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PubMed1975

Cerebral function before and after carotid endarterectomy.

Twenty men had their cerebral function measured preoperatively and three months after carotid endarterectomy using the Halstead-Reitan neuropsychological test battery. Thirteen patients were cerebrally impaired preoperatively, but 12 of them improved appreciably after surgery. Changes in internal carotid arterial blood flow measured preoperatively showed no significant correlation with the improvement in neuropsychological status. We think that carotid endarterectomy carries an even better prophylaxis for the brain as a whole than had been thought.

Carotid Arteries↗
PubMed1986

Patency and flow velocity profiles in the internal carotid artery assessed by digital subtraction angiography and Doppler studies three months following endarterectomy.

Pulsed Doppler spectral analysis and intravenous digital subtraction angiography have been carried out in 55 patients, three months after a total of 60 carotid endarterectomies. Five patients were operated on both sides and there were no re-operations. There were no re-stenoses and only one of the 60 internal carotid arteries was occluded. Spectral spreading of of the Doppler signal at the site of the endarterectomy was found in 52% of the internal carotid arteries, whereas wall irregularities were demonstrated in 25% by intravenous digital subtraction angiography. A stenosis or occlusion was found in 11 (18%) of the 60 ipsilateral external carotid arteries.

Carotid Artery Diseases↗
PubMed1991

Post-endarterectomy headache and the role of the oculosympathetic system.

A study was carried out on headache after carotid endarterectomy. A specific type of headache, similar in its characteristics to "cluster headache", occurred on the operative side in 30% of 54 patients, whereas no such headache occurred after extra-intracranial bypass or peripheral vascular surgery. This postoperative headache was not spontaneously reported by 56% of patients unless they were specifically asked about it. Pharmacological pupillary testing performed in 37 patients revealed that a decreased oculosympathetic activity (with or without adrenoceptor supersensitivity) was constantly associated with post-endarterectomy headache. Although this same abnormality was also observed in 54% of the patients without headache, a statistically significant (p less than 0.01) higher prevalence of decreased oculosympathetic responses was found in the patients with headache. The results suggest that damage to the sympathetic plexus due to the surgical procedure is involved in the development of postoperative "cluster-like" headache.

Carotid Artery Thrombosis↗
PubMed1997

Carotid artery stenosis: external validity of the North American Symptomatic Carotid Endarterectomy Trial measurement method.

PURPOSE: To assess the generalizability of the North American Symptomatic Carotid Endarterectomy Trial method for determining the degree of stenosis on angiograms. MATERIALS AND METHODS: Six good-quality, baseline angiograms of carotid arteries that were less than 70% stenosed were reviewed by 14 experienced neuroradiologists at different academic institutions. All reviewers determined the degree of stenosis by calculating the ratio of the diameter of the artery at the point of maximal narrowing to the normal diameter distal to the stenosis (well beyond the carotid artery bulb). The reviewers marked the location of their measurements on the angiogram. Comparisons were performed among the reviewers' results and with the reference measurements. RESULTS: Interobserver agreement was 0.84 (95% confidence interval = 0.65, 0.97). The average interobserver disagreement of +/-7% was comparable with that reported in the literature. The overall bias was 6%, which indicated a tendency of the reviewers to overestimate the degree of stenosis in comparison with the reference determination. CONCLUSION: The North American Symptomatic Carotid Endarterectomy Trial reference measurements can be generalized beyond the bounds of this clinical trial, provided that attention is paid to details of the measurement method.

Angiography↗
PubMedDate not supplied

Impact of carotid endarterectomy upon cognitive functioning. A systematic review of the literature.

BACKGROUND AND PURPOSE: The extent to which carotid endarterectomy (CEA) influences cognitive functioning has been the subject of a number of studies often with conflicting conclusions. This paper systematically reviews the literature in an attempt to clarify this issue. RESULTS: Although the majority of studies (16/28) reported an improvement in cognition after surgery, a substantial minority (12/28) found no change. Studies before 1984 tended to report an improvement, while later studies tended to report no change in cognition. Cognitive improvement was also more likely the longer the time interval between CEA and assessment. The studies were found to differ on many methodological factors, e.g. sample size, type of patient and control group, severity and side of carotid stenosis, the range of cognitive tests and timing of postoperative assessment. CONCLUSION: Given the conflicting findings, and the methodological issues, it is not possible to draw a clear conclusion regarding the impact of carotid endarterectomy upon cognition. Future research which pays attention to these methodological factors is needed in order to adequately resolve the current debate.

Carotid Arteries↗
PubMedDate not supplied

A follow-up analysis of transient ischemic attack patients suggests unsatisfactory disease management and possible underutilization of carotid endarterectomy in Lazio, Italy.

We evaluated the disease management of transient ischemic attack in patients admitted to Lazio hospitals from July 1997 to June 1998. We assessed the effects of patient characteristics including chronic comorbidities on the use of diagnostic procedures, endarterectomy, and on the risk of adverse cerebrovascular outcome or death. There were 2,608 patients in the study who were followed up over a 18- to 30-month period. Carotid surgery was performed on 1.15% of the subjects, total mortality was 34.7 per 1,000 person-years and adverse cerebrovascular outcome was observed in 38.1 per 1,000 person-years. Chronic comorbidities did affect the mortality rate and the rate of adverse outcome, but not the rate of endarterectomies. Carotid surgery was infrequently performed in study subjects. It seems that this potentially stroke-preventive treatment was not offered to suitable candidates in many instances.

Aged↗
PubMed2004

The Stent-Supported Percutaneous Angioplasty of the Carotid Artery vs. Endarterectomy Trial.

The Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE) Trial is investigating if both treatment modalities are equivalent in the treatment of severe symptomatic carotid stenoses. Patients with symptomatic (transient ischaemic attack or minor stroke) stenosis (above 50% following the North American Symptomatic Endarterectomy Trial criteria) eligible for both methods can be recruited into this trial. The primary endpoint is the incidence of an ipsilateral stroke or death between randomisation and day 30 after treatment. Surgeons as well as the interventionalists have to demonstrate their expertise prior to participation in the trial. Funding is mostly by public institutions (Federal Ministry of Education and Research and German Research Foundation). An external monitoring is applied. Thirty-two centres are currently taking part in the SPACE Trial that has been running in Germany, Austria and Switzerland for 3 years, and they have been able to recruit a total of around 670 patients. The definitive results of this study cannot be expected before 3-5 years.

Angioplasty↗
PubMed2006

Primary stroke unit treatment followed by very early carotid endarterectomy for carotid artery stenosis after acute stroke.

BACKGROUND: Although it is recognized that carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery (ICA) stenosis, in the past, very early CEA has been shown to carry substantial risks. We assessed an interdisciplinary concept of very early CEA in patients with high-grade (>70%) symptomatic ICA stenosis at a single center. PATIENTS AND METHODS: The course of treatment and outcomes of patients who underwent CEA as early as possible after being referred to the stroke unit for symptoms of transient ischemic attack and stroke were prospectively evaluated, including the following parameters: age, severity of ischemia-related symptoms according to the modified Rankin scale, duration of symptoms until admission, multimodal imaging findings (color-coded duplex, cranial computed tomography, magnetic resonance imaging, positron emission tomography), duration until CEA, perioperative course and complications, as well as duration of in-hospital care. RESULTS: Fifty consecutive patients (median age 68 years, range 44-90) with clinical and imaging signs of transient ischemic attack (n = 19) or stroke (n = 31) were included from January 2000 until December 2004. All except 1 patient showed a preoperative Rankin < 4. There was a median time period of 6 h between the onset of symptoms and admission (range 1 h to 15 days) and a median duration of 4 days after admission until operation (range 1-21 days). Seven patients underwent CEA of the contralateral, severely stenosed ICA after symptomatic ipsilateral ICA occlusion. Four out of 5 patients who primarily underwent systemic thrombolysis recovered almost completely. Three patients (6%) experienced a clinical deterioration before surgery. In the majority of patients (43/50), CEA was performed under local anesthesia with selective shunt use which became necessary in 26%. Three patients (6%) had postoperative worsening due to new infarcts. In 2 cases, an intracerebral hemorrhage occurred, of which 1 remained asymptomatic. In 1 case, surgical revision was necessary because of an ICA thrombosis without permanent neurological decline. Patients were discharged after a median time of 14.5 days (range 4-44). CONCLUSIONS: After careful selection and preparation in a stroke unit, patients with acute stroke due to carotid stenosis can undergo very early CEA under local anesthesia with a perioperative risk comparable with the risk of later endarterectomy, therefore preventing very early stroke recurrences.

Adult↗
PubMed2006

How good is the management of vascular risk after stroke, transient ischaemic attack or carotid endarterectomy?

BACKGROUND: Patients remain at high risk of vascular events after stroke, transient ischaemic attack or carotid endarterectomy. We studied how well this risk is addressed by the effective treatment of modifiable risk factors. METHODS: A total of 198 consecutive attenders at a rapid access stroke clinic and 98 consecutive patients undergoing carotid endarterectomy were studied. Treatment of hypertension and hyperlipidaemia, smoking status and the use of antithrombotic therapy were assessed at baseline and 6 months later. The findings were compared with targets from the UK National Clinical Guidelines for Stroke. RESULTS: Baseline and follow-up data were available on 284 patients. The rates of control of vascular risk factors improved only slightly during follow-up. Blood pressure was below target levels in only 69 (24%) at baseline and 79 (28%) at 6 months, and serum cholesterol was below target levels in only 55 (19%) at baseline and 63 (22%) at 6 months. At baseline, 55 (19%) were smokers, of whom 12 (22%) had quit at 6 months. Anticoagulant therapy was prescribed in 19 of 37 patients (51%) in atrial fibrillation at 6 months. Antiplatelet therapy was prescribed in 90% of patients in sinus rhythm. CONCLUSIONS: Despite the identification of vascular risk factors at the time of clinic or surgery, 6 months later these risk factors remain poorly addressed. More effective methods of managing vascular risk in these patients are needed.

Aged↗
PubMed1986

Long-term prognosis after carotid endarterectomy.

This study analyzed 76 consecutive patients with carotid transient ischemic attacks (TIA) and carotid lesions appropriate to symptoms who underwent endarterectomy during the period 1975-1981. The mean age of the patients was 51.9 +/- 8 years at the time of surgery. Hypertension was present in 32.9%, diabetes mellitus in 13%, ischemic cardiopathy in 8.2% and peripheral vascular disease in 6.6%. Operative mortality was 1.3% and harder morbidity 4%. The average follow-up was 2.6 years (range 1-7 years). The observed 5-year survival rate was 85.2% compared to the expected rate of 92.4% in a normal population. During the follow-up 5 patients had a stroke: the cumulative stroke rate was 4.6% at 1 year and 7.9% at 3 years. 18 patients had further TIAs (13 carotid TIAs and 5 vertebro-basilar TIAs). 6 patients suffered myocardial infarction. The prognosis of TIA patients treated with endarterectomy is difficult to evaluate because the natural history of TIAs is still undefined.

Actuarial Analysis↗
PubMed2000

Specific cellular features of atheroma associated with development of neointima after carotid endarterectomy: the carotid atherosclerosis and restenosis study.

BACKGROUND: The purpose of this study was to investigate whether some cellular and molecular features of tissue retrieved at carotid endarterectomy are associated with the extent of neointima formation at ultrasound follow-up. METHODS AND RESULTS: One hundred fifty patients were studied. Endarterectomy specimens were tested by immunocytochemistry with the use of (1) monoclonal antibodies that identify smooth muscle cells (SMCs) and fetal-type SMCs on the basis of smooth muscle and nonmuscle myosin content, (2) the anti-macrophage HAM 56, and (3) the anti-lymphocyte CD45RO. The maximum intima-media thickness (M-IMT) of the revascularized vessel was assessed by the use of B-mode ultrasonography 6 months after surgery. The M-IMT values were related positively to the number of SMCs (r=0.534, P<0.0005) and negatively to that of macrophages and lymphocytes (r=-0.428, P<0.0005, and -0.538, P=0.001, respectively). Patients were classified as class 1 (M-IMT </=1.0 mm), class 2 (1. 0 1.3 mm). An abundance of SMCs, mostly of fetal type, was found in the plaque of class 3 patients, whereas lesions from class 1 patients were rich in macrophages and lymphocytes. In the multivariate analysis, factors related to M-IMT were the number of SMCs and the percentage of fetal-type SMCs present in the plaque. CONCLUSIONS: Although the classic risk factors did not play a role, an abundance of SMCs and a scarcity of macrophages characterized the primary lesion of patients in whom neointima developed after surgery. In patients in whom neointima did not develop, lesions were rich in macrophages and lymphocytes. This approach can be useful in defining patients at risk of restenosis.

Aged↗
PubMed1992

Relation of plasma lipid and apoprotein levels to progressive intimal hyperplasia after arterial endarterectomy.

BACKGROUND: To examine the relation of plasma lipoproteins to the proliferative response after arterial injury in humans, we examined the plasma lipid, lipoprotein, and apoprotein levels of 20 patients with early recurrent stenosis caused by intimal hyperplasia after carotid endarterectomy. These were compared with 20 controls who had no evidence of recurrent stenosis by duplex ultrasound scanning. METHODS AND RESULTS: By univariate analysis, the reoperated patients had higher levels of plasma cholesterol (251 versus 225 mg/dl, p less than 0.05), total triglycerides (173 versus 105 mg/dl, p less than 0.03), and low density lipoprotein (LDL) apoprotein B (99.8 versus 77.2 mg/dl, p less than 0.003). The ratio of cholesterol to apoprotein B in LDL was lower in patients with restenosis (p less than 0.04), suggesting LDL of smaller diameter. High density lipoprotein (HDL) cholesterol level was reduced (45 versus 55 mg/dl, p less than 0.01) in patients with restenosis. With statistical adjustment for the correlations between these variables by multivariate analysis, both LDL apoprotein B and HDL cholesterol were independent predictors of the risk of restenosis. Ten patients with restenosis but only two controls had one or two apolipoprotein E4 alleles. CONCLUSIONS: Elevated lipid levels usually associated with an increased risk of atherosclerosis may predispose patients to an increased incidence of intimal hyperplasia after endarterectomy.

Aged↗
PubMed2002

Computed tomography angiography for the evaluation of carotid atherosclerotic plaque: correlation with histopathology of endarterectomy specimens.

BACKGROUND AND PURPOSE: The goal of this study was to determine the efficacy of CT angiography for the characterization of plaque morphology and composition in carotid atherosclerotic disease. METHODS: Fifty-five patients undergoing carotid endarterectomy were imaged preoperatively with single-slice spiral CT angiography. One hundred sixty-five endarterectomy sections were examined histologically at selected levels through the distal common and proximal internal carotid arteries. Plaque density was measured (in Hounsfield units) on axial CT sections, and the presence or absence of ulceration was noted. These observations were compared with the histological findings at corresponding levels. Data were analyzed with 2-sample t tests and 1-way analysis of variance (ANOVA). RESULTS: ANOVA testing showed a statistically significant decrease in CT attenuation values with increasing plaque lipid but with a very high standard deviation of values. No other histological factor showed a statistically significant link with CT attenuation. Plaque ulceration was detected by CT with a sensitivity of 60% and a specificity of 74%. CONCLUSIONS: Analysis of plaque attenuation with single-slice spiral CT does not give useful information concerning plaque composition. The predictive value of CT for the detection of plaque ulceration was moderate. Single-slice CT angiography is insufficiently robust to be a useful tool for the characterization of carotid plaque composition and morphology.

Analysis of Variance↗
PubMed2002

Autoantibodies against oxidatively modified lipoproteins and progression of carotid restenosis after carotid endarterectomy.

BACKGROUND: The purpose of this study was to determine whether LDL oxidation could play an important pathogenic role in early restenosis after carotid endarterectomy. An immunologic and biochemical study was performed on a group of patients who underwent carotid endarterectomy, and the degree of intima-media thickness was measured 6 months after surgery. SUMMARY OF REPORT: Fifty-two consecutive patients were included in the study. The presence of antibodies against oxidized LDL in the serum at the time of surgery was evaluated and compared with echo Doppler flow imaging 6 months after the operation. A statistically significant correlation was found between the arterial wall thickness at the site of surgery and the absolute value of IgG antibodies against oxidized LDL (P<0.012) and IgM immunocomplexes (P<0.043). CONCLUSIONS: The presence of antibodies against oxidized LDL at the time of surgery seems to predict a greater intima-media wall hyperplasia at 6 months after surgery, usually recognized as early restenosis.

Aged↗
PubMedDate not supplied

Ineffectiveness of the Doppler Ophthalmic Test (DOT) in post-endarterectomy evaluation.

In an effort to evaluate the effectiveness of the Doppler Ophthalmic Test (DOT) following carotid endarterectomy, a large group of patients was examined both pre- and postoperatively with non-invasive techniques. The DOT, which has proven to be a useful non-invasive diagnostic test for the determination of significant carotid artery stenosis, was found to be persistently abnormal in 46% of patients with a preoperative positive test. This occurred in spite of the fact that operative arteriography, direct ultrasonic auscultation, and Doppler imaging studies were all within normal limits. It is suggested from this study that the Doppler Ophthalmic Test alone is not adequate to follow patients postoperatively, especially if an abnormal study persists following a satisfactory endarterectomy. Other non-invasive techniques, which employ direct ultrasonic imaging of the carotid flow, may be more accurate in determining vessel patency.

Carotid Arteries↗
PubMedDate not supplied

Steal phenomenon at unclamping during carotid endarterectomy.

A patient is reported who during vigorous back bleeding after unclamping of the internal carotid artery during endarterectomy had EEG slowing and a postoperative increase in neurological deficit. This phenomenon, an apparent steal, has not been reported and suggests that EEG monitoring is as vital at unclamping as it is after clamping. The patient also raises questions about the risk of early endarterectomy for those who have persistent deficits, even with unobstructed vessels.

Arterial Occlusive Diseases↗
PubMedDate not supplied

Asymptomatic carotid disease in the cardiovascular surgical patient: is prophylactic endarterectomy necessary?

This prospective study used non-invasive techniques to screen for asymptomatic carotid occlusive disease in 314 patients who were to have coronary or peripheral arterial reconstruction. Hemodynamically significant carotid obstruction (greater than or equal to 50% stenosis or occlusion) was present in 54 arteries of 41 patients (13.1%), but only one-third of these lesions were accompanied by a cervical bruit. Among 48 carotid arteries where a bruit was heard, only 18 (37.5%) were associated with significant obstruction demonstrated by non-invasive screening. No prophylactic carotid endarterectomies were performed. There was only one perioperative TIA and one non-fatal stroke, neither of which was related to detectable carotid obstruction. In patients with peripheral vascular disease and detectable carotid obstruction or bruit, the perioperative mortality was higher than in patients without carotid obstruction or bruit (15.0% and 18.2 vs 3.1% and 2.1%, respectively). The deaths were primarily due to myocardial infarction. This study suggests that asymptomatic carotid occlusive disease, while common in patients with other cardiovascular disease, does not necessarily predispose to perioperative stroke and thus does not necessitate prophylactic carotid endarterectomy prior to indicated coronary or peripheral vascular reconstruction.

Adult↗
PubMedDate not supplied

Cranial nerve paralysis following carotid endarterectomy.

During the past seven years 347 patients have been entered into a data bank at the Duke University Medical Center for evaluation of transient neurologic ischemia. One hundred fifty eight of these patients had carotid endarterectomies of whom 24 (15.1%) developed 26 (16.4%) peripheral cranial nerve palsies. Injury to the peripheral portion of the hypoglossal nerve was noted in 13 patients, to the cervical branch of the facial nerve in five and to the recurrent laryngeal nerve branch of the vagus in eight. Complete recovery of nerve function usually occurred within four months but residual deficit was present at one year in two patients with facial nerve and four with hypoglossal nerve involvement. Even though these complications of carotid endarterectomy are generally benign and transient, the frequency of occurrence can be reduced if careful attention is given to anatomic localization of the cranial nerves during surgery.

Aged↗