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PubMed1998

The fall and rise of carotid endarterectomy in the United States and Canada.

BACKGROUND: Randomized clinical trials have demonstrated the efficacy of carotid endarterectomy in the prevention of stroke when the procedure is performed in regional centers of surgical excellence. However, the relative effects of these studies on the rates of carotid endarterectomy in the United States and Canada have been unclear. METHODS: We calculated the annual rate of carotid endarterectomy in the U.S. states of California and New York and in the Canadian province of Ontario from 1983 through 1995. We also studied whether patients in the early 1990s were selectively referred to hospitals with high volumes of procedures and historically low in-hospital mortality rates. RESULTS: Rates of carotid endarterectomy fell in all three regions from 1984 to 1989 (from 126 to 66 per 100,000 adults 40 years of age or older in California, from 65 to 40 per 100,000 in New York, and from 40 to 15 per 100,000 in Ontario), after the publication of studies demonstrating that the rates of complications of carotid endarterectomy were unacceptably high. However, the clinical trials of the 1990s, which showed benefit from carotid endarterectomy, were associated with a dramatic resurgence in the rates of the procedure from 1989 to 1995 (from 66 to 99 per 100,000 in California, from 40 to 96 per 100,000 in New York, and from 15 to 38 per 100,000 in Ontario). These increased rates were not associated with proportionally greater numbers of referrals of patients to hospitals with low mortality rates. CONCLUSIONS: There have been a dramatic fall and rise in the rates of carotid endarterectomy in both the United States and Canada, which correlate with the publication of first unfavorable and then favorable clinical studies. The absence of selective referral of patients to centers with the lowest mortality rates raises questions about whether the benefits of carotid endarterectomy in the general population are similar to those demonstrated in the clinical trials.

Adult↗
PubMed1991

Unilateral iliofemoral occlusive disease: long-term results of the semi-closed endarterectomy with the ring-stripper.

Nowadays, fewer endarterectomies are performed for treatment of occlusive arterial disease; more often a bypass procedure is done. This study investigates whether the results of the semiclosed endarterectomy for unilateral iliofemoral occlusive disease indeed indicate a wider use of bypass procedures for such short obstructions. Ninety-four patients with an obstructed external iliac and common femoral artery, but with patent ipsilateral common iliac and contralateral iliac arteries, underwent 101 operations. Seven of these patients were operated on at a later stage for occlusive disease on the contralateral side. Ninety-three endarterectomies were performed, and an iliofemoral bypass graft was inserted eight times because an endarterectomy was not feasible. Sixty-two operations were performed for disabling claudication, and 39 operations were performed for limb-threatening ischemia. Eighty-five percent of the patients who underwent an endarterectomy for disabling claudication became asymptomatic. Eighty percent of the patients who underwent an endarterectomy for limb-threatening ischemia became asymptomatic or improved to claudication. After endarterectomy no deaths, false aneurysms, or infections occurred. The patency rates at 1, 5, and 10 years were 94%, 83%, and 65%, respectively. We conclude that the semiclosed endarterectomy with the ringstripper of a unilateral obstruction of one external iliac and common femoral artery can be performed with a low morbidity and without deaths and gives good long-term results.

Adult↗
PubMed2001

Saratin, an inhibitor of von Willebrand factor-dependent platelet adhesion, decreases platelet aggregation and intimal hyperplasia in a rat carotid endarterectomy model.

PURPOSE: Post-carotid endarterectomy, thrombosis, and intimal hyperplasia may be decreased by the inhibition of platelet adhesion and activation. In this study, a novel agent, saratin, was used to inhibit platelet-to-collagen adhesion in a rat carotid endarterectomy model. Saratin is a recombinant protein isolated from the saliva of the medicinal leech Hirudo medicinalis, which is thought to act by binding to collagen, and inhibits von Willebrand factor-collagen interaction under conditions of increased shear and therefore, the adherence and activation of platelets at the vessel wall. Saratin has the advantage of being a nonsystemic, site-specific topical application. METHODS: A rat carotid endarterectomy model was used in which an open technique with arteriotomy and intimectomy was used. Saratin was applied to the endarterectomized surface of the carotid artery before arterial closure. End point measurements included platelet adhesion, thrombosis rate, intimal hyperplasia development, bleeding times, and platelet counts. Electron micrographs of carotid arteries were used for quantitative analysis of platelet aggregation and platelet counts. Intimal hyperplasia and thrombosis were assessed with computer-assisted morphometric analysis of elastin-stained carotid artery sections with direct measurement of the intimal hyperplasia area. RESULTS: The topical application of saratin significantly decreased platelet adhesion compared with controls at 3 hours after carotid endarterectomy (64 +/- 17 vs 155 +/- 33 platelets per grid, P = .05), and 24 hours after carotid endarterectomy (35 +/- 11 vs 149 +/- 37 platelets per grid, P = .0110), respectively. A percent luminal stenosis, as a measure of intimal hyperplasia, was significantly decreased with saratin application compared with controls (10.9% +/- 1.8% vs 29.8% +/- 6.8%, P = .0042). This decrease in intimal hyperplasia formation correlated with the inhibition of platelet adhesion. Thirty-three percent of control arteries were found to be thrombosed 2 weeks after carotid endarterectomy compared with a 0% thrombosis rate in the saratin-treated group (P = .0156). No increased bleeding was encountered along the arterial suture line in the saratin group. Bleeding times and systemic platelet counts were not found to change significantly in the saratin-treated rats compared with control rats at 3 and 24 hours after endarterectomy. CONCLUSION: Saratin significantly decreased platelet adhesion, intimal hyperplasia, luminal stenosis, and thrombosis after carotid endarterectomy in rats. Saratin did not increase suture line bleeding or bleeding times, and did not decrease platelet counts. Saratin may serve as a topical agent to be used for the site-specific inhibition of thrombosis and intimal hyperplasia after vascular manipulation.

Administration, Topical↗
PubMed1994

Endarterectomy of the left anterior descending coronary artery.

Increasing numbers of patients with extensive coronary artery disease present for surgical revascularization. Diffuse atherosclerosis of the anterior descending artery remains a significant challenge and endarterectomy may be required to increase graft outflow. A surgeon may choose local endarterectomy or be accidentally forced into endarterectomy when attempting to split a lesion distal to a critical stenosis. Distal traction endarterectomy may be performed through a medium sized arteriotomy and closed with a vein patch, to which an internal mammary artery (IMA) or saphenous vein graft is constructed. More diffuse disease, or the breaking of an endarterectomy specimen, may require a direct vision total endarterectomy of the entire length of the left anterior descending coronary artery (LAD), which is then closed by a long vein patch. The IMA is not usually grafted to such an extensive reconstruction. There has not been an increase in perioperative risk from LAD endarterectomy when compared to patients undergoing coronary artery bypass grafting without endarterectomy.

Cineangiography↗
PubMed2003

Long-term relative survival in elderly patients after carotid endarterectomy: a population-based study.

BACKGROUND AND PURPOSE: Octogenarians were not included in the major trials of carotid endarterectomy. Concern has been expressed about the role of carotid endarterectomy in this age group. This concern is based in part on uncertainty about the long-term survival of elderly patients after carotid endarterectomy. The aim of the present study was to assess relative survival in those patients >or=80 years of age undergoing carotid endarterectomy. METHODS: A population-based record linkage study of all patients who underwent carotid endarterectomy from 1988 to 1998 in Western Australia was undertaken. Long-term relative survival after carotid endarterectomy was assessed against age- and sex-matched controls. RESULTS: During the period 1988 to 1998, 1796 (1306 male, 490 female) cases were identified. There were 151 patients >or=80 years of age. The cumulative survival at 5 years was 64.9% for those >or=80 years of age compared with 80.1% for those <80 years of age. Relative survival at 5 years was 118% (95% CI, 102 to 134) for those >or=80 years of age compared with 94.7% (95% CI, 92 to 97) for those <80 years of age. CONCLUSIONS: Long-term relative survival after carotid endarterectomy in patients >or=80 years of age was better than that of an age-matched population. The likelihood of living long enough to gain benefit from a carotid endarterectomy is not jeopardized by being too old.

Aged↗
PubMedDate not supplied

Platelet deposition at carotid endarterectomy sites in humans.

Following carotid endarterectomy, early postoperative thrombosis or late restenosis occurs in up to 20% of vessels. Both complications may be related to platelet mechanisms. To assess platelet deposition at endarterectomy sites, we injected indium-111 labelled platelets in 24 men less than 30 minutes after carotid endarterectomy, with subsequent imaging 24-96 hours later. To determine if deposition decreased over time, 12 patients had follow-up studies 0.5-24 months later. For comparison, 2 control groups were studied: 1) patients with noncarotid surgery (n = 6) and 2) normal young subjects without endarterectomy and without evidence of carotid disease (n = 12). Quantitative analysis was performed performed using a deposition index that compared activity in operated with unoperated sites in surgical patients or activity in the right with left carotid arteries in normal subjects. Patients with recent endarterectomy had a mean deposition index of 1.7 +/- 0.5 (range 1.2-3.5) compared with a similarly determined ratio of 1.1 +/- 0.1 in normal subjects and 1.2 +/- 0.1 in the surgical controls (both p less than or equal to 0.05 vs. acute endarterectomy). At follow-up after endarterectomy, the mean deposition index decreased to 1.0 +/- 0.1, documenting reduced platelet deposition over time. We conclude that the arterial injury of carotid endarterectomy results in early platelet deposition, which is no longer present in most patients who are studied late. These findings suggest a reduction in platelet thrombus formation with time and are compatible with reendothelialization of the endarterectomized surface. This model may be useful for the in vivo assessment of therapies designed to reduce platelet accumulation following endothelial injury in humans.

Aged↗
PubMed1994

Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms.

BACKGROUND AND PURPOSE: Randomized clinical trials have shown that carotid endarterectomy decreases the risk of subsequent stroke in patients with high-grade carotid stenosis and ipsilateral transient ischemic attack or minor stroke. The benefit of surgery is highly dependent on surgical risk. We previously found that patients with ipsilateral hemispheric symptoms were at greater risk of carotid endarterectomy complications compared with those who were asymptomatic or had nonipsilateral symptoms. The goals of the present study were (1) to identify preoperative clinical factors that may increase the risk of complications after carotid endarterectomy in patients with ipsilateral hemispheric symptoms and (2) to develop a risk index based on this patient-level data. METHODS: Records from 1160 carotid endarterectomies performed at 12 academic medical centers composed the primary data set. Hospital charts for the admission during which carotid endarterectomy was performed were systematically reviewed by abstractors using a defined protocol. The present analysis was carried out on data from the subset of patients who had carotid endarterectomy for ipsilateral hemispheric symptoms. Candidate variables were identified based on univariate Fisher's exact tests or chi 2 tests. A risk index was then developed using those variables with a greater than 90% probability of being associated with adverse outcomes. RESULTS: Of the 697 patients with ipsilateral symptoms, 8.5% had either stroke, myocardial infarction, or died during the postoperative period of hospitalization. Those over the age of 75 had a greater risk of myocardial infarction (6.6% versus 2.3%, P = .024) but not of stroke or death (P > .10). The overall frequencies of adverse outcomes were also higher in the 5 patients with complete ipsilateral carotid occlusions (40% versus 8.2%, P < .01), the 28 patients with ipsilateral intraluminal thrombus (17.9% versus 8.1%, P = .07), and the 65 patients with ipsilateral carotid siphon stenosis (13.9% versus 7.9%, P = .10). There were no differences in adverse outcomes among those with different degrees of ipsilateral stenosis (30% to 49%, 50% to 69%, and 70% to 99%). Adverse outcome rates were similar regardless of the type of symptom (transient ischemic attack, recent ipsilateral minor stroke, remote ipsilateral minor stroke). There were no significant differences in adverse outcome rates based on sex, race, history of angina, recent myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, hypertension, degree of stenosis of the contralateral carotid artery, or presence of ulceration in the ipsilateral artery (Fisher's exact tests, P > .10). A count of variables with greater than 90% probability of being associated with adverse outcomes (age > or = 75 years or angiographic evidence of ipsilateral carotid occlusion, stenosis in the region of the carotid siphon, or intraluminal thrombus) was used to form a simple risk index. "High-risk" patients (one or more risk factors) had more than two times the risk of complications compared with "low-risk" patients who had no risk factors (odds ratio, 2.18; 95% confidence interval, 1.25 to 3.81). CONCLUSIONS: Certain preoperative clinical variables may place patients with ipsilateral symptoms at greater risk of perioperative complications after carotid endarterectomy. Prospective validation of a simple risk index would provide an additional method for assessing preoperative risk in endarterectomy candidates.

Age Factors↗
PubMed2000

Systematic comparison of the early outcome of angioplasty and endarterectomy for symptomatic carotid artery disease.

BACKGROUND AND PURPOSE: Endoluminal treatment is being increasingly used for carotid artery disease. The aim of this study was to compare the stroke and death risk within 30 days of endovascular treatment or endarterectomy for symptomatic carotid artery disease. METHODS: systematic comparison of the 30-day outcome of angioplasty with or without stenting and endarterectomy for symptomatic carotid artery disease reported in single-center studies, published since 1990, was performed. RESULTS: Thirty-three studies (13 angioplasty and 20 carotid endarterectomy) were included in this analysis. Carotid stents were deployed in 44% of angioplasty patients. Mortality within 30 days of angioplasty was 0.8% compared with 1.2% after endarterectomy (OR 0.68, 95% CI 0.43 to 1.05; P=0.6). The stroke rate was 7.1% for angioplasty and 3.3% for endarterectomy (OR 2.22, CI 1.62 to 3.04; P<0.001), while the risk of fatal or disabling stroke was 3.2% and 1.6%, respectively (OR 2.09, CI 1.3 to 3.33; P<0.01). The risk of stroke or death was 7.8% for angioplasty and 4% for endarterectomy (OR 2.02, CI 1.49 to 2.75; P<0.001), while disabling stroke or death was 3.9% after angioplasty and 2.2% after endarterectomy (OR 1.86, CI 1.22 to 2.84; P<0.01). CONCLUSIONS: In the treatment of symptomatic carotid artery disease, the risk of stroke is significantly greater with angioplasty than carotid endarterectomy. At present, carotid angioplasty is not recommended for the majority of patients with symptomatic carotid artery disease.

Angioplasty, Balloon↗
PubMed2005

Carotid endarterectomy--an evidence-based review [RETIRED]: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

OBJECTIVE: To assess the efficacy of carotid endarterectomy for stroke prevention in asymptomatic and symptomatic patients with internal carotid artery stenosis. Additional clinical scenarios, such as use of endarterectomy combined with cardiac surgery, are also reviewed. METHODS: The authors selected nine important clinical questions. A systematic search was performed for articles from 1990 (the year of the last statement) until 2001. Additional articles from 2002 through 2004 were included using prespecified criteria. Two reviewers also screened for other relevant articles from 2002 to 2004. Case reports, review articles, technical studies, and single surgeon case series were excluded. RESULTS: For several questions, high quality randomized clinical trials had been completed. Carotid endarterectomy reduces the stroke risk compared to medical therapy alone for patients with 70 to 99% symptomatic stenosis (16% absolute risk reduction at 5 years). There is a smaller benefit for patients with 50 to 69% symptomatic stenosis (absolute risk reduction 4.6% at 5 years). There is a small benefit for asymptomatic patients with 60 to 99% stenosis if the perioperative complication rate is low. Aspirin in a dose of 81 to 325 mg per day is preferred vs higher doses (650 to 1,300 mg per day) in patients undergoing endarterectomy. CONCLUSIONS: Evidence supports carotid endarterectomy for severe (70 to 99%) symptomatic stenosis (Level A). Endarterectomy is moderately useful for symptomatic patients with 50 to 69% stenosis (Level B) and not indicated for symptomatic patients with <50% stenosis (Level A). For asymptomatic patients with 60 to 99% stenosis, the benefit/risk ratio is smaller compared to symptomatic patients and individual decisions must be made. Endarterectomy can reduce the future stroke rate if the perioperative stroke/death rate is kept low (<3%) (Level A). Low dose aspirin (81 to 325 mg) is preferred for patients before and after carotid endarterectomy to reduce the rate of stroke, myocardial infarction, and death (Level A).

Aspirin↗
PubMed2006

Techniques and outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

Cardiopulmonary function in patients with chronic thromboembolic pulmonary hypertension can almost be normalized by pulmonary endarterectomy. The procedure involves the removal of organized and incorporated fibrous obstructive tissue from the pulmonary arteries during circulatory arrest under deep hypothermia. Mortality rates reported for patients who have undergone pulmonary endarterectomy range from 4 to 24%. The operation is not an embolectomy but a true endarterectomy. After proximal intrapericardial pulmonary artery incision, the correct endarterectomy plane is established and circumferentially followed down to the lobar, segmental, and sometimes subsegmental pulmonary artery branches in each lobe. Completion of the endarterectomy procedure in one lung is usually possible within a 15-min period of circulatory arrest. This is followed by reperfusion and another period of circulatory arrest for the endarterectomy on the contralateral side. Additional cardiac procedures can be performed after arteriotomy closure, during the rewarming period, if necessary. The outcomes with regard to functional status, quality of life, hemodynamics, right-ventricular function, and gas exchange are very favorable. After surgery, significant and persistent decreases of pulmonary artery pressures and pulmonary vascular resistance are observed in a large majority of patients. Cardiac output is increased and right-heart function is persistently improved. Postoperative management of patients undergoing pulmonary endarterectomy can be challenging. Important complications are persistent pulmonary arterial hypertension due to inadequate endarterectomy or significant secondary vasculopathy, and reperfusion edema in the endarterectomized parts of the lung. Adequate postoperative care is therefore essential. Preoperative hemodynamic severity and the site of anatomic obstruction are believed to be key predictors of postoperative outcome.

Chronic Disease↗
PubMed1988

Results of coronary artery endarterectomy and reconstruction.

Since 1978, 5005 patients have had coronary artery bypass operations: 50% had conventional grafts only (group A), 25.1% required one coronary artery endarterectomy (group B), and 24.9% required multiple endarterectomies (group C). Operative mortality and long-term survival were stratified within each group according to the presence of additional risk factors: severe left ventricular dysfunction, repeat operation, insulin-dependent diabetes mellitus, female sex, and age over 70 years. Operative mortality was 4.0% in group A patients, 6.3% in group B, and 10.4% in group C; it increased in each group as the number of risk factors increased. Mortality was higher in patients with a left coronary artery endarterectomy compared to those with a right coronary endarterectomy only when multiple risk factors were present. Perioperative myocardial infarction occurred in 5.6% of group A patients, 6.5% of group B, and 13.1% of group C patients. Early graft patency (940 patients, 18.8%) was 801 of 901 (88.9%) for endarterectomy grafts and 2939 of 3248 (90.5%) for conventional grafts. Late patency (over 1 year) in 288 symptomatic patients was 137 of 191 (71.1%) for endarterectomy grafts and 644 of 850 (75.8%) for conventional vein grafts. Long-term (5-year) actuarial survival rate was reduced in patients requiring endarterectomy. Current anginal status is available for 3011 of 3305 patients (91.1%): 28.9% of group A patients, 32.5% of group B, and 33.7% of group C patients have recurrent angina at an average follow-up of 58.3 months. The results of this study show increased operative mortality and morbidity in patients requiring coronary artery endarterectomy and reconstruction. However, the early results and particularly the late survival, clinical status, and continued graft patency justify this approach in patients with diffuse coronary artery disease, many of whom would otherwise be inoperable.

Adult↗
PubMed1984

Early carotid endarterectomy in patients with small, fixed neurologic deficits.

Patients who have sustained a large hemispheric stroke are not candidates for early carotid endarterectomy, but there is less agreement regarding the role of carotid endarterectomy in patients with small, fixed neurologic deficits. Accepted practice in many centers is to wait 4 to 6 weeks after the onset of the deficit before proceeding with carotid endarterectomy because of the fear that early revascularization will increase the size of the infarct. Earlier endarterectomy, however, in patients with significant residual ipsilateral carotid territory at risk may prevent repeated infarctions. For the past 5 years our approach to patients with a small stable stroke and significant stenosis (greater than 75%) has been prompt ipsilateral endarterectomy. Of the 337 carotid endarterectomies at our institution since 1979, a subset of 28 patients with hemodynamically significant carotid lesions presented with a small, fixed stroke. The period of time between the appearance of the stroke and carotid endarterectomy averaged 11 days, but 53% of patients were operated on within 7 days of the onset of symptoms. Selective shunting based on intraoperative EEG monitoring was utilized and 40% of the 28 patients required shunts. Operative mortality consisted of one death from a pulmonary embolus, and no patient sustained a new postoperative deficit. Long-term follow-up was available for 96% of patients over a mean of 2 years. During this time two new neurologic events occurred: one fatal stroke and one transient deficit. This experience indicates that patients with small, fixed neurologic deficits who continue to have carotid territory at risk may safely undergo carotid endarterectomy without waiting 4 to 6 weeks.

Aged↗
PubMed1998

Carotid endarterectomy trends in the patterns and outcomes of care at academic medical centers, 1990 through 1995.

OBJECTIVE: To evaluate whether the patterns of inpatient care and patient characteristics have changed for patients undergoing a carotid endarterectomy across a group of academic medical centers from 1990 through 1995. If changes occurred, we investigated whether they had an impact on patient outcomes. DESIGN: Retrospective evaluation of patients undergoing a carotid endarterectomy using a hospital discharge data set compiled by the Academic Medical Center Consortium. SETTING: Ten academic medical centers. PATIENTS: A total of 7019 hospital admissions for patients who had 1 carotid endarterectomy performed as a principal procedure from January 1990 to December 1995. MAIN OUTCOME MEASURES: Trends in patient demographics, comorbidities, length of stay, days in the intensive care unit, and inpatient cerebral arteriogram use were determined. Patient outcomes included inpatient mortality, discharge to an institution, 30-day readmission rate, and selected diagnoses (postoperative hemorrhage, infection, or seizure; acute myocardial infarction; or cranial nerve palsy) and postprocedure diagnostic tests (computed tomography and magnetic resonance imaging of the head and electroencephalogram) indicative of complications. RESULTS: Over the 6-year study period, the number of carotid endarterectomies performed more than doubled and the percentage of hospital admissions for patients 65 years or older increased from 65% to 75%. The mean and median length of stay halved and the percentage of admissions with transfers to the intensive care unit decreased from 56% to 26% of cases. In addition, the percentage of cases with a cerebral arteriogram during the same admission but prior to the day of the carotid endarterectomy decreased from 52% to 27%. There were no trends in inpatient mortality, discharge to an institution, or 30-day readmission rate. There were no significant trends indicative of poorer quality of care as measured by the frequency of secondary diagnoses or postprocedure diagnostic test use. CONCLUSIONS: Despite dramatic changes that have occurred in patient characteristics and in hospital management practices for patients undergoing a carotid endarterectomy from 1990 to 1995, we were unable to detect any measurable impact on patient outcomes. These data have implications for monitoring and evaluating the impact of systemwide change on the overall quality of care for patients undergoing a carotid endarterectomy.

Academic Medical Centers↗
PubMed1983

Effects of carotid endarterectomy on blood flow in the internal carotid artery.

A retrospective study of patients operated upon for carotid stenosis was undertaken with special emphasis on the internal carotid artery (ICA) blood flow. A total of 212 endarterectomies were performed in 198 patients. The overall operative mortality was 1.4%, and the cerebral morbidity was 2.8%. A temporary inlying shunt was used routinely during endarterectomy. In two of 198 endarterectomies the shunt itself could not be excluded as a possible cause of postoperative neurological deficits. The ICA blood flow before and after endarterectomy was determined by electromagnetic flowmetry in 160 operations. Flow measurements were compared in TIA and stroke patients, in patients with high and low degrees of luminal constriction, and in patients with occluded or "open" (minimal stenosis) contralateral ICA. The results indicate that the preoperative blood flow, as well as the increase in blood flow after removal of the stenosis, is determined not only by the degree of luminal constriction, but also by the magnitude of blood flow from all precerebral feeding arteries and their intracranial collateral circulation. In treatment of carotid stenosis critical evaluation of symptoms, angiography, and haemodynamics are essential. Endarterectomy is beneficial because an embolic source is removed, and probably because perfusion is improved to areas of the brain with marginal circulation. The main factors regulating the normal cerebral perfusion are cardiac output (mean perfusion pressure), arterial pCO2 and PO2, haematocrit, and the arterial and venous blood pressures. Comparatively few investigations have been published on the effect of endarterectomy upon internal carotid artery (ICA) blood flow 4, 12, 14, 27. Since 1970 we have routinely measured the ICA blood flow before and after endarterectomy. This paper reviews the clinical and haemodynamic results of our patients operated on for carotid stenosis.

Adult↗
PubMed1995

Renal endarterectomy vs. bypass for combined aortic and renal reconstruction: is there a difference in clinical outcome?

Are there differences in the patient characteristics and clinical outcome for transaortic renal endarterectomy vs. bypass grafting when either technique is combined with infrarenal aortic replacement for occlusive or aneurysmal disease? Two common perceptions persist: (1) combined aortic and renal procedures have a high risk and (2) bypass is easier and safer than endarterectomy. To address these controversies we compared 52 consecutive patients undergoing concomitant aortic and renal reconstruction between 1987 and 1991: 26 with bypass and 26 with endarterectomy. Bypass patients were older (70 vs. 64 years, p = 0.001), had more extensive plaque extending into the distal renal artery and more severe baseline azotemia (creatinine = 2.6 vs 1.7 mg/dl, p = 0.01), more clinically evident coronary heart disease (89% vs. 56%, p = 0.001), and a greater need for nephrectomy of a small nonfunctional pressor kidney (23% vs. 0%) than endarterectomy patients. In contrast, endarterectomy patients more commonly required aortic replacement for occlusive disease than for an aortic aneurysm (endarterectomy: 65% vs. 35%; bypass: 19% vs 81%, p = 0.002) and tended to require more intraoperative technical revisions (12% vs. 4%) than bypass patients. Both groups, however, experienced no operative mortality, had similar cardiorespiratory morbidity, and achieved equal improvement in hypertension (69% vs. 65%). Bypass patients, who already had more severe preoperative azotemia than endarterectomy patients, showed less improvement in the creatinine level (Cr = 2.1 vs. 1.4 mg/dl, p = 0.01) and had greater need for late dialysis (30% vs. 4%, p = 0.01). Only one patient on dialysis had graft occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2004

Concomitant carotid endarterectomy and coronary bypass surgery: outcome of on-pump and off-pump techniques.

BACKGROUND: There continues to be a dilemma regarding the best means of surgical management of significant carotid artery disease in patients requiring coronary artery bypass surgery. A combined approach of coronary artery bypass and carotid endarterectomy has shown good results in patients with concomitant carotid and coronary artery disease. We reviewed our results of coronary artery surgery using conventional cardiopulmonary bypass or off-pump techniques and carotid endarterectomy done as a combined procedure. METHODS: Between January 1996 and June 2002, 358 patients underwent concomitant coronary artery bypass and carotid endarterectomy. There were 140 males (84.3%) and 26 females (15.7%) in group I. Group II consisted of 158 males (82.3%) and 34 females (17.7%). One hundred sixty-six patients (group I) were done off pump whereas in 192 patients (group II), the procedure was done using conventional cardiopulmonary bypass. Carotid endarterectomy was performed before coronary artery bypass surgery in both groups. RESULTS: The average number of grafts were 3.4 +/- 0.8 with average operative time of 4.2 +/- 0.4 hours in group I, and 3.3 +/- 0.8 graft with operative time of 5.3 +/- 1.2 hours in group II (p = 0.239 and p < 0.001, respectively). There were 2 deaths (1.2%) in group I and 3 deaths (1.6%) in group II (p = 0.870). No patient from group I and 1 patient (0.5%) from group II had postoperative stroke (p = 0.941). Mean hospital stay was 9.0 +/- 1.2 days in group I and 11.2 +/- 1.7 days in group II (p < 0.001). At mean follow-up of 2.8 +/- 0.9 years in group I, 2 patients (1.2%) had late death due to cardiac failure and contralateral carotid endarterectomy was done in 2 patients (1.2%). Group II had mean follow-up of 2.4 +/- 0.6 years, during which 4 patients (2.1%) had late death and contralateral carotid endarterectomy was done in 3 patients (1.6%). Late stroke was seen in 1 patient (0.6%) from group I and 2 patients (1.0%) from group II. CONCLUSIONS: Concomitant carotid endarterectomy and coronary artery bypass is a safe and effective procedure in patients with significant coronary and carotid artery disease. Equally good results can be reproduced using cardiopulmonary bypass or off-pump techniques for coronary artery surgery, with low morbidity, mortality, and good long-term results.

Aged↗
PubMed2005

Results of coronary artery endarterectomy and coronary artery bypass grafting for diffuse coronary artery disease.

BACKGROUND: Coronary artery endarterectomy with coronary artery bypass grafting for diffuse coronary artery disease has been associated with increased morbidity and mortality. We evaluated our institutional experience to redefine the role of coronary endarterectomy for diffuse coronary artery disease. METHODS: From 1985 to 2002 isolated coronary artery endarterectomy with coronary artery bypass grafting was performed in 1,478 consecutive patients. The short-term outcomes were compared with concurrent series of conventional coronary artery bypass graft surgery, and risk factors for adverse outcomes after coronary endarterectomy were identified. RESULTS: Patients in the coronary endarterectomy group were of higher risk with increased incidence of comorbidities and three-vessel coronary disease. The operative mortality (3.2% versus control 2.2%; p = 0.03) and the incidence of major postoperative morbidity (not significant) were comparable between the groups. Prolonged cardiopulmonary bypass time, recent acute myocardial infarction, redo surgery, and poor ventricular function were important predictors of in-hospital mortality. Vessel endarterectomized, technique of endarterectomy, and cardiopulmonary bypass versus off-pump technique did not alter results. At long-term follow-up, 5-year and 10-year survivals were 83% +/- 5%, and 74% +/- 3%, respectively, and freedom from angina at 5 and 10 years was 75% +/- 5%, and 69% +/- 4%, respectively, with 96% of survivors in New York Heart Association class II. CONCLUSIONS: In selected patients with diffuse coronary artery disease, coronary endarterectomy can be used as a tool for myocardial revascularization. The operative mortality and major morbidity were comparable or similar to coronary artery bypass grafting, and short-term and long-term results were favorable.

Aged↗
PubMed2006

Long-term recovery of exercise ability after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

BACKGROUND: The exercise capacity of patients with thromboembolic pulmonary hypertension was investigated to clarify the long-term effects of pulmonary endarterectomy. This capacity was assessed by measuring cardiopulmonary factors during cardiopulmonary exercise testing at the maximal level of exercise and a 6-minute walk test at the submaximal level. Their survival rate was also determined. METHODS: We conducted a retrospective review of the clinical records of 102 patients who underwent pulmonary endarterectomy (63 women; median age, 53 years). RESULTS: Eight (7.8%) hospital mortalities were encountered. Three late mortalities due to fulminant hepatitis, breast cancer, and pneumonia in a patient under steroid therapy were unrelated to pulmonary endarterectomy. The actual survival rate including hospital mortalities was 90.9% at 3 years and 84.0% at 5 years. All hemodynamic measurements significantly improved and reached a plateau 1-month after endarterectomy. The cardiopulmonary exercise test at the maximal exercise level revealed that peak oxygen uptake (V(O2)) baseline was 13.8 +/- 3.2 mL/min/kg, and at 1-month was 16.2 +/- 4.2 mL/min/kg (p = 0.0015) and ventilatory response to carbon dioxide production (V(E)-V(CO2)) slope baseline was 46.5 +/- 8.4 mL/min/kg, and at 1-month was 39.9 +/- 7.4 (p = 0.0006), which gradually and significantly improved during the first year after endarterectomy (peak V(O2), 19.9 +/- 3.9 mL/min/kg [p < 0.0001] and V(E)-V(CO2) slope, 33.2 +/- 5.4 mL/min/kg [p <0.0001]). The 6-minute walk test, which reflects the systemic response at the submaximal level of functional capacity, showed that the walking distance gradually and significantly increased for up to 1 year after endarterectomy (baseline, 358 +/- 102 meters [m]; at 1-month, 433 +/- 105 m; and at 1-year, 490 +/- 80 m [p < 0.0001]) and then reached a plateau. CONCLUSIONS: After pulmonary endarterectomy, the hemodynamic recovery occurred immediately, and the patients' exercise capacity improved during the year. The 6-minute walk test was a good indicator to assess the recovery of exercise capacity.

Adult↗