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PubMed1996

The natural history of the external carotid artery after carotid endarterectomy: implications for management.

PURPOSE: Most surgeons perform some type of endarterectomy of the external carotid artery (ECA) routinely during standard carotid endarterectomy (CEA). This approach has been shown to result in a small percentage of ECA occlusions, the clinical significance of which remains poorly understood. We have modified our approach to the management of the ECA during standard CEA by averting any attempt at external CEA. To evaluate the natural history of the untreated ECA after CEA, we reviewed the preoperative, postoperative, and follow-up duplex scans obtained from 232 CEAs over the past 4 years. METHODS: Preoperative and postoperative carotid artery duplex examinations with specific evaluation of the extent of ECA stenosis were available for review on 114 CEAs performed between January 1991 and July 1994. All CEAs were performed for internal carotid artery stenosis greater than 75% as determined by duplex scanning, which was confirmed by either contrast arteriography or magnetic resonance angiography. RESULTS: Seventy-three (64.0%) procedures were performed for symptomatic lesions, whereas 41 (36.0%) were performed for asymptomatic stenosis. There were no perioperative strokes or transient ischemic attacks in this group, and there was one postoperative death (0.9%). Short- and intermediate-term follow-up demonstrated insignificant changes in ECA diameter after operation, with no cases of ECA occlusion and only five cases progressing to greater than 75% on the 1-year follow up duplex examination. CONCLUSION: We conclude from these data that averting external CEA during standard CEA does not result in significant progression of ECA stenosis or occlusion.

Aged↗
PubMed1996

The changing face of carotid endarterectomy.

PURPOSE: The economic milieu and improvements in care have altered the diagnostic and therapeutic algorithm of the patient with carotid stenosis. This study analyzes the efficacy and safety of these changes. METHODS: The records of patients who underwent 320 consecutive carotid endarterectomies performed by three surgeons at our institution from 1990 to 1994 were reviewed retrospectively. Use of diagnostic angiography, use of carotid duplex ultrasound, length of hospital stay, postanesthesia recovery observation, intensive care unit (ICU) observation, complications, and hospital charges were analyzed. RESULTS: The average length of hospital stay decreased from 6.18 days to 2.00 days (p < or = 0.001). The day of discharge decreased from 3.10 days to 1.24 days after surgery (p < or = 0.01). By 1993, 68% were discharged by the first day after surgery, increasing to 73% by 1994. From 1990 to 1992, average postoperative ICU observation time fluctuated between 18 and 25 hours; this time decreased to 12.2 hours by 1994. In 1993, only 12.5% of patients were admitted to the ICU, down from 94.8% in 1990; by 1994, only 7.3% were admitted to the ICU (p < or = 0.001). Postanesthesia recovery observation time decreased from 3.77 hours to 1.63 hours during this time (p < or = 0.04). With regard to preoperative diagnosis, angiography was performed in 93.1% of patients in 1990; by 1994, only 32.8% underwent this procedure (p < or = 0.0001). Average hospital charges decreased significantly (1990, $14,378; 1994, $10,436) with these modifications in patient care (p < or = 0.001). The complication rate reflected no significant changes over the course of the study. There were six incidences of cerebrovascular accident (6/320, 1.9%), including one death. There were four incidences of transient ischemic attack (4/320, 1.3%), with no significant differences noted from year to year. CONCLUSIONS: This study confirms the changing nature of carotid endarterectomy and documents that these changes have not adversely affected the safety of the operation.

Adult↗
PubMed1997

Impact of a critical pathway on the results of carotid endarterectomy in a tertiary care university hospital: effect of methods on outcome.

PURPOSE: A carotid endarterectomy critical pathway (CP) targeting a 3-day postoperative course was introduced in March 1994. This retrospective analysis assesses its impact on operative results, postoperative length of stay (POD), and cost of hospitalization (COH). METHODS: One hundred eighty-six patients who underwent 201 carotid endarterectomy procedures from Nov. 1992 to Feb. 1994 (Pre-CP; n = 67) and from Apr. 1994 to Jul. 1995 (Post-CP; n = 134) at Johns Hopkins Hospital, a tertiary care referral center, were evaluated. RESULTS: The Pre-CP and Post-CP groups had similar risk factors, postoperative morbidity rates, and mortality rates. Furthermore, they had similar mean POD (Pre-CP, 6.0 +/- 0.5 days; Post-CP, 5.7 +/- 0.6 days; p = 0.79) and COH. However, only 85 of the Post-CP (63%) patients were actually placed on the CP (CP-starters); the mean POD was 3.4 +/- 0.3 days among these CP-starters (p < 0.0001) and 2.8 +/- 0.1 days among the 74 Post-CP patients (55%) that remained on the pathway (CP-finishers; p < 0.0001). The mean COH was reduced from $12,881 (Pre-CP) to $9701 for the CP-starters (p = 0.01) and to $8572 for the CP-finishers (p = 0.0001). However, we found that only 47 of the Pre-CP patients (70%) would have been eligible for the CP, and the mean POD among those cases was 4.2 +/- 0.4 days, which was not different than the mean POD among the CP-starters (p = 0.17). The mean COH of the eligible Pre-CP cases, $9508, was not significantly different from the COH of the CP-starters (p = 0.97). CONCLUSIONS: This subset analysis emphasizes the importance of establishing an accurate "control" group when studying a CP, because using all of the Pre-CP cases as the "control" group in the original analysis, including patients who would not have been candidates for the CP, clearly overstated the beneficial impact of the CP.

Analysis of Variance↗
PubMed1997

Wall thickness after carotid endarterectomy in patients with paired vein and Dacron patch reconstruction.

PURPOSE: This is an analysis of early postcarotid endarterectomy (CEA) wall thickness in patients who have undergone bilateral operations with vein and Dacron patch reconstructions. METHODS: In the past 5 years 23 patients had staged bilateral CEA within 2 months with an autologous greater saphenous vein patch on one side and a knitted Dacron patch on the other. Duplex scans with adequate B-mode resolution to measure common carotid bulb total wall thickness were performed in all 23 patients during the first post-CEA year and in 12 patients in the post-CEA second year. RESULTS: There were no hemodynamically detectable restenoses by Doppler velocity criteria. All peak systolic velocities were < or = 110 cm/sec. In the first post-CEA year the total wall thickness of the 23 vein patch CEA was 1.7 +/- 1.0 mm (mean +/- 1 SD; range, 0.6 to 5.5 mm), and the total wall thickness of the 22 Dacron patch CEA was 1.7 +/- 1.1 mm (range, 0.6 to 6.1 mm, p = 0.93). In the second post-CEA year wall thickness was 2.1 +/- 1.8 mm (range, 0.6 to 5.8 mm) in the vein patch arteries and 2.0 +/- 1.5 mm (range, 0.6 to 5.4 mm, p = 0.91) in the Dacron patch arteries. Although wall thickness of both vein and Dacron patch CEA varied widely between patients, the within-patient absolute difference between the two sides was quite small, 0.1 +/- 0.3 mm in the first year and 0.2 +/- 0.5 mm in the second. With a 5% chance of a type I statistical error (alpha = 0.05) to detect a 0.5 mm difference in wall thickness between Dacron and vein patch CEA, the power of the paired t test is > 0.999, and the probability of a type II error, beta, is < 0.001 (power = 1-beta) in the first year. In the second year beta = 0.34. Wall thickness was bilaterally eccentric in 17 patients. The minimum thickness was in the patch wall, and the maximum was in the opposite endarterectomized wall. It was circumferentially uniform in five patients with < 1 mm wall thickness. The single patient with significant bilaterally concentric wall thickness in the first year was the only one who had a marked increase in wall thickness between the first and second years. Wall thickness > 2 mm was associated with continued smoking (p = 0.03). CONCLUSIONS: Post-CEA wall thickening is highly patient-dependent but is patch material-independent. Knitted Dacron and saphenous vein patch reconstructed carotid arteries develop almost identical wall thickness in a given patient in the first 2 years after endarterectomy. These results support the use of knitted Dacron as an acceptable alternative to greater saphenous for a CEA patch.

Aged↗
PubMed1997

Production of plasminogen activator inhibitor-1 by human saphenous vein endothelial cells seeded onto endarterectomy surfaces in vitro.

PURPOSE: Endothelial cells produce many biologically important factors that may be used as functional markers, including plasminogen activators and their inhibitors (PAI). PAI-1 is a common peptide with a central role in the balance of thrombosis and fibrinolysis in vivo, and its production by vascular endothelial cells has been demonstrated for many in vitro cell lines. METHODS: The basal rate of PAI-1 release from cultured human adult endothelial cells was studied in both a well-plate-seeding model and after seeding onto human endarterectomy specimens. The effect of nonspecific stimulation with thrombin on PAI-1 release was examined in well-plate cultures. PAI-1 was measured by enzyme-linked immunosorbent assay. RESULTS: Cultured human saphenous endothelial cells release PAI-1 constitutively at a steady rate, which can be increased in the short term by the addition of thrombin. CONCLUSION: After seeding onto endarterectomy specimens, seeded endothelial cells release significant amounts of PAI-1, which suggests that they retain functional integrity and may potentially influence thrombosis in vivo after seeding.

Adult↗
PubMed1998

Cerebral microembolism and ischemic changes associated with carotid endarterectomy.

PURPOSE: The purpose of this study is to characterize microembolic signals (MS) that occur during the various phases of carotid endarterectomy (CEA) and to consider their relationship to postoperative changes on magnetic resonance imaging (MRI). METHODS: This was a retrospective study of 76 patients who underwent 78 carotid endarterectomies at a referral center. Perioperative transcranial Doppler monitoring and MRI were performed before and after CEA. The types of MS that occurred during phases of surgery were analyzed and compared with MRI changes. RESULTS: We observed a clinical stroke in one patient (1.3%) and ipsilateral small areas of silent ischemic change on seven postoperative MRI studies (9.0%). In 95% of CEAs, MS were detected. Only those MS observed in the recovery room that occurred at a rate of more than five per 15 minutes were associated with postoperative MRI ischemic changes (p < 0.0001). CONCLUSIONS: Ischemic changes on MRI after CEA are related to postoperative MS.

Brain Ischemia↗
PubMed1998

Comparison of simultaneous electroencephalographic and mental status monitoring during carotid endarterectomy with regional anesthesia.

PURPOSE: This study examines the accuracy of intraoperative electroencephalographic (EEG) monitoring for the detection of cerebral ischemia by comparing EEG with simultaneous mental status evaluation (MSE) during carotid endarterectomy in awake patients. METHODS: Between 1994 and 1997, 208 consecutive carotid endarterectomies were prospectively evaluated for cerebral function during surgery with simultaneous MSE and EEG monitoring. Regional anesthesia (RA), which consisted of superficial cervical block, was chosen preferentially in 75% of the cases, with general anesthesia (GA) reserved for the patients who did not fulfill the criteria for RA. When available, 8-channel EEG monitoring was performed (59% with RA and 55% with GA). RESULTS: The EEG was a reliable predictor in comparison with MSE in most but not all cases of cerebral ischemia. Significant neurologic changes were noted using MSE in 4 of 89 patients (4.5%) that were not detected using EEG (false negative results). Conversely, 6 of 89 cases (6.7%) showed unilateral slowing without associated changes in MSE (false positive results). For the awake patients, 21 of 150 cases (14%) showed MSE changes that required a shunt. By contrast, 9 of 32 GA cases (28%) showed EEG changes that would have led to shunting (P = NS). In the RA group, there were no strokes versus 3 of 58 cases (5.2%) with strokes in the GA group. Two of 150 cases (0.1%) had transient ischemic attacks in the RA group. There was 1 myocardial infarction in the GA group; no deaths occurred in this series. CONCLUSION: EEG monitoring yielded a significant number of false positive (6.7%) and false negative (4.5%) results in the detection of neurologic deficits when compared with MSE in the awake patients. In this series, the preferential use of RA resulted in less shunt use and was possibly associated with a lower stroke rate.

Aged↗
PubMed1999

Is carotid endarterectomy cost-effective in symptomatic patients with moderate (50% to 69%) stenosis?

OBJECTIVE: Recently published data from the North American Carotid Endarterectomy Trial revealed a benefit for carotid endarterectomy (CEA) in symptomatic patients with moderate (50% to 69%) carotid stenosis. This benefit was significant but small (absolute stroke risk reduction at 5 years, 6.5%; 22.2% vs 15.7%), and thus, the authors of this study were tentative in the recommendation of operation for these patients. To better elucidate whether CEA in symptomatic patients with moderate carotid stenosis is a proper allocation of societal resources, we examined the cost-effectiveness of this intervention. METHODS: A decision-analytic Markov process model was constructed to determine the cost-effectiveness of CEA versus medical treatment for a hypothetical cohort of 66-year-old patients with moderate carotid stenosis. This model allowed the comparison of not only the immediate hospitalization but also the lifetime costs and benefits of these two strategies. Our measure of outcome was the cost-effectiveness ratio (CER), defined as the incremental lifetime cost per quality-adjusted life year saved. We assumed an operative stroke and death rate of 6.6% and a declining risk of ipsilateral stroke after the ischemic event with medical treatment (first year, 9.3%; second year, 4%; subsequent years, 3%). The hospitalization cost of CEA ($6,420) and the annual costs of major stroke ($26,880), minor stroke ($798), and aspirin therapy ($63) were estimated from a hospital cost accounting system and the literature. RESULTS: CEA for moderate carotid stenosis increased the survival rate by 0.13 quality-adjusted life years as compared with medical treatment at an additional lifetime cost of $580. Thus, CEA was cost-effective with a CER of $4,462. Society is usually willing to pay for interventions with CERs of less than $60,000 (eg, CERs for coronary artery bypass grafting at $9,100 and for dialysis at $53,000). CEA was not cost-effective if the perioperative risk was greater than 11.3%, if the ipsilateral stroke rate associated with medical treatment at 1 year was reduced to 4.3%, if the age of the patient exceeded 83 years, or if the cost of CEA exceeded $13,200. CONCLUSION: CEA in patients with symptomatic moderate carotid stenosis of 50% to 69% is cost-effective. Perioperative risk of stroke or death, medical and surgical stroke risk, cost of CEA, and age are important determinants of the cost-effectiveness of this intervention.

Aged↗
PubMed1999

A rational algorithm for duplex scan surveillance after carotid endarterectomy.

PURPOSE: This study was undertaken to determine the appropriate timing and frequency of duplex ultrasound scanning after carotid endarterectomy (CEA) for the detection of high-grade stenosis caused by recurrent carotid stenosis or contralateral atherosclerotic disease progression. METHODS: In 221 patients who underwent 242 CEAs, duplex scanning was performed before, during, and after operation (in 3-month to 6-month intervals). High-grade internal carotid artery (ICA) stenosis (peak systolic velocity, >300 cm/s; diastolic velocity, >125 cm/s; ICA/common carotid artery ratio, >4) prompted the recommendation for repair. An average of four postoperative scanning procedures was performed during a mean follow-up period of 27.4 months. RESULTS: Intraoperative duplex scan results prompted the immediate revision of 12 repairs (4.9%), and one perioperative stroke (<1%) occurred. Six CEAs (2.7%) had asymptomatic recurrent stenosis (>50% diameter-reduction [DR]; systolic velocity, >125 cm/s) develop. Only one of six patients had >75% DR stenosis develop and underwent reoperation (<1% yield for CEA surveillance). The yield of surveillance of the unoperated ICA was higher (P =.003), and 12% of unoperated sides had progressive stenosis (n = 21) or occlusion (n = 3) develop, which led to seven CEAs for high-grade stenosis. Disease progression to >75% DR stenosis was five times as frequent (P =.002) in patients with >50% DR stenosis initially. All patients but one who required contralateral endarterectomy for disease progression had >50% ICA stenosis when first seen. During the follow-up period, no disabling strokes ipsilateral to an operated carotid artery occurred, but three strokes occurred in the hemisphere of the contralateral unoperated ICA. CONCLUSION: The yield of duplex scan surveillance after CEA was low. Only 13 patients (5.9%) had severe disease develop to warrant additional intervention. Progression of contralateral disease rather than restenosis was the most common abnormality that was identified. Duplex scanning at 1-year to 2-year intervals after CEA is adequate when a technically precise repair is achieved and minimal contralateral disease (<50% DR) is present. A policy of duplex scan surveillance and reoperation for high-grade stenosis was associated with a 1.6% incidence rate of disabling stroke during the follow-up period.

Adult↗
PubMed1999

Immediate reoperation for perioperative stroke after 2250 carotid endarterectomies: differences between intraoperative and early postoperative stroke.

PURPOSE: After carotid endarterectomy, intraoperative findings and outcome of immediate reoperation of patients who had an intraoperative stroke were compared with those of patients who had an early postoperative stroke. METHODS: We retrospectively analyzed 2250 carotid endarterectomies performed between 1980 and 1997. Intraoperative stroke (group A) was detected after 41 of the 2250 operations (1.8%), whereas early postoperative stroke (group B) developed after 18 of the 2250 operations (0.8%). Patients from both groups were reoperated on within 1 hour after neurological examination. RESULTS: Positive intraoperative findings that could be corrected during immediate reoperation were: (1) thrombotic occlusion of the carotid artery that was operated on caused by technical error, which was found in nine of 41 patients (22%) in group A and in 11 of 18 patients (61%) in group B (P =.009); (2) mural thrombus caused by technical error without occlusion, which was detected in seven of 41 patients (17%) in group A and in two of 18 patients (11%) in group B (P >.05); and (3) technical error without a thrombus, which was found in eight of 41 patients (20%) in group A and in three of 18 patients (17%) in group B (P >.05). A patent carotid artery was found in 17 of 41 patients (42%) in group A and in two of 18 patients (11%) in group B (P =.046). Twenty of the 41 patients (49%) in group A died, and four of 18 patients (22%) in group B died (P > 0.05). Major neurological deficit remained in nine of 41 patients (22%) in group A and four of 18 patients (22%) in group B (P > 0.05). Total recovery occurred in seven of 41 patients (17%) in group A and in eight of 18 patients (45%) in group B (P = 0.058). CONCLUSION: Carotid artery thrombosis during immediate reoperation was more frequent in patients who had an early postoperative stroke than in patients who had an intraoperative stroke. It appears that patients who had an intraoperative stroke have a higher incidence of uncorrectable lesions.

Carotid Stenosis↗
PubMed1999

Intraoperative stenting of the internal carotid artery after unsuccessful eversion endarterectomy.

Stenting of the internal carotid artery (ICA) has been shown to be feasible in atherosclerotic lesions, in restenosis after carotid endarterectomy, and in spontaneous carotid dissections. To correct an intimal flap that detached distal occlusion of the ICA after eversion carotid endarterectomy, as shown with intraoperative completion angiography, we successfully used stenting of the ica with a self-expandable stainless steel stent placed during surgery through the common carotid artery.

Carotid Artery, Internal↗
PubMed1999

Carotid endarterectomy in patients with significant renal dysfunction.

PURPOSE: Recent reports suggest that carotid endarterectomy (CEA) should not be performed in patients with end-stage renal disease (ESRD) because of an unacceptable rate of perioperative stroke and other morbidity. Because these conclusions were based on a small number of patients, we reviewed the perioperative and long-term outcome of patients with ESRD and chronic renal insufficiency (CRI) who underwent CEA at our institution. METHODS: The 1081 patients who had a CEA between 1990 and 1997 were cross-referenced with those patients in whom renal insufficiency had been diagnosed. These charts were reviewed for patient demographics and perioperative and long-term outcome. Patients undergoing CEA during a 1-year period (1993) served as controls. RESULTS: Fifty-one CEAs were performed in 44 patients with CRI (32 in 27 patients) and ESRD (19 in 17 patients). In the CRI+ESRD group, 66.7% were symptomatic, and 70.7% of the control group were symptomatic. Six operations (11.8%) in the CRI+ESRD group were redo endarterectomies. There were no perioperative strokes in the CRI+ESRD group, but one patient died 29 days postoperatively because of a myocardial infarction, for a combined stroke-mortality rate of 2.0%. The control group had a 2.6% combined stroke-mortality rate. Long-term survival analysis revealed a 4-year survival rate of 12% for patients with ESRD and 54% for patients with CRI, compared with 72% for controls (P <.05). CONCLUSION: CEA can be performed safely in patients with ESRD or CRI, with perioperative stroke and death rates equivalent to that of patients without renal dysfunction. However, the benefit of long-term stroke prevention in the asymptomatic patient with ESRD is in question because of the high 4-year mortality rate of this patient population.

Aged↗
PubMed2001

[Clonidine combined with flunitrazepam before carotid endarterectomy decreases cerebrovascular CO2 reactivity].

OBJECTIVE: Assess cerebrovascular CO2 reactivity changes using transcranial Doppler sonography (TCD) after oral premedication associating clonidine (2 micrograms.kg-1) and flunitrazepam (70 micrograms.kg-1) in patients scheduled for carotid stenosis surgery. STUDY DESIGN: Prospective study, not randomized, the patient being his own "control". PATIENTS AND METHODS: Thirteen patients undergoing carotid endarterectomy under cervical plexus block were included. The monitoring included: automated arterial pressure cuff, ECG, radial artery catheter, TCD with probe secured in temporal window. The study of the cerebrovascular CO2 reactivity was performed with TCD recording on the side of operation, on the day before, and on the day of carotid endarterectomy, 90 min after the premedication, immediately before surgery. To change PaCO2, four ventilatory states were successively performed: (1) normoventilation, (2) hyperventilation, (3) hypoventilation, (4) "breath-holding test". At each state, it was noted: HR, MAP, PaCO2, mean blood flow velocity in the middle cerebral artery (Vm-MCA), resistance index of Pourcelot (RI), cerebrovascular reactivity (slope Vm-MCA/PaCO2). The results (+/- SEM) were analyzed by Wilcoxon test or t test. RESULTS: After premedication, cerebrovascular CO2 reactivity decreased (0.043 +/- 0.019 vs 0.034 +/- 0.013; p < 0.05) without modification of RI (0.578 +/- 0.291 vs 0.612 +/- 0.025; NS). No complication during carotid clamping was reported. CONCLUSION: Inclusion of clonidine in premedication before carotid stenosis surgery must be questioned because a decrease of cerebrovascular CO2 reactivity could be deleterious in case of intraoperative stroke.

Adrenergic alpha-Agonists↗
PubMed1988

[Carotid endarterectomy under cervical epidural anesthesia. Analysis of neurologic manifestations].

Carotid endarterectomy can be complicated by neurological events due to different mechanisms. Monitoring cerebral function is difficult under general anaesthesia. By contrast, the monitoring of awareness and neurological deficit is very easy under regional anaesthesia. The aim of this study was to assess the requirement for arterial shunting during endarterectomy performed under cervical epidural anaesthesia, to analyse the neurological events and to compare the value of clinical and electroencephalographic monitoring. Sixty-four patients were included in this study. Cervical epidural anesthesia was performed with 0.375% bupivacaine and 100-150 micrograms fentanyl. In 19 high risk patients, a one-channel electroencephalographic filter processor (Cerebral function monitor, Critikon) was placed over the affected hemisphere. Before surgery, it was estimated, on angiographic and Doppler data, that 18 patients needed an arterial shunt for carotid clamping. An arterial shunt was in fact inserted during surgery in only four patients, because of cerebral ischaemia after carotid clamping. Transient obnubilation was observed during carotid clamping in three other patients; it disappeared on unclamping in two, and on increasing blood pressure in the third. An additional patient suffered from a very short loss of awareness after declamping, due to cerebral embolism. The cerebral function monitor never documented false positive results, but failed to detect one out of every five neurological events. Controlateral carotid occlusion and preoperative stroke were documented to correlate with peroperative neurological events. Cervical epidural anaesthesia, which maintains consciousness during surgery, reduced in high-risk patients the need for arterial shunting as well as that for the analysis of neurological events.

Aged↗
PubMed1989

Intravenous labetalol for the treatment of hypertension after carotid endarterectomy.

Hypertension after carotid endarterectomy has a variable incidence ranging up to 56%. Blood pressure (BP) control is essential due to possible increased risk of morbidity from neurologic deficits or cardiovascular complications. This study evaluated intravenous labetalol for control of hypertension after carotid endarterectomy. Sixty ASA II-IV patients were studied; 20 developed BP high enough for treatment with labetalol. The anesthetic technique was standardized. Labetalol was administered at the conclusion of surgery as a 20-mg bolus over two minutes followed by 40 mg every 10 minutes until the desired BP was achieved (BP less than or equal to 10% above average preoperative BP or less than 150 mmHg, systolic) or 300 mg had been given. The mean total dose of labetalol was 42.0 +/- 33.0 mg (mean +/- SD) and mean time to reach the desired BP was 16.2 +/- 21.4 minutes. Systolic, diastolic, mean arterial pressure and heart rate significantly decreased after labetalol treatment and remained so for the remainder of the 180-minute study period. There was no hypotension, bradycardia, evidence of myocardial ischemia or central nervous system dysfunction present with labetalol treatment. Blood samples were obtained for determination of plasma renin activity, epinephrine, and norepinephrine in 10 patients who developed hypertension and received labetalol, and 10 patients who did not develop hypertension. In the patients developing hypertension, there was a significant elevation in epinephrine just before treatment, that decreased by 30 minutes after treatment. Norepinephrine levels became significantly elevated five minutes after labetalol treatment in the group with hypertension and remained elevated for 120 minutes. Concomitantly, there was a significantly lower plasma renin activity seen in this group.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗
PubMed1988

External carotid endarterectomy in the treatment of symptomatic patients with internal carotid artery occlusion.

In patients with internal carotid artery (ICA) occlusion, the external carotid artery (ECA) can be both a source of collateral flow and a pathway for emboli. We identified 11 patients with ICA occlusion and ipsilateral ECA stenosis who underwent ECA endarterectomy to determine its role in treating extracranial cerebrovascular disease. Follow-up ranged from 1-65 months, with a mean of 27 months. Seven of eight patients with unilateral disease remained symptom free. The eighth patient had recurrent symptoms that were subsequently diagnosed as hemi-Parkinsonism. Two of three patients with bilateral occlusive disease had developed non-hemispheric symptoms at 12 and 24 months, respectively; the third remains asymptomatic after extracranial-intracranial bypass. None of the seven patients who presented with amaurosis fugax had recurrent visual symptoms. ECA endarterectomy is a safe and effective operation in treating symptomatic patients with ICA occlusion, especially those with transient monocular blindness or unilateral occlusive disease. It is less effective in those patients who have diffuse bilateral occlusive disease.

Aged↗
PubMed1986

Rationale for simultaneous carotid endarterectomy and aortocoronary bypass.

Seventy-eight patients were treated for coexistent carotid and coronary stenosis by simultaneous reconstructions. Five patients died (6.4%), one from a stroke contralateral to the carotid reconstruction. Four others suffered a perioperative stroke (total stroke incidence 6.4%). Three myocardial infarctions occurred (3.8%) including one fatal infarct. Analysis of the most recent 36 combined reconstructions indicates that the extramorbidity in this group increased the stroke or death rate for all carotid endarterectomies carried out in the same period by only 1%. Alternatively if these patients had been operated upon by aortocoronary grafting alone the mortality would have increased by 0.1% assuming no neurologic complications. Since these 36 patients had severe carotid stenosis and would have been refused carotid endarterectomy as an isolated procedure the results seem better than would have been achieved by staged operations.

Adult↗
PubMed2004

Can randomized trial outcomes for carotid endarterectomy be achieved in community-wide practice?

The benefit of carotid endarterectomy (CEA) is dependent upon achieving procedural outcomes comparable to those observed in randomized trials. We have extensively examined outcomes of the procedure in the community with a complete medical record (hospital chart) review of over 20,000 Medicare patients undergoing CEA in 10 states. In patients with comparable indications, overall risk of stroke or death of 6.9% in our Medicare studies was comparable to the 6.5% combined event rate in the North American Symptomatic Carotid Endarterectomy Trial. In asymptomatic patients, however, the overall Medicare study result of 3.8% was inferior to the benchmark perioperative combined event rate of 1.5% achieved in the Asymptomatic Carotid Atherosclerosis Study. Our data demonstrated that the randomized trial benchmarks could be achieved or even exceeded at a statewide level. Our studies also documented that evidence-based processes that can reduce perioperative stroke and death (eg, perioperative antiplatelet therapy, patching) are underutilized in the community. Overall process and outcomes assessment show considerable room for improvement. All surgeons performing CEA should use a system-based approach to ensure that all evidence-based processes are employed for patients undergoing CEA and should use indication stratification to document their own outcomes for the procedure.

Aged↗