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PubMed1997

Combined coronary artery bypass grafting and carotid endarterectomy.

Combined carotid endarterectomy and coronary artery bypass grafting was performed in 52 patients between January 1982 and September 1994. Forty-nine patients had stable or unstable angina and three had symptom-free coronary artery disease detected by stress testing. Thirty-one patients had triple-vessel disease and 17 had left main trunk or left main equivalent coronary artery disease. Five patients had symptom-free carotid artery disease, 12 had non-specific neurological symptoms, and 35 had transient ischaemic attacks. Carotid endarterectomy was performed first, followed by coronary artery bypass grafting. There were three postoperative deaths, two cardiac and one neurological, for a mortality rate of 5.8%. One patient suffered a permanent neurological deficit (1.9%). It is concluded that combined carotid endarterectomy/coronary artery bypass grafting can be performed in selected patients with acceptable neurological morbidity, although cardiac mortality was not eliminated by the combined approach.

Angina Pectoris↗

PubMed1998

Routine carotid endarterectomy without a shunt, even in the presence of a contralateral occlusion.

UNLABELLED: A 10-year prospective experience with routine non-shunting, even in the presence of a contralateral internal carotid artery occlusion, is reviewed. METHOD AND RESULTS: Carotid endarterectomy was performed without a shunt in 654 consecutive patients: group 1, 513 patients with contralateral stenosis of less than 79%: group 11, 74 patients with a greater than 80% contralateral stenosis; and group 111, 67 patients with a contralateral occlusion. Average cross-clamp time was 23 min. Neurological complications occurred within 30 days in 20 (3.0%) patients (10 strokes, seven transient ischemic attacks in group I, one transient ischemic attack in group II, and one stroke and one transient ischemic attack in group III). Immediate postoperative strokes, i.e. those five cases that could be implicated as caused by lack of a shunt, were rare (0.76%). There were five perioperative deaths (0.76%). CONCLUSION: Carotid endarterectomy may be performed safely without a shunt even in the presence of a contralateral occlusion. Age, sex, preoperative indication, anesthetic agent and contralateral stenosis were not associated with an increased risk of postoperative neurological deficit.

Aged↗

PubMed1998

Transcranial cerebral oximetry during carotid endarterectomy: agreement between frontal and lateral probe measurements as compared with an electroencephalogram.

OBJECTIVE: Transcranial cerebral oximetry, which is considered a novel technique, was evaluated during carotid endarterectomy. For practical reasons, the use of a single probe attached to the forehead and overlying the territory of the anterior cerebral artery is recommended. Other monitoring systems (transcranial Doppler, electroencephalograms (EEG)) focus more on the territory of the middle cerebral artery. The aim of this study was to evaluate whether a probe in the frontal area is as representative for monitoring cerebral ischaemia during carotid cross-clamping as a probe in the lateral area. DESIGN: Clinical prospective study. MATERIALS: Sixty patients who underwent carotid endarterectomy were studied with continuous and simultaneous EEG and transcranial cerebral oximetry. Forty-three patients (72%) simultaneously underwent frontal and lateral transcranial cerebral oximetry. The lateral probe was only used in 17 patients. METHODS: The percentage decrease of transcranial cerebral oximetry was calculated during cross-clamping. Using the EEG findings as the gold standard in order to detect cerebral ischaemia during carotid cross-clamping, the relationship with transcranial cerebral oximetry was described in terms of sensitivity, specificity and the area under the curve in a receiver operating characteristic curve. RESULTS: The 95% confidence interval of the area under the curve of the receiver operating characteristic of the lateral probe was 0.61-1.00 and that of the frontal probe was 0.65-1.00; therefore there is virtually no difference between the two methods. In 18% of the cases the lateral transcranial cerebral oximetry was hindered by practical failures. CONCLUSION: Considering the lack of additional information and the practical problems experienced with the lateral probe, it was concluded that transcranial cerebral oximetry with a single frontal probe is a practical non-invasive monitoring system and is at least as representative for monitoring cerebral ischaemia during carotid cross-clamping as a lateral probe.

Brain↗

PubMed1999

The blood supply of the hypoglossal nerve and its relevance to carotid endarterectomy.

Since the hypoglossal nerve is liable to injury during carotid endarterectomy and similar procedures, its blood supply was examined in microinjection studies of human cadavers. The nerve is supplied by arteries that arise from the ascending pharyngeal artery as it exits from the hypoglossal canal, the occipital artery as the nerve passes under its branch to the sternomastoid muscle, direct branches from the external carotid artery, and branches from the ascending pharyngeal artery just near the bifurcation of the common carotid artery. Within and close to the tongue, the nerve is supplied by branches from the lingual artery. Damage to the vessels supplying the nerve may account for some cases of hypoglossal palsy after carotid endarterectomy. Possible mechanisms are ischaemia, thermal or electrical injury from diathermy current conducted to the nerve, or intraneural haematoma from rupturing one or more of these fine vessels.

Arteries↗

PubMed1999

The value and limitations of magnetic resonance angiography of the circle of Willis in patients undergoing carotid endarterectomy.

Magnetic resonance angiography is a useful technique to determine the patency of the circle of Willis when compared with conventional four-vessel angiography. The purpose of this study is to determine whether the integrity of the circle of Willis, assessed by magnetic resonance angiography, provides adequate collateral cerebral circulation during carotid endarterectomy and correlates with internal carotid artery back pressure. Over a recent 20-month period, 35 patients were studied preoperatively with magnetic resonance angiography of the carotid bifurcations of the circle of Willis and the vertebrobasilar system. All patients underwent standard carotid endarterectomy with intraoperative measurement of internal carotid artery back pressure. Patients with an internal carotid artery back pressure < 50 mmHg had an intraluminal shunt placed. Deficiencies in branches of the circle of Willis, the carotid bifurcation and the vertebrobasilar system determined by magnetic resonance angiography were correlated with internal carotid artery back pressure using Fisher's exact test. Only one patient had a completely intact circle of Willis. Eleven of 16 patients (69%) who had an internal carotid artery back pressure < 50 mmHg had an occluded A1 segment of the anterior cerebral artery combined with an occluded posterior communicating artery, whereas only five of 19 patients (26%) who had an internal carotid artery back pressure > 50 mmHg had similar findings (P < 0.03). Severity of occlusive disease of the contralateral internal carotid artery and the basilar artery did not independently predict internal carotid artery back pressure. An occluded anterior branch of the circle of Willis in combination with an occluded posterior branch of the circle of Willis is associated with an internal carotid artery back pressure < 50 mmHg. Although magnetic resonance angiography of the circle of Willis may provide valuable anatomic information, it is not sufficiently accurate to predict the need for carotid shunting and therefore its use cannot be justified on a routine basis.

Aged↗

PubMed1999

The significance of early postoperative duplex studies following carotid endarterectomy.

This study was conducted to evaluate the significance of duplex ultrasound performed soon after carotid endarterectomy. The records of patients with 150 carotid endarterectomies and postoperative duplex ultrasound within 24 h were reviewed. Eleven (7.3%) had abnormal studies with > or =50% stenosis. Two patients with abnormal studies sustained a perioperative stroke and three patients underwent reoperation for persistent lesions (P<0.0001). Preoperative and postoperative cerebral imaging studies (computed tomography (CT) or magnetic resonance imaging (MRI)) were performed on 114 patients. Seven of these demonstrated areas of infarction and all seven had abnormal duplex ultrasound studies. Twenty-six CT scans were performed with two positive for cerebral infarction in the two patients with clinical stroke. In the 88 MRI studies, five demonstrated small, subcortical focal areas of ischemia, which were clinically silent. The relationship of infarction on postoperative cerebral studies and abnormal postoperative duplex ultrasound was significant (P<0.0001). It was concluded that early postoperative duplex ultrasound studies of > or =50% stenosis demonstrate significant association with postoperative stroke or reoperation, as well as with ischemic changes on brain imaging studies. Earlier detection with intraoperative duplex would probably be more advantageous than postoperative duplex ultrasound.

Aged↗

PubMed1999

Angioscopic video-assisted pulmonary endarterectomy for post-embolic pulmonary hypertension.

OBJECTIVES: To assess whether the use of video-assisted angioscopy would increase the outcome of pulmonary thromboendarterectomy (PTE). METHODS: PTE included a median sternotomy, intrapericardial dissection of the superior vena cava, institution of cardiopulmonary bypass, deep hypothermia and sequential circulatory arrest periods. It was always performed through two separate arteriotomies on both main intrapericardial pulmonary arteries, into which a rigid 5 mm angioscope connected to a video camera was introduced to increase the visibility and endarterectomies. RESULTS: From January 1996 to July 1998, 68 consecutive patients (35 males and 33 females) aged 54.3 +/- 13.5 years underwent PTE. Patients were in New York Heart Association (NYHA) class II (n = 2), III (n = 43) or IV (n = 23) with the following hemodynamics: mean pulmonary arterial pressure (PAP) 54 +/- 13 mmHg; cardiac output (CO): 3.8 +/- 0.8 l/min, and total pulmonary resistance (TPR): 1207 +/- 416 dyne x s x cm(-5). The cumulated circulatory arrest time was 23 +/- 12 min and postoperative length of ventilatory support 10 +/- 12 days. Nine patients died, for an overall in-hospital mortality of 13.2%. The functional outcome in surviving patients was significantly improved (P < 0.0001) both clinically (NYHA class 3.2 +/- 0.5 vs. 1.3 +/- 0.6) and hemodynamically (PAP (mmHg) 53.1 +/- 13 vs. 30.2 +/- 11.8, CI (l/min per m2) 2.1 +/- 0.5 vs. 2.8 +/- 0.6, TPR (dyne x s x cm(-5)) 1174 +/- 416 vs. 519 +/- 250). CONCLUSIONS: Video-assisted angioscopy improves the quality and degree of pulmonary endarterectomy expanding the indications to include patients with previously inaccessible distal disease.

Adult↗

PubMed1996

Comparative effects of plain and epinephrine-containing bupivacaine on the hemodynamic response to cervical plexus anesthesia in patients undergoing carotid endarterectomy.

OBJECTIVES: This study was designed to investigate whether the addition of epinephrine as a vasoconstrictor additive to local anesthetic affects the hemodynamic profile after cervical plexus block in patients presenting for carotid endarterectomy. DESIGN: A prospective, double-blind, randomized trial. SETTING: A university hospital. PARTICIPANTS: Forty patients scheduled for carotid endarterectomy under regional anesthesia (cervical plexus block). INTERVENTIONS: Patients were randomized to one of two groups. Group P (20 patients) received plain bupivacaine; group E (20 patients) received bupivacaine with epinephrine, 5 micrograms/mL. All patients received 2 mg/kg of bupivacaine, and group E received 2 micrograms/kg of epinephrine. The electrocardiogram and intra-arterial blood pressure were monitored continuously, and recordings of heart rate and blood pressure were recorded at predetermined intervals from before the block until the skin incision. RESULTS: After the block, group E developed a sustained increase in heart rate of approximately 15% (p < 0.01), whereas group P showed no change. Systolic blood pressure increased significantly with time over the study period in both groups (p < 0.01). Diastolic blood pressure increased significantly in group P (p < 0.01) but not in group E. CONCLUSIONS: Concerning cervical plexus block with bupivacaine, the use of epinephrine is associated with an increase in heart rate consistent with a beta-adrenergic effect from systemic absorption of the epinephrine. An increase in systolic blood pressure independent of the use of epinephrine also occurs, but epinephrine appears to mitigate against an increase in diastolic blood pressure.

Adult↗

PubMed1997

The effects of carotid sinus nerve blockade on hemodynamic stability after carotid endarterectomy.

OBJECTIVE: To determine whether intraoperative administration of bupivacaine reduces the incidence of hypotension after carotid endarterectomy (CEA). DESIGN: Prospective, double-blinded, randomized controlled trial. SETTING: A single-institute, tertiary-care medical center. PARTICIPANTS: Patients (n = 135) who were referred for CEA without prior ipsilateral CEA, diabetes mellitus, or allergies to local anesthetics. INTERVENTIONS: 2 mL of 0.25% bupivacaine or 2 mL NaCl (control) injected by the surgeon at the carotid sinus immediately after CEA. MEASUREMENTS AND MAIN RESULTS: Blood pressure and heart rate were measured before induction, before carotid reperfusion, 2 minutes after reperfusion, before carotid sinus injection, and every 15 minutes thereafter for 2 hours. Anesthesia was induced and maintained with fentanyl, pancuronium, and 0.5% to 1% enflurane. Hypertension was defined as a systolic blood pressure 30% above baseline or greater than 180 mmHg. Hypotension was defined as a systolic blood pressure 30% below baseline or less than 100 mmHg. Postoperative incidences of hypertension, hypotension, and the associated use of corrective medications were compared in both groups using the chi-squared test to determine statistical significance. Patients in the bupivacaine group (n = 61) had a similar incidence of postoperative hypotension as controls (n = 74) but a higher incidence of hypertension (40% v 24%; p = 0.043). The bupivacaine group required vasodilators more often (33% v 18%; p = 0.04). Baseline hypertension and preoperative use of beta-blockers also were predictive of postoperative hypertension. CONCLUSIONS: Carotid sinus area infiltration with bupivacaine after CEA does not reduce the incidence of postoperative hypotension but significantly increases the incidence of postoperative hypertension. Thus, its routine use cannot be recommended in carotid endarterectomy.

Aged↗

PubMed1995

Fibrin sealant reduces suture line bleeding during carotid endarterectomy: a randomised trial.

OBJECTIVES: To determine whether topical fibrin sealant reduced suture line bleeding during carotid endarterectomy with polytetrafluoroethylene (PTFE) patch closure. DESIGN: Prospective randomised non-blinded control trial. SETTING: Regional vascular surgery unit. MATERIALS: Seventeen patients undergoing carotid endarterectomy were randomised either to receive fibrin sealant as a topical haemostatic agent at the arteriotomy suture line or to act as control. OUTCOME MEASURES: Time taken to achieve haemostasis at the suture line. Intraoperative blood loss. Total operative time. RESULTS: The median time to achieve haemostasis was 5.5 min (range 4-31 min) in the treatment group and 19 min (range 10-47 min) in the control group. This difference was statistically significant p < 0.005 by Mann-Whitney test. There was no statistical difference in total operative time. Operative blood loss was lower in the treatment group (median 420ml, range 300-500ml) than in the control group (median 550ml, range 350-1200ml) but this difference was not statistically significant. One patient in the control group suffered a perioperative thrombo-embolic event. CONCLUSION: Fibrin sealant is an effective topical haemostatic agent for arteriotomy suture lines involving PTFE material.

Aged↗

PubMed1995

Seizures following carotid endarterectomy in patients with severely compromised cerebral circulation.

OBJECTIVES: To determine the incidence of postoperative neurological complications following carotid endarterectomy in patients with severely compromised cerebral circulation. DESIGN: Prospective open clinical study. SETTING: Department of Vascular Surgery, University Hospital. MATERIALS AND METHODS: We determined the incidence of postendarterectomy seizures related to haemodynamic impairment in terms of intraoperatively measured perfusion pressure in 151 patients undergoing 153 carotid endarterectomies. MAIN RESULTS: Cerebral perfusion pressure index (ICA/CCA pressure ratio) was significantly reduced (25% or more) in 47% (55/118) of patients with 70-99% stenosis compared to 6% (2/35) of patients with 30-69% stenosis (p < 0.00005). Among the 57 haemodynamically compromised patients five developed seizures considered due to cerebral hyperperfusion five to seven days after surgery. The seizures were associated with headache in two, focal neurological deficits in four and hypertensive episodes in all cases. The symptoms remitted within 2 weeks and no patients suffered cerebral haemorrhage. CONCLUSIONS: Seizures following correction of high grade stenoses causing severe pressure reduction may be more common than previously assumed. Patients at risk should be identified and postoperative blood pressure controlled meticulously.

Carotid Artery, Internal↗

PubMed1996

Infected false aneurysms of the carotid arteries after carotid endarterectomy.

OBJECTIVE: To determine the incidence and management of infected false aneurysms following carotid endarterectomy. DESIGN: Case notes of patients undergoing carotid endarterectomy (CEA) between the years of 1980 and 1993 at two major teaching hospitals, or those patients who represented with complications were reviewed. RESULTS: Eight patients were identified with infected false aneurysms, an incidence of 0.625%, in five CEA had been performed at one of the teaching hospitals, whilst in three other cases the primary operation had been done elsewhere. Presentation was a median 19 days following CEA. In five cases the original arteriotomy was closed by direct suture whilst in three a saphenous vein patch was used. Staphylococcal organisms were cultured in all cases. Antibiotics had not been administered at the original operation. Repair with saphenous vein graft from the common to the internal carotid artery had the least complications. CONCLUSION: Infected false aneurysms are a rare complication following CEA, resection of the false aneurysm and reconstruction with autologous saphenous vein is recommended. Ligation alone is associated with a high incidence of stroke.

Aged↗

PubMed1996

Neutrophil activation in jugular venous blood during carotid endarterectomy.

OBJECTIVES: Neutrophils may play an important role in cerebral ischaemia. We investigated whether neutrophil activation can be detected in cerebral venous blood during the mild cerebral hypoxia and reperfusion that occurs during carotid cross clamping and declamping for endarterectomy. DESIGN, SETTING AND MATERIALS: The ipsilateral jugular bulb was cannulated at operation in 16 patients undergoing carotid endarterectomy. Blood was taken immediately prior to and 30 seconds following internal carotid cross clamping; then immediately prior to, 30 s and 2 m following declamping. Blood was also taken from a peripheral vein in the foot. Intracerebral oxygen saturation (CsO2) was measured continuously by near infrared cerebral spectroscopy. Neutrophil activation was measured by flow cytometric detection of fluorescence to hydrogen peroxide in unstimulated cells and phorbol myristate acetate stimulated cells, and expressed as mean fluorescent intensity (MFI). OUTCOME MEASURES: Neutrophil activation and cerebral oxygenation. MAIN RESULTS: CsO2 fell from 68% (95% Confidence interval 64%-72%) to 63% (59%-68%) following carotid cross clamping (p < 0.05, repeated measures analysis of variance). This recovered slightly during the cross clamp period to 64% but only returned to preclamp levels following declamping (p > 0.05). Neutrophil hydrogen peroxide generation by stimulated neutrophils rose significantly from 0.79 mean fluorescent intensity (0.53-1.19) to 1.46 (0.98-2.20) but no there was no further rise following cross clamp release. There was no significant neutrophil activation in the peripheral samples. CONCLUSIONS: These results indicate that even mild cerebral hypoxia is associated with priming of neutrophils in cerebral venous blood.

Aged↗

PubMed1996

The differing effects of regional and general anaesthesia on cerebral metabolism during carotid endarterectomy.

OBJECTIVES: To examine the effects of either regional (RA) or general (GA) anaesthesia upon parameters of cerebral metabolism (near infrared spectroscopy, continuous jugular venous oximetry) during carotid endarterectomy. DESIGN: Prospective, non-randomised, observational study. MATERIALS: Sixty-five consecutive patients (33 RA; 32 GA) undergoing carotid endarterectomy. METHODS: (i) Near infrared spectroscopy: measurement of concentrations of cerebral oxyhaemoglobin (HbO2), deoxyhaemoglobin (HHb) and oxidised cytochrome oxidase (caa3). (ii) Continuous jugular venous oximetry: O2 saturation of jugular venous blood (SJvO2). (iii) Stump pressure in internal carotid artery. RESULTS: A reduction in SJvO2 (RA: 13% (95% CI-3 to 29%) GA: 9% (95% CI-2 to 20%), p < 0.08) and a fall in caa3 levels (RA vs. GA: 25/31 vs. 19/31, p = 0.2) was more likely in patients given a RA following application of the carotid clamps. When HbO2 and caa3 did fall however spontaneous recovery occurred more often (RA vs. GA; caa3: 18/25 vs. 5/19, p < 0.005; HbO2: 30/31 vs. 4/28, p < 0.001). CONCLUSIONS: Although GA may offer a degree of cerebral protection by reducing cerebral metabolic rate (lower falls in SJvO2 and caa3) RA preserved cerebral autoregulation as judged by the spontaneous recovery in caa3 and HbO2 levels.

Aged↗

PubMed1996

Endovascular remote endarterectomy in femoropopliteal occlusive disease: one-year clinical experience with the ring strip cutter device.

OBJECTIVES: One-year clinical outcome of a new endovascular treatment for long segmental arterial occlusive disease using a ring strip cutter (RSC) to minimise surgical exposure. DESIGN: Prospective, open study. MATERIALS: Thirty-eight consecutive RSC procedures in 36 consecutive patients with lengthy occlusive (34) or multiple stenotic (4) femoropopliteal lesions were performed. Indications for operation were disabling claudication in 25 (66%), rest pain in 3 (8%), and gangrene in 10 (26%) patients. METHODS: A newly developed endovascular ring strip cutter device was used to perform a remote endarterectomy through a single groin incision. Clinical data were analysed based on intention-to-treat. RESULTS: Initial angiographic, clinical and haemodynamic success was achieved in all 38 (100%) limbs. Mean ankle-brachial index increased significantly from 0.62 +/- 0.14 to 1.02 +/- 0.14 postoperatively (p = 0.01). Four failures have occurred during follow-up. After one-year experience the cumulative (assisted) primary and secondary patency rates are 80% and 85% respectively. Duplex surveillance has detected progressive recurrent stenoses in 10 cases. CONCLUSIONS: Remote endarterectomy of long segmental femoropopliteal occlusive disease through a single groin incision with the Ring Strip Cutter device is a safe and effective procedure. The early patency rates are good. Further long-term results are needed to evaluate this technique.

Aged↗

PubMed1997

Local versus general anaesthesia in carotid endarterectomy: a systematic review of the evidence.

OBJECTIVE: To determine whether carotid endarterectomy under local anaesthesia is safer and as effective as under general anaesthesia. DESIGN: Systematic review of the randomised and non-randomised studies. MATERIALS: Studies were identified from the Cochrane Stroke Group's database plus additional handsearching and electronic searching. METHODS: Two authors independently selected studies for inclusion and extracted details of trial quality and data on death, any stroke, myocardial infarction and other operative complications. Meta-analysis was performed using the Peto method. RESULTS: There were 17 non-randomised studies (about 5970 patients) and only three randomised studies (143 patients). The non-randomised studies suggested that the use of local anaesthesia may be associated with clinically important reductions (approximately 50%) in the odds of stroke, stroke or death, myocardial infarction and pulmonary complications during the perioperative period, and with reductions in hospital stay. There were far too little data from the randomised trials to confirm or refute these findings: only one death and seven strokes were reported. CONCLUSIONS: Non-randomised studies suggest potentially important benefits from performing carotid endarterectomy under local anaesthesia. However, these studies were seriously flawed and can only be hypothesis generating. The results must be confirmed in large well-designed randomised trials before any recommendations on the use of local anaesthetic can be made.

Aged↗

PubMed1998

The effect of perioperative embolisation on visual function in patients undergoing carotid endarterectomy.

OBJECTIVES: To investigate the effect of carotid artery embolisation detected by transcranial Doppler (TCD) monitoring during carotid endarterectomy (CEA) on visual function. DESIGN: A prospective study. Visual function was assessed by an independent ophthalmalogist. MATERIALS: One hundred consecutive patients undergoing carotid endarterectomy. METHODS: All patients underwent pre- and postoperative retinal fundoscopy and automated visual field analysis. Intraoperative emboli were detected by continuous TCD monitoring of the middle cerebral artery. RESULTS: Preoperatively, six patients had fundoscopic evidence of silent retinal embolisation, five patients had visible emboli associated with amaurosis fugax. Visual field analysis found no significant difference between ipsi- and contralateral eye scores. Only patients with occlusions of major retinal vessels had clinically reduced visual function. Intraoperatively TCD identified embolisation in 83/91 of monitored operations. Postoperatively, ipsilateral visual field scores deteriorated while contralateral eye scores remained unchanged, however only one new retinal embolus was detected. The incidence of TCD detected embolisation was not associated with a corresponding deterioration in postoperative visual function. CONCLUSIONS: (1) A group of patients can be identified who experience "silent" retinal embolisation prior to CEA. (2) Clinically significant retinal embolisation resulting from CEA is uncommon. (3) CEA is associated with a deterioration in the visual field scores for the ipsilateral eye compared with the contralateral eye but the mechanism for this small but significant deterioration remains unclear.

Blindness↗

PubMed1998

Carotid endarterectomy without angiography does not compromise operative outcome.

OBJECTIVES: Carotid angiography is associated with a 2% risk of stroke and, since the advent of colour-duplex ultrasound, its role in the assessment of patients with carotid disease has been the subject of debate. The aim of this study was to evaluate a policy of adopting routine duplex supplemented by selective angiography on operative outcome over a 5-year period. METHODS: A prospective audit of the results of carotid endarterectomy without routine angiography from January 1992 to December 1996. Angiography was performed only if the ultrasonography was concerned about the distal or proximal extent of disease or to assess subocclusion. RESULTS: During the study period, 494 carotid endarterectomies were performed but only 35 patients underwent carotid angiography. The indications for angiography were subocclusion/string sign in 22 patients, to assess the limits of proximal or distal disease in 12 and abnormal anatomy in one. During the 5-year study period the overall perioperative death and/or stroke rate was 4.2%. By 1997, the perioperative stroke rate had fallen to 1.3%. In no case in this series was the operation abandoned due to unexpected findings. CONCLUSION: Although concerns exist about the precise duplex criteria for diagnosing a severe stenosis, this study has shown that a policy of selective angiography does not compromise patient safety or operability and avoids the unnecessary mortality, morbidity and costs associated with routine angiography.

Angiography↗