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At least 973 records · Page 54Linked to original sources
PubMed1979

The morbidity of carotid endarterectomy.

The results of 72 carotid endarterectomy operations carried out by three consultant surgeons were analysed. Thirty-eight operations (32.8 per cent) were performed in patients with mild or resolving stroke and 33 operations (45.9 per cent) in patients with transient ischaemic attacks and/or amaurosis fugax. Five patients (7 per cent) died in the early postoperative period, 2 as a result of strokes and the others from cardiac causes. Seventy-six per cent of patients had a satisfactory long term result, remaining free from storke, blindness or recurrent transient ischaemic attacks over the follow-up period of 1--7 years. There were 10 patients (13.8 per cent), including 2 who died, who developed early postoperative neurological deficits; 4 (5.5 per cent) had transient defects and 6 (8.3 per cent) had permanent deficits. Of these patients, 4 had proved occlusions of the reconstructed artery. In 3 patients, cerebral embolization during operation was suspected as the cause. There were, in addition, 2 asymptomatic patients whose reconstruction was shown to be occluded on follow-up postoperative angiography. The continued absence of symptoms, therefore, is no guarantee that the reconstruction is patent and some more objective method of assessment is necessary if the results of carotid endarterectomy are to be critically analysed. The incidence of neurological deficits could, it is believed, be reduced by greater experience with the operation, the routine use of peroperative intra-arterial shunting and peroperative angiography to confirm the patency of the reconstruction.

Adult↗
PubMed1983

Cranial and cervical nerve damage associated with carotid endarterectomy.

Carotid endarterectomy may be complicated by damage to the adjacent cranial and cervical nerves. The true incidence and severity of these complications is rarely reported. In a prospective study of 43 carotid endarterectomies there was a 25 per cent incidence of temporary vocal cord palsy, 5 per cent incidence of hypoglossal nerve damage and anaesthesia of the greater auricular and transverse cervical nerves was found in 60 per cent and 69 per cent of patients respectively 1 week postoperatively. There was some recovery of these nerve injuries over a 6-month period.

Adult↗
PubMed1984

Carotid endarterectomy and the Javid shunt: the early results of 215 consecutive operations for transient ischaemic attacks.

This paper describes a consecutive series of 215 carotid bifurcation endarterectomies performed by one surgeon for transient ischaemic attacks. One patient died from a pulmonary embolism (0.47 per cent). One patient developed a permanent stroke related to the contralateral hemisphere 3 days after operation (0.47 per cent). Five patients developed a weakness of one arm or hand which had clinically recovered 2 months after operation (2.35 per cent); four patients had a transient weakness of one arm or hand which had recovered in less than 24 h of the operation. There were no serious ocular complications. The incidence of serious permanent complications was therefore 0.94 per cent. The Javid shunt could not be used in only 4 of the 193 operations in which its insertion was attempted. It caused arterial damage in only one patient. The results suggest that the routine use of the shunt was of value and that carotid endarterectomy can be a safe, relatively complication-free, procedure.

Blood Vessel Prosthesis↗
PubMed1985

Asymptomatic carotid stenosis: is prophylactic endarterectomy justifiable?

Carotid endarterectomy is well established in the treatment of selected cases of atherosclerosis of the carotid bifurcation; however, its role in the management of asymptomatic stenosis of the internal carotid artery remains controversial. Over a 4 year period 190 patients with 209 asymptomatic stenoses of the internal carotid artery were prospectively studied by means of Doppler ultrasound in combination with real time spectral analysis to determine the natural history of asymptomatic carotid stenosis. We report a cumulative stroke-free survival of 97 per cent at 3 years and we therefore question the merit of prophylactic endarterectomy in the management of asymptomatic carotid disease.

Adult↗
PubMed1987

Transcranial Doppler assessment of cerebral collateral during carotid endarterectomy.

Sixteen patients (mean age 59 +/- 9 years) who were to undergo carotid endarterectomy were examined pre- and peroperatively using pulsed Doppler-shifted ultrasound; blood velocities in the middle cerebral artery were measured before and during common carotid compression in the conscious patient, and before and during measurement of carotid stump pressures at surgery in the anaesthetized patient. Measurements at endarterectomy showed a significant difference in middle cerebral artery blood velocities from patients with stump pressures of greater and less than 50 mmHg (t = 4.0, P less than 0.005). A threshold of 10 cm s-1 distinguished between stump pressures of greater and less than 50 mmHg in 15 of the 16 patients. Pre-operative blood velocity measurements during carotid compression did not correlate with those taken peroperatively at carotid clamping.

Adult↗
PubMed1987

Prospective assessment of carotid endarterectomy by clinical and ultrasonic methods.

Sixty-three carotid endarterectomies in 60 patients were followed by clinical and duplex scanning at 2 weeks postoperatively and at 3-monthly intervals for 3 years (mean 18 months). Four patients died (two of stroke, two of myocardial infarction) and four survivors had recurrent ipsilateral symptoms. Two had an immediate mild hemiparesis which recovered completely within 36 h; in both, the endarterectomized arteries were patent on scanning. The other two experienced amaurosis fugax for 2-3 weeks at 2 and 24 weeks; scanning showed that the sites of both endarterectomies had become occluded. Ultrasound assessment at 2 weeks showed that 43 of 61 (70.5 per cent) endarterectomized arteries were widely patent. There were three occlusions, one stenosis of greater than 75 per cent, three stenoses of greater than 50 per cent and eleven stenoses of less than 50 per cent. At 6 months a total of five vessels were occluded, with greater than 75 per cent stenosis in three and greater than 50 per cent stenosis in eight. At latest follow-up, six of eight arteries with greater than 50 per cent stenosis shown earlier had scans which had reverted to normal. Tacking down of the distal intima was associated with higher incidence of restenosis and occlusion (P less than 0.01). Women were more predisposed to restenosis by neointimal hyperplasia (P less than 0.05). All restenosis occurred within the first 6 months postoperatively (26.2 per cent) and fell to 16.4 per cent at the end of the study.

Arterial Occlusive Diseases↗
PubMed1990

Aortoiliac endarterectomy: an 11-year review.

Fifty-seven patients underwent aortoiliac endarterectomy over an 11-year period, the majority (86 per cent) for disabling claudication. No patient died within 30 days of surgery, but nine patients suffered significant complications. The cumulative survival rate was 98 per cent at 1 year, and was 94 and 78 per cent at 5 and 10 years respectively. Cumulative operated segment patency rates were 92 per cent at 5 years and 68 per cent at 10 years. There was no significant difference in survival rates between patients who smoked after surgery and those who did not, but smokers had significantly worse rates for cumulative patency, limb failure and symptom status than non-smokers. Twenty-seven patients developed worsening symptoms during follow-up and 24 patients required secondary vascular intervention. Fourteen patients subsequently required aortofemoral bypass and the largest single cause of operated segment failure was recurrent disease in the external iliac artery. Our evidence suggests that, while aortoiliac endarterectomy should be considered in young patients with localized disease not involving the external iliac artery, those who do not fit these criteria should be considered for primary aortofemoral bypass. Regardless of the choice of operation, the chance of success is jeopardized if the patient continues to smoke.

Adult↗
PubMed1990

Role of duplex scanning in the selection of patients for carotid endarterectomy.

A retrospective review of 63 patients undergoing duplex scanning and angiography for suspected carotid artery disease was performed to evaluate the need for routine angiography before carotid endarterectomy. A consultant surgeon (M.H.) made a simulated management decision on the basis of a clinical summary and a duplex scan report. Twenty-four patients were selected for surgery without angiography; duplex scanning had a sensitivity of 100 per cent and a specificity of 90 per cent in the detection of internal carotid artery stenosis. In two cases duplex scanning misdiagnosed a total occlusion as a critical stenosis. Eighteen patients failed to meet the criteria for surgery and were referred for angiography. Twenty-one patients were selected for conservative treatment on the basis of the duplex scan report. Combining the surgical and conservative groups (45 patients), duplex scanning had a sensitivity of 96 per cent and specificity of 95 per cent for the detection of stenosis greater than 50 per cent. In the identification of a total occlusion, duplex scanning had a poor sensitivity of 50 per cent. These results suggest that routine angiography before carotid endarterectomy is unnecessary in selected patients but that a suspected occlusion should be confirmed by angiography.

Adult↗
PubMed1992

Monitoring and cerebral protection during carotid endarterectomy.

Two recently published multicentre trials have confirmed the overall benefit of carotid endarterectomy in symptomatic patients with severe carotid artery disease. The key to improving further the long-term advantages of carotid endarterectomy, however, remains the continued reduction of the initial operative risk. While the principal responsibility for this continues to be borne by the surgeon, specifically in reducing technical error, the time is perhaps approaching when he or she might also be able to apply some of the recent advances in cerebrovascular research to reduce operative morbidity still further in the future. This article summarizes the aetiology and pathophysiology of operation-related neurological deficits and reviews current approaches towards intraoperative monitoring, cerebral protection and assessment of quality control.

Brain Ischemia↗
PubMed1992

Role of topical lignocaine during carotid endarterectomy.

Forty carotid endarterectomies were undertaken in 34 patients. Operations were prospectively randomized to periarterial application of either 1 per cent lignocaine (n = 19) or normal saline (n = 21), and detailed measurements taken of intraoperative pulse rate and blood pressure. Patients receiving lignocaine demonstrated a lower pulse rate, and lower systolic and mean blood pressures than those receiving placebo, with significance in relation to clamp application and shunt removal (P < 0.05). It was particularly noticeable that patients receiving lignocaine demonstrated less intraoperative variation in pulse rate and blood pressure. Topical lignocaine stabilizes pulse rate and blood pressure during carotid endarterectomy.

Administration, Topical↗
PubMed1993

Carotid endarterectomy improves haemodynamics on the contralateral side: implications for operating contralateral to an occluded carotid artery.

The importance of the patency of the contralateral carotid artery on the haemodynamic effect of a carotid stenosis was investigated. The breath-holding index was used to estimate cerebral perfusion reserve. The percentage rise in middle cerebral blood flow velocity, measured by transcranial Doppler ultrasonography, occurring during breath-holding was divided by the time of breath-holding. In study 1, ten subjects with no carotid stenosis, 13 with unilateral and eight with bilateral stenosis were studied. For unilateral stenosis the breath-holding index was reduced on the stenosed side compared with normal (0.85 versus 1.34 per cent per s, P < 0.05). For bilateral disease, in the presence of severe stenosis on the side contralateral to that being examined, even a moderate stenosis (30-50 per cent) resulted in a much greater reduction in the breath-holding index. In study 2, the breath-holding index was measured before and after carotid endarterectomy in ten patients. The index increased significantly following operation, not only on the operated side (1.31 versus 0.79 per cent per s, P < 0.01), but also on the contralateral side (1.23 versus 0.87 per cent per s, P < 0.05). In three of four patients with contralateral stenosis > 90 per cent or occlusion, operation improved the breath-holding index markedly (> 90 per cent) on the non-operated side above the stenosis or occlusion. These results demonstrate the importance of patency of the contralateral carotid artery in determining the haemodynamic effect of a carotid stenosis. In addition, operating contralateral to an occlusion may improve haemodynamic status above the occlusion. Implications in selecting patients for carotid endarterectomy are discussed.

Aged↗
PubMed1993

Serial imaging of the carotid bifurcation and cerebrovascular reserve after carotid endarterectomy.

A radioisotopic method of quantifying mean cerebral transit time was used to assess the immediate effects of carotid endarterectomy on cerebrovascular reserve (CVR) in 69 patients. In addition, serial postoperative data were acquired on CVR, clinical status and non-invasive imaging of the internal carotid arteries in 56 patients over a period of 6-48 (median 24) months. Twenty-one patients (30 per cent) had preoperative evidence of impaired CVR in the symptomatic hemisphere. Within 4 days of surgery, however, reserve had returned to normal in 17 of the 21 patients. During follow-up, four of the 56 patients developed recurrent stenosis (> 50 per cent) or occlusion of the artery operated on but only two of these had impairment of CVR and none was symptomatic. Three patients suffered recurrent transient ischaemic attacks (TIAs) but none had recurrent internal carotid artery disease or impaired CVR. One patient suffered a TIA in the territory of the non-operated artery during follow-up in association with disease progression and CVR impairment. However, the TIA preceded recognition of either of these changes. Twelve other patients had (or developed) stenosis (> 50 per cent) in the non-operated artery during follow-up but none was symptomatic or developed impairment of CVR. Although assessment of CVR provided useful information on the frequency of haemodynamic compromise before carotid endarterectomy and on the natural history of disease progression, neither serial assessment of reserve nor non-invasive imaging of the carotid bifurcation influenced clinical practice during follow-up.

Blood Flow Velocity↗
PubMed1993

Factors influencing the hyperaemic response after carotid endarterectomy.

Transcranial Doppler ultrasonography was used to evaluate serially the changes in middle cerebral artery blood flow velocity (MCAV) in 37 consecutive patients during the first 72 h after carotid endarterectomy to identify factors that may predispose towards postoperative hyperaemia. Within 6 h of endarterectomy, median MCAV in the operated hemisphere was 48 per cent (95 per cent confidence interval 37-60 per cent) above that on admission and remained 27 per cent (95 per cent confidence interval 19-37 per cent) higher at 72 h. There was a similar, but less marked, increase in MCAV in the contralateral middle cerebral artery during the same time period. There was no association between the postoperative increase in MCAV and clinical presentation, admission MCAV, the presence or absence of a residual neurological deficit or infarction on computed tomography before operation, carotid clamp time, shunt usage, internal carotid artery stump pressure or MCAV during clamping. The greatest increase in MCAV was observed in patients with internal carotid artery stenosis > or = 50 per cent and, more particularly, in those with preoperative evidence of impaired cerebrovascular reserve. In the latter patients, MCAV was 100 per cent above the admission level within 12 h of operation and was still 50 per cent raised at 72 h.

Blood Flow Velocity↗
PubMed1994

Role of completion angioscopy in detecting technical error after carotid endarterectomy.

Completion fibreoptic angioscopy was performed in 30 consecutive patients after carotid endarterectomy. The aim was to evaluate the potential role of angioscopy as a quality-control technique. Major abnormalities (two initial flaps, two large thrombi) were identified in four patients and minor adherent thrombus was encountered in five. All abnormalities were corrected before restoration of flow. This preliminary experience suggests that completion angioscopy merits further study as a method for the intraoperative detection of potentially harmful lesions after carotid endarterectomy.

Angioscopy↗
PubMed1994

Light-reflective cerebral oximetry and jugular bulb venous oxygen saturation during carotid endarterectomy.

A novel instrument using reflected near-infra-red light spectroscopy to measure cerebral oxygen saturation non-invasively was evaluated during carotid endarterectomy; cerebral perfusion was compared with jugular bulb venous oxygen saturation and transcranial Doppler ultrasonographic measurements. Initially, oximetry sensors with light source-detector separation distances of 10 and 27 mm were positioned over the frontal area, while a cannula positioned in the jugular bulb permitted sampling for jugular bulb venous oxygen saturation. To increase cerebral oxygen saturation sensitivity, modified sensors with light source-detector separation distances of 30 and 40 mm were relocated over the middle cerebral artery territory. The changes in cerebral and jugular bulb venous oxygen saturation, and in peak blood flow velocity before and 30 s after carotid clamping and declamping were recorded. The modified cerebral perfusion system achieved improved correlations between cerebral and jugular bulb venous oxygen saturation changes during carotid clamping and declamping (r = 0.92, P < 0.001). The correlation between change in cerebral oxygen saturation and the percentage change in peak flow velocity on both cross-clamping and declamping was equally strong (r = 0.90, P < 0.001). Near-infra-red cerebral spectroscopy reliably detects changes in cerebral oxygen saturation during carotid endarterectomy and may have wide applications in monitoring brain perfusion during neurosurgery and cardiopulmonary bypass surgery, and in closed head injury.

Blood Flow Velocity↗
PubMed1996

Carotid endarterectomy without angiography.

Between 1 January 1990 and 1 September 1994 a total of 109 carotid endarterectomies were performed without preoperative angiography. Only two cases were considered by the surgeon to have a poor correlation between the duplex examination results and intraoperative findings; the outcome was good in both. The perioperative mortality rate was 1.8 per cent, one patient dying from sudden haematoma causing asphyxia and the other from unrelated causes following a myocardial revascularization procedure. Two non-disabling strokes also occurred. These results suggest that carotid endarterectomy based on carotid duplex scanning alone without preoperative angiography is safe in selected patients.

Aged↗
PubMedDate not supplied

Cranial nerve injuries following carotid endarterectomy: an analysis of 336 procedures.

Cranial nerve injuries may result from carotid endarterectomy. From January 1984 to December 1987, a total of 336 carotid endarterectomies were performed at University Hospitals of Cleveland and Cleveland Veterans Administration Hospital. Forty-five cranial nerve injuries were documented (13.5%). Twenty patients (6%) had documented unilateral vocal cord paralysis, 16 (4.8%) had hypoglossal injuries, 8 (2.4%) had facial nerve paresis, and 1 (0.3%) had an injury to the spinal accessory nerve. Although most injuries were due to either retraction or edema of cranial nerves, long-term follow-up regarding recovery of function is very important. We feel that proper clinical evaluation of these patients should be routinely done preoperatively in order to document possible preexisting cranial nerve deficits. Postoperatively, if symptoms of possible cranial nerve abnormalities occur, these patients should have a thorough head and neck evaluation in order to identify possible lesions and institute further treatment to improve their quality of life.

Accessory Nerve Injuries↗
PubMed1985

Laser endarterectomy.

Laser radiation can be applied directly at a diseased artery to dissect the plaque away from the media and perform an open endarterectomy. The appropriate cleavage plane within the media can be achieved with the laser beam for precise reconstruction of the artery. Laser endarterectomy offers a technique for the study of laser radiation upon arteriosclerosis and may become a new modification of a standard surgical technique.

Animals↗