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PubMedDate not supplied

Combined carotid endarterectomy and myocardial revascularization: personal experience.

A significant percentage of patients undergoing myocardial revascularization suffer from extracranial cerebrovascular disease; recognition of such combined lesions identifies patients at risk for cerebrovascular accidents during the cardiac procedure. Simultaneous or staged coronary artery bypass graft (CABG) and carotid endarterectomy operations have been performed for the last 20 years, however, the clinical indications and the timing of the procedures remain controversial issues. Between November 1988 and January 1994, 1122 patients underwent myocardial revascularization at our Institute and in 35 cases (3.7%) carotid endarterectomy was simultaneously performed; 502 isolated carotid endarterectomies were performed in the same period. Trivascular coronary artery disease was found in 27 cases and low ejection fraction in six. Each patient received an average of 3.7 coronary grafts. Hospital mortality was 5.7% and major neurologic morbidity 2.8%. We believe that a simultaneous approach is recommended in patients with unstable angina and symptomatic carotid artery disease; in patients with a critical but asymptomatic carotid artery stenosis the indication for operation is subject to individual clinical judgment.

Journal Article↗
PubMed2004

Carotid endarterectomy, carotid artery shunting and outcome: an historical perspective.

PURPOSE OF REVIEW: Carotid endarterectomy is now celebrating its 50th anniversary! Yet, despite millions of these operations having been performed, there is little agreement about the best methods of surgical technique, cerebral protection, anesthetic technique and monitoring methods. In this time of evidence-based medicine, carotid endarterectomy fares badly, with only the indications for the surgery having been subjected to the appropriate methodology of clinical trials and biostatistics for proper evaluation. This review is designed to look back over the history of carotid endarterectomy in order to understand the evolution of current practices. RECENT FINDINGS: Within the past 5 years, despite the publication of many papers dealing with issues surrounding carotid shunting, no randomized controlled trials evaluating this aspect of carotid artery surgery have appeared. One must probe further into the past to understand how so much can be written yet so little learned! SUMMARY: Current evidence is not able to support the hypothesis that shunting during carotid artery surgery reduces the risk of perioperative stroke or death or that its use is associated with an increase in perioperative or long-term complications. Routine, selective or no shunting protocols during carotid artery surgery remain a matter of local custom and tradition.

Journal Article↗
PubMed1996

Carotid Endarterectomy and Intraoperative Emboli Detection: Correlation of Clinical, Transcranial Doppler, and Magnetic Resonance Findings.

Carotid endarterectomy (CEA) performed with continuous transcranial Doppler (TCD) monitoring provides a unique opportunity to determine the number of cerebral microemboli and to relate their occurrence to the surgical technique. The purpose of this study was to assess in CEA the impact of cerebral microembolism on clinical outcome and brain morphology. We also evaluated the influence of the audible TCD signal on the surgeon and his/her technique. In a prospective series of 301 endarterectomies, brain function was monitored with electroencephalography and TCD ultrasonography. Preoperative and intraoperative risk factors were entered in a logistic regression analysis program to assess their correlation with cerebral outcome. To evaluate the impact of cerebral microembolism on brain morphology, we compared preoperative and postoperative magnetic resonance (MR) images of the brain in a subgroup of 40 patients. Microemboli (>10) observed during the dissection phase of the operation were related to intraoperative (P < 0.002) and postoperative (P < 0.02) cerebral complications. Microemboli that occurred during shunting were also related to intraoperative complications (P < 0.007). Finally, the phenomenon of >10 microemboli during dissection was significantly (P < 0.005) related to new hyperintensive lesions on the postoperative T(2)-weighted MR images. The presence of microembolism (>10) during the dissection phase of carotid endarterectomy shows a statistically significant relationship with perioperative cerebral complications and with new ischemic lesions on MR images of the brain. Microembolism during shunting is also related to intraoperative complications. Surgeons can be guided by the audio Doppler and emboli signals by changing their technique, which may result in a decline of the intraoperative stroke rate. (ECHOCARDIOGRAPHY, Volume 13, September 1996)

Journal Article↗
PubMed1994

Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial.

BACKGROUND AND PURPOSE: The importance of carotid plaque ulceration as a cause of cerebral ischemic symptoms remains uncertain. Moreover, its prominence in symptomatic patients with severe carotid stenosis is unknown. METHODS: The association between angiographically defined plaque ulceration and risk of subsequent stroke was assessed using Cox proportional hazards regression in 659 patients with severe (70% to 99%) carotid stenosis from the North American Symptomatic Carotid Endarterectomy Trial. RESULTS: Treatment assignment (medical versus surgical) and degree of ipsilateral stenosis were identified as having a significant influence on the results. The risk of ipsilateral stroke at 24 months for medically treated patients with ulcerated plaques increased incrementally from 26.3% to 73.2% as the degree of stenosis increased from 75% to 95%. For patients with no ulcer, the risk of stroke remained constant at 21.3% for all degrees of stenosis. The net result yielded relative risks of stroke (ulcer versus no ulcer) ranging from 1.24 (95% confidence interval, 0.61 to 2.52) to 3.43 (95% confidence interval, 1.49 to 7.88). Conversely, for surgically treated patients with antecedent presence of an ulcerated plaque, the risk of stroke increased slightly at the highest degrees of stenosis. Overall, carotid endarterectomy reduced the risk of ipsilateral stroke at 24 months by at least 50%. Similar results were obtained for risk of major ipsilateral stroke and risk of all strokes and death. CONCLUSIONS: The presence of angiographically defined ulceration for medically treated symptomatic patients is associated with an increased risk of stroke. The risk of stroke more than doubles at higher degrees of stenosis. Carotid endarterectomy is beneficial in substantially reducing the risk of stroke, regardless of plaque ulceration and degree of severe carotid stenosis.

Carotid Artery Diseases↗
PubMed2006

Off-pump coronary endarterectomy in high-risk patients.

The outcome of off-pump endarterectomy in patients with diffuse coronary artery disease and increased risk factors for cardiopulmonary bypass was reviewed. Thirty-eight procedures were carried out in 32 patients (21 men and 11 women) aged 59 to 78 years (mean, 69 years). Mean left ventricular ejection fraction was 38.6% (range, 24% - 55%). The number of grafts per patient was 2.6. The left internal mammary artery was used in 29 patients (91%). Endarterectomy was performed on the right coronary artery and its branches (18), the left anterior descending artery (15), diagonal branch (2), and the circumflex system (3). Overall operative mortality was 3.1%. Perioperative myocardial infarction occurred in 6.2%. Follow-up was complete in 30 patients (94%). The mean follow-up period was 14 +/- 3.3 months. Late survival was 93%. Freedom from cardiac events that required hospital re-admission was 89%. Freedom from angioplasty of the endarterectomized vessel was 96%. These findings indicate that off-pump endarterectomy can be performed with good results in patients with diffuse coronary artery disease.

Aged↗
PubMed1981

Arteriography after carotid endarterectomy.

Of 55 patients undergoing carotid endarterectomy, 16 had abnormal postoperative angiograms by accepted literature criteria. Five of the 16 were symptomatic. The other 11 were neurologically stable or improved from their preoperative condition. None of the 16 patients underwent reoperation. Of those 11 who had abnormal postoperative angiograms but a good clinical result, four had a second postoperative angiogram some months later that demonstrated marked improvement in the appearance of the endarterectomy site. Patients undergoing carotid endarterectomy should not be subjected to routine postoperative angiography without clinical indications nor should they undergo reoperation on the basis of angiographic findings alone without consideration of their clinical status.

Adult↗
PubMed1977

EVERSION ENDARTERECTOMY: A NEW APPLICATION OF AN OLD TECHNIQUE.

Restoration of arterial flow to a severely ischemic extremity remains a major challenge in vascular surgery. The procedure of choice for limb salvage is a bypass utilizing reversed saphenous vein. When the saphenous vein is unsuitable or unavailable, the surgeon must turn to endarterectomy of the femoral and popliteal systems or synthetic, composite, heterologous, autologous, or homologous grafts. To avoid the problems associated with these techniques and to improve the results of limb salvage, we have revived and modified the technique of superficial femoral artery eversion endarterectomy and combined it with other reconstructive techniques in an effort to salvage the severely ischemic lower extremity. Of 38 patients treated for incapacitating claudication or severe limb ischemia during a one-year period, six patients had an unsuitable saphenous vein for the proposed reconstruction. Five of these patients underwent superficial femoral eversion endarterectomy. These six patients have 100% patency at follow-up seven months to one year postoperatively. Our experience with these six patients, including angiographic follow-up, will be presented.

Journal Article↗
PubMed2003

Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis.

BACKGROUND: Endarterectomy reduces risk of stroke in certain patients with recently symptomatic internal carotid stenosis. However, investigators have made different recommendations about the degree of stenosis above which surgery is effective, partly because of differences between trials in the methods of measurement of stenosis. To accurately assess the overall effect of surgery, and to increase power for secondary analyses, we pooled trial data and reassessed carotid angiograms. METHODS: We pooled data from the European Carotid Surgery Trial (ECST), North American Symptomatic Carotid Endarterectomy Trial, and Veterans Affairs trial 309 from the original electronic data files. Outcome events were re-defined, if necessary, to achieve comparability. Pre-randomisation carotid angiograms from ECST were re-measured by the method used in the other two trials. RESULTS: Risks of main outcomes in both treatment groups and effects of surgery did not differ between trials. Data for 6092 patients, with 35000 patient-years of follow-up, were therefore pooled. Surgery increased the 5-year risk of ipsilateral ischaemic stroke in patients with less than 30% stenosis (n=1746, absolute risk reduction -2.2%, p=0.05), had no effect in patients with 30-49% stenosis (1429, 3.2%, p=0.6), was of marginal benefit in those with 50-69% stenosis (1549, 4.6%, p=0.04), and was highly beneficial in those with 70% stenosis or greater without near-occlusion (1095, 16.0%, p<0.001). There was a trend towards benefit from surgery in patients with near-occlusion at 2 years' follow-up (262, 5.6%, p=0.19), but no benefit at 5 years (-1.7%, p=0.9). INTERPRETATION: Re-analysis of the trials with the same measurements and definitions yielded highly consistent results. Surgery is of some benefit for patients with 50-69% symptomatic stenosis, and highly beneficial for those with 70% symptomatic stenosis or greater but without near-occlusion. Benefit in patients with carotid near-occlusion is marginal in the short-term and uncertain in the long-term.

Aged↗
PubMed1995

The risk of stroke in patients with first-ever retinal vs hemispheric transient ischemic attacks and high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial.

BACKGROUND: The prognosis of amaurosis fugax has been considered to be favorable compared with that of hemispheric transient ischemic attacks. However, this has remained uncertain for patients with significant carotid stenosis as the assessment of progression of the disease has been confounded when patients undergo carotid endarterectomy. In the North American Symptomatic Carotid Endarterectomy Trial, patients with high-grade (70% to 99%) carotid stenosis were randomized to receive either medical or surgical treatment, thus making an unconfounded analysis possible. METHOD: We identified 129 medically treated patients with high-grade carotid stenosis who had their first-ever transient ischemic attack as the entry event into the trial. Fifty-nine patients with retinal transient ischemic attacks (RTIAs) were compared with 70 patients with hemispheric transient ischemic attacks (HTIAs). RESULTS: Patients with HTIAs were older, with a higher prevalence of most risk factors for stroke. Average time of delay from the onset of transient ischemic attacks to medical treatment was longer for patients with RTIAs than for patients with HTIAs (48.5 vs 15.2 days). Kaplan-Meier estimates of the risk of ipsilateral stroke at 2 years were 16.6% +/- 5.6% for patients with RTIAs and 43.5% +/- 6.7% for patients with HTIAs (P = .002 for the difference in risk between RTIAs and HTIAs). From corresponding Cox's proportional hazards regression analyses, the risk of ipsilateral stroke ranged from 11.2% to 28.9% for patients with RTIAs and from 37.4% to 96.3% for patients with HTIAs across stenoses, spanning 75% to 95%. Overall, the relative risk of ipsilateral stroke (HTIAs compared with RTIAs) was 3.23 (95% confidence interval, 1.47 to 7.12), regardless of the degree of high-grade stenosis. CONCLUSION: To our knowledge, this study is the first report on the expected outcome for medically treated patients with high-grade (70% to 99%) carotid stenosis in whom the first-ever event was either an RTIA or HTIA. The presence of RTIAs carries a considerable risk of ipsilateral strokes, particularly at higher degrees of stenosis. However, in comparison with HTIAs, patients with RTIAs still have a better prognosis.

Aged↗
PubMed1975

Retinal artery emboli. Indications for angiography and carotid endarterectomy.

Six patients with ocular symptoms were referred by the Eye Service to the Vascular Service because of the presence of cholesterol emboli on fundoscopic examination of the retinal arteries. None of the six patients had classic intermittent retinal or cerebral ischemic attacks. Four-vessel aortic arch arteriogram was suggested and significant ipsilateral carotid disease was found in all patients. Four patients underwent carotid endarterectomy, with removal of ulcerated plaques from the carotid bifurcation. Two patients had total occlusion of the ipsilateral internal carotid artery and therefore were not operative candidates. The presence of retinal cholesterol emboli is an indication for extracranial arteriography. When ipsilateral ulcerative disease is found, carotid endarterectomy is indicated regardless of the symptoms.

Aged↗
PubMed1977

Ipsilateral blindness: a complication of carotid endarterectomy.

We report on three patients in whom ipsilateral blindness developed following carotid endarterectomy. Fundoscopic examination of the retina documented ischemia and the visual field defects were permanent. In one patient, the internal carotid artery was patent and thought to be the conduit for embolization to the eye. Two patients had chronic occlusion of the internal carotid artery, and blindness resulted from atheromatous emboli to the eye through the external carotid artery in one and from postoperative thrombosis of the external cartoid artery in the other. Our experience calls attention to this infrequently reported complication of carotid endarterectomy and emphasizes the importance of the external carotid artery, especially when the internal carotid artery is occluded.

Aged↗
PubMed1978

Results of carotid endarterectomy for vertebrobasilar insufficiency: an evaluation over ten years.

A review was performed of 114 patients with symptoms of vertebrobasilar insufficiency (VBI) alone, or in combination with carotid territory transient ischemic attacks or carotid territory completed stroke (cCS) with follow-up extending to ten years. The most frequent symptoms of VBI were visual changes (50%), dizziness (31%), and syncope (30%). Patients with symptoms of VBI and arteriographic evidence of intracranial disease, regardless of stump pressure, are at high risk for cerebral ischemia during endarterectomy. At late follow-up, ranging from one to ten years, 63% of the patients were alive; 88% were asymptomatic. Causes of death were mainly cardiac (44%) and stroke (36%), but patients with symptoms of VBI and cCS died earlier and from a second cerebrovascular accident. When a correct preoperative diagnosis was established, carotid endarterectomy produced relief of symptoms in 90% of the patients.

Adult↗
PubMed1979

Restenosis or occlusion after carotid endarterectomy: a survey with ocular pneumoplethysmography.

One hundred seventy-three carotid endarterectomies in 141 patients operated on during a 12-year period were surveyed both clinically and by ocular pneumoplethysmography (OPG)-Gee. Seventeen (12%) patients had positive OPG examinations. Three arteries (1.7%) demonstrated symptomatic recurrent stenosis in accord with earlier reports. An additional 8.1% of the operated arteries had asymptomatic recurrent stenosis. A total recurrence rate of 9.8% was found. Because of the considerable silent recurrence rate we have found, we recommend annual screening by OPG. Angiography and repeated endarterectomy are then used when appropriate.

Air↗
PubMed1980

Carotid stenosis plus occlusion: endarterectomy or bypass?

In 15 patients with unilateral internal carotid artery occlusion and contralateral internal carotid artery stenosis of pressure significance (75% cross-sectional area or greater), the ocular pneumoplethysmograph (OPG-Gee) has documented bilateral improvement in the ophthalmic systolic pressure in 12/15 patients who underwent endarterectomy of the stenosed carotid artery as the sole operative procedure. External carotid to internal carotid shunt on the side of the internal carotid occlusion need be entertained only in those patients who remain symptomatic on the side of the internal carotid occlusion after contralateral stenosis endarterectomy.

Arterial Occlusive Diseases↗
PubMed1980

Stump pressure: an unreliable guide for shunting during carotid endarterectomy.

A correlative analysis was made between the neurological status of the awake patient and the internal carotid artery stump pressure in 125 consecutive patients undergoing carotid endarterectomy. There was no mortality in this series. Twenty-four patients lost consciousness immediately after carotid cross-clamping, even though stump pressures were above 50 mm Hg in more than one third of the cases. The majority (80.8%) of the patients tolerated cross-clamping (stump pressures were between 20 and 90 mm Hg). This study demonstrated the variability of cerebral tolerance relative to absolute stump pressure guidelines, such as 25 or 50 mm Hg; reliance on these values to determine the need for intraoperative shunting could lead to stroke at operation. Our experience also showed that assessment of the awake but tranquil patient continues to be the safest and most reliable guide to selective shunting during carotid endarterectomy.

Aged↗
PubMed1981

Morbidity and mortality of carotid endarterectomy: rates of occurrence in asymptomatic and symptomatic patients.

During a six-year period ending December 1979, a retrospective study of 252 carotid endarterectomies in 211 patients was undertaken to review morbidity and mortality, and factors related to them. For purposes of the study, patients were categorized into asymptomatic and symptomatic groups. Indications for operation were internal carotid artery stenosis that occluded 50% or more of the vessel, an ulcerated plaque proved by angiography, or both. There were no postoperative deaths or neurological complications in the asymptomatic group. In the symptomatic group, there was an overall postoperative mortality of 2% and a stroke rate of 2%. All postoperative CNS deaths and strokes occurred in patients in whom there was difficulty in controlling blood pressure postoperatively. We conclude that with regard to carotid endarterectomy for treatment of extracranial occlusive disease (1) there is an acceptable morbidity and mortality in the symptomatic patient, (2) in the asymptomatic patient the procedure is associated with minimal complications, and (3) strict control of blood pressure in the immediate postoperative period is a critical factor in preventing neurological morbidity and mortality.

Carotid Artery Diseases↗
PubMed1981

Noninvasive detection of carotid stenosis following endarterectomy.

Noninvasive diagnostic studies (oculoplethysmography, pulsed Doppler arteriography, and phonoangiography) were used to follow the postoperative courses of 172 patients who had 199 carotid endarterectomies. There were 24 restenotic arteries in 21 patients who underwent 29 operations. Fifteen restenotic lesions in 14 patients were detected solely by noninvasive testing. These patients are being observed closely and remain asymptomatic. One has been operated on for progression of disease. Either transient or permanent neurologic deficits developed in nine as the initial indication of recurrent stenosis or occlusion; three of these subsequently have undergone reoperation. Patients with bilateral disease are at increased risk of restenosis. Routine testing of all patients undergoing carotid endarterectomy is recommended 1, 3, and 12 months postoperatively to detect and observe stenosis on both the side operated on and the contralateral side before clinical symptoms develop.

Aged↗
PubMed1981

Endarterectomy for segmental occlusive disease of the superficial femoral artery.

Endarterectomy for segmental disease is a reliable method for restoring the continuity of the superficial femoral artery (SFA). Operative morbidity was negligible and mortality absent. Long-term patency compares favorably with that of femoropopliteal saphenous vein grafts. The purpose of segmental endarterectomy is to restore arterial continuity, which hopefully will prevent major occlusions of the SFA. To maintain the integrity of the SFA, however, frequent interval examination and repeated arteriography are indicated as segmental disease tends to recur. Relief of intermittent claudication is a major event in the patient's life-style, and this technique of restoring arterial continuity while preserving the greater saphenous vein is a concept worthy of consideration.

Arterial Occlusive Diseases↗