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PubMed2003

Teflon guide-wire-assisted semi-closed Vollmar endarterectomy of the superficial femoral artery. A review of 25 cases and the state of the art from a literature review.

In this retrospective study, we analysed 25 guide-wire-assisted Vollmar endarterectomies of an occluded superficial femoral artery. In 96% of the cases, the patient suffered from a Fontaine stage III or IV. After a mean follow-up of 24.7 months, limb salvage is 96%. The patency rate is 84% which is comparable with a femoropopliteal bypass with a reversed greater saphenous vein graft. We advocate the Vollmar endarterectomy as a valuable alternative surgical treatment for occlusive superficial femoral artery in the absence of a greater saphenous vein or in young smoking patients (< 65 years).

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PubMed2006

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Ten years experience in Denmark.

OBJECTIVES: To evaluate survival and functional outcome in patients treated by pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension in Denmark. DESIGN: Follow-up of the first 50 patients operated at Aarhus University Hospital, Denmark. RESULTS: Fifty patients underwent PEA in the period from 1994 to mid 2004. Prior to surgery all patients were in World Health Organization (WHO) function class III (n=33) or IV (n=17). The mean pulmonary artery pressure was 50 mmHg (range 25-76), cardiac index 1.8 l min(-1)m(-2) (range 0.8-2.8) and pulmonary vascular resistance 819 dyn s cm(-5) (range 241-3,067). In-hospital mortality was 12/50 (24%). Surgical mortality was highest in the early period. Since year 2000 in-hospital deaths occurred in only 2 among 23 patients (9%). Leading causes of death were persistent pulmonary hypertension and bleeding. Three patients died during long-term follow-up with a median observation time of 3 years. The overall 5 year survival rate was 74%. At 3 months follow-up 90% of the patients (34/38) had improved one or more WHO functional classes and the systolic pulmonary artery pressure estimated by Doppler echocardiography had decreased from 80 mmHg (range 49-115) to 43 mmHg (range 14-95). CONCLUSION: Pulmonary endarterectomy has been successfully implemented in Denmark. The perioperative mortality was reduced over time to 9% during the past 5 years. Functional outcome and long-term survival were excellent stressing the importance of surgical treatment for chronic thromboembolic pulmonary hypertension.

Adult↗
PubMed1997

Isolation of Chlamydia pneumoniae from a carotid endarterectomy specimen.

Chlamydia pneumoniae has been associated with atherosclerotic cardiovascular disease by both seroepidemiologic studies and direct detection of the organism in atherosclerotic plaque by electron microscopy (EM), immunocytochemistry (ICC), and polymerase chain reaction (PCR). Despite the frequent detection of the organism in atheromatous cardiovascular specimens by these methods, only 1 cardiovascular isolate of C. pneumoniae, obtained from a coronary artery, has been previously reported. This study reports the isolation of C. pneumoniae from a prospectively obtained carotid endarterectomy specimen. The organism appears to be identical to other C. pneumoniae isolates by EM morphology, reactivity to species-specific monoclonal antibodies, and Southern hybridization analysis of chromosomal digests using C. pneumoniae-specific DNA probes. C. pneumoniae was detected by PCR or ICC (or both) in 11 (69%) of 16 other endarterectomy specimens tested by both of these methods. These results provide further evidence for an association of C. pneumoniae and atherosclerosis by confirming the presence of viable bacteria within atherosclerotic plaque.

Chlamydophila pneumoniae↗
PubMed1985

EEG changes during carotid endarterectomy: drug effect and embolism.

Clinical neurological status and the electroencephalogram (EEG) were monitored during right carotid endarterectomy under regional anaesthesia in a patient who had suffered two prior cerebral infarctions. No change in EEG or clinical status was seen with occlusion of the carotid artery, but generalized encephalopathic changes were seen after a small dose of narcotic given before carotid occlusion. Bihemispheric changes in EEG and neurological status occurred upon release of carotid occlusion. This case demonstrates three important points. First, EEG changes can be seen with sedative or anaesthetic agents in patients who have previously suffered brain injury. Second, temporary neural dysfunction may be seen remote from the site of a localized injury to the brain--a phenomenon known as diaschisis. Finally, this report reiterates the observation that the risk of injury to the brain during carotid endarterectomy is not limited to the period of possible ischaemia during occlusion of the carotid artery.

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PubMed1996

Airway problems after carotid endarterectomy.

Respiratory obstruction has been reported as a complication of carotid endarterectomy; the causes include traumatic mucosal oedema, direct tracheal compression by haematoma and oedema secondary to lymphatic and venous congestion. We report four cases of acute respiratory obstruction complicating carotid endarterectomy. Two of these cases suffered respiratory arrest in the postoperative ward and required emergency tracheal intubation in difficult circumstances. All of these patients had developed wound haematomas and all required surgical intervention.

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PubMed2000

Nitrous oxide-induced increased homocysteine concentrations are associated with increased postoperative myocardial ischemia in patients undergoing carotid endarterectomy.

UNLABELLED: Nitrous oxide anesthesia causes increased postoperative plasma homocysteine levels. Acute increases in plasma homocysteine are associated with impaired endothelial function and procoagulant effects. This nitrous oxide-induced plasma homocysteine increase may therefore affect the risk of perioperative cardiovascular events. This prospective, randomized study was therefore designed to evaluate the effect of nitrous oxide anesthesia and postoperative plasma homocysteine levels on myocardial ischemia in patients undergoing carotid endarterectomy. After institutional review board approval and written informed consent, 90 ASA Class I-III patients presenting for elective carotid endarterectomy were randomized to receive general anesthesia with or without nitrous oxide. Prior to induction, on arrival in the postanesthesia care unit, and after 48 h, blood samples were obtained for homocysteine analysis. Three hours prior to induction and for 48 h postoperatively patients were monitored by a three-channel, seven-lead Holter monitor. Postoperatively in the postanesthesia care unit and at 48 h the nitrous oxide group had increased mean plasma homocysteine concentrations of 15.5 +/- 5.9 and 18.8 +/- 14.7 when compared with the nonnitrous group of 11.4 +/- 5.2 and 11.3 +/- 4.0 micromol/L, P: < 0.001. The nitrous oxide group had an increased incidence of ischemia (46% vs. 25%, P: < 0.05), significantly more ischemia (63 +/- 71 vs. 40 +/- 68 min, P: < 0.05), had more ischemic events (82 vs. 53, P: < 0.02), and had more ischemic events lasting 30 min (23 vs. 14, P: < 0.05) than the nonnitrous group. This study reconfirmed that intraoperative nitrous oxide is associated with postoperative increases in plasma homocysteine concentration. This was associated with an increase in postoperative myocardial ischemia. IMPLICATIONS: Use of nitrous oxide during carotid artery surgery induces increases in postoperative plasma homocysteine concentration and is associated with increases in postoperative myocardial ischemia.

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PubMed1976

Internal carotid artery stump pressure and cerebral blood flow during carotid endarterectomy: modification by halothane, enflurane, and innovar.

Carotid endarterectomy requires temporary surgical occlusion of the involved carotid artery. During occlusion, the minimally acceptable (critical) internal carotid artery stump pressure is reported to be 50 torr, whereas for regional cerebral blood flow (rCBF), a critical range is reported to be 18-24 ml/100 g/min. During 90 carotid endarterectomies, rCBF and stump pressure were measured and the EEG continuously monitored. A positive correlation between rCBF and stump pressure (i.e., when both were either above or below their respective critical values) was observed in only 58 per cent of the cases. In 28 per cent stump pressures of less than 50 torr were observed despite rCBF's above 24 ml/100 g/min and normal EEG's. In 8 per cent stump pressures were more than 50 torr but rCBF's were less than 18 ml/100 g/min and EEG changes of ischemia were commonly observed. In the remaining 6 per cent rCBF's were marginal (18-24 ml/100 g/min) while stump pressures were more than 50 torr and EEG changes were not observed. The relationship between stump pressure and rCBF was influenced by the anesthetic. In the absence of transient ischemia during occlusion (that is, rCBF greater than 18 ml/100 g/min), halothane and enflurane anesthesia were associated with significantly higher rCBF's and lower stump pressures than was neuroleptanesthesia. Pre-occlusion and post-occlusion rCBF measurements also demonstrated cerebral vasodilation by halothane and enflurane (halothane greater than enflurane) and vasoconstriction by neuroleptanesthesia. It is concluded that stump pressure is an unreliable index of CBF during carotid occlusion and that its relationship to CBF is considerably influenced by the anesthetic.

Blood Flow Velocity↗
PubMed1991

Monitoring electrophysiologic function during carotid endarterectomy: a comparison of somatosensory evoked potentials and conventional electroencephalogram.

There is no consensus as to the most appropriate monitor for detecting ischemia during carotid endarterectomy. Accordingly, simultaneous 16-channel continuous electroencephalogram (EEG) and somatosensory evoked potential (SSEP) monitoring were performed in 64 normocapnic patients undergoing carotid endarterectomy and anesthetized with isoflurane or halothane-nitrous oxide (supplemented with fentanyl). Recordings were obtained before, during, and for 15 min after cross-clamping of the internal carotid artery. Internal shunt was not used in any patient, regardless of EEG and SSEP changes. Significant amplitude reduction in the cortical component of the primary negative peak (greater than 50%) in SSEP occurred in 6 patients, and an increase in central conduction time (CCT) (greater than 1 ms) occurred in 5 patients. Major EEG changes occurred in 6 patients, 4 of whom also had SSEP changes. Two patients had transient neurologic deficits postoperatively, with both having SSEP changes (amplitude reduction greater than 50%), whereas one had EEG changes. Based on these observations, the relative sensitivity and specificity for EEG and SSEP (amplitude reduction greater than 50%) in detecting postoperative neurologic deficits were 50% and 92% for EEG and 100% and 94% for SSEP, respectively, differences that were not statistically significant. Regarding SSEP, the use of latency change (CCT) as a criterion was associated with a sensitivity of 0% (P = 0.046 from sensitivity of amplitude) and a specificity of 87% (P = 0.17 from specificity of amplitude).(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed1998

Correlation of regional cerebral blood flow with ischemic electroencephalographic changes during sevoflurane-nitrous oxide anesthesia for carotid endarterectomy.

BACKGROUND: Carotid endarterectomy necessitates temporary unilateral carotid artery occlusion. Critical regional cerebral blood flow (rCBF) has been defined as the rCBF below which electroencephalographic (EEG) changes of ischemia occur. This study determined the rCBF50, the rCBF value at which 50% of patients will not demonstrate EEG evidence of cerebral ischemia with carotid cross-clamping. METHODS: Fifty-two patients undergoing elective carotid endarterectomy were administered 0.6-1.2% (0.3-0.6 minimum alveolar concentration) sevoflurane in 50% nitrous oxide (N2O). A 16-channel EEG was used for monitoring. The washout curves from intracarotid 133Xenon injections were used to calculate rCBF before and at the time of carotid occlusion by the half-time (t(1/2)) technique. The quality of the EEG with respect to ischemia detection was assessed by an experienced electroencephalographer. RESULTS: Ischemic EEG changes developed in 5 of 52 patients within 3 min of carotid occlusion at rCBFs of 7, 8, 11, 11, and 13 ml x 100 g(-1) x min(-1). Logistic regression analysis was used to calculate an rCBF50 of 11.5 +/- 1.4 ml x 100 g(-1) x min(-1) for sevoflurane. The EEG signal demonstrated the necessary amplitude, frequency, and stability for the accurate detection of cerebral ischemia in all patients within the range of 0.6-1.2% sevoflurane in 50% N2O. CONCLUSIONS: The rCBF50 of 0.6-1.2% sevoflurane in 50% N2O, as determined using logistic regression analysis, is 11.5 +/- 1.4 ml 100 g(-1) x min(-1). Further, in patients anesthetized in this manner, ischemic EEG changes due to carotid occlusion were accurately and rapidly detected.

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PubMed2000

Evaluation of a cerebral oximeter as a monitor of cerebral ischemia during carotid endarterectomy.

BACKGROUND: Stroke is an important contributor to perioperative morbidity and mortality associated with carotid endarterectomy (CEA). This investigation was designed to compare the performance of the INVOS-3100 cerebral oximeter to neurologic function, as a means of detecting cerebral ischemia induced by carotid cross-clamping, in patients undergoing carotid endarterectomy with cervical plexus block. METHODS: Ninety-nine patients undergoing 100 CEAs with regional anesthesia (deep or superficial cervical plexus block) were studied. Bilateral regional cerebrovascular oxygen saturation (rSO2) was monitored using the INVOS-3100 cerebral oximeter. Patients were retrospectively assigned to one of two groups: those in whom a change in mental status or contralateral motor deficit was noted after internal carotid clamping (neurologic symptoms; n = 10) and those who did not show any neurologic change (no neurologic symptoms; n = 90). Data from 94 operations (neurologic symptoms = 10 and no neurologic symptoms = 84) were adequate for statistical analyses for group comparisons. A relative decrease in ipsilateral rSO2 after carotid occlusion (calculated as a percentage of preocclusion value) during all operations (n = 100) was also calculated to determine the critical level of rSO2 decrease associated with a change in neurologic function. RESULTS: The mean (+/- SD) decrease in rSO2 after carotid occlusion in the neurologic symptoms group (from 63.2 +/- 8.4% to 51.0 +/- 11.6%) was significantly greater (P = 0.0002) than in the no neurologic symptoms group (from 65.8 +/- 8.5% to 61.0 +/- 9.3%). Logistic regression analysis used to determine if a change in rSO2, calculated as a percentage of preclamp value, could be used to predict change in neurologic function was highly significant (likelihood ratio chi-square = 13.7; P = 0.0002). A 20% decrease in rSO2 reading from the preclamp baseline, as a predictor of neurologic compromise, resulted in a sensitivity of 80% and specificity of 82.2%. The false-positive rate using this cutoff point was 66.7%, and the false-negative rate was 2.6%, providing a positive predictive value of 33.3% and a negative predictive value of 97.4%. CONCLUSION: Monitoring rSO2 with INVOS-3100 to detect cerebral ischemia during CEA has a high negative predictive value, but the positive predictive value is low.

Adult↗
PubMed1977

Improved results with carotid endarterectomy.

Two hundred ninety patients undergoing carotid endarterectomy were reviewed. From 1968 to 1972, 188 patients had carotid endarterectomy under general anesthesia with use of a shunt and hypercarbia. Stump pressures were not recorded in this group. There were three deaths, three postoperative hemiplegias and two complications of transient limb weakness. From 1973 to 1975, 102 patients were operated on under local anesthesia with systemic Innovar and Sublimaze, normocarbia and intra-operative assessment of stump pressure. In this group there was one death, no hemiplegia, and no complications of transient limb weakness. Twenty of the 102 were shunted either on the basis of stump pressure or the loss of motor ability or consciousness on carotid clamping. Those shunted had stump pressures ranging from 10 to 70 mm Hg with a mean of 20 while those not shunted had stump pressures ranging from 20 to 85 mm Hg with a mean of 53 mm Hg. Five patients lapsed into unconsciousness despite internal carotid stump pressures of 30, 30, 34, 36 and 70 mm Hg respectively, thus requiring intraoperative shunting. This experience seriously questions the reliability of carotid stump pressure as the sole determinant to identify those patients who require intraoperative shunting. We have come full circle, back to operation under local anesthesia, since intraoperative assessment of the patient's motor ability and consciousness alone provide the only absolute criteria for assessing the need for intraoperative shunting. Since the operation can be performed with greater technical efficiency without a shunt and without the potential complications of shunting itself, it behooves the surgeon to have a reliable method of knowing when it is not required.

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PubMed1982

Motor speech deficit following carotid endarterectomy.

Stroke as a complication of carotid endarterectomy has been extensively reviewed. Considerably less attention has been directed to local injuries of the cranial nerves and their branches. Verta, Hertzer, Imparato, DeWeese, and Matsumoto have reported experience with these injuries. DeWeese found a 9.7% rate of cranial nerve injury, while in Hertzer's series, 15% of patients had nerve dysfunction in the early postendarterectomy period. In 1980, Liapis in a preliminary report found that when postoperative examination was supplemented by detailed evaluation by speech pathologists, the incidence of early abnormalities reached 27%. The purpose of this study was to expand upon Liapis' early observation and to clarify the contribution of the speech pathologists in identifying cranial nerve dysfunctions, specifically those resulting in motor speech abnormalities, following carotid endarterectomy.

Adult↗
PubMed1983

Life expectancy and late stroke following carotid endarterectomy.

A review of the UCSD experience with 456 consecutive carotid endarterectomy procedures confirms the acceptably low operative mortality and morbidity associated with this operation. Immediate complications were not different when routine or selective shunting was performed, but the patients with a low internal carotid artery back pressure had higher operative complication rates. The coexistence of atherosclerosis in other parts of the body severe-enough to warrant surgery for them was not associated with either higher early or late carotid surgery complication rates. Following both coronary bypass and carotid procedures, the late mortality was decreased, and the late incidence of stroke was particularly low in comparison to the remainder of the patient group. Late follow-up emphasized the high continuing attrition rate from all causes in these patients. Late strokes continued to occur, particularly in patients with prior strokes and severe preoperative bilateral carotid disease. The late course of patients with posterior circulation transient ischemic attacks treated by carotid endarterectomy was quite similar to that of patients treated for anterior circulation transient ischemia attacks (TIAs). Newer postoperative screening procedures may decrease the incidence of late postoperative stroke by identifying recurrent carotid stenosis while it is still in the asymptomatic stage.

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PubMed1984

Carotid endarterectomy in patients with asymptomatic intracranial aneurysm.

The patient with symptomatic extracranial carotid artery disease who, on angiography, is found to have a coexisting intracranial aneurysm presents a therapeutic dilemma. Relief of the carotid stenosis, with a potential increase in cerebral blood pressure, might increase the risk of aneurysm rupture. Conversely, repair of the aneurysm may be hazardous because of the low flow imposed by the carotid stenosis, particularly in the event of perioperative hypotension. We reviewed 19 patients treated with 20 carotid endarterectomies in the face of concurrent asymptomatic intracranial aneurysm. There were no instances of aneurysm rupture during the operation or the 30 days following operation. The literature reported to date consists of a total of 20 patients with only one incidence of aneurysm rupture in the postoperative period. We conclude that carotid endarterectomy is unlikely to precipitate rupture of an intracranial aneurysm during the operation or postoperative period.

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PubMed1986

Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits.

Emergency revascularization procedures for patients with acute stroke are controversial. Thirty-four patients with acute internal carotid artery occlusion documented at the time of emergency endarterectomy were analyzed. Before operation, all these patients had profound neurological deficits including hemiplegia and aphasia. There was a 94% success rate in restoring patency. In follow-up, nine patients (26.5%) had a normal neurological exam, four (11.8%) had a minimal deficit, 10 (29.4%) had a moderate hemiparesis, which was improved over their preoperative deficit, 4 (11.8%) remained hemiplegic, and seven (20.6%) died. The natural history of patients with acute carotid occlusion and profound neurological deficits is dismal. In comparison, 13 patients (38%) made a dramatic recovery. The surgical mortality rate compares favorably with the natural history. Good collateral flow was a good prognostic factor, while a simultaneous middle cerebral artery embolus was associated with a poorer prognosis. An emergency carotid endarterectomy may be indicated in selected patients with acute internal carotid artery occlusion with profound neurological deficits. Full preoperative angiography may identify those patients who would benefit from surgical intervention and reduce the operative mortality rate.

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PubMed1986

The risk-benefit ratio of intraoperative shunting during carotid endarterectomy. Relevancy to operative and postoperative results and complications.

The relative risk of shunting versus not shunting during carotid endarterectomy was analyzed retrospectively in 1935 cases undergoing carotid endarterectomy for carotid ulcerative stenosis. The need for shunting was based on a correlation between electroencephalographic changes and a fall in cerebral blood flow below the critical level required for adequate perfusion during the period of carotid occlusion. Patients were divided into four risk categories for surgery, based on medical and neurological risks and angiographic findings. Shunts were required in 30% of the low risk group and 56% of the high risk group. Based on the severity of reductions of cerebral blood flow during the period of carotid occlusion it is concluded that 12% of all patients would have sustained a major deficit, 15% a minor or transient deficit, and 20% a transient deficit without shunting. The risk of shunting 792 cases in this series was 0.5%. Overall minor morbidity, major morbidity, and mortality each approximated 1% in this series.

Arterial Occlusive Diseases↗
PubMed1987

A prospective study of vein patch angioplasty during carotid endarterectomy. Three-year results for 801 patients and 917 operations.

From 1983 through 1985, 801 consecutive patients (mean age: 66 years) underwent 917 primary carotid endarterectomies at the Cleveland Clinic. Conventional arteriotomy closure was performed during 483 operations, while patch angioplasty using a distal segment of saphenous vein was employed in 434. Preoperative risk factors, surgical management, and antiplatelet therapy were equivalent in the vein patch (VP) and nonpatch (NP) groups. Early results were evaluated by intravenous angiography (DSA) in 715 patients (89%), and 332 reconstructions (36%) have been reassessed by objective imaging during a mean follow-up interval of 21 months. Ischemic strokes occurred after 18 (1.9%) of the 917 procedures (0.7% VP, 3.1% NP; p = 0.0084), and symptomatic (N = 9) or unsuspected (N = 8) thrombosis of the internal carotid artery was confirmed by neck exploration or routine DSA after 1.9% of all operations (0.5% VP, 3.1% NP; p = 0.0027). Only ten patients (1.2%) have required reoperations for severe recurrent lesions, but the cumulative 3-year incidence of new defects (greater than or equal to 30% stenosis) documented by objective studies in the VP and NP groups was 9% and 31%, respectively (p = 0.0066). These results strongly suggest that VP angioplasty enhances the safety and durability of carotid endarterectomy.

Adult↗
PubMed1993

Impact of completion angiography on operative conduct and results of carotid endarterectomy.

OBJECTIVE: This study assessed the impact of operative completion angiography on conduct and results of carotid endarterectomy (CEA). SUMMARY BACKGROUND DATA: Completion imaging by angiography, ultrasound or angioscopy reveals occasional residual lesions after CEA. The importance and appropriate management of these lesions remain controversial with respect to operative morbidity and long-term restenosis. METHODS: Carotid endarterectomy was performed 410 times for transient ischemic attack (44%), amaurosis fugax (19%), prior stroke (10%), and asymptomatic carotid stenosis (27%). Routine intraoperative completion angiograms were obtained to exclude significant residual lesions. Postoperative ultrasound follow-up was obtained in 232 patients over a mean interval of 17.3 months. RESULTS: Angiography revealed 71 defects warranting correction in 66 cases (16.1%), including kinks (23), external carotid flaps (18), common carotid plaque (10), thrombus (10), distal internal carotid stenosis (8), intracranial occlusion (1), and spasm (1). Operative morbidity included seven ipsilateral strokes (1.7%) and operative mortality was 0.7%. During follow-up, restenosis > 80% was detected in 17 (7.3%) of 232 arteries, 9 (3.9%) of which underwent reoperation. Rates of restenosis of > 80% were similar between sexes and patched versus unpatched arteries. CONCLUSIONS: Routine completion angiography after CEA guides use of selective operative revision contributing to low rates of perioperative morbidity and restenosis.

Adult↗