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PubMed2000

[The flowmetric assessment of the adequacy of carotid endarterectomy].

The authors made an analysis of ultrasonic flowmetry in 36 operations of carotid endarterectomy in 22 patients with stenosis of brachiocephalic arteries. After removal of atherosclerotic plaques the volumetric blood flow in carotid arteries increased from 65-260 ml/min up to 210-400 ml/min. No substantial difference was noted between the increase of blood flow after classical endarterectomy and after the formation of a new carotid bifurcation. Flowmetry allows the estimation of adequacy of vascular reconstruction and the choice of correct management of the patients at the postoperative period.

Aged↗

PubMed2000

Supervised training of general surgery residents in carotid endarterectomy performed on awake patients under regional block is safe and desirable.

Previous studies have documented the safety and efficacy of general surgery residents and vascular fellows performing carotid endarterectomy (CEA) under the supervision of an attending surgeon. With the proper supervision of the attending surgeon, these operations can be performed with an acceptably low perioperative stroke and mortality rate. The question remains, however, whether these desirable results can be obtained by general surgery residents when operating on awake patients under regional block (RB) anesthesia. We set out to determine whether it is prudent to promote this technique in this teaching setting. We analyzed 128 CEAs performed at a community teaching hospital training three chief residents a year. These operations were performed by residents under the direct supervision of a single attending vascular surgeon. RB was preferred and was used in 67 operations. General anesthesia (GA) was used in the remaining 61 procedures. Overall mortality was 0 per cent. Patients in the RB group were converted intraoperatively to GA in 4 of 67 (6%) procedures. There was one perioperative stroke in this series (1/128, 0.78%), occurring in a patient under RB (1/67, 1.5 %) leaving the patient with a minor sensory deficit. No strokes occurred in the GA group. There were five temporary cranial nerve deficits (3.9%). Three were in the RB group (4.5%) and two in the GA group (3.3%). General surgery residents can be trained in the performance of carotid endarterectomy using regional block anesthesia in awake patients without compromising patient safety. Suggestions to the effect that only attending physicians and/or vascular fellows can perform these procedures under regional block are without merit.

Aged↗

PubMed2000

[Acute glaucoma following endarterectomy of internal carotid artery].

A 71 year-old woman had 85% and 60% stenoses of the right and left internal carotid arteries, respectively. Right-sided endarterectomy was performed because of amaurosis fugax. Two days postoperatively, she developed classical symptoms and signs of acute glaucoma. Right-sided acute angle closure glaucoma was diagnosed by tonometry and gonioscopy, and treated with laser-iridectomy. The patient was discharged two days later without neurological or ophthalmological deficits. Manifest acute glaucoma postoperatively seems never to have been reported. However, the choroid is not autoregulated, and the intraocular pressure has been reported to increase after internal carotid-endarterectomy.

Acute Disease↗

PubMedDate not supplied

Carotid endarterectomy without pre-operative angiography.

Carotid endarterectomy is being performed with increasing frequency without the benefit of preoperative angiography, based purely on duplex scanning. The available data attest to its safety, with the caveats that the duplex scan is unimpeachable, and that the symptoms and duplex scan findings are consistent. Given the well documented risk of stoke as a consequence of cerebral angiography being at least 1%, the elimination of this risk by the omission of contrast angiography would reduce the neurological morbidity and mortality rate of the diagnosis and treatment of carotid bifurcation disease by approximately 50%. The available data make a compelling case for carotid endarterectomy based on duplex scanning, without preoperative angiography, as the preferred approach to treatment of carotid artery stenosis.

Cerebral Angiography↗

PubMed2000

Is semi-closed endarterectomy of the superficial femoral artery combined with a short venous bypass in case of insufficient venous material an acceptable alternative for limb-threatening ischemia?

BACKGROUND: The aim of this study was to analyse the results of infragenual arterial revascularisation using semiclosed endarterectomy of the superficial femoral artery combined with a short venous bypass in patients with critical leg ischemia and insufficient venous material for a straightforward femorocrural reconstruction. METHODS: From December 1990 through December 1998 thirty patients were studied (22 males and 8 females; mean age 65 years, range 31-92 years). The mean follow-up was 26 months (range 1-96 months). Cumulative primary patency and limb salvage rates were calculated according to life-table analysis. RESULTS: The cumulative primary patency was 60.3% at 1 year and 48.4% at 3 years. The limb salvage rate was 68.6% at 1 and at 3 years. CONCLUSIONS: In patients with limb-threatening ischemia and lack of venous material for a straightforward venous femorocrural bypass, semi-closed endarterectomy of the superficial femoral artery combined with a short popliteo-crural bypass provides a good alternative.

Adult↗

PubMed2001

Carotid angioplasty with stenting in post-carotid endarterectomy restenosis.

Recurrent stenosis post-carotid endarterectomy (CEA) is not a solitary or unusual phenomenon. Compared to the initial CEA, the reoperation is often more technically challenging and frequently results in local and neurological complications. Carotid artery angioplasty with stenting (CAS) is currently being investigated as an alternative to carotid endarterectomy. In our study, ninety-nine patients underwent CAS in 110 arteries. Procedural success was 99% (109/110). Our results show that CAS treatment in post-CEA restenosis, especially with improved technique and distal protection, is safe with a low neurological complication rate, without any "local" complications and without any cranial nerve palsies. This study suggests that the future primary mode of treatment of post-CEA restenosis might be carotid stenting rather than surgery.

Aged↗

PubMed2000

Cranial nerve dysfunction following carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is the most common surgical procedure performed for the treatment of symptomatic carotid stenosis greater than 70%. Among the recognised complications, such as stroke and myocardial infarction, is injury to cranial nerves. METHODS: We report the incidence and follow-up of cranial nerve injury in 269 patients who underwent carotid endarterectomy between January 1994 and December 1997 at the Royal Liverpool University Hospital. RESULTS: Fifteen cranial nerve injuries were documented (5.6%). Seven patients (2.6%) had unilateral vocal cord paralysis, nine (3.3%) hypoglossal palsy, two (0.7%) glossopharyngeal nerve injury and one (0.4%) facial nerve palsy (marginal mandibular nerve). All patients showed improvement within a few weeks and none had residual disability at the last follow-up (two weeks to 14 months). CONCLUSIONS: Patients manifesting symptoms of cranial nerve dysfunction should undergo a thorough otolaryngological evaluation and long-term follow-up. Most cranial nerve injuries are transient and result from trauma during dissection, retraction or carotid clamping. Knowledge of cranial nerve anatomy is essential if the surgeon is to avoid such injuries.

Aged↗

PubMedDate not supplied

[Cranial and neck nerve injuries following carotid endarterectomy intervention. Review of the literature].

The aim of the study was to establish the operative techniques and findings that can influence the reported incidence of cranial and cervical nerve injuries. Eight main studies comprising 1,616 carotid endarterectomies and published over the period from 1990 to October 2000 were reviewed. There were no statistically significant differences between neck incision (vertical or transverse) and number of injuries. In one study, multiple deficits were observed most frequently in patients treated by the eversion technique (P = 0.2). Additional prospective trials are needed in large numbers of patients to assess the incidence of cranial and cervical nerve injuries. Most injuries are transient and involve the vagus and hypoglossal nerves. A number of factors related to the operation, such as general anaesthesia, eversion technique and the surgeon's experience, may influence the incidence of such injuries. Repeat endarterectomy is associated with a high incidence of cranial and/or cervical nerve injuries. This is extremely important for establishing the real advantage of endovascular angioplasty or stenting of the carotid artery.

Aged↗

PubMed2001

Detection of clinically silent infarcts after carotid endarterectomy by use of diffusion-weighted imaging.

BACKGROUND AND PURPOSE: Intraprocedural transcranial Doppler sonography has identified multiple microembolic events during and immediately after carotid endarterectomy (CEA) or angioplasty, yet the rate of clinically evident stroke is small. To determine the significance of the transcranial Doppler sonography findings, we examined patients by use of diffusion-weighted imaging and fluid-attenuated inversion recovery MR imaging before and immediately after CEA for evidence of clinically silent ischemic events. METHODS: Twenty-five patients with atherosclerotic disease of the carotid arteries underwent diffusion-weighted imaging and fluid-attenuated inversion recovery MR imaging performed, on average, 3 days before and 12 hours after CEA. Diffusion-weighted images were acquired in three orthogonal directions at b = 900. Pre- and postoperative neurologic examinations were performed by the same physician. RESULTS: After endarterectomy, 4.0% of the patients (one of 25 patients) showed a single, cortical focus of restricted diffusion and new fluid-attenuated inversion recovery hyperintensity, measuring <1 cm in diameter, ipsilateral to the CEA. The postoperative neurologic examination showed no change in status from the preoperative baseline state. This patient had an intraoperative course complicated by the development of a large luminal thrombus, necessitating thrombectomy. CONCLUSION: The use of diffusion-weighted imaging may serve to improve conspicuity of clinically silent infarcts after CEA. An important next step is to determine the risk factors that predispose to detectable parenchymal ischemic events.

Aged↗

PubMed2001

[Arterial autograft reconstruction of the internal carotid artery after endarterectomy using the superior thyroid artery].

The author presents his experience with the technique of alternative plastic closure of longitudinal arteriotomy of the internal carotid artery (ACI) using an autoarterial graft from the ipsilateral arteria thyroidea superior (ATS) [1]. Autoarterial plastic operations were sued so far in eight patients, in six instances endarterectomy of a primary ACI stenosis with a narrow lumen was involved, and in this group in two instances a peripheral intimal step was involved. In two instances an autoarterial patch was used after resection of kinking of the thin ACI. The graft is collected from an incision commonly used in plastic operations of carotid endarterectomy and takes roughly 10 minutes. In all instances ATS provided enough material, although in two instances it had a rather thin lumen. The described plastic operation is rapid, effective, limited to one surgical field and easily performed. The favourable results of subsequent sonographic controls of the patency of the reconstructed ACI, implemented so far 1-2 years after surgery confirm that this technical solution is suitable.

Arteries↗

PubMed2000

Post carotid endarterectomy seizure.

Post carotid endarterectomy seizure is a known clinical presentation in patients who suffer from hyperperfusion syndrome. This case focuses on the importance of identification of high risk patients for developing this syndrome and delaying their discharge from the hospital after successful carotid endarterectomy.

Aged↗

PubMed2001

Neurobehavioral effects of carotid endarterectomy.

OBJECTIVE: Nineteen patients with symptomatic carotid stenosis (>70%) were subjected to carotid endarterectomy in a prospective study to evaluate neurobehavioral changes before and 6 months following the operation. METHODS: All patients were subjected to neurobehavioral rating scale one week before and 6 months after the operation. RESULTS: There were no significant changes in the 27 items of this scale before and 6 months following the operation. Some patients showed no difference at all in some items of this scale before and after operation such as suspiciousness excitement, speech and articulation using Mann-Whitney rank test, P values were (> 0.05) as regards to all items of neurobehavioral rating scale. CONCLUSION: Uncomplicated carotid endarterectomy does not seem to be associated with significant long time neurobehavioral impairment following the operation.

Carotid Stenosis↗

PubMed2001

Completion angioscopy following carotid endarterectomy by the eversion technique or the standard longitudinal arteriotomy with patch closure.

INTRODUCTION: Technical defects are a potential cause of peri-operative strokes following carotid endarterectomy (CEA) by either the eversion technique or the standard method of longitudinal arteriotomy with or without patch closure. AIM: A non-randomised retrospective study was undertaken to assess the value of angioscopy for the identification of technical errors following CEA and to compare those detected following eversion and standard endarterectomy with patch closure. MATERIALS AND METHODS: Intra-operative completion angioscopy was performed following 110 CEAs (56 eversion, 54 standard). Angioscopy was omitted in 5 patients because of technical problems (2) or extreme shunt dependency (3). RESULTS: Significant technical defects were identified and corrected in 10 cases (9%) and were equally distributed between the eversion and standard procedures. There was no peri-operative stroke or death in this series. CONCLUSIONS: Significant residual defects may occur after CEA by either technique. Angioscopy allows their correction peri-operatively and has the potential to reduce peri-operative stroke.

Adult↗

PubMed2001

Predictors of carotid endarterectomy in middle-aged individuals.

The objective was to investigate which screening variables in a population study predicted carotid endarterectomy. Among 793 carotid endarterectomies performed at Malmö University Hospital between 1991 and 1998, 85 patients (14 females) were identified that had participated in a population screening between 1974 and 1991. Median time from screening to operation was 16 years (range 6-26 years). Screening variables were compared with corresponding values from the background screening population (n = 33261). As operated patients were older than the background population at screening (49 [37-60] vs. 46 [26-61] years; p < 0.0001), comparisons were age-adjusted. Operated patients had higher systolic blood pressure (SBP; 130 [126-133] vs. 125 [125-125] mmHg; p < 0.01), serum total cholesterol (6.1 [5.9-6.3] vs. 5.7 [5.7-5.7] mmol/l; p < 0.0001), serum triglyceride (1.4 [1.3-1.6] vs. 1.1 [1.1-1.1] mmol/l; p < 0.0001), serum glutamic acid transferase (0.46 [0.40-0.53] vs. 0.40 [0.40-0.41] microkat/l; p < 0.05), and plasma fibrinogen (3.77 [3.42-4.16] vs. 3.35 [3.30-3.41] mmol/l; p < 0.05) levels, a lower 120-min insulin/glucose ratio at an oral glucose tolerance test (OGTT; 0.48 [0.38-0.58] vs. 0.60 [0.59-0.61]; p < 0.05) and forced vital lung capacity (3.7 [3.6-3.9] vs. 3.9 [3.9-4.0] l/min; p < 0.05), and a higher prevalence of smoking at screening (68% vs. 45%; p < 0.0001). Smoking, SBP, serum total cholesterol, and the 120-min insulin/glucose ratio remained independent predictors for carotid surgery in multivariate analysis. No differences existed among patients operated on because of symptomatic and asymptomatic stenosis. In conclusion, increased SBP and total cholesterol, lower 2-h insulin/glucose ratio at an OGTT, and smoking predict carotid surgery at long-term follow-up.

Acyltransferases↗

PubMedDate not supplied

[Severe and prolonged EEG depression after induction of general anesthesia for carotid endarterectomy. Report of a clinical case].

A large number of methods are available for intraoperative neurologic monitoring during endarterectomy, although no single method is infallible. Debate over choice of regional or general anesthesia for this surgery persists because of differing conclusions of various studies of risks and benefits. The case of patient undergoing left carotid endarterectomy under general anesthesia is described, in whom after the induction of anesthesia with: midazolam 2 mg, fentanyl 50 g, propofol (fractionate dose of 180 mg) and cisatracurium 12 mg, a total EEG depression occurred persisting for over 10 minutes and was followed by slow recovery, during the awakening of the patient. No significant hemodynamic changes were noted during the induction. No neurologic deficit was observed in the patient after arousal. It is suggested that the probable reason for the EEG response is the particular sensitivity of the patient to some of the induction drugs or to their association. Two weeks later surgery was successfully performed using cervical plexus block, without any anesthetic support. Regional anesthesia allows continuous neurologic assessment of the awaken patient, it is the most sensitive method for detecting inadequate cerebral perfusion and function.

Anesthesia, General↗

PubMed1999

[Endarterectomy for carotid stenosis].

OBJECTIVE: To discuss the indications, anesthesia and surgical techniques of carotid endarterectomy (CEA). METHODS: Twenty-two sides of carotid stenosis were revealed in 20 patients. CEA was performed under general anesthesia in 21 sides and local anesthesia in one. The time of carotid occlusion ranged from 27 to 52 minutes (average 35.5 min) in 20 operations, and intraoperative shunt was used in the other two. Fifteen operations were monitored with EEG. RESULTS: The postoperative course was uneventful in 17 patients after 18 operations, while transient muscle strength decrease on contralateral side and ipsilateral lower facial paresis occurred after three operations in the other three patients. Nineteen patients were followed-up for 38 months on the average. Among nine patients with TIA, ischemic attacks ceased in eight and decreased in one. Improvement was achieved in six patients with cerebral infarction. One patient without symptoms of carotid ischemia was still normal after operation. CONCLUSION: Carotid endarterectomy is a safe and effective way for treating carotid stenosis.

Adult↗

PubMed2001

Simultaneous bilateral carotid endarterectomy: our first experience.

UNLABELLED: Indications for and against bilateral carotid surgery as a simultaneous or a staged procedure and patient selection criteria for simultaneous bilateral carotid endarterectomies (SBCE) are discussed. METHODS: Six patients who underwent 12 SBCE (group A) were compared with 20 patients who underwent 40 bilateral staged endarterectomies (group B). The indications and surgical management were similar and the accompanying risk factors were comparable in both groups. A shunt or patch was not used and the occlusion time was 12.5+/-2'. Total occlusion time in the SBCE was 25+/-2.5'. RESULTS: The results are comparable in both groups. In the SBCE group no major neurological complications were noted except for a transient hypoglossal paresis. In group B a case with transient ischemic attack (TIA) was noted; however no mortality, myocardial infarct, respiratory problems or permanent damage of the central nerves were observed in either groups. CONCLUSION: Although our number of patients was not satisfactory to yield a conclusion, our results, together with that of the international literature were encouraging for SBCE. SBCE can be safely performed, in experienced hands with a better preoperative assessment of the function of the circle of Willis in association with meticulous surgical technique and proper patient selection.

Aged↗

PubMed2001

Decreasing process variation in the care of carotid endarterectomy patients.

Avoidable complications after successful carotid endarterectomy surgery typically occur in the immediate postoperative period; most of these complications are related to hemodynamic instability. At Saint Agnes Medical Center, process variation resulted from 22 anesthesiologists and 11 surgeons doing the same process 242 ways. We introduced a Post-Anesthesia Care Unit Carotid Order Set to standardize the process, drug sequence, and drug choices for postoperative carotid endarterectomy patients. Ongoing monitoring demonstrated that this reduction in process variability resulted in a lower complication rate for stroke and wound hematoma.

Algorithms↗