an institutional incidence of 14.2% for all coronary operations. Five of seven patients who died early (three in group 1 and four in group 2) had left main disease. No advantage of one method over the other could be demonstrated. Patients with left main coronary artery disease and carotid disease have an increased operative risk.

Aged↗
PubMedDate not supplied

Perioperative stroke during carotid endarterectomy: the value of intraoperative angiography.

Stroke following carotid endarterectomy is ordinarily attributed to carotid occlusion without adequate shunting, to embolization of air, atheroma, or thrombus, or to the elevation of an intimal flap. In 146 carotid endarterectomies in which intraoperative arteriography was not used, we observed a mortality of 4.8% and an incidence of perioperative stroke of 6.8%. In a subsequent group of patients in which 137 endarterectomies were performed with 107 intraoperative arteriograms to assess the immediate post-surgical results, there was a mortality of 1.5% and an incidence of perioperative stroke of 3.6%. We attribute this difference, in part, to the revision of 12 internal carotid artery defects observed on the arteriograms. Intraoperative arteriography was easy to perform and without complication; however, we recommend that consideration be given to ultrasound as a potentially useful way in the future of assessing technical results.

Arterial Occlusive Diseases↗
PubMed1981

Effect of carotid endarterectomy on the antihypertensive properties of the carotid sinus reflex.

In eight patients subjected to carotid reconstructive surgery, the reflex effect on systemic pressure of an increase in carotid sinus transmural pressure was studied, before and two months after endarterectomy. The increase in carotid sinus transmural pressure was obtained by applying subatmospheric pressure to the neck. It was found that the closed loop gain of the carotid sinus reflex, calculated as the ratio of change in systemic pressure to change in carotid sinus transmural pressure, was 0.53 before and 0.52 two months after endarterectomy. It is thus concluded that carotid endarterectomy has no persisting effect on the antihypertensive properties of the carotid sinus reflex.

Blood Pressure↗
PubMed1980

Supraorbital photoplethysmographic monitoring during carotid endarterectomy with the use of an internal shunt: an added dimension of safety.

Photoplethysmograph (PPG) has added a new dimension of safety to carotid endarterectomy operations. Used to monitor adequate shunt blood flow during carotid endarterectomy, the PPG has proven to be a sensitive, reliable, and accurate device. Temporary intraoperative shunt occlusion is immediately indicated by marked amplitude reductions in the supraorbital artery pulse waveform. The cause of the occlusion is usually found to be impingment of the distal end of the shunt against the arterial wall, which is easily corrected by proximal positioning of the shunt. Also, occasionally occlusion will occur from kinking of the internal carotid artery distal to the shunt, which is corrected by slight proximal retraction on the artery. Repositioning retractors in the upper extent of the operative field will alleviate any occlusions from retractor pressure on the internal carotid artery. Without a method of sensing hemodynamically significant decreases in shunt flow during operation for carotid endarterectomy, there exists a risk of prolonged unrecognized intraoperative cerebral ischemia.

Blood Vessel Prosthesis↗
PubMed1980

Experience with simultaneous myocardial revascularization and carotid endarterectomy.

Fifty-four patient had coexisting stenosis of the carotid artery (70% or greater) and coronary artery disease. Simultaneous carotid endarterectomy and myocardial revascularization were done in all cases. One permanent postoperative neurologic deficit occurred (1.9%). There were no deaths. Our experience with simultaneous correction of combined carotid and coronary disease leads us to conclude that simultaneous myocardial revascularization and carotid endarterectomy have low mortality and neurologic morbidity rates. The policy at Loyola University Medical Center at this time is to routinely perform simultaneous endarterectomy and myocardial revascularization in all patients with significant coexisting carotid and coronary disease.

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PubMed1980

Carotid endarterectomy: regional versus general anesthesia.

The records of 421 patients who underwent carotid endarterectomy were reviewed. Between 1967 and 1972 carotid endarterectomy was performed with regional anesthesia in 232 patients. Ten per cent of these patients required the use of general anesthesia and a temporary indwelling shunt, because of the development of neurologic symptoms after temporary cross-clamping (5.6%) or the inability to tolerate regional anesthesia (4.3%). The 30-day mortality was 2.6 per cent. The incidence of fixed neurologic deficits was 2.2 per cent, and the incidence of transient neurologic deficits was 3 per cent. Between 1974 and 1976, 189 carotid endarterectomies were performed with general anesthesia and the routine use of a temporary indwelling shunt. The 30-day mortality was 0.5 per cent. The incidence of fixed neurologic deficits was 2.6 per cent; the incidence of transient neurologic deficits was 2.6 per cent. The use of general anesthesia with a shunt has not significantly changed the mortality or incidence of postoperative neurologic complications when compared with the authors' series performed with regional anesthesia. All patients in whom postoperative strokes occurred had multiple stenotic or occlusive lesions. Special precautions should be taken in this high-risk group.

Anesthesia, Conduction↗
PubMed1981

Emergency carotid endarterectomy for fluctuating neurologic deficits.

The merit of emergency carotid endarterectomy for patients with fluctuating neurologic deficits remains controversial. Twenty-four patients with fluctuating neurologic deficits underwent emergency carotid endarterectomy and were compared to 31 patients managed nonoperatively. Both groups were similar in age and sex distribution, indicence of hypertension (50%), myocardial infarction (16%), and diabetes mellitus (12%). The two groups were subdivided into patients with crescendo transient ischemic attack (CTIA) and patients with stroke in evolution (SIE). Within the operative CTIA group, all seven patients recovered completely. Among the five nonoperative CTIA patients, one recovered, three sustained moderate or severe neurologic deficits, and one died. Within the operative SIE group of 17 patients, none had a worsening of the deficit, four remained unchanged (24%), and 12 patients (70%) had complete recovery or only a mild deficit. One patient (6%) died postoperatively. Among 26 nonoperative SIE patients, five recovered or sustained mild deficits (19%), 17 had moderate or severe deficits (66%), and four died (15%). The 12 patients with complete or near recovery of neurologic function represented more than a threefold improvement (P less than 0.01) in the quality of life with endarterectomy. When compared with the natural history of fluctuating neurologic deficits, these data suggest that immediate operative intervention will result in better salvage.

Carotid Arteries↗
PubMed1995

[Monitoring somatosensory evoked potentials during carotid endarterectomy].

The tromboembolic and ischemic events during carotid endarterectomy can be avoided or detected with appropriate monitoring. Median nerve somatosensory evoked potentials recorded from the parietal cortex correlate with the blood flow in the middle cerebral artery. The good evoked responses after cross-clamping of the carotid artery indicate a sufficient collateral circulation, enabling a surgery without shunt, thus minimizing the risk of embolisation. Insufficient collateral circulation after cross-camping results in an amplitude reduction of the parietal N20-P25 complex of more than 50%. In this case an ischemic event can be prevented by shunting. As a total 83 carotid endarterectomies were done. In 65 cases (78.3%) the evoked potentials showed no significant alteration, and no postoperative neurological deficit occurred. Seven patients (8.45%) needed to be operated with a shunt, because of cross-clamping ischaemia. One of them presented a transient postoperative hemiparesis, which was predicted by the long-term loss of the SEP-s, and which resolved within 4 hours. Seven further patients (8.45%)--operated primarily with shunt, and 4 patients (4.8%)--monitored with transcranial Doppler sonography, showed no postoperative neurological deficit. We found that median nerve somatosensory evoked potential monitoring during carotid endarterectomy is a simple, sensitive and reliable method.

Arteriovenous Shunt, Surgical↗
PubMed1995

Update on carotid endarterectomy.

Progress in therapeutic decision-making for patients with carotid artery disease has come from evaluations made by several major randomized clinical trials. For patients who are symptomatic and have arteriographically proven stenoses of 70% or more, endarterectomy is clearly established as the treatment of choice. Symptomatic patients with stenoses of less than 70% remain the subject of ongoing study. Asymptomatic patients are at low risk of stroke save for those with the highest (80% to 90%) degrees of stenosis, and even for these subjects the annual stroke rate is close to the operative risk. Four trials have been reported but the practicing physician is still without clear guidelines. The appropriateness of endarterectomy remains unsettled for any group of patients with narrowing of the carotid artery in the absence of symptoms. The decision to apply endarterectomy to symptomatic and to asymptomatic patients must attend to not only the prognostic importance of the degree of stenosis, but also to the vascular risk profile of the individual patient.

Carotid Artery Diseases↗
PubMed1993

Early results of combined carotid endarterectomy and coronary artery bypass grafting in patients with severe coronary and carotid artery disease.

The management of patients with carotid artery disease who require coronary artery bypass grafting (CABG) remains controversial. Several published series from the USA (including one with prospective randomization) advocate a combined approach of carotid endarterectomy (CEA) followed immediately by coronary artery bypass surgery. However, experience of combined carotid endarterectomy and coronary bypass grafting has not been previously reported by a centre from the United Kingdom. Between 1986 and 1991 we performed this combined procedure on 18 patients who required myocardial revascularization and had co-existing severe (> 70%) carotid stenosis. Sixteen patients (89%) had angina and 11 patients (61%) had symptomatic carotid artery disease. The perioperative mortality was 5.5% and the ipsilateral perioperative stroke rate was 5.5%. These early results are encouraging and suggest that further evaluation of combined carotid endarterectomy and coronary artery bypass surgery is warranted.

Adult↗
PubMed1994

Randomized clinical trial results define operative indications in symptomatic and asymptomatic carotid endarterectomy patients.

Randomized clinical trials on the efficacy of carotid endarterectomy have assisted in the selection of patients for operative intervention. Three such trials involving symptomatic carotid stenosis have confirmed the value of endarterectomy in patients with stenoses 70% or greater. Patients with recent transient ischemic attack or nondisabling stroke should be referred for noninvasive testing. If the patient's stenosis exceeds a threshold level (50% to 70% diameter-reducing lesion), arteriography should be performed and prompt endarterectomy scheduled, rather than antiplatelet therapy, as the primary means of treatment. Furthermore, the results of one clinical trial on asymptomatic stenosis have demonstrated benefits for operative intervention in reducing neurologic events (transient ischemic attack plus stroke). These data require additional confirmation in the analysis of stroke alone, which should be available within the next year from another clinical trial. These trials help to define indications for operation, and the thorough knowledge of their results has become essential to our practices.

Carotid Stenosis↗
PubMed1994

Saphenous vein patch versus polytetrafluoroethylene patch after carotid endarterectomy.

Although carotid patch angioplasty has been performed on a selective or routine basis in all large series of carotid endarterectomy, the choice of patch material still remains in question. The objective of this study has been a prospective randomized evaluation of the relative risks and benefits of saphenous vein patch versus PTFE patch material for carotid endarterectomy. During a 4-year period, 84 patients undergoing 95 carotid endarterectomies were randomized into two groups: 45 venous patch (n = 40) and 50 PTFE patch (n = 44). All operations were carried out under general anesthesia and systematic placement of a shunt. The patients were evaluated at 1, 3, 6 months and every year with doppler, periorbitary photoplethysmography, intravenous digital subtraction angiography, and neurologic assessment (mean follow-up 29 +/- 1 month). Operative time among patients having PTFE patch was significantly longer (p < 0.05) than among those having saphenous vein patch, due to bleeding from suture holes. Perioperatively, no neurologic complications or deaths were observed in venous patch patients, however there was a permanent stroke and one death from arterial wall disruption in the PTFE patch group. The incidence of aneurysmal dilatation in the saphenous vein patch group (15.5%) was higher than for the PTFE patch group (2%). On late follow-up, no deaths, carotid thrombosis or patch rupture were observed in either group. Recurrent stenosis occurred in 2 cases having PTFE patch. One reoperation for recurrence was required. In addition, one patient with PTFE patch angioplasty developed an infected false aneurysm at 7 months.(ABSTRACT TRUNCATED AT 250 WORDS)

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