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PubMed2004

Carotid endarterectomy with routine electroencephalography and selective shunting.

Carotid endarterectomy requires some sort of cerebral protection in some patients. Available strategies include routine shunting, pharmacologic cerebral protection, or selective shunting. Selective shunting may be based on preoperative criteria or, more commonly, some intraoperative determinant of adequacy of cerebral perfusion. There are several commonly used methods, but electroencephalography is a sensitive marker for adequacy of cerebral perfusion and we have found it an excellent tool in our strategy of selective shunting. This article reviews the various approaches to cerebral protection during carotid endarterectomy with emphasis on our experience with electroencephalography.

Aged↗
PubMed1993

Post-carotid endarterectomy hyperperfusion syndrome: preliminary observations for identifying at risk patients by transcranial Doppler sonography and the acetazolamide test.

Patients at risk of hyperperfusion syndrome after carotid endarterectomy are often severely hypertensive and have a high grade internal carotid artery stenosis with disordered autoregulation due to a loss of reserve capacity (RC). Cerebral RC can be studied by sophisticated and expensive technical devices (SPECT, PET). Recently it has been demonstrated that the transcranial Doppler (TCD) and acetazolamide provocation test can be used to assess RC. From September 1991 to January 1992, 36 patients were studied by the TCD and acetazolamide test prior to carotid endarterectomy to identify patients at high risk of the hyperperfusion syndrome. Preoperatively, the patients were studied by TCD at rest and after vasolidation with acetazolamide 1 g intravenously (i.v.). Mean blood flow velocity on the middle cerebral artery (MCAv) was recorded for the following 20 min at 5 min intervals. MCAv at rest was 49 +/- 17 cm/s. After acetzaolamide infusion in 33 patients (92%), the mean MCAv was 62 +/- 19 cm/s with an increase of 19 +/- 13 cm/s (normal RC). In three patients (8%), the mean MCAv was 43 +/- 22 cm/s with a decrease of -6 +/- 3 cm/s with respect to base values (reduction of RC). (t = 3.30; p = 0.0022). All these patients were hypertensive (BP > 180/100 mmHg) and had a carotid artery stenosis > 90%. Postoperatively, the three patients with reduction of RC complained of homolateral headache. TCD showed a mean MCAv of 67 +/- 17 cm/s, an increase compared to the preoperative rest values of 17 +/- 8 cm/s, the 33 patients with normal RC showed a mean change in MCAv -2 +/- 12 cm/s.(ABSTRACT TRUNCATED AT 250 WORDS)

Acetazolamide↗
PubMed1990

Eight to ten years follow-up after carotid endarterectomy: clinical evaluation and Doppler examination of patients operated on between 1978-1980.

Follow-up information was obtained on 185 patients who consecutively underwent carotid endarterectomy eight to ten years previously. Doppler ultrasound examination was performed in 59 patients who were still alive and living within 100 miles of the hospital. Using lifetable analysis, the annual rate of focal strokes was estimated to be 2% and 1.5% on the operated and the contralateral, non-operated carotid artery, respectively. Doppler examination revealed 48% re-stenoses, including 14% occlusion and 15% greater than 50% stenosis. However, there was no association between the occurrence of restenosis and the development of symptoms, perhaps with the exception of internal carotid artery occlusion, which is not an accepted indication for carotid endarterectomy. Together with recent data from the literature, these observations challenge the indication for reoperative carotid surgery.

Carotid Arteries↗
PubMed1990

Antiplatelet therapy following carotid bifurcation endarterectomy. Evaluation of a controlled clinical trial. Prognostic significance of histologic plaque examination on behalf of survival.

To determine whether antiplatelet therapy following carotid bifurcation endarterectomy influences postoperative survival and whether signs of progression in the plaques harvested at the time of surgery might be a prognostic indicator, a controlled clinical trial was undertaken. During 1982 to 1985, 66 patients were recruited, operated on (carotid endarterectomy) and assigned, using the method of adaptive randomisation to the therapy group (n = 32) receiving 1.0 g acetylsalicylic acid (ASA) per day, starting day two prior to surgery, or to the control group (n = 34), which remained without antiplatelet medication. The plaques harvested at the time of surgery were processed using standard histopathological methods and examined "blindly" by light microscopy for signs of arterio-sclerotic progression. The final endpoint was patient survival. The last assessment of the participants survival status was done by June 1989. During follow-up, 20 patients died, six in the treatment group and 14 in the untreated group, the difference being statistically significant (P less than 0.013 Breslow, P less than 0.029 Mantel). In 27 instances the histo-pathological examination showed signs of progression. In this subgroup ASA yielded a significant prolongation of patient survival (P less than 0.017 Breslow, P less than 0.048 Mantel). In the remaining patients no signs of cellular infiltration were evident and no influence of ASA on patient survival was demonstrable (P less than 0.503 Breslow, P less than 0.390 Mantel).

Aged↗
PubMed1992

Transcranial Doppler for detection of cerebral ischaemia during carotid endarterectomy.

We evaluated transcranial Doppler sonography (TCD) for the detection of cerebral ischaemia during carotid endarterectomy in 30 male and 14 female patients with ipsilateral focal cerebro-vascular symptoms. Surgery was performed during halothane-nitrous oxide anaesthesia with moderate hypocapnia. Eight patients had a temporary shunt owing to contralateral occlusion or a stump pressure below 40 mmHg, and/or EEG flattening. Transcranial Doppler sonography was followed intra-operatively together with electro-encephalography (EEG), internal carotid artery (ICA) pressures and cerebral blood flow (CBF). Middle cerebral artery mean flow velocity (Vmean) was 38 (22-96) cm s-1 (median and range) and decreased during cross-clamping to 28 (10-60) cm s-1 (p less than 0.0001). After removal of the clamp it increased to 42 (20-102) cm s-1 (p less than 0.0001). AVmean clamp of less than 30 cm s-1 together with a Vmean clamp: Vmean pre-clamp ratio of less than 0.6 showed an accuracy with respect to CBF below 20 ml 100 g-1 min-1 of 89%. AVmeanclamp:Vmean pre-clamp ratio below 0.4 detected all all patients with EEG flattening (n = 3) (accuracy 97%). The corresponding level of accuracy obtained with stump pressure was 80%. The results indicate that middle cerebral flow velocity enables an increase in the accuracy of detecting cerebral ischaemia during carotid endarterectomy.

Aged↗
PubMed1993

Can recurrent stenosis after carotid endarterectomy be prevented by low-dose acetylsalicylic acid? A double-blind, randomised and placebo-controlled study.

Recurrent stenosis (> 50%) after carotid endarterectomy is reported with a frequency ranging from 7-20%. 232 patients undergoing carotid endarterectomy were randomised to low-dose acetylsalicylic acid (ASA, 75 mg daily) or placebo (identical tablets). The treatment was started the day before surgery and continued for 6 months. All patients were followed clinically for 1 year. Doppler examination was performed preoperatively (n = 230) and postoperatively (n = 228) and at follow-up at 2 (n = 220) and at 6 months (n = 174) after surgery. The degree of stenosis was estimated from the maximum Doppler frequency shift in the internal carotid artery. Recurrent stenosis of 30% or more was detected in 85 of the 220 patients (38.6%) at 2 months, and at 6 months in 73 of the 174 examined patients (42.0%). Stenosis > 50% was seen in 16 patients (9.2%) and occlusion was found in four patients (1.8%) at 6 months. No difference between the low-dose ASA-treated group (n = 112) compared to the placebo group (n = 108) was seen regarding recurrent stenosis. Women had an increased risk of recurrent stenosis (p < 0.001), whereas other factors such as age, hyperlipidaemia, diabetes and smoking were not associated with increased risk. Importantly, the number of neurological events did not differ between those with or without restenosis. Therefore, the indications for surgery of asymptomatic recurrent stenosis are questionable. The progress of arteriosclerosis in the contralateral carotid artery did not differ between the treatment groups.

Adult↗
PubMed1994

Prediction of intracerebral haemorrhage after carotid endarterectomy by clinical criteria and intraoperative transcranial Doppler monitoring: results of 233 operations.

OBJECTIVE: Identification of predictors of intracerebral haemorrhage after carotid endarterectomy. DESIGN: Retrospective comparison of patients who developed intracerebral haemorrhage and patients who did not, with special attention to intraoperative transcranial Doppler monitoring of the ipsilateral middle cerebral artery and postoperative signs and symptoms of hypoperfusion. SUBJECTS AND MATERIALS: Two-hundred and thirty-three patients were studied with regard to the increase of peak blood flow velocities and pulsatility indices after endarterectomy and to the occurrence of unilateral throbbing headache or hypertension. RESULTS: Intracerebral haemorrhage occurred in five cases. Seventeen patients complained of headache or showed hypertension, four of whom developed an intracerebral haemorrhage (p < 0.001; Fisher's exact test). The positive predictive value of headache, hypertension, or both, was 24% (diagnostic gain 22%). The negative predictive value, sensitivity and specificity were 99, 80 and 94%, respectively. The increase of peak blood flow velocities and pulsatility indices in patients who developed intracerebral haemorrhage was significantly higher than in patients who did not (p < 10(-5); one-way ANOVA). When cut-off levels for the increase of peak blood flow velocities and pulsatility indices were set to 175 and 100%, respectively, the positive predictive value of intraoperative transcranial Doppler was 100% (diagnostic gain 98%). The negative predictive value, the sensitivity and specificity were 99, 80 and 100%, respectively. CONCLUSION: An increase of peak blood flow velocity > or = 100% or pulsatility index > or = 100% after declamping predicts intracerebral haemorrhage more accurately than the occurrence of headache or hypertension. Transcranial Doppler monitoring can be used to identify patients at risk for intracerebral haemorrhage, in whom control of blood pressure and modest degrees of anticoagulation may be appropriate.

Cerebral Hemorrhage↗
PubMed1993

Cerebral blood flow during carotid endarterectomy determined by three dimensional SPECT measurement; relation to preoperative risk assessment.

Cross-clamping of the carotid artery during carotid endarterectomy implies a risk of developing an ischaemic insult. To evaluate the effects of carotid artery occlusion on cerebral blood flow (CBF), both hemispheric and regional CBF (rCBF) were investigated using intravenously (i.v.) administered 133Xenon with 3 min clearance recording time for two-dimensionally (hemispheric CBF) and 99m-technetium-hexamethylpropylene amine oxime (99mTC-HMPAO) for three-dimensionally single photon emission computed tomography (SPECT) measurements (rCBF). Thirteen patients scheduled to undergo carotid endarterectomy anaesthetised with fentanyl/isoflurane participated in the study. Preoperative evaluation included investigation of rCBF with SPECT in all participants. Two intraoperative 133Xe CBF measurements were performed in each patient, before and after occlusion of the carotid artery. The preoperative rCBF measurement constituted the reference, for technical reasons, for the intraoperative investigations of rCBF during cross-clamping, which was completed immediately after the hemispheric measurements. The increase in preoperative risk evaluation as described by Sundt et al. and modified by Cho et al. corresponded excellently to a decrease in hemispheric CBF due to cross-clamping. A significant decrease in rCBF (p < 0.005) was present between patients with high and low preoperative risk score for the region of the middle cerebral artery. In this region, a correlation between decrease in rCBF and corresponding decrease in hemispheric CBF was also present. The present study demonstrates that the vascular regions of the ipsilateral middle cerebral artery are the most vulnerable vascular area during cross-clamping in individuals with high preoperative risk score.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

The assessment of cerebral oxygenation during carotid endarterectomy utilising near infrared spectroscopy.

Near infrared spectroscopy is a non-invasive method for continuous monitoring of tissue oxygenation. In 11 patients undergoing unilateral carotid endarterectomy, changes in cerebral oxygenation following carotid cross-clamping and declamping detected by a near infrared spectrometer were compared with corresponding changes in ipsilateral middle cerebral artery flow velocity measured by transcranial Doppler ultrasonography. Spectroscopic traces were obtained in all patients but adequate Doppler signals in only eight. Changes in cerebral haemoglobin oxygenation correlated closely (r = 0.908, p < 0.001) with changes in middle cerebral artery velocity. The near infrared spectrometer was also sensitive to the changes in cerebral haemodynamics due to intraoperative hypo- and hypertensive episodes. No evidence of cerebral intracellular hypoxia was seen and all patients made an uneventful recovery. Near infrared spectroscopy compares well with transcranial Doppler ultrasound as a monitor of cerebral function during carotid endarterectomy and may have a future role in the elucidation of cerebral perfusion and oxygenation changes following surgery.

Aged↗
PubMed1991

Risk factors for intra-operative neurological deficit during carotid endarterectomy.

Although embolism is considered to be the major cause of intra-operative neurological deficit (IOND) during carotid endarterectomy, the possibility that patients may vary in susceptibility to ischaemic damage following minor embolisation or falls in cerebral perfusion pressure is rarely considered. A prospective study was undertaken in 60 consecutive patients undergoing carotid endarterectomy to identify risk factors for IOND. The hypothesis was that patients with impaired cerebral vascular reserve (CVR) may be more vulnerable to intra-operative emboli or falls in cerebral perfusion pressure than normal subjects. Recent work using Positron Emission Tomography has indicated that the best index of CVR is the ratio of cerebral blood flow to cerebral blood volume, which is another expression for the reciprocal of mean cerebral transit time (MCTT). In this study, a new isotopic method of quantifying MCTT was used to identify patients with impaired CVR. Six patients (10%) recovered from anaesthesia with an IOND, only one of which was disabling. Significant risk factors for IOND were: (i) age over 65 years (Odds Ratio 13.0 (95%CI 1.4-121), p = 0.013); (ii) a residual neurological deficit prior to operation (Odds Ratio 7.0 (95%CE 1.1-43), p = 0.038); (iii) complex plaque morphology (Odds Ratio 6.4 (95%CI 1.06-34), p = 0.046); and (iv) the combination of impaired CVR and a CT scan infarct in the symptomatic hemisphere (Odds Ratio 9.8 (95%CI 1.5-62), p = 0.026). These observations suggest that certain risk factors for IOND can be identified preoperatively and this may enable a more discriminating approach to patient selection for operation and a more critical evaluation of operative technique and methods for intra-operative protection and monitoring in the future.

Age Factors↗
PubMed1987

Intracerebral haemorrhage after carotid endarterectomy.

Among 662 consecutive carotid endarterectomies eight cases of postoperative ipsilateral intracerebral haemorrhage were identified, occurring into brain areas which, preoperatively were without infarction. As blood pressures across the stenosis were routinely measured during surgery, the internal carotid artery (ICA) perfusion pressure could be related to the occurrence of haemorrhage. In addition, cerebral blood flow (CBF) was studied with the intravenous xenon-133 technique in four patients and histopathologic examination of the brain was available in four patients who died subsequent to their haemorrhage. All eight patients had a high grade of ICA stenosis and a marked reduction of ICA perfusion pressure (average of 40%) which was significantly greater than that observed (average of 6%) in the other patients undergoing carotid surgery (P less than 0.0001). Relative hyperperfusion of the ipsilateral hemisphere was seen in the four patients studied postoperatively. In at least two cases the haematoma was preceded by an asymptomatic postoperative ischaemic infarct. Histologic examination did not confirm previous findings of changes resembling those seen in malignant hypertensive encephalopathy. These results substantiate the view, that patients at risk of haemorrhage after endarterectomy are those with a low preoperative cerebral perfusion pressure and postoperative hyperperfusion. Postoperative silent brain infarction is an additional risk factor.

Adult↗
PubMed2000

Carotid endarterectomy and local anaesthesia: reducing the disasters.

PURPOSE: The study was designed to assess one surgeon's operative mortality and morbidity for carotid endarterectomy using local anaesthetic (LA) compared to general anaesthetic (GA) techniques. METHOD: Data were collected prospectively from 200 patients undergoing LA carotid surgery compared with 243 patients undergoing carotid surgery using GA technique. Indication for surgical, pathology, postoperative morbidity and mortality was assessed. RESULTS: No major strokes or deaths occurred in the LA group (0/200). Significantly more major strokes and/or deaths occurred in the GA group (11/243, 4.5%; P=0.016). Significant less shunt usage was associated with LA (LA 18/200, 9% versus 94/243, 39%; P=0.001). The absence of a shunt was associated with more major events in the GA group (5/143, P=0.001. Age greater than 74 yr was associated with greater major events (4/31, P=0.002). No significant difference in the frequency of cardiovascular complications was observed (LA, 15/200 (7.5%) vs GA, 19/243(7.8%); P=0.924). CONCLUSION: Local anaesthesia enables the surgeon to assess the level of cerebral perfusion with an awake patient, gives greater assurances of cerebral protection during arterial clamping and a provides for a more relaxed and cautious endarterectomy and repair. This study demonstrates reduction in mortality and major stroke events in patients operated on with these conditions.

Aged↗
PubMed2000

Carotid endarterectomy with reimplantation of the internal carotid artery: perioperative risk, and incidence of recurrent stenosis in 167 procedures.

Between 1990-1998, 167 carotid endarterectomies with reimplantation were performed on 153 patients. Indications for operation were asymptomatic stenosis >60% (50.2%), transient ischemic attacks (17. 4%), amaurosis fugax (14.4%) and previous stroke (18%). Our method involves transection of the internal carotid artery at its origin, standard endarterectomy without any eversion maneuver and reimplantation. Our results showed one postoperative stroke, which occurred at the contralateral side and no deaths with an overall perioperative morbidity and mortality rate of 0.59%. In addition, two (1.19%) transient ischemic attacks and one (0.59%) temporary ataxic event were noted with complete resolution of the symptoms. The 5-yr primary patency rate was 96% with a 95% 5-yr freedom from ipsilateral stroke. The mean follow up period was 22 months. In conclusion, we believe that our method, is relatively easy to perform, it has excellent results and it eliminates some of the disadvantages associated with the eversion technique.

Aged↗
PubMed2002

Inflammatory components in endarterectomy lesions: an immunohistological study.

The aim of this study was to characterize the immunohistological components of chronic inflammation in endarterectomy lesions. Therefore, in 24 patients endarterectomy specimens were obtained from coronary arteries during CABG surgery (16 from RCA and 8 from LCA) and immunohistologically analyzed using avidin-biotin method (LSAB(R)/AP) with monoclonal antibodies. Macrophages and CD3 lymphocytes were counted under 200x magnification but MHC class II and ICAM-1 adhesion molecules were analyzed semi-quantitatively (scale from 0 to 3+). The mean macrophages density was 47.8+/-9.8 cells per mm2 and mean CD3 lymphocyte density was 1.3+/-0.6 cells per mm2. Lack or weak expression of HLA-DR (0-1+) on macrophages was found in 17 of 24 cases (70.8%). In the remaining seven cases (29.2%) there was a moderate and strong expression (2+ and 3+) of HLA-DR antigens. Similarly, no or weak ICAM-1 expression on macrophages was detected in 19 cases (79.2%). These cells were positively stained for ICAM-1 in only five cases (20.8%). Our data suggest that in advanced primary atherosclerotic lesions chronic inflammation is still present. On the other hand, the small number of activated inflammatory cells and the absence of positively stained endothelium suggests that inflammatory process tends to be burnt-out.

Antibodies, Monoclonal↗
PubMed2002

Carotid endarterectomy in the elderly: does gender effect outcome?

OBJECTIVES: Carotid endarterectomy (CEA) has a positive effect on stroke free survival in patients with either symptomatic or asymptomatic severe carotid bifurcation stenosis. However, most trials have excluded octogenarians. In addition, concerns have arisen regarding the benefits of CEA in the elderly population, especially in women. In this study, we performed an outcome analysis in patients undergoing CEA comparing those eighty and older to their younger counterparts. Additionally, we evaluated the elderly group based on gender. METHODS: Over the past 10 years, all patients undergoing CEA for asymptomatic and symptomatic carotid disease have been entered into our vascular surgery registry. Demographics, indications for operative intervention, outcomes and survival of patients who had undergone CEA were reviewed. Procedures were preferentially performed under regional anesthesia with selective shunting. Chi square analysis was used to assess significance and assumed for P<0.05. RESULTS: Over the last 10 years, 125 carotid endarterectomies were performed in 125 patients eighty years of age or older. Fifty-six were male and 69 were female. Mean age was 83 (range: 80-97). Asymptomatic disease was identified in 28 of the male patients (50%) and 44 of the female patients (64%). There were no deaths and a permanent neurological deficit occurred in one female patient. There was no difference in thirty-day morbidity or mortality in female patients compared to males. CONCLUSIONS: These observations suggest that CEA can be safely performed in selected elderly patients with asymptomatic or symptomatic carotid artery stenosis. Furthermore, women over 80 may expect equally optimistic results as their male counterparts.

Age Factors↗
PubMed2003

Intra-operative assessment of technical defects after carotid endarterectomy: a comparison between angiography and colour duplex scan.

We compared the intra-operative diagnostic value of CDS vs IA-DSA in identifying major and minor technical defects after CEA. Between August 1997 and December 1998, 138 consecutive patients undergoing 141 carotid endarterectomies were intra-operatively investigated with colour duplex scan and intra-arterial digital subtraction angiography. Thirty-six (25.5%) technical defects were identified. Four (11.1%) major defects were detected by both methods and they were immediately corrected. Fifteen (41.6%) minor defects were detected by both methods, thirteen (36.1%) minor defects were detected by colour duplex but ignored by angiography. Angiography detected four (11.1%) kinkings missed with the colour duplex. The overall sensitivity of both methods for major defect was 100%. The sensitivity of colour duplex for minor defects was 87% vs 59% for angiography. On the basis of our study, colour duplex could be considered the choice method for quality control after carotid endarterectomy.

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↗
PubMed1997

Five hundred consecutive carotid endarterectomies: emphasis on vein patch closure.

This study reviews 500 consecutive carotid endarterectomies performed in 429 patients in one practice over a 12-year period, emphasis being placed on the technique of vein patch closure and its durability. The records of all such patients were reviewed. Data collected included indication, age, sex, angiogram and duplex scan results, technique of carotid closure, complications within 30 days, and follow-up postoperative duplex scans. The technique emphasized generous exposure, distal arteriotomy, routine shunting, and narrow vein patch angioplasty. The mean patient age was 68 years; 245 (57.1%) were men, and 184 (42.9%) were women. Indications for surgery were transient ischemic attack 256 (51.2%); symptom-free stenosis 144 (28.8%); recovered stroke 60 (12%); and non-hemispheric symptoms 40 (8%). The arteriotomy was closed primarily in 71 (14.2%) instances and with a patch in 429 (85.8%). Complications included five (1%) deaths, one (0.2%) stroke, nine (1.8%) transient ischemic attacks, and four (0.8%) wound hematomas. One (0.2%) vein patch rupture occurred. Serial postoperative duplex scans were reviewed in 455 (91%) patients. No significant residual disease was found in any of these patients; three (0.7%) patients were identified with recurrent symptom-free stenoses of >80%; one (0.2%) silent carotid occlusion occurred; and no aneurysms were identified. Classic descriptions of carotid endarterectomy limited the carotid arteriotomy to the bulb area, while contemporary carotid surgery emphasizes wide internal carotid exposure and distal arteriotomy. The authors' experience with vein patch closure confirms the validity of this technique and its low short- and long-term morbidity.

Adult↗