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PubMed1996

Carotid atherosclerosis. Immunocytochemical analysis of the vascular and cellular composition in endarterectomies.

Papers dealing with rupture of carotid plaque surface are few in spite of the growing importance of the subject. The aim of this study was to analyze the cellular and vascular components of surgically excised carotid endarterectomies in order to obtain information about their role in the pathogenesis of the plaque rupture and intraplaque hemorrhage. Seventy-six surgical specimens of carotid endarterectomies were used for this study. The findings of immunophenotyping of the cellular constituents of the plaques were: 1) endothelial lining: the fibrous cap at the site of the rupture showed an eroded surface with loss of the endothelial lining. Conversely, in the remaining surface a continuous, not damaged row of endothelial cells stained with anti-CD31 and anti-CD34 was observed; 2) fibrous cap: the collagenous fibrous cap at the site of erosion was attenuated and the phenotypic characterization of the cells showed inflammatory components consisting mainly of macrophages (CD68 positive), 2/3 of the total infiltration. The remaining 1/3 was composed of T-lymphocytes and scarce B-lymphocytes. A close interaction between macrophages and capillaries and macrophages and T-lymphocytes was observed; 3) lipid cores: two different types of lipid cores could be depicted. Avascular or mildly vascularized lipid cores and highly vascularized, with neoformed vessels stained with CD34 and CD31. CD34 stained endothelia of all kind of vessels; conversely, neoformed vessels showed a weak stain with CD31. T-lymphocytes were found to be in close contact with neoformed vessels, and in some cases, migrating through the endothelial cells; 4) deeper layers of the plaque: the base and the shoulder of the plaques showed in 28/76 cases neoformed vessels, thin or thick walled, CD34 positive, generally surrounded by mild to extensive mononuclear infiltrates. Atherosclerotic plaques were found to belong to six different lesions: plaque rupture plus thrombosis (18/76, 23.6%), plaque rupture plus intraplaque hemorrhage plus thrombosis (18/76, 23.6%), intraplaque hemorrhage without plaque rupture (16/76, 21.0%), plaque rupture plus intraplaque hemorrhage (5/76, 6.5%), stable calcified non complicated plaque (14/76, 18.4%) and unstable, soft, non complicated plaque (5/76, 6.5%). The first four lesions were considered as "complicated lesions". Complicated plaques presented neoformed vessels in the periphery, shoulder and base of the plaque in 22/57 (38.5%) cases. Conversely only 1/14 (7.1%) of non complicated, stable calcified plaques presented neoformed vessels, (p < 0.05). Of note, the 5 causes of unstable, soft non complicated plaque presented neoformed vessels surrounding the plaque. In 10/57 (17.5%) complicated plaques unequivocal histological signs of old hemorrhages were found surrounding those vessels. Irrespective of presenting no rupture, 11/35 plaques showed a mononuclear infiltrate in the fibrous cap. In conclusion, rupture of carotid plaques (50% of the cases), is characterized by the presence of a macrophagic infiltration of the caps and by the direct apposition of T-lymphocytes to macrophages and a close relation of these cells to endothelial cells. This highly suggests a cell-to-cell interaction, which results in an inflammatory process. Intraplaque hemorrhage without rupture represented 21% of the endarterectomies. These lesions are not related to cap erosion, but to plaque vascularization. Most lipid cores were highly vascularized with neoformed vessels with macrophages and T-cells in close contact and in some cases disrupting the endothelium. The abrupt growing of the lipid core and/or an overproduction of oxygen free radicals could lead to the breakdown of core vessels and intraplaque hemorrhage.

Adult↗
PubMed1996

Carotid endarterectomy in a community hospital.

Despite the popularity of carotid endarterectomy, considerable debate remains regarding the appropriateness of these procedures. Critics of carotid endarterectomy cite the excessive morbidity and mortality associated with these procedures, particularly when performed in a community hospital setting. A retrospective study of 130 procedures, involving 124 patients within a medium size community hospital setting, was conducted. Indications for the procedure, associated comorbidities, and complication rates were reviewed. The incidence of stroke with subsequent mortality was 0.8% within the study group. One patient (0.8%) developed acute coronary insufficiency and underwent coronary artery bypass surgery. Five (4.0%) other patients experienced minor complications. Carotid endarterectomy is a proven prophylactic measure against the prevention of stroke in a selected group of patients. This study reinforces that this procedure may be performed in a community hospital setting with very low morbidity and mortality rates.

Aged↗
PubMed1996

Neovascular glaucoma after carotid endarterectomy.

The authors examined a patient who had neovascular glaucoma (NVG) shortly after ipsilateral carotid endarterectomy and followed the patient's clinical course. The authors speculate that the sudden reperfusion after endarterectomy that occurs in patients with combined central retinal artery occlusion and carotid occlusive disease may enhance the circulation of preformed angiogenesis factors, leading to the development of neovascularization. The authors recommend frequent and careful surveillance of patients with central retinal artery occlusion associated with carotid occlusive disease if ipsilateral carotid endarterectomy is performed.

Aged↗
PubMed1996

The impact of advanced age on the results of carotid endarterectomy: an outcome analysis.

BACKGROUND: This study examined whether advanced age adversely influences the outcome of carotid endarterectomy. STUDY DESIGN: The records of 173 patients who underwent 187 carotid endarterectomies performed by the author from January 1990 through December 1995 were retrospectively reviewed. Group 1 included 58 patients, ranging in age from 75 to 92 years (mean, 79.4 years), who underwent 63 procedures, and group 2 included 115 patients, ranging in age from 41 to 74 years (mean, 66.3 years), who underwent 124 procedures. The operation was performed for symptomatic disease in 67 percent of the cases in each group. The operated lesion was more than 80 percent stenotic in 85 percent of the group 1 and 79 percent of the group 2 cases. RESULTS: No significant differences were found in the operative mortality (1.6 percent compared with 1.6 percent), incidence of perioperative stroke (4.8 percent compared with 1.6 percent), or rate of major cardiac complications (7.9 percent compared with 7.3 percent) between groups 1 and 2. No significant difference was found in the mean postoperative length of hospital stay between the group 1 and group 2 patients (4.13 +/- 2.58 days compared with 3.68 +/- 1.40 days). However, during the last 2 years of the study, the mean postoperative length of stay among the group 2 patients (3.06 +/- 1.44 days) was significantly shorter than among the group 1 patients (4.15 +/- 1.45 days) (p < .05). CONCLUSIONS: Advanced age does not adversely affect the results of carotid endarterectomy. However, the very elderly may be expected to experience a longer postoperative length of stay because of associated comorbid conditions.

Adult↗
PubMed1997

[Carotid endarterectomy--5-year results in St. Gallen canton hospital].

The 5-year results following carotid endarterectomy at our institution were analysed retrospectively. The aim of this study was to compare our results with those published in the ECST and NASCET studies as a measure of quality control. We studied the outcome of 101 carotid endarterectomies which were performed between 1989 and 1993 in 90 patients. 74 operations were carried out in "symptomatic" and 27 in "asymptomatic" patients. The standard anaesthetic procedure was a cervical plexus block, which was completed in 87% of all operations. The 84 surviving patients on December the 31th 1993 were all followed up with a clinical and directional Doppler examination in our angiologic outpatient clinic during the first half of 1994. The perioperative stroke rate was 1.98% for the whole group and 2.7% for the "symptomatic" group. The cumulative stroke rate for a period of three years (measured by the Kapplan-Meier method) amounted to 3% (1% per year); the cumulative stroke rate for the "symptomatic" group was 4% in a two year period (2% per year). The results and outcome of carotid endarterectomy at our institution are comparable to the ECST and NASCET studies regarding perioperative mortality, perioperative stroke rate and rate of ipsilateral stroke during the first 2 years after operation.

Aged↗
PubMed1997

Early morbidity and patterns of survival after carotid endarterectomy.

OBJECTIVE: Assessment of operative morbidity and survival patterns after carotid endarterectomy. DESIGN: Retrospective clinical study. SETTING: University hospital, Norway. SUBJECTS: One hundred and ninety-four carotid endarterectomies done in 165 patients over a 16 year period. MAIN OUTCOME MEASURES: Long term survival was investigated using the product limit method. Expected survival of a demographically matched population was calculated from death-rate tables. Relative was defined as the ratio of the observed: expected survival. RESULTS: The combined stroke rate and mortality after 30 days was 5.1%. The estimated weight year survival rate of 73% did not differ from the expected. Relative survival seemed unaffected by the age at the time of the operation, hypertension or bilateral disease. Ischaemic heart disease was present in 69 patients (42%). This group had a mortality rate that was 2.4 times that expected during the first five years after operation. CONCLUSIONS: The overall long term survival of patients undergoing carotid endarterectomy seems to be similar to that of the general population. The patients with symptomatic ischaemic heart disease have a significantly lower long term survival than the expected.

Adult↗
PubMed1996

[Indications for endarterectomy in asymptomatic stenoses of the internal or common carotid artery--results of the North American ACAS Study].

OBJECTIVE: To determine the effect of endarterectomy on the primary prevention of ischemic stroke in patients with asymptomatic carotid artery stenosis. METHODS: In a prospective, randomized, multicenter trial 1659 patients with asymptomatic carotid stenosis of 60% or more were studied in two treatment arms (endarterectomy: n = 825; medical therapy: n = 834). Endpoints were: (1) ischemic stroke in the vascular territory of the study artery, (2) any perioperative stroke or any perioperative death. RESULTS: The Kaplan-Meier 5-year-risk estimation showed a relative risk reduction of 53% (confidence interval: 22%-72%) for patients in the surgical arm. The combined perioperative morbidity and mortality rate was 2.3%. CONCLUSION: Endarterectomy of asymptomatic carotid artery stenosis performed with a perioperative complication rate of less than 3% reduces the 5-year risk of ipsilateral stroke.

Adult↗
PubMed1996

AANA journal course: update for nurse anesthetists--carotid endarterectomy: anesthetic implications.

Carotid endarterectomy reduces the risk of stroke or death in patients with high-grade symptomatic carotid artery disease. Regional anesthesia-which uses the awake patient as a monitor for cerebral ischemia-is a viable alternative to general anesthesia for patients undergoing carotid endarterectomy. There are very few complications with the deep and superficial cervical plexus blocks when administered by a careful anesthetist trained to perform this procedure. Patients receiving regional anesthesia also have fewer intraoperative carotid artery shunts and cardiac complications. The preoperative, intraoperative, and postoperative management of the carotid endarterectomy patient receiving either a regional or general anesthetic is reviewed.

Carotid Stenosis↗
PubMed1996

Our experience with carotid endarterectomy without patch and shunt.

The purpose of the present study was to assess the efficacy of endarterectomy without patch and shunt using a homogeneous group of patients. From January 1987 through December 1994, ninety-eight patients (70 males and 28 females) with mean age 67 years and unilateral atherosclerotic carotid stenosis underwent endarterectomy without the use of a shunt, patch, EEG, stump pressure measurements or other methods. The patients were preoperatively classified into three groups according to clinical symptoms. The overall neurologic morbidity consisted of 2 (2%) permanent and 3 (4%) temporary deficits. Based on our results we concluded that endarterectomy without a shunt is a simple, safe method in cases with no hemodynamically concomitant significant lesions. The neurological complications are probably due to embolization rather than temporary ischemia during operation.

Aged↗
PubMed1997

[Does intraoperative transcranial doppler monitoring improve results of carotid endarterectomy?].

UNLABELLED: We evaluated the role of intraoperative transcranial Doppler sonography in improvement of carotid endarterectomy results. We analyzed the outcome of 38 carotid endarterectomies (CEA) performed in 22 female and 16 male patients with symptomatic carotid stenosis, aged between 43 and 78 years (av. 61.8 years). Constant measurements of peak and average velocity (Va) were taken during following stages of CEA:-after anaesthesia--during 120 s crossclamp test, -after shunt insertion (5 patients),-immediately after and 5 min after crossclamp release. RESULTS: We obtained following values of Va in particular stages of CEA:-after anaesthesia 0.54 m/s (0.38-1.08),-during 120 s crossclamp test 0.25 m/s (0.12-0.58),-after shunt insertion 0.47 m/s (0.32-0.78),-immediately after crossclamping 0.72 m/s (0.51-1.40),-5 min. after crossclamp release 0.62 m/s (0.42-1.27). In 2 cases no blood flow velocity increase was found after shunt insertion. The immediate correction of shunt positioning was done. In 2 other patients no hemodynamic effect after CEA was detected (no blood flow velocity increase in MCA and at the same time, no neurological impairments were noticed). After quick investigation inferior carotid artery kinking above the arteriotomy site and its stenosis after suturing were found. Both of these abnormalities were removed and since that moment the blood flow velocity in MCA increased, in comparison with preoperative values. CONCLUSIONS: intraoperative transcranial doppler monitoring 1) allows to identify any kind of blood flow disturbance in MCA during each stage of CEA which appears before neurological impairment, 2) gives the possibility of shunt functioning evaluation, 3) enables to avoid intraoperatively unpredictable situations that may result in imminent cerebral ischemia, 4) 70% decrease of blood flow velocity in MCA is the indication for shunt insertion, 5) proved to be very helpful in (in 10% of our material) improving the results of all carotid endarterectomies.

Adult↗
PubMedDate not supplied

[Rationale for using a patch graft in carotid endarterectomy].

OBJECTIVES: To determine whether carotid patch angioplasty influences early and long-term complications after carotid endarterectomy. MATERIALS AND METHODS: Six prospective, randomized trials (882 procedures) compared effectiveness of patch angioplasty with primary closure after carotid endarterectomy: statistical Odds Ratio analyses was performed. We also thought it appropriate to report our personal experience: a consecutive series of 758 patients (615 males and 143 females) who, from January 1980 to February 1996, underwent 850 procedures of carotid endarterectomy using P.T.F.E. patch, assessing early (at 30 days) results and the long-terms one relative to the period from 1980 to 1990. RESULTS: Odds Ratio analyses performed have documented that patch angioplasty is more effective then primary closure in reducing the risk of ipsilateral stroke and early and long term Neurological Relevant Complication Rate (NRCR). Significant reduction in restenosis > 50%, using the patch, is assessed. Our personal experience have assessed an early N.R.C.R. of 1.05% and a long term NRCR of 3.3% at five years and 13.3% at 16 years. Restenosis greater of 50% was assessed in 10% of patients. Moreover only in 3% of patients was assessed restenosis > 80% or arterial occlusion. CONCLUSIONS: Reduction in risk of perioperative and postoperative ipsilateral stroke and NRCR using patch angioplasty appears clinically and statistically significant. Moreover this method increase the diameter of the carotid artery lumen, seat for potential development of myointimal proliferation or atherosclerosis.

Blood Vessel Prosthesis Implantation↗
PubMedDate not supplied

[Carotid endarterectomy using direct suturing].

The authors report the surgical technique and their experience in direct suture of arterial wall during carotid endarterectomies, comparing their results with reported data from literature. Selective or routinely utilization of direct suture or patch angioplasty are still a matter of discussion and reports from literature are controversial. In the Vascular Surgery Division of Busto Arsizio Hospital from January 1982 to December 1995, 870 carotid endarterectomies have been performed; direct arterial wall suture has been done in the 95.5% of these. The mean follow-up is 72 months, the restenosis rate is 6.6%, but only the 0.7% of the cases required a new surgical intervention with a patch angioplasty. From these data and according to the reports of international literature, we can assume that the use of a patch or direct arterial wall reconstruction, is a factor of less influence on restenosis rate than systemic or local factors (intimal flaps, surgical mistakes). Carotid endarterectomy has to be performed with great accuracy, in order to avoid surgical mismanagements which could negatively influence on early and late results.

Adult↗
PubMed1998

The timing of carotid endarterectomy after acute stroke.

Evidence exists that carotid artery endarterectomy prevents a second stroke in those patients who initially present with a stroke. However, the timing of the operation is controversial. Some authors advise a delay of 6 weeks, and others recommend an early endarterectomy as soon as the patient is clinically stable. The clinical studies addressing this problem are retrospective and nonrandomized, providing no definite answers. But they do provide some guidance. It is probably safe to perform early endarterectomy in clinically stable patients with negative computed tomography (CT) scans. Delay is recommended for more serious neurological events with positive CT scans. Early operation may also be indicated in patients with a significant threatening carotid arterial lesion.

Carotid Stenosis↗
PubMed1998

Patching with carotid endarterectomy: when to do it and what to use.

This is an analysis of published data on the outcomes of carotid endarterectomy patch reconstruction with the commonly used materials--autologous greater saphenous vein, Dacron, and polytetrafluoroethylene. Taken individually, these prospective randomized, prospective nonrandomized, and retrospective studies have mixed findings with respect to both the advantage of patching over primary closure and the superiority, if any, of one patch material. A major problem with these reports is small sample size and the associated low statistical power of tests on outcomes. Comparative outcomes are often marginally statistically significant or not significant at the .05 level. However, when the data from similarly designed studies are pooled, as with a meta-analysis, the sample sizes are large enough to allow definitive statistical evaluation. This analysis indicates that obligatory patching or selectively patching more than 90% of carotid endarterectomies gives clearly superior outcomes (in terms of early postoperative thrombosis, perioperative stroke, and 50% or more residual or restenosis in the first year) when compared with primary closure. There is softer, but clearly important, evidence that carotid endarterectomy patch reconstruction with greater saphenous vein has better perioperative stroke and restenosis outcomes than that obtained with Dacron and polytetrafluoroethylene.

Blood Vessel Prosthesis↗
PubMed1998

Current indications for carotid endarterectomy.

Randomized, prospective trials examining the effectiveness of carotid endarterectomy have given distinct information into the mechanisms and prevention of embolic strokes. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS) have demonstrated the benefits of carotid endarterectomy for patients who meet the precise selection criteria and are treated according to established study protocols. The existing challenge to clinicians lies in the application of trial results to the individual patient.

Carotid Stenosis↗
PubMedDate not supplied

[Carotid endarterectomy: postoperative morbimortality and requirements for intensive care].

OBJECTIVES: To analyze risk factors, morbidity and mortality of carotid endarterectomy, and to determine whether prolonged attention in the postoperative intensive care recovery unit is needed by all patients. PATIENTS AND METHODS: A retrospective study of 102 carotid endarterectomy patients between January 1991 and February 1997. The following data were analyzed: preoperative risk factors, prior neurologic symptoms, time of stay in the recovery unit, postoperative complications requiring intensive treatment and the time of onset of such events, and mortality after 30 days. RESULTS: Some type of postoperative complication developed in 35% of patients in the recovery unit, requiring specialized medical attention; 94.8% occurred within eight hours of admission to the unit and the most common complication was hypertension. After transfer to the ward, 9 more patients (8.8%) suffered severe complications, most commonly coronary ischemia. Mortality was 1.9% and the combined rate of mortality plus severe neurologic event was 2.9%. Preoperative hypertension and the presence of more than three risk factors in the same patient was statistically related to the development of postoperative complications. Presurgical coronary disease was related to postoperative ischemic complications. CONCLUSIONS: Patients undergoing carotid endarterectomy with fewer than four risk factors and no ischemic heart disease or severe hypertension can probably be transferred to the hospital ward eight hours after admission to the recovery unit if no complications have developed, thus reducing hospital costs. We believe that appropriate vigilance of such patients should then be provided on the ward.

Critical Care↗
PubMed1998

Resting ECG changes in long term survivors after carotid endarterectomy.

OBJECTIVE: To evaluate the prevalence of resting ECG findings preoperatively and at the follow-up examination in long term survivors after carotid endarterectomy and to find out possible alteration in ECG pattern between preoperative and follow-up ECG records. SETTING: Tampere University Hospital. PATIENTS: 150 patients intended to control examination. There were 97 men and 53 women with the mean age of 63.7 years. INTERVENTIONS: Carotid endarterectomy. MEASURES: Preoperative and follow-up ECG records were classified according to Minnesota coding system. RESULTS: No reportable ECG items were found in 92.0% of patients preoperatively and in 78.5% at the follow-up examination. In 13.3% of patients ECG pattern was changed during the follow-up. Q-QS-changes were found in 6.7% of patients preoperatively and in 16.1% of patients at the follow-up examination. Atrial fibrillation appeared in 4.7% of patients during the follow-up. One new RBBB was found at the follow-up ECG. CONCLUSIONS: In this selected material resting ECG changes in long term survivors after carotid endarterectomy were relatively few. ECG changes found were mostly suggestive of ischemic heart disease and progression to more frequent ischemic changes during the follow-up was obvious.

Adult↗
PubMed1998

Carotid endarterectomy: changing practice patterns.

BACKGROUND: Cost-effective carotid endarterectomy implies a good outcome; low morbidity, a short hospital stay and selective use of non-invasive preoperative diagnostic tests done alone. METHODS: A solo surgeon's clinical experience with two hundred and eighteen consecutive operations, over seven years, at two Community Hospitals in Northern Virginia. RESULTS: There were three perioperative strokes, of which one resulted in death, for a mortality rate of 0.45%, and a stroke rate of 1.4%. The majority of the operations in the past two years were done on the basis of Duplex ultrasonography and magnetic resonance angiography, but without invasive angiography. General anesthesia, routine use of shunt and use of autogenous vein patch in almost every case was employed. Patients were selectively observed in the Intensive Care Unit postoperatively. Forty eight percent of the series and 75% of the most recent 121 patients operated on in 1995 and 1996 were discharged on the first postoperative day without any need for re-admission to the hospital. CONCLUSIONS: Carotid endarterectomy can be performed with a short hospital stay and an extremely low morbidity and mortality. Carotid endarterectomy is a highly effective surgical procedure both from the medical and economy stand-points.

Aged↗