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PubMed1994

Successful treatment of an acute thrombosis of an intracranial vertebral artery endarterectomy with urokinase.

This is a case report of a 47-year-old man admitted with a 7-month history of disequilibrium, multiple reversible vertebrobasilar ischemic attacks, and one submaximal completed stroke in the left posterior inferior cerebellar artery distribution. Vertebrobasilar ischemic attacks continued despite anti-coagulation, and orthostatic symptomatology suggested a significant hemodynamic component contributing to the posterior circulation ischemia. Angiography confirmed bilateral high-grade stenoses of the intracranial vertebral arteries. A right intracranial vertebral artery endarterectomy was performed with electroencephalographic and somatosensory evoked potential monitoring and protection with barbiturate infusion. The arteriotomy was closed with a vein patch. Postoperatively, the endarterectomy site thrombosed. This thrombosis was completely reversed with 220,000 U of urokinase selectively infused intra-arterially at the site of thrombosis. This procedure was not complicated by hemorrhage or distal embolization. The vertebral artery was confirmed to be patent 24 hours and 7 days after the urokinase injection. The patient sustained a borderzone infarction in the right cerebellar hemisphere without neurological deficits and was discharged home well.

Blood Vessel Prosthesis↗
PubMed1995

Intraoperative urokinase infusion for embolic stroke during carotid endarterectomy.

Embolic stroke is an infrequent complication of carotid endarterectomy. Somatosensory evoked potential monitoring detected delayed acute neurological deterioration during endarterectomy performed on a 71-year-old woman. Intraoperative arteriography performed via an indwelling shunt revealed thrombus within the middle cerebral artery and distal branches. A microcatheter was placed into the internal carotid artery via the arteriotomy and advanced into the middle cerebral artery. Urokinase was infused into and around the thrombus until almost complete thrombolysis had been achieved. The patient recovered quickly and was discharged without neurological deficit.

Aged↗
PubMed2004

Preoperative localization of the carotid bifurcation for carotid endarterectomy using magnetic resonance angiography without tomography: technical note.

OBJECTIVE: Carotid endarterectomy without angiography is becoming increasingly common. Magnetic resonance imaging accurately demonstrates vascular anatomy and the degree of stenosis but may not localize the cervical carotid bifurcation for incision planning without tomography. We report a method for preoperative localization of the bifurcation using the relatively constant axial coplanar relationship between the horizontal petrous (C2) segment of the internal carotid artery and the external auditory canal (EAC). METHODS: The vertical distance between the midpoint of the C2 segment and the cervical carotid bifurcation was measured on magnetic resonance angiography images in five patients. Before surgery, a transverse incision was planned the same distance below the EAC. After exposure, the distance from the EAC to the bifurcation was measured with calipers. The distances from the anterior, posterior, superior, and inferior wound margins during retraction were also measured. RESULTS: The mean vertical distance between the C2 segment and the bifurcation was 7.2 cm on preoperative imaging and 7.6 cm between the EAC and bifurcation using intraoperative measurement (difference, 0.4 cm). The average distances between the midportion of the bifurcation and the wound margins after retractor placement were 2.9, 2.4, 2.8, and 3.5 cm for anterior, posterior, superior, and inferior measurements, respectively. CONCLUSION: The C2 segment-cervical carotid bifurcation distance may be used to estimate accurately the vertical distance from the EAC to the bifurcation. When coupled with a transverse incision for carotid endarterectomy, the use of this preoperative measurement produces a target well centered within the operative field.

Carotid Artery Diseases↗
PubMed2006

High dose magnesium infusions are not associated with increased pressor requirements after carotid endarterectomy.

INTRODUCTION: Although magnesium provides cerebral protection in animal stroke models, magnesium therapy has significant side effects in humans. Therefore, we sought to examine the incidence of alpha-agonist treated hypotension in our ongoing, prospective, randomized, double-blind, placebo-controlled Phase I/IIa dose escalation study of magnesium therapy in patients undergoing carotid endarterectomy. METHODS: Eighty patients undergoing elective carotid endarterectomy were randomly assigned to a placebo control group (n = 38) or to one of the three intravenous magnesium groups. Magnesium levels were obtained before induction, and then 15 minutes, 1 hour, 2 hours, 6 hours, 12 hours, and 24 hours after a loading dose and infusion. After surgery, a target systolic blood pressure range was chosen, and the amount and duration of phenylephrine needed to maintain that pressure was compared across treatment groups. RESULTS: All treatment groups achieved levels significantly different from baseline at 12 and 24 hours (P < 0.01). Magnesium treatment did not significantly increase the proportion of patients requiring pressure support. For those requiring pressure support, the amount and average duration of phenylephrine required was not different between control patients and those receiving magnesium, even when the individual minimum systolic blood pressures required were subdivided on the basis of dose of magnesium administered. CONCLUSION: There were no significant differences detected in the 1) percentage of patients requiring pressor support, 2) the duration of postoperative pressor support, or 3) the amount of phenylephrine support needed between controls and magnesium treated patients. The percentage of patients requiring pressure support depended on the minimum systolic blood pressure ordered after surgery.

Adrenergic alpha-Agonists↗
PubMed1992

Coronary ostial endarterectomy in Takayasu's aortitis--confirmation of patency nine years postsurgically.

A case of Takayasu's aortitis with severe bilateral coronary ostial stenosis is reported. A transaortic coronary endarterectomy was performed and sufficient patency was confirmed angiographically 9 years after the operation. This is the first report of late coronary angiography after a transaortic coronary ostial endarterectomy in Takayasu's aortitis. The efficacy of this procedure for coronary ostial stenosis in Takayasu's aortitis is emphasized.

Adolescent↗
PubMedDate not supplied

Does conversion of intended remote iliac artery endarterectomy alter the early and long-term outcome?

The purpose of this study was to compare the perioperative and long-term results of initial successful remote iliac artery endarterectomies (RIAEs) with converted procedures. From April 1994 to September 2003, 63 remote endarterectomies of the external and/or common iliac artery were planned in 62 patients (41 males, 42 procedures). The median age was 65 years (range 39-83 years), and the indication for operation was severe claudication in 37 (59%), rest pain in 16 (25%), and gangrene in 10 (16%) procedures. Initial technical success was achieved in 56 (89%) procedures (group 1); seven conversions (group 2) were necessary. In group 1, the 5-year primary patency rate improved from 64 +/- 15% to a primary assisted patency of 88 +/- 9.3% after percutaneous transluminal angioplasty in 11 patients, with 7 requiring stent placement. The 5-year secondary patency rate was 94 +/- 7.4%. The primary and secondary patency rates in group 2 were 86 +/- 19% and 100%, respectively. RIAE can be offered to patients with long occlusions of the iliac arteries as a first treatment option. The inherent risk of a possible conversion of an intended RIAE to a more invasive surgical procedure has no significant adverse clinical effect on the early and 5-year clinical outcomes.

Adult↗
PubMed1997

Does carotid duplex imaging render angiography redundant before carotid endarterectomy?

Carotid duplex imaging is now recognized as the best non-invasive screening test for carotid artery stenosis. The evidence for its use as the sole diagnostic imaging modality prior to carotid endarterectomy is examined. Providing it is carried out by experienced trained operators using validated duplex criteria, carotid duplex imaging is safe, highly sensitive and specific, and superior to angiography at plaque characterization and evaluation of flow disturbance. Cerebral CT or MRI should be performed if symptoms are atypical or if there is an evolved stroke. Angiography is required when duplex imaging is suboptimal or equivocal, in the presence of atypical symptoms or uncommon vascular abnormalities. In the majority of patients requiring endarterectomy for symptomatic high grade ICA stenosis, angiography seldom adds relevant information, and clinical assessment and carotid duplex imaging alone can be safely used in preoperative assessment.

Angiography↗
PubMed1999

Carotid endarterectomy under local anaesthesia.

Carotid endarterectomy has been widely used for the surgical treatment of carotid stenosis, and may be performed under either general or local anaesthesia. This article examines the relative merits of both techniques for carotid endarterectomy, and describes the local anaesthetic technique used by the authors for this procedure.

Anesthesia, General↗
PubMed2005

Carotid narrowing degree and plasma thiol levels in carotid endarterectomy patients.

The aim of this work was to study the association between plasma thiol levels and percentage carotid narrowing in a group of 68 patients who underwent a carotid endarterectomy, pertained as a risk factor for vascular and cardiovascular disease. Total plasma thiols were measured by capillary electrophoresis laser-induced fluorescence. The mean values of the hematological parameters studied were within normal limits and 25% of the patients were hyperhomocysteinemic (homocysteine >15 micromol/L). Pearson's correlation between carotid narrowing degree and the most common risk factors for atherosclerosis showed a positive relationship only between carotid narrowing degree and cysteine levels (r=0.252; p<0.05). Stepwise multiple linear regression with carotid narrowing degree as the dependent variable, and cysteine, homocysteine, age, triglyceride and low-density lipoprotein-cholesterol as independent variables confirmed that cysteine was significantly associated with these variables. By regrouping the population according to cysteine and homocysteine concentration percentiles, we found positive correlation between these parameters and median values of carotid narrowing degree. Our study provides experimental evidence to confirm that plasma homocysteine and cysteine are involved in carotid narrowing after carotid endarterectomy intervention, suggesting that cysteine may be involved in the deleterious molecular mechanisms active in carotid stenosis.

Aged↗
PubMed2004

Intraoperative innominate and common carotid intervention combined with carotid endarterectomy: a "true" endovascular surgical approach.

PURPOSE: To report the technique of carotid endarterectomy (CEA) combined with retrograde balloon angioplasty and stenting of proximal "tandem" lesions in the supra-aortic trunk. TECHNIQUE: Intraoperative techniques in 34 patients with 23 left common carotid artery (CCA) and 11 innominate artery lesions included general anesthesia, low-dose dextran, prosthetic patching, selective shunting, 8-F sheath entry into the native CCA before the CEA, manual CCA sizing, and balloon-expandable stent placement after predilation. The technique has a high procedural success rate (97%) and appears durable. Over a mean 34-month follow-up, 2 >70% ostial CCA restenoses were found at 24 months. CONCLUSIONS: Intraoperative innominate or left CCA balloon angioplasty/stenting combined with carotid endarterectomy is safe, effective, and durable.

Angiography↗
PubMed2006

Carotid artery stenting with filter protection in high-risk patients showing severe electroencephalographic alterations during carotid endarterectomy.

PURPOSE: To describe the results and efficacy of stent treatment in patients with carotid stenosis who had aborted carotid endarterectomy procedures due to the appearance of severe electroencephalographic (EEG) alterations. METHODS: A retrospective study was conducted of 18 patients (11 men; mean age 72 years, range 62-84) with symptomatic high-grade carotid artery stenoses (> or = 70%) who experienced severe EEG alterations during carotid endarterectomy, causing the procedure to be aborted. Twelve patients had shown no hemodynamic alterations during preoperative transcranial Doppler evaluation after external compression of the common carotid artery; the remaining 6 could not be evaluated. The patients were referred for carotid artery stenting (CAS); 7 had contralateral internal carotid artery stenosis and 5 had contralateral occlusion. Endovascular intervention was carried out using standard techniques under filter protection. Follow-up was scheduled at 3, 6, and 12 months. RESULTS: All patients were successfully treated without immediate complications. The EEG did not display any significant alterations during the endovascular procedure. Mean follow-up was 43 months. Magnetic resonance imaging at 6 months showed no signs of cerebral ischemia. Color Doppler ultrasound imaging documented normal stent patency in all patients. CONCLUSION: Patients with symptomatic severe carotid stenosis (> or = 70%) who are considered at risk due to the appearance of severe EEG alterations during surgical treatment may benefit from CAS with respect to both major and minor complications. Larger studies are needed to confirm these findings.

Aged↗
PubMed1995

Superficial femoral endarterectomy with intra-arterial PTFE grafting.

PURPOSE: To report early experience with a new endovascular approach to treating occluded Wallstents in the superficial femoral artery (SFA). METHODS AND RESULTS: A symptomatic female patient with a 20-cm SFA occlusion involving a 10-cm Wallstent placed 2 years previously was offered an endovascular intervention. However, when percutaneous recanalization techniques failed, a semiclosed endarterectomy was undertaken using a conventional ring stripper. Although the atherosclerotic core and stent were removed smoothly, a small perforation was seen in the distal SFA. To avoid surgical repair, the endarterectomized segment was lined endoluminally using a 3-mm diameter, thin-walled polytetrafluoroethylene graft. A 15-mm Palmaz stent was used for distal fixation, with a plasty procedure performed at the proximal arteriotomy. There were no postoperative complications, and the patient, who was discharged on the second day, remains asymptomatic with normal flow through the graft at 3 months. CONCLUSION: Newer endovascular techniques may be applied in concert with conventional semiclosed endarterectomy to successfully treat lengthy SFA occlusions, particularly those involving stents.

Arterial Occlusive Diseases↗
PubMed2000

Bilateral carotid endarterectomy combined with myocardial revascularization during the same surgical act.

The best surgical approach for the treatment of patients with severe cerebral artery disease and simultaneous serious coronary artery disease still remains controversial. In this report we present a case of a 72-year-old female patient admitted to the hospital with unstable angina. Triple coronary artery obstructive disease and severe bilateral carotid artery stenosis were diagnosed. A combined, simultaneous surgical procedure was performed. After total circulatory by-pass with a membrane oxygenator, the patient's body temperature was lowered to 32 degrees C. During the cool-down period, three proximal anastomoses of segments of autologous saphenous veins were performed in the ascending aorta. Immediately afterwards, bilateral carotid endarterectomy was performed, followed by three distal anastomoses to coronary arteries. The patient showed a satisfactory post-operative outcome. It was concluded that the combination of moderate hypothermia, hemodilution with appropriate hemodynamic control, as used in this patient, was an effective method of cerebral protection. The simultaneous approach of carotid endarterectomy and coronary artery by-pass surgery should be seen as a safe option for the treatment of this type of patient.

Aged↗
PubMed2006

[Combined carotid endarterectomy and coronary artery bypass grafting. Analysis of the results].

OBJECTIVE: To evaluate the results of combined surgery (carotid endarterectomy and coronary artery bypass grafting) in patients with concomitant carotid and coronary artery disease. METHODS: The authors reviewed 49 different reports describing several aspects of the combined surgery in 4788 patients to analyze early events in the perioperative period. RESULTS: Overall stroke, acute myocardial infarction (AMI), and mortality rates were 4.3%, 2.2%, and 4.2%, respectively. Most recent papers (1990 to 2000) show significant lower incidence of strokes compared to those published earlier (1972 to 1989) (4.1% x 10.2%; p < 0.05). In this same survey, the incidence of postoperative stroke was higher in the series with a small sample (n < 50) than in those with a larger population (n > 100) (7.2% x 3.9%; p < 0.05), denoting the impact of surgeons' experience on postoperative results. CONCLUSION: In sum, we believe that combined carotid endarterectomy and coronary artery bypass grafting is a safe and effective procedure when performed by experienced and qualified surgeons.

Carotid Artery Diseases↗
PubMed1989

Risk of carotid endarterectomy in the elderly.

We used the Medicare claims files to describe operative mortality for 2,089 New England residents over the age of 65 who underwent carotid endarterectomy in 1984 and 1985. For patients ages 65 to 69, the risk of death within 30 days of surgery was 1.1 percent, (95% confidence interval = 0.5, 2.1), for those ages 70 to 74, 2.8 percent (1.7, 4.4), for those ages 75 to 79, 3.2 percent (1.8, 5.2), and for those over age 80, 4.7 percent (2.3, 8.5). Nearly 80 percent of patients underwent surgery at hospitals performing 40 or fewer carotid endarterectomies per year on the Medicare population. The adjusted odds ratio for 30 day mortality for patients undergoing surgery in these low-volume hospitals was 2.8 (95% CI = 1.1, 7.2) compared to higher volume hospitals. Although the Medicare claims data provided only limited data about post-operative strokes, analysis of post-operative stroke risk supported these findings.

Age Factors↗
PubMed1993

Hemodynamic study on flow patterns in the carotid bifurcation before and after carotid endarterectomy using cine magnetic resonance imaging.

Blood flow in the cervical carotid bifurcation was investigated by cine magnetic resonance imaging. In patients without stenosis, a low-intensity stream was demonstrated from the beginning of the carotid bulb, which was more distinct in the systolic phase. In patients with stenotic carotid bifurcations, the low-intensity flow was also present but was more prominent than in the non-stenotic bifurcation. This low-intensity stream may be due to the change from steady to turbulent flow due to the geometric characteristics of the carotid bifurcation or atheromatous plaque, similar to the flow separation phenomenon in fluid dynamics because of the coincidence of location and flow pattern. After carotid endarterectomy, turbulent flow was seen at the proximal and distal ends of the endarterectomy. Close follow-up and administration of antiplatelet agents are necessary to prevent restenosis due to mural thrombosis induced by such turbulent flow.

Carotid Arteries↗
PubMed1993

Clinical application of angioscopy during carotid endarterectomy for patients with internal carotid artery stenosis.

The accuracy of angioscopy in detecting atherosclerotic changes, such as plaque, ulcer, and mural thrombus, in the extracranial cerebral arteries was evaluated during carotid endarterectomy by comparison with angiographic and operative findings. Ten patients with internal carotid artery stenosis underwent intraoperative angioscopy during surgery. After clamping the carotid bifurcation, intra-arterial atherosclerotic lesions were observed with an angioscope (0.8 or 1.4 mm outer diameter) inserted through a small incision in the common carotid artery. Angioscopic findings correlated well with both angiographic and operative findings in six patients, and provided additional information in two patients, such as organized thrombi within the ulcer and mural thrombi. Angioscopic findings were quite different to those from angiograms in two patients. In one, an ulcer on angiograms was false positive, and in the other, false negative. These findings were confirmed intraoperatively. Our results suggest that preoperative carotid angioscopy is of great value in detecting ulcers more accurately than angiography, and in selecting candidates for carotid endarterectomy, although further development of equipment is needed.

Adult↗
PubMed1997

Technical aspects of carotid endarterectomy with Hemashield patch graft.

In this review I describe my method of carotid endarterectomy with synthetic patch angioplasty. The use of Hemashield patch angioplasty is relatively new in my practice, and since I have adopted it I feel it has reduced or eliminated early restenosis and acute postoperative occlusion. The technique is simple and straightforward, and does not require any special preparation of the patch material. The patch is stronger and safer than saphenous vein. The other steps of the endarterectomy are unchanged, and the same suture can be used for patch placement. I also describe here a new commercial shunt which I have developed and which I feel is an improvement over the shunts I previously used. I place an indwelling shunt selectively, if electroencephalography criteria indicate that a shunt is needed. In my series this occurs in 15% of cases, increasing to 25% in patients with contralateral carotid artery occlusion. The overall stroke rate in my carotid artery series is 1.8% at present.

Blood Vessel Prosthesis Implantation↗