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PubMed1976

The improvement of cognition and personality after carotid endarterectomy.

Seventeen patients with at least 50% carotid artery stenosis were given intelligence and personality tests just prior to and 6 weeks after carotid endarterectomy. When compared with nine control patients, the endarterectomy patients showed increases in verbal-comprehension I.Q., perceptual-organization I.Q., decreases in time to complete perceptual motor tasks, decrease in asphasic signs, and significant reductions in anxiety, suspicion, confusion, disorientation, and other personality symptoms generally associated with senility. Statistical evaluation showed these results to be valid.

Aged↗
PubMed1997

Analysis of outcome in carotid endarterectomy trials.

The trials for carotid endarterectomy have had a major impact on the practice of medicine. Beyond demonstrating the efficacy of this procedure for stroke prevention in certain patient cohorts, these studies have set a standard for the evaluation of surgical procedures by carefully planned, scientifically rigorous, prospective randomized controlled trials. In addition, data from these trials have been used to develop clinical guidelines (2, 12, 24), determine reimbursement policies, and establish criteria for perioperative morbidity. Concordance of methodology (especially primary outcome measures) among the various trials has enabled important valid comparisons between different patient cohorts. The benefit provided by carotid endarterectomy in most trials was so profound that the relative imprecision of stroke-related outcome measures did not significantly affect the findings. New outcome measures for stroke that evolved during these studies are being applied to ongoing trials for a variety of stroke therapies.

Carotid Stenosis↗
PubMed1998

[Eversion endarterectomy of the internal carotid artery].

Eversive endarterectomy of the internal carotid artery is an alternative method of conventional endarterectomy from a longitudinal incision. It resolves ulcerative and stenotic affections of the artery along with possible correction of the associated elongation. The operation creates favourable haemodynamic conditions in the area of the carotid circulation.

Carotid Artery, Internal↗
PubMed1999

A clinical comparison of Dacron patch closure of small-caliber carotids compared with primary closure of large-caliber carotids after endarterectomy.

The objective was to study results of carotid endarterectomies performed between 1975 and 1991, comparing primary closure to Dacron patch closure. This was a retrospective study. Data from patient follow-up by physical examination, chart review, and Duplex study were used. Scan data were obtained in 92 of the primary cases, at a mean of 5 years postoperatively, and in 63 of the patch cases, at a mean of 4.1 years postoperatively. During this period, 269 endarterectomies were closed primarily and 101 were closed with a knitted Dacron patch. Twenty patients in the primary group and nine patients with patch closure were lost to follow-up, which extended for up to 12.5 years, with a mean of 4.7 +/- 3.6 years. No acute closures, infections or aneurysms developed in either group. Perioperative stroke incidence was 4.1 per cent for primary closure and 3.0 per cent for the patch group (P > 0.05). Late stenosis occurred in 17.3 per cent of the primary group and 11.1 per cent of the patch closure group (P > 0.05). Five-year survival was 76.2 per cent in the primary group, compared with 79.2 per cent for patch closure. Late stroke incidence was 2.8 per cent in the primary group and 3.3 per cent in the patch closure group. Results of smaller (< or = 3.5 mm) carotid arteries closed with knitted Dacron patches are equivalent to those of larger carotid arteries closed primarily.

Aged↗
PubMed1999

Clamping ischemia, threshold ischemia and delayed insertion of the shunt during carotid endarterectomy with patch.

BACKGROUND: Shunt insertion during carotid endarterectomy (CEA) is mandatory to avoid neurological damage due to clamping ischemia; however shunt insertion before plaque removal has many inconveniences (atheroembolism, intimal dissection, difficulty of endarterectomy). The aim of this study is to verify whether and how long shunt insertion may be safely delayed to permit plaque removal and ensure cerebral perfusion during the further time consuming manoeuvres of CEA (peeling, patch angioplasty). METHODS: From July 1990 to February 1996 383 patients underwent 411 CEAs under general anesthesia with EEG continuous monitoring and PTFE patch angioplasty. A Pruitt-Inahara shunt was routinely inserted only after atherosclerotic plaque removal. In 316 CEAs (76.9%) without EEG signs of cerebral ischemia (Group A) the mean clamping time was 10 min +/-4.8 (range 2-37 min). In 95 CEAs (23.1%) with EEG signs of cerebral ischemia (Group B) it was 7.3 min +/-3.5 (range 3-20 min). All patients had normal EEG signals after delayed shunt insertion and reperfusion (mean 21 min, range 5-45 min). RESULTS: In the short term results (within 30 days) there was a relevant neurological complication rate of 0.96% (2 major stroke and 2 lethal stroke); at awakening we observed 5 RINDs (1.21% of total) 1 in a patient of Group A (0.31%) and the other 4 in patients of Group B (4.21%). CONCLUSIONS: These data confirm the rationale of a delayed insertion of the shunt: actually the cerebral parenchyma may tolerate under general anesthesia a sufferance due to carotid clamping, EEG detectable, without neurological deficits for at least 7.3 min. This time is sufficient to perform the most difficult steps of CEA (plaque removal, distal intima checking) allowing shunt insertion in a clean operatory field, without inconveniences. Finally the shunt allows complementary time consuming steps, as patch angioplasty, with improvement of both short- and long-term results.

Aged↗
PubMedDate not supplied

[Evaluation of middle cerebral artery blood flow velocity with transcranial Doppler in carotid endarterectomy].

Thirty patients, submitted to 34 carotid endarterectomies, from September, 1992 to April, 1996, on Hospital Albert Einstein, São Paulo, have been studied. In these surgeries, Middle Cerebral Artery (MCA) was miniaturized with Transcranial Doppler (TCD). The purpose of this study were to verify the relationship between MCA blood flow velocity with postoperative neurologic complications: studying the velocity variations with risk of cerebral low perfusion and carotid stump back pressure, during carotid clamping; confirming that the TCD information, could show when it is necessary to use shunting, and its efficiency; and to know whether the method could detect intraoperative embolization. The equipment used was a Transpect TCD-EME 2000. During surgery, when carotid stump back pressure was bellow of 54.4 mmHg, Pruitt-Inahara shunt was applied. The flow velocity value observed with TCD was divided in 3 parts: phase 1, basal, since anesthesy induction until carotid clamping; phase 2, clamping, during the period when the carotid artery was occluded; phase 3, post-declamping, from the time the carotid artery was declamping until the end of surgery. The MCA flow velocity was available on three phases, in cm/s and percentually on phases 2 and 3, in relation to basal phase. The embolizations, detected by TCD, were classified in: a) a few embolizations in less than 10 second period, b) many embolizations in more than 10 second period. Based on the results obtained, its possible to conclude that the MCA flow velocity is related to the risk of cerebral low perfusion during carotid clamping; it was not possible to stablish any relation of MCA flow velocity to carotid stump back pressure; the TCD informs when the use of shunt is necessary and its efficiency; the postoperative neurologic complications were caused by embolizations. The conclusion is that the TCD is useful and easily applicated on carotid endarterectomy.

Aged↗
PubMedDate not supplied

Carotid endarterectomy in a community hospital setting: a three-year experience.

The need for all medical institutions that treat carotid artery occlusive disease to continuously monitor their surgical experience is quite evident. Nonetheless, a national survey in 1995 found that only 15% of physicians reported knowing the perioperative stroke rate at the hospitals where they perform or refer patients for carotid endarterectomy. Neurologic morbidity related to the performance of carotid endarterectomy has been continuously monitored at Howard County General Hospital for the past decade, but the true significance of this data could not be appreciated without a more comprehensive analysis of the clinical experience. The present study was undertaken with the intent of providing this information.

Aged↗
PubMed1999

[Total intravenous anesthesia with propofol, fentanyl and ketamine for carotid endarterectomy under somatosensory evoked potential monitoring--combination with intraoperative hypothermia].

We reported anesthetic management combined with hypothermia for carotid endarterectomy under somatosensory evoked potential monitoring. Anesthesia was induced by propofol, fentanyl and ketamine, and maintained by infusion of propofol and ketamine and intermittent injections of fentanyl. Perioperative hypothermia was induced by gradually reducing the temperature of a circulating water mattress underneath the body to 15 degrees C. Additionally, somatosensory evoked potential monitoring was performed and recordings were obtained immediately after induction of anesthesia, and before as well as during cross-clamping of the internal carotid artery. Rectal temperature was reduced to 33.7 degrees C when cross-clamping of carotid artery was carried out, but major changes between before and during the procedure was not observed. All procedures were done uneventfully and gradual rewarming was accomplished by electric blanket. No neurological deficits were observed following recovery from anesthesia. Total intravenous anesthesia with propofol, fentanyl and ketamine may be useful for carotid endarterectomy under hypothermia and somatosensory evoked potential monitoring. This method may provide neuronal protection against ischemia injuries induced by cross-clamping of the carotid artery.

Aged↗
PubMed1999

Selective patching in carotid endarterectomy: is patching always necessary?

BACKGROUND: The value of carotid patching in carotid endarterectomy in achieving low perioperative morbidity and long-term freedom from restenosis is controversial. We hypothesized that if large internal carotid arteries were closed primarily and smaller arteries selectively patched, there would be no difference in early or long-term results between the two groups. METHODS: A retrospective analysis of 133 carotid endarterectomies performed by one surgeon in a community teaching hospital was performed to evaluate a selective approach to patching vs primary closure. Primary closure was performed if the arteriotomy could be closed without tension over a Javid shunt. Seventy-seven arteries underwent primary closure and 56 underwent patching (Vein-14, PTFE-17, Dacron-25). Postoperative (>6 month) duplex scans were available on 46/77 (60%) patients undergoing primary closure, and 33/56 (59%) of patients with patch repair. RESULTS: There were 2 perioperative neurologic deficits, both in the patch group. Restenosis of equal or greater than 50% at 11 months occurred in 5/46 (10.8%) of patients with primary closure and 2/34 patients (5.9%) with patch closure (p=ns). No patient in either group had a late neurologic event or required a redo operation. CONCLUSIONS: Selective primary closure is not associated with increased risk of perioperative neurologic events or statistically significant evidence of late postoperative stenosis if primary closure is performed in large internal carotid arteries.

Aged↗
PubMed1999

[Results of carotid endarterectomy in patients with obliterating atherosclerosis based on data of neuropsychological status and electrophysiologic indices].

The clinical picture and functional indices were investigated in 22 patients with hemodynamically significant stenosis of the major arteries of the carotid basin before and after carotid endarterectomy at the period up to 3 years. It was shown that medical efficiency of the carotid endarterectomy was more pronounced in patients with the intact compensatory blood flow.

Adult↗
PubMed1999

Carotid endarterectomy: improved clinical outcome and reduced length of hospitalization.

AUDIENCE: This exercise is intended for vascular surgeons, neurologists, cardiologists, and primary care physicians caring for persons who are at risk for or who have suffered a stroke. GOAL: To present data from a single institution on the incidence and costs associated with carotid endarterectomy compared with other techniques to diagnose and prevent stroke. OBJECTIVES: 1. Outline the prevalence of stroke in the United States and the role of carotid endarterectomy (CEA) in its treatment. 2. Discuss the various preoperative tests that help determine a patient's suitability for CEA. 3. Discuss the cost implications of stroke prevention.

Adult↗
PubMed2000

[Malfunctioning of cerebral function monitors in three cases of carotid endarterectomy].

In three patients, EEG, jugular venous oxygen saturation (Sjvo2) and near infrared spectroscopy (NIRS) were monitored to detect cerebral ischemia during carotid endarterectomy. In all cases, no changes in Sjvo2 and NIRS were observed during carotid artery occlusion, but in two patients EEG showed changes when carotid artery was clamped. It is important to know the precise mechanism of cerebral monitors to assess the cerebral ischemia in patients with preexisting neurological disorder during carotid endarterectomy.

Arterial Occlusive Diseases↗
PubMed2000

Carotid endarterectomy: general principles and surgical technique.

In this article, the authors describe their standard technique for carotid endarterectomy and discuss the various surgical options and different variations of the procedure. Although there are numerous ways to perform carotid endarterectomy, several basic principles of carotid reconstruction must be adhered to. The surgeon must have complete preoperative knowledge of the patient's vascular anatomy, must maintain complete vascular control at all times, must have sufficient working anatomic knowledge to prevent harm to adjacent structures, and must assure the patient a patent repair that is free of technical errors. The most important factor in assuring a technically acceptable carotid surgery is the availability of a skilled cerebrovascular surgeon who has demonstrable morbidity and mortality rates below 3% and a proper understanding of both vascular principles and cerebral physiology.

Endarterectomy, Carotid↗
PubMed2000

[Conventional thrombendarterectomy with carotid patch plasty vs. eversion endarterectomy: technique, indications and results].

We report our experience with carotid surgery during the past 11 years and a prospective randomized study on 600 patients with conventional thromb-endarterectomy (TEA) versus eversion-endarterectomy (EEA). First results gave EEA a slight advantage, which could not be proved in the following years. Both methods are equivalent in terms of postoperative and long-term results. Follow-up showed one difference between the two methods: Restenosis occurred more often in the TEA-group (14.7% TEA versus 6.5% EEA). The frequency of symptomatic restenosis was the same in both groups (3.8% TEA versus 3.9% EEA). EEA did not show late restenosis. We attribute this to the avoidance of patch-suture and the introduction of patch material, as was observed by other authors. No ruptures of venous patches occurred in our study after primary implantation, while two venous grafts ruptured after substitution of an infected Dacron patch. Infection rate for the Dacron patch was below 0.2% and is therefore negligible. Duplex-ultrasound is indispensable in evaluating plaque-morphology, although sensitivity is low in the detection of dangerous atherosclerotic lesions (73.4% for the soft plaque, 31.9% for ulcerations). In view of these results and a critical analysis of the current literature, we see slight advantages for EEA over TEA inspite of equivalent operative results. However, EEA is a suitable procedure only in connection with subtile intraoperative control and in the hand of an experienced surgeon.

Angiography↗
PubMedDate not supplied

Gas endarterectomy with distal bypass of the coronary arteries.

Carbon dioxide gas endarterectomy was first applied in cases of total occlusion of the right coronary artery. The early technique involved removal of the disease core along the entire length of the vessel. At follow-up, progressive changes were observed to cause segmental stenosis within the proximal and middle portions of the vessel which led to complete reocclusion of the artery at 36 months. In every case, however, the distal branches of the endarterectomized arteries appeared unaffected. On the basis of these results, we have modified our technique. The present treatment involves distal endarterectomy with aortocoronary bypass to the endarterectomized segment. This surgical approach is appropriated only in cases of diffuse atherosclerotic involvement of the distal arterial branches. It can be applied to any one of the three main coronary artery branches and has therefore broadened the range of patient selection for direct myocardial revascularization. The operative mortality in our series of 58 patients was 6.9 per cent (4 patients), but all deaths were associated with such aggravating factors as anerurysm formation, valve disease, and the preoperative evolution of myocardial infarction. The associated morbidity rate was 6.8 per cent; two patients had disruption of the sternal wound, and one suffered uncomplicated myocardial infarction. The fourth patient had a myocardial infarction followed by development of conduction defect and required operation for the insertion of a permanent transvenous pacemaker. To date, follow-up indicates a high patency rate among the surviving 54 patients.

Arizona↗
PubMed1999

Postcarotid endarterectomy symptoms. Pre- and postoperative clinical and MRI findings.

BACKGROUND: The hyperperfusion syndrome represents a highly debated clinical entity, without having yet any clinically identifiable limits. The correlation of clinical with pre- and postoperative magnetic resonance imaging (MRI) findings following carotid endarterectomy in patients with a possible hyperperfusion syndrome was investigated. METHODS DESIGN: Prospective clinical and laboratory study. SETTING: At the Aretaieio University Hospital. MEASURES: Comparison to the postoperative clinical symptomatic and MRI findings. Patients. We studied 30 patients (mean age 66.6) of whom 14 (46.6%) were asymptomatic, 16 (53.4%) were symptomatic, 17 (56.6%) were hypertensive, 18 (60%) hyperlipidaemic, 5 (16.6%) diabetic and 17 (56.6%) had coronary artery disease. RESULTS: Twenty-one patients (70%) exhibited disturbances such as ipsilateral headache, seizures, vomiting or facial pain; immediate postoperative MRI scans revealed new ischaemic foci in 4 (19%) without any objective neurological findings. Lesions displayed in postoperative MRI scans did not always cause symptoms and normal findings on MRI did not exclude the presence of symptoms. Hypertension favoured the presence of subjective disturbances, without necessarily any change in the MRI appearances. Preoperative MRI and clinical findings did not contribute to the identification of patients who might have exhibited postoperative symptoms. Thus, the symptomatology remains unclear and open to debate, as a variety of other conditions may produce the same clinical picture postoperatively. CONCLUSIONS: Subjective disturbances, objective neurological findings and MRI abnormalities with or without hypertension may appear independently after carotid endarterectomy, a fact which makes the pathogenesis of the hyperperfusion syndrome more difficult to elucidate.

Aged↗
PubMed1976

Endarterectomy of the left anterior descending and mainstem coronary arteries: a technique for reconstruction of inoperable arteries.

The proximal left anterior descending coronary artery (PLAD) is an area of predilection for such severe and diffuse calcific arteriosclerosis that reconstruction of these vessels often is impossible. The branches of this segment include the septal perforators, median artery, the left anterior descending coronary artery, and its first and second diagonal branches. Successful endarterectomy, therefore, would revascularize large areas of the left ventricle and interventricular septum. We have performed 45 such operations during the past 13 months. Following endarterectomy there are several methods of reconstructing the endarterectomized vessel, the preferable technique being the addition of a saphenous vein bypass to the endarterectomized segment. Patients selected for this operation were mostly in the fair (58%) and poor risk (42%) categories; there were no good risk patients. Diffuse arterial disease was the rule. The average ejection fraction was 0.48. The operation was successful with respect to graft patency, bypass flow rates, and symptomatic relief. The operative mortality rate in the entire group was 15%, including the 19 poor risk patients in six of whom elective preoperative use of an antra-aortic balloon pump was required. Most of the surviving patients (92%) were either symptom free or greatly improved. Only two patients were clinically unchanged. There was one late sudden death. This operation is indicated when there is extensive involvement of the life main, the proximal left anterior descending coronary artery and its major branches. It is the only possible way to revascularize otherwise inoperable arteries.

Aged↗
PubMed2000

CREST (Carotid Revascularization Endarterectomy versus Stent Trial): background, design, and current status.

The Carotid Revascularization Endarterectomy versus Stent Trial (CREST) contrasts the relative efficacy of carotid endarterectomy (CEA) and carotid angioplasty-stent (CAS) in preventing primary outcomes of stroke, myocardial infarction, or death during a 30-day periprocedural period, or ipsilateral stroke over the follow-up period extending up to 4 years. Stroke events will be verified by an Adjudication Committee masked to the assigned treatment. The primary eligibility criterion is a significant (> or =50%) stenosis of the carotid artery in patients with transient ischemic attack or ipsilateral nondisabling stroke within the prior 180 days. Men and women will be eligible for the trial, but patients with medical conditions likely to limit their participation during the follow-up or to interfere with outcome evaluation will be excluded. After a credentialing and training phase, 2,500 patients will be randomized to the treatments. Statistical analysis of the primary outcome will employ standard survival techniques and will result in 90% power to detect annual differences between groups of 1.2% or higher in event rates of the primary outcomes.

Carotid Stenosis↗