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PubMed1989

Comparison of regional and general anesthesia for carotid endarterectomy.

Two hundred twenty-one patients undergoing carotid endarterectomy were studied for morbidity and mortality. Thirty-seven had general anesthesia and 138 had regional anesthesia. The two groups were similar in preoperative risk factors and were operated on by a single surgeon and similar operative teams. Patient selection was prospective in the sense that the first 37 procedures were performed with general anesthesia and the next 184, with regional anesthesia. No significant difference in incidences of death, myocardial infarction, stroke, or transient ischemic attack was found. Hospital lengths of stay were similar. The type of anesthetic used for carotid endarterectomy should be the choice of the surgeon and operative team.

Aged↗
PubMed1989

Carotid and aortic arch endarterectomy using hypothermic arrest with coronary bypass.

A 67-year-old man with symptomatic bilateral carotid artery obstructions and a large, friable atheromatous plaque of the transverse aortic arch required coronary artery bypass grafting for severe triple-vessel disease. An endarterectomy of the transverse arch and a left carotid endarterectomy were performed using deep hypothermic circulatory arrest concomitant with quadruple coronary artery bypass grafting. Recovery was uneventful. Hypothermic circulatory arrest provides adequate protection for this combined procedure and may eliminate cerebral embolization.

Aged↗
PubMed1991

Endarterectomy, vein patch, and mammary bypass of the anterior descending artery.

Occasionally the left anterior descending (LAD) coronary artery contains such diffuse calcific atherosclerosis that an area suitable for distal anastomosis with the internal mammary artery (IMA) cannot be found. Additionally, the LAD of some patients contains multiple areas of stenosis, which would prevent free outflow from the IMA graft. In these cases the potentially increased operative risk of LAD endarterectomy is justified to avoid leaving poorly revascularized areas of anteroseptal heart. In an effort to provide the long-term patency benefits of IMA grafting for these patients without the technical difficulty of a lengthy IMA to LAD anastomosis, we have combined saphenous vein patch reconstruction with IMA bypass when LAD endarterectomy is required.

Blood Vessel Prosthesis↗
PubMed1996

Endarterectomy for calcified porcelain aorta associated with aortic valve stenosis.

BACKGROUND: A calcified porcelain aorta may complicate aortic valve insertion and require an alternative, more complex method for valve replacement. The reason for this is that sutures cannot be inserted through the calcific plates in the annulus and ascending aorta. METHODS: In 6 patients with an average age of 73.8 years (range, 65 to 81 years), we performed the simpler procedure of aortic endarterectomy of the calcific plates with the aortic valve replacement. We realized that there may be an increased risk of postoperative complications, particularly stroke. The calcific plates were fractured to allow debridement of the calcium. In addition, an end-arterectomy was performed of the left main coronary ostium in 2 patients, and 5 patients also had coronary artery bypass grafting performed. RESULTS: All 6 patients underwent successful operations without major complications. On follow-up, echocardiography or computed tomographic scans in 3 patients have not shown dilation of the ascending aorta. CONCLUSION: Endarterectomy of the aorta may be an option in the management of patients with calcification of the aorta.

Aged↗
PubMed1984

Carotid endarterectomy in patients with transient cerebral ischaemia.

A randomised controlled trial of endarterectomy in patients with carotid artery disease showed that operation significantly reduced the frequency of transient ischaemic attacks (TIA) in the relevant vascular territory. Because of the high post-operative morbidity in the surgical group, the trial was abandoned before conclusions could be drawn as to the influence of endarterectomy on long-term survival or on the incidence of subsequent strokes.

Aged↗
PubMed1982

Endarterectomy of the vertebral artery from C2 to posterior inferior cerebellar artery intracranially.

A new technical approach to endarterectomy of the vertebral artery at the cranial cervical junction is discussed. A patient had symptoms of vertebrobasilar insufficiency on clinical examination. Angiography demonstrated a stenotic plaque in the vertebral artery at the level of C1, and an additional tandem lesion at the origin of the posterior inferior cerebellar artery. He underwent vertebral endarterectomy and was symptomatically improved postoperatively. The surgical approach used and possible alternatives will be discussed in detail.

Cerebellum↗
PubMed1985

Intracranial hematoma with subsequent brain abscess after carotid endarterectomy.

A 62-year-old man developed an infected left carotid endarterectomy with false aneurysm formation and subsequent bacteremia after staged carotid endarterectomies. He was found to have a right frontal lobe hemorrhage that developed into a staphylococcal brain abscess. We postulate there was bacterial seeding of the hematoma resulting in brain abscess formation.

Brain Abscess↗
PubMed1985

Complications following carotid endarterectomy for all indications: report of 192 operations.

The complications (stroke, myocardial infarction, and death) with 192 endarterectomies performed on 162 patients were evaluated and categorized according to the presenting syndrome: asymptomatic bruit, transient ischemic attack, stroke, stroke in progress, and posterior fossa ischemia. Each group's complication rate was then evaluated over several postoperative periods (0.5 hour to 30 days) and compared with rates in comparable studies. Overall mortality for the entire series was 0.5%. This study points out the need to separate patients having undergone endarterectomy into presenting groups before comparing with other studies having similar postoperative observations.

Carotid Artery Diseases↗
PubMed1989

Stroke, myocardial infarction, and survival during long-term follow-up after carotid endarterectomy.

Epidemiological data on 211 patients undergoing 256 carotid endarterectomies were reviewed, and current data for the 205 perioperative survivors were analyzed by the actuarial method. The median follow-up period was 7.0 years (range: 1 month to 23.2 years). Seven percent of patients were lost to follow-up. Actuarial survival was 77% (5 years) and 49% (10 years), but lower than for the general population. Late stroke occurred in 27 patients (13%) (fatal in 9), being ipsilateral to an endarterectomy in only 10 (4.9%). The annual ipsilateral stroke rate (0.41%), comparable to that of the general population, suggests protection from subsequent stroke. Myocardial infarction occurred in 69 patients (34%), and accounted for 49% of late deaths.

Actuarial Analysis↗
PubMed1994

Outcome after carotid endarterectomy for asymptomatic carotid stenosis.

OBJECTIVE: To compare the long-term outcome in patients with asymptomatic carotid stenosis (ACS) among those treated with carotid endarterectomy (CE) or medical therapy. BACKGROUND: Until randomized trials are completed, treatment of ACS will depend on identification of subgroups likely to benefit from CE. METHODS: A retrospective cohort study was done on 215 patients with ACS: 107 underwent CE, and 108 were treated medically (MED). A neurologist reviewed medical records and performed a telephone interview to detect outcome (stroke and death). Mean follow-up was 3.8 years; only 4% were lost to follow-up. RESULTS: Among CE patients, there was a 4.7% risk of postoperative ipsilateral stroke within 30 days. Four of five postoperative strokes occurred among patients with prior contralateral symptoms. There was no significant difference between CE and MED in the cumulative life-table 5-year risk of ipsilateral stroke, any stroke, or survival free of any stroke. Among diabetics, however, there were no ipsilateral strokes at 5 years after CE compared to 20% in MED (p = 0.03). Excluding postoperative complications, the 5-year risk of ipsilateral stroke was reduced among CE patients who "ever smoked" (CE 1%, MED 8%, p = 0.03) and the 5-year risk of any stroke was reduced among CE patients who had no prior myocardial infarction (CE 6%, MED 16%, p = 0.02). Among those with prior contralateral carotid territory symptoms, the 5-year risk of any stroke was worse in the MED patients (CE 5% MED 32%, p = 0.004). Among CE patients, a Cox proportional hazards model determined that the independent predictors of worse long-term outcome were: a history of myocardial infarction; admission systolic blood pressure greater than 160 mm Hg; and age greater than 65. CONCLUSION: The approach to patients with ACS will await completion of large, randomized clinical trials, now in progress. Even if these studies are negative, there may remain specific subgroups of patients who show clear benefit from carotid endarterectomy.

Adult↗
PubMed1979

Endarterectomy and patchgraft angioplasty in treatment of atherosclerotic renovascular hypertension.

From 1962 to 1978, 56 patients underwent transrenal endarterectomy as surgical treatment for renovascular hypertension. Over-all results were 39 per cent cured, 36 per cent improved, and 25 per cent failed. Criteria for selecting patients with atherosclerotic renal artery disease for surgical treatment are reviewed. Transrenal endarterectomy is a simple operation and should continue to be applied in the management of properly selected patients.

Adult↗
PubMed1994

Intraoperative recording of parietal SEP can miss hemodynamic infarction during carotid endarterectomy: a case study.

Serial recording of median nerve somatosensory evoked potentials (SEPs) provides reliable intraoperative information on critical lowering of brain perfusion which compares favorably with other monitoring methods. However, single-channel parietal SEP recording may not detect hemodynamic cerebral infarctions affecting the pre-rolandic area. Following left carotid endarterectomy for high-grade symptomatic stenosis in a 66-year-old male, predominantly motor hemiparesis and aphasia were detected which were largely reversible. Pre- and intraoperative SEPs were normal. Postoperative SEPs showed significant interhemispheric amplitude differences. Postoperative CT examinations demonstrated hemodynamic watershed-type infarctions. This rare complication of carotid endarterectomy was not detected by intraoperative single-channel parietal SEP monitoring.

Aged↗
PubMedDate not supplied

Post-endarterectomy carotid ultrasonic duplex scanning concordance with contrast angiography.

The results of ultrasonic duplex scanning combined with spectral analysis are compared with the results of contrast angiography in patients after endarterectomy in which recurrence of carotid arterial disease was suspected. Thirty-six patients underwent a duplex scan study within 3 months of their post-operative angiogram, performed at their physician's discretion (44 studies). The overall accuracy of the method was 80%. Our ability to predict a greater than 50% diameter reduction along with total occlusion was 94%. The measure of agreement corrected for chance between arteriography and duplex scanning as expressed by the Kappa statistic was 0.675 +/- SE (K) 0.096. This level of agreement compared favorably to that of inter- and intra-observer variability in reading cerebral angiograms. The accuracy reported justifies the clinical use of ultrasonic duplex scanning in the detection of recurrent stenosis after carotid endarterectomy.

Blood Flow Velocity↗
PubMed1988

Triple vessel coronary artery endarterectomy and reconstruction: results in 144 patients.

Coronary artery endarterectomy and reconstruction are valuable adjuncts to conventional bypass surgery when attempting to revascularize "diffusely" diseased coronary arteries. One hundred forty-four consecutive patients were operated on through February 1986, all of whom required endarterectomy and reconstruction of the left anterior descending, left circumflex and right coronary arteries. There were 130 men (90%), ranging in age from 29 to 83 years (average 55.8), whose left ventricular ejection fraction ranged from 0.20 to 0.75 (average 0.54). One hundred thirty-one patients (91%) had angina preoperatively, which was Canadian Cardiovascular Society class III or IV in 85 (59%). Fifteen operations (10%) were repeat procedures. All operations were performed using intermittent ischemic arrest. There was an average of 5.0 grafts per patient (range 3 to 8), with an average of 3.8 endarterectomized vessels per patient (range 3 to 7). There were 14 surgical deaths (10%), all cardiac in origin. Statistically significant (p less than 0.01) risk factors for increased operative mortality included repeat surgery, ejection fraction less than or equal to 0.30 and age greater than or equal to 70 years. The operative mortality rate in 106 low risk patients (male gender, age less than 70 years, ejection fraction greater than 0.30, first operation) was 3.8% (4 patients). Nonfatal complications included 13 perioperative myocardial infarctions (10%). Long-term follow-up data are available for all 102 surviving patients for an average of 30 months (range 7 to 92). There were 12 late deaths 1 to 52 months postoperatively. The 5 year actuarial survival rate is 71% for the entire group and 87% for the 106 low risk patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Carotid endarterectomy: a safe cost-efficient approach.

The diagnosis-related groups have encouraged physicians to become more efficient in the care of their patients; often, however, raising the question of safety. For 3 years all patients undergoing carotid endarterectomy at our institution were monitored in the intensive care unit for 24 hours and the majority were discharged on the second postoperative day. After review of these patient's hospital records and direct patient interviews, it was clear that many patients did not require a stay in the intensive care unit and could be discharged on the first postoperative day. In January 1991 a prospective policy was established to evaluate the safety and efficacy of outpatient arteriography, same-day admission, selective use of the intensive care unit, and early discharge on the first postoperative day when feasible. During a 10-month period all patients undergoing carotid endarterectomy at our institution were evaluated (n = 52). Eleven patients had had a prior stroke (21%), 31 had either amaurosis fugax or transient ischemic attacks (60%), and 10 had no symptoms (19%). The arteriogram for 49 of the patients was obtained on an outpatient basis or during a prior admission, and these patients were admitted to the hospital on the day of operation. Nine patients were placed under general anesthesia and had shunting procedures, and 43 patients had cervical block anesthesia, eight of whom had shunting (19%). Only five patients required an intensive care unit stay for either hypertension, hypotension, or neurologic complication (one transient ischemic attack and one minor stroke). Forty-six patients (88%) were discharged on the first postoperative day; average length of stay was 1.29 days/patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Concomitant renal endarterectomy and aortic reconstruction.

PURPOSE: This retrospective study is to determine the efficacy and durability of renal endarterectomy in patients undergoing simultaneous aortic reconstruction. In addition, the operative risk to patients with symptomatic and asymptomatic renal artery stenosis is evaluated. METHODS: The results of a retrospective study of 101 patients who underwent combined procedures are presented. All patients demonstrated at least a 75% stenosis of the renal artery ostium by arteriography and underwent surgical repair of aneurysmal (n = 33) or aortic occlusive (n = 68) disease. The indications for renal revascularization were hypertension necessitating multiple medications (47%), hypertension combined with renal insufficiency (18%), renal insufficiency alone (5%), and asymptomatic stenosis (30%). Blood pressure and antihypertension medications were monitored during the follow-up period (mean 3.3 years). RESULTS: The perioperative mortality rate was 1%, with a postoperative morbidity rate of 15%. The conditions of 74% of patients with hypertension were improved or cured, 23% were unchanged, and 3% were worse after surgery. Systolic and diastolic blood pressure in all patients remained significantly diminished during follow-up visits at 3 months, 6 months, 1 year, 3 years, and 6 years (p < 0.01). There was no significant improvement in serum creatinine levels in patients with preexisting renal insufficiency. A small but statistically significant decrease in systolic blood pressure and serum creatinine level was noted after operative intervention in the symptom-free patients (p < 0.005). There were no deaths in the asymptomatic subgroup, and significant azotemia did not develop in any of these patients after operation. CONCLUSIONS: Renal endarterectomy is an effective and durable method of renal revascularization. Furthermore, it is a technique that can be safely combined with aortic surgery and can be considered in the treatment of high-grade, asymptomatic lesions in patients undergoing aortic reconstruction.

Adult↗
PubMed1994

On-table diagnosis of incipient carotid artery thrombosis during carotid endarterectomy by transcranial Doppler scanning.

We present a case where transcranial Doppler ultrasound monitoring of a carotid endarterectomy enabled us to detect the incipient thrombosis of the operated artery before reversal of anesthesia. The use of transcranial Doppler ultrasound monitoring in carotid endarterectomy has the potential to detect this complication before serious neurologic damage has occurred and therefore reduce the morbidity and mortality rates associated with the operation.

Aged↗
PubMed1996

Processed bovine pericardium as patch angioplasty for carotid endarterectomy: a preliminary report.

Although the routine use of a patch for closure of the arteriotomy after carotid endarterectomy is still debated, patch angioplasty is frequently used to avoid residual stenosis and to lower the incidence of later restenosis. Several materials are widely used for carotid patching, notably, autologous vein, Dacron and polytetrafluorethylene (PTFE). During recent years a heterologous stabilized graft made from bovine pericardium has been introduced. This paper reports the authors' experience of 52 carotid endarterectomies in which a patch of bovine pericardium was used to close the arteriotomy. The patients were followed with colour-duplex scanning over 12-30 months. This biograft did not require preclotting and proved to be easy to suture. Follow-up did not uncover any complications related to graft use. Although this is a preliminary report, it is concluded that bovine pericardium is a promising material for carotid patch angioplasty.

Animals↗