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PubMed2001

[Carotid endarterectomy under remifentanil].

OBJECTIVE: Carotid endarterectomy can be performed under general or locoregional anesthesia. If locoregional anesthesia is chosen, the state of awareness of the patient allows for direct viewing of the effect of vascular clamping of the corresponding neurological territory. We present the results of an anesthetic procedure using only an analgesic in patients who were intubated and ventilated but with a level of consciousness that allowed us to view the effect of carotid clamping on motor functions. METHOD: Forty-eight patients, ASA II-III, underwent surgical carotid endarterectomy. The anesthetic protocol began with preoxygenation for 2 min; induction with remifentanil 0.75-1 microgram kg-1 for 2 min., followed by perfusion of 1 microgram/kg-1.min-1 of remifentanil and propofol 1 microgram/kg-1; and orotracheal intubation by local anesthesia of the glottis with 5% lidocaine spray. Ventilation was with FiO2 100%, FR 12 min. and VT 8 ml. kg-1. For maintenance the dose of remifentanil was regulated to obtain a coordinated motor response (maximum 1.5 microgram/kg-1.min-1, minimum 0.35 microgram/kg-1. min-1). For all patients we monitored hemodynamics continuously and non-invasively, including aortic output by the transesophageal Doppler echocardiography. RESULTS: The objective of anesthesia was reached in all the patients. The most common hemodynamic alterations were bradycardia (28), arterial hypotension (25), elevated blood pressure (3) and altered aortic output. All changes were corrected quickly with the treatment used, guided by the evolution of hemodynamic parameters. Postanesthetic recovery came in less than 4 min. The only episodes of hyper -and hypotension consisted of a few episodes of mild hyper- (12) and hypotension (1), which were soon corrected. No alterations attributable to hemodynamic instability occurred. During surgery, an intracarotid shunt was necessary in only one patient. Three suffered surgically-related neurological complications after the operations. No complications could be attributed to anesthesia. DISCUSSION: An advantage of this technique is that the duration of anesthesia is not limited, with adequate ventilation and maintenance of an adequate state of consciousness for clinical evaluation of the repercussions of carotid clamping. Hemodynamic monitoring detected the appearance of imbalances requiring therapeutic intervention. The procedure is interesting provided it is performed according to a strict protocol, with continuous clinical and instrumental monitoring of the patient's status.

Aged↗
PubMed2000

Carotid endarterectomy: creating the pathway to 1-day stay.

Use of a collaborative team approach to design a care pathway and standing orders for carotid endarterectomy patients achieved the project's goals. Variation, LOS, and resource consumption were decreased while quality of care and patients' satisfaction levels were maintained. Education of patients, patients' families, and staff members increased. Coordination between caregivers increased. The consistent concurrent database provided a feedback loop for continued change and for setting the target. Essential to the success was sponsorship from key leadership via the hospital's steering committee. The diverse membership of key associates on the CQI team helped to create an excellent revised carotid endarterectomy process and ensured full implementation. This membership of the CQI team was essential to comprehensive education and implementation. The step-by-step implementation kept the project moving forward. Creating a care pathway and changing practice require collaboration between nurses, doctors, and administrators. Creativity and systematic, thorough steps are what move a practice change from idea to inception.

Cooperative Behavior↗
PubMed1975

Carotid endarterectomy: survival rates of 227 patients.

From March 1963 to March 1974, 227 patients with carotid stenosis underwent unilateral or bilateral carotid endarterectomy at l'Hôpital de l'Enfant-Jésus in Québec. Survival during the first 7 years after operation was analysed by life-table methods based on full intervals. The observed probability of death in this group was significantly higher than the probability expected in the general population, by 6.8% in the 1st year and 3.9% in the 2nd year. In the next 3 years the differences were much smaller (0.5, 0.9 and 1.4%). The major causes of death were myocardial infarction and stroke. Women fared somewhat better than men after the 1st year of follow-up. Unexpectedly, patients who underwent unilateral endarterectomy had lower survival rates in each of the first 5 years after operation than patients who underwent staged bilateral operations, whether survival was measured from the date of the first or the second operation.

Adult↗
PubMed2002

The effect of a critical pathway on patients' outcomes after carotid endarterectomy.

BACKGROUND: In 1996, an integrated plan of care was implemented to improve quality of care for patients undergoing elective carotid endarterectomy. Goals were to reduce length of stay, costs, number of preoperative and intensive care unit admissions, and use of diagnostic procedures yet maintain good outcomes. OBJECTIVES: To determine whether use of the integrated plan of care met the goals. METHODS: Data on financial and process outcomes, use of angiographic diagnostic procedures, and demographics were retrieved from the hospital's database for all patients who had elective carotid endarterectomy without cerebral infarction. RESULTS: A total of 783 patients met inclusion criteria: 129 before implementation of the plan of care, 66 during the 6-month transition, and 588 after implementation. Preoperative angiography was done in 32% of patients before implementation, 11% during the transition, and 4% after implementation. Percentages of patients admitted to the intensive care unit were 77% before implementation, 24% during transition, and 9% after implementation. Mean lengths of stay were 2.93 days before implementation, 2.12 days during transition, and 1.68 days after implementation. Costs per case were $7798 before implementation, $5750 during transition, and $5387 after implementation. Analysis of variance revealed significant differences between groups in total length of stay (P = .001), preoperative length of stay (P<.001), and costs (P<.001). CONCLUSION: Use of the integrated plan of care reduced length of stay, costs, admissions to intensive care units, and use of cerebral angiography. Use of the plan improved resource utilization while maintaining quality of care.

Adult↗
PubMed2002

[Carotid endarterectomy, clinical analysis of 43 cases].

OBJECTIVE: To evaluate the important points in carotid endarterectomy. METHODS: Carotid endarterectomy was performed upon 43 cases of carotid artery stenosis under cervical plexus anaesthesia. The operation was performed with shunting between the common carotid artery and the internal carotid artery in 2 cases. RESULTS: The average clamping time of carotid artery was 27 min +/- 7 min. There were one case suffering from transient ischemic attack (TIA), 7 cases suffering from hypertension and 2 cases suffering from light edema of the wound. All of the patients recovered uneventfully. Twenty-six patients who had suffered from TIA before operation felt much better after operation. The follow-up of one month to one year showed a better condition among all patients. CONCLUSION: Cervial plexus anaesthesia helps diagnose stroke during operation. Shunting between the common carotid artery and internal carotid artery helps avoid ischemic brain injury. The effect of operation depends upon complete removal of the residual tunica intima, complete exsufflation, and control of hypertension postoperationally.

Carotid Stenosis↗
PubMed2002

A reassessment of carotid endarterectomy in the face of contralateral carotid occlusion: surgical results in symptomatic and asymptomatic patients.

OBJECTIVE: Total occlusion of the contralateral internal carotid artery has often been considered to be a predictor of poor outcome after carotid endarterectomy (CEA) of ipsilateral carotid stenosis. Data from both the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study have suggested this to be true. However, each of these trials had relatively few patients with contralateral occlusion in the surgical arms of the studies. Recently, advocates of carotid angioplasty and stenting have suggested that this technique may be preferable in patients with a contralateral occlusion because of the perceived poor outcome with surgery. The purpose of this study was to review a large series of CEAs performed in patients with contralateral occlusion to see whether results differed from patients with patent contralateral arteries and to determine whether the presence of preoperative symptoms was an important factor in outcome in these cases. PATIENTS AND METHODS: A review was conducted of a prospectively compiled database of all primary CEAs performed at our institution from 1985 to 1999. Surgery was performed on 2420 patients, of whom 338 (14.0%) had contralateral total occlusion. RESULTS: Patients with contralateral total occlusion were more likely to be symptomatic (65.7% versus 60.1%; P =.1), male (70.9% versus 58%; P <.001), and hypertensive (63.9% versus 58.4%; P =.07) with a positive smoking history (42.6% versus 31.4%; P <.001) than patients with patent contralateral carotid artery. No significant difference was seen in the rates of perioperative neurologic events between patients with contralateral occlusion (3.0%) and those without (2.1%; P =.34). Among the total of 913 asymptomatic patients, of whom 115 had contralateral occlusion, no difference was seen in the rate of perioperative neurologic events (1.8% for contralateral occlusion cases; 1.9% for cases without contralateral occlusion). Among the total of 1507 symptomatic patients, of whom 223 had contralateral occlusion, no significant difference was seen in the rate of perioperative neurologic events (3.7% for contralateral occlusion cases; 2.2% for cases without contralateral occlusion; P =.2). CONCLUSION: The presence of contralateral occlusion does not appear to increase the perioperative risk of CEA. Although the risk of CEA in symptomatic patients with contralateral occlusion may be slightly increased, this must be weighed against the risk with medical treatment alone. CEA can be performed safely in patients with contralateral occlusion, which should not necessarily be considered a high-risk condition for surgery in favor of angioplasty and stenting.

Aged↗
PubMed2002

Carotid endarterectomy using regional anesthesia: a benchmark for stenting.

Regional block (RB) anesthesia for carotid surgery offers the advantage of continuously monitoring the awake patient's neurologic status during carotid cross-clamping. We retrospectively studied our experience with RB for carotid endarterectomy (CEA) procedures performed during the period January 1, 1995 through December 31, 2001. A total of 388 consecutive CEA procedures were performed; RB was used in 314 and general anesthesia (GA) in 74. Three patients required conversion from RB to GA. GA was used only in patients who could not tolerate a block or needed combined coronary artery bypass grafting (CABG) and carotid surgery. New ipsilateral stroke did not occur in RB patients; one patient extended a previous stroke. Three in-hospital deaths occurred; these were all cardiac-related. In GA patients undergoing CEA without CABG (CEA only, n = 58), one stroke and no deaths occurred. The combined stroke and mortality rate for all CEA-only patients was 1.3 per cent (five of 372). RB allows 90 per cent of procedures to be performed without shunting, thus facilitating endarterectomy and patch angioplasty. CEA performed under RB is similar to carotid stenting because both procedures allow monitoring of the awake patient's neurologic status. The very low procedural complication rate in this study warrants the consideration of carotid surgery under regional block as a benchmark for future carotid angioplasty and stenting studies.

Aged↗
PubMedDate not supplied

Carotid endarterectomy. Which diagnostic imaging technique is suitable for the indication and planning of surgery?

Based on data of recent literature, the most suitable preoperative diagnostic approach to cerebrovascular insufficiency, is evaluated. Correct indications for carotid endarterectomy in symptomatic and asymptomatic carotid stenoses are related to the degree of stenosis. This is also the most important predictive factor of stroke ipsilateral to the stenosis. Arteriography is being used selectively, while color Doppler US is the examination of first choice, combined with MR-angiography, cerebral CT and transcranial Doppler in most cases of carotid stenosis to be treated with surgery. An accurate and reliable preoperative diagnostic evaluation, together with an impeccable surgical procedure represents the indispensable prerequisite to maintain the mortality and complications within those strict limits that make a prophylactic intervention as carotid endarterectomy, advantagious to the patient.

Carotid Stenosis↗
PubMed1992

Correlation of carotid B-mode scanning with endarterectomy findings in Japanese patients.

In this study, 13 Japanese patients who underwent carotid endarterectomy with en bloc method were prospectively evaluated by high-resolution B-mode scanning. B-mode imaging was carried out 1-2 days before operation. The most suitable consecutive longitudinal planes of the carotid bifurcation were photographed (5-8 planes). The echogain was gradually changed from a lower to a higher intensity during B-mode scanning to identify the echogenicity of the atheromatous plaques. Three-dimensional reconstructions were made of the carotid plaques before performing carotid endarterectomy, and the author investigated the correlations between the echo characteristics and the histology of the resected plaques. The echogenicity of all atheromatous plaques, except for those with calcification, was lower than that of the normal medial layer of the vessel wall. The consecutive B-mode image data correlated well with the histological findings of the resected plaques in this study. In 2 out of 13 cases, it was found to be very difficult to distinguish an ulcerated plaque from a region of fresh intraplaque hemorrhage. High-resolution B-mode scanning was found to be a very useful and reliable method for identifying the detailed structure of atheromatous plaques in the cervical carotid artery.

Aged↗
PubMed1992

[Immediate and long-term results of carotid endarterectomy: the Zurich experience].

Extracardial carotid artery disease is a frequent cause of transient ischemic attack and of cerebral infarction. The records of 485 patients who underwent carotid endarterectomy between 1978 and 1991 were reviewed, with special attention to both cardiac and neurological complications. 432 patients had symptomatic carotid disease whereas 53 were asymptomatic but presented with significant carotid stenosis or a large ulceration at doppler-duplex examination and/or angiography. These examinations showed the following lesions in symptomatic patients: unilateral stenosis > 75% (331; 68.5%), ulceration (41; 8.5%), bilateral stenosis (61; 12.5%) and unilateral stenosis with contralateral occlusion (51; 10.5%). Intraluminal shunt was used in nearly all patients whereas special management of cerebral metabolism (intraoperative electroencephalogram, somatosensory evoked potentials) were used in high-risk patients only. Overall early mortality was 1.8%. Three patients died from the sequelae of a neurologic injury, whereas six patients died from myocardial infarction or intractable arrhythmia. Mortality decreased from 2.4% between 1978 and 1984 to 0.8% between 1985 and 1991. At 6 and 8 years, actuarial survival rates of 88.1% and 76.1% and stroke-free survival rates of 86% and 81.5% were observed. Late mortality was essentially due to ischemic cardiac complications (38.5% of the actuarial late mortality at 8 years). Review of the literature shows that carotid endarterectomy is the treatment of choice for symptomatic high-grade extracranial carotid stenosis in patients who are not high-risk candidates.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2003

[Effects of carotid endarterectomy on quality of life of patients with ischemic disease of the brain].

Effects of operation of carotid endarterectomy (CE) on indicators of quality of life were investigated in patients with ischemic disease of the brain (IDB). The quality of life was assessed in 45 patients at the preoperative stage and in the remote postoperative period with the help of questionnaire SF-36. All the patients were divided into two groups according to the degree of the initial neurological symptoms. The first group included 25 patients with an "asymptomatic" or "minimally symptomatic" course of IDB. The second group had 20 patients with a stable neurological defect resulting from "great" ischemic stroke. It was shown that in the first group of patients there was a reliable improvement of the life quality after CE in 6 out of 8 indicators. In the second group a reliable improvement of the life quality was noted in one of the 8 indicators only. The average values of the life quality indicators after CE in the first group patients were close to those in healthy population. At the same time in the second group they were considerably lower. The carotid endarterectomy gives the maximum effect of improving the patients' life quality if fulfilled at the early stages of IDB and is considered to be of probhylactic character.

Aged↗
PubMed2003

GPs' views of quality initiatives to improve stroke outcomes following carotid endarterectomy.

BACKGROUND: General practitioners' satisfaction with previous referral of patients may influence their future specialist referral patterns. METHOD: A postal survey of 123 GPs assessing satisfaction with discharge planning and communication from operating surgeons for patients following carotid endarterectomy. General practitioners' views of quality indicators for patient referral also were assessed. RESULTS: General practitioners were significantly more likely to be 'very satisfied' with the level of communication from the operating surgeon (83%) than the discharge planning (65%), (p < 0.001). The most highly ranked quality indicator for use in referring a patient for carotid endarterectomy was the 30 day postoperative complication rate per surgeon (n = 69, 56% 'very useful'). Over one-third (35%) remembered seeing the relevant guidelines for GPs. DISCUSSION: General practitioners value information about surgeon performance when making referral decisions. They are less satisfied with discharge planning than other aspects of care.

Attitude of Health Personnel↗
PubMed2003

[Comparative assessment of the results of open carotid endarterectomy and carotid aftery stenting].

A comparative study of 48 carotid stent grafting and 23 open carotid endarterectomies was carried out. Patients of both groups were comparable by cerebrovascular insufficiency degree and concomitant diseases. General rate of complications after carotid stent grafting (CSG) was 5.1%. There was a small ischemic stroke with right-sided hemiparesis and aphasia in one patient during CSG. Complete regress of the neurological symptoms was seen on the 5th day. In the nearest postoperative period after CSG there was a big ischemic stroke in the territory of MCA in one patient. Rate of complications after open carotid endarterectomy (OCEAE) was 8.7% Transient ischemic attacks were seen in 2 patients in early postoperative period. Paresis of the IX cranial nerves was in one patient. In long-term postoperative period after CSG 2 patients died due to cardiac causes. One patient died 18 months after OCEAE due to ischemic stroke. In long-term period after OCEAE restenosis of the internal carotid artery was seen in 4.5% cases, while there were no restenosis after CSG. It is concluded that CSG is an effective method of treatment of carotid stenosis with lower lethality and postoperative complications rate compared with OCEAE. Indications for CSG are symptomatic stenosis of ICA (>60%), asymptomatic stenosis of ICA(>70%), two-sided lesions of the carotid arteries, carotid stenosis with lesions of other brachiocephalic arteries, insufficiency of Willis circle.

Adult↗
PubMed1992

Endarterectomy with arterial dilators: surgical technique.

A simplified technique of semi-closed endarterectomy with arterial dilators that insures complete removal of intimal fragments was used by the authors. Complications, such as arterial wall penetration and residual intimal fragments, are reduced. This technique has proven useful in aortoiliac and short-segment femoral artery endarterectomy. It is also helpful for proximal anastomosis of femoral/popliteal/tibial in situ bypass where termination of saphenous vein cannot reach femoral artery.

Arterial Occlusive Diseases↗
PubMed2004

[Evaluation of cerebral blood perfusion in patients undergoing carotid endarterectomy using densitometric analysis of conventional cranial CT].

OBJECTIVE: To evaluate the efficacy of densitometric analysis of cranial CT imaging in the measurement of areas with low cerebral blood flow and lack of hemodynamic reserve in patients undergoing carotid endarterectomy. PATIENTS AND METHODS: 40 consecutive patients undergoing carotid endarterectomy have been included in the study. All of them had preoperative cranial CT, pre and postoperative basal and acetazolamide SPECT. Cranial CT imaging after digitalization and computer processing were obtained with 4 densitometric patterns: 1). normal cerebral blood perfusion; 2). ischemic or low brain blood perfusion (patron I); 3). parenchyma without cerebral hemodynamic reserve (patron nR), and 4). brain infarction. RESULTS: 32 out of 40 (80 %) patients had abnormal densitometric patterns: 19 nR patterns (47.5 %), 11 I pattern (27.5 %) and 2 established brain infarction. The correlation between densitometric cranial TC imaging and SPECT was 92% when analyzing areas with hypoperfusion (S: 96.5 %; E: 82 %). Cranial CT detected 12/13 of patients who lacked cerebral hemodynamic reserve in the SPECT analysis (S: 74 %; E: 92 %; Vpp: 95 %). CONCLUSIONS: There is a good correlation between analysis of densitometric cranial TC imaging and SPECT in determining low cerebral blood flow areas and lack of cerebral hemodynamic reserve. This method could help to improve carotid surgery indications in patients with carotid stenosis.

Aged↗
PubMed2003

Patient characteristics, operative complications and long-term survival of patients aged 75 years or older subjected to carotid endarterectomy.

AIM: The aim of this study is to report risk factors, operative results and long-term survival of old patients operated on for carotid stenosis in order to evaluate their candidature for surgery. METHODS: Fifty-two patients aged 75 years or older subjected to 56 carotid endarterectomies performed during the years 1992 to 2001 were examined and compared to data concerning 161 younger patients (172 operations) operated during the same period. RESULTS: Preoperatively registered hypertension, cardiac disease, renal impairment, diabetes mellitus, cerebrovascular symptoms and involvement of the contralateral carotid artery distributed similarly among the old and young patients. The older patients suffered an operative combined stroke and mortality rate non-significantly higher than the younger. The older patients experienced a 3-year survival rate of 92%. This was significantly superior to that of a demographically matched population, and similar to the survival of the younger patients. The younger patients had a survival rate significantly inferior to the expected. CONCLUSION: Patients aged 75 years or older operated on for carotid stenosis appear to have similar preoperative characteristics, similar early operative complication rates and a significantly better long-term relative survival, as compared to younger patients going through carotid endarterectomy.

Adult↗
PubMed2003

Emergency and early carotid endarterectomy in patients with acute ischemic stroke selected with a predefined protocol. A prospective pilot study.

AIM: The appropriateness of early carotid endarterectomy (CEA) in patients with acute ischemic stroke is still unsettled. The aim of this study was to verify the safety and feasibility of early CEA in a consecutive series of patients with acute ischemic stroke observed in an emergency Department Stroke Unit. METHODS: During a 24-month study, out of 756 patients with acute ischemic stroke 33 (4.4%) were scheduled for early CEA. Endarterectomy procedures were distinguished according to the time between the onset of stroke and operation as emergency (within 8 hours), early CEA (1-18 days). Patients with impaired consciousness or an infarct larger than 2.5 cm on computed tomographic (CT) or magnetic resonance (MR) scans or both were excluded from surgery. All patients underwent spiral CT, echo-color-Doppler (ECD) sonography, transcranial Doppler (TCD) sonography and, when necessary, MR angiography within 6 hours of admission. No patient underwent conventional angiography. Most patients were operated on under cervical block (CB) anesthesia; general anesthesia (GA) was used only for those with an unstable neurological deficit. Selective shunting was used on the basis of intra-operative transcranial Doppler in patients under GA and the onset or worsening of neurological deficit under CB anesthesia. RESULTS: Of the 6 patients operated on within a median 6 hours after the onset of stroke, 1 (16.5%) had a fatal hemorrhagic transformation of the infarct, while the remaining 5 (83.5%) stopped fluctuating or progressing and had a favourable neurological outcome. Of the 16 patients operated on within a median 36 hours and of the 11 patients operated on within 7 days, none deteriorated after operation. CONCLUSION: Emergency CEA is feasible for acute ischaemic stroke provided that strict selection criteria are applied and the door-to-surgery interval is kept short (within 8 hours). Early CEA for secondary prevention is feasible and safe, confirming that a delayed operation is in most cases unwarranted. Large randomized trials are warranted before implementing emergent and early CEA in routine clinical practice.

Acute Disease↗
PubMed2004

Remote superficial femoral artery endarterectomy.

The advent of minimally invasive procedures such as percutaneous transluminal angioplasty with or without stent, laser-assisted balloon angioplasty, and atherectomy, whose results have proven disappointing in the treatment of long-segment (> more than 15 cm) superficial femoral artery (SFA) occlusive disease, stimulated a reassessment of SFA endarterectomy. With the evolution of remote superficial femoral artery endarterectomy (RSFAE) a minimally invasive technique became available which could be performed through a single incision, allowed, debulking of the arterial plaque, and placement of an endovascular stent. We report results of RSFAE in an initial trial, results of RSFAE in concert with the aSpire Covered Stent which is a flexible ePTFE covered Nitinol stent with significant radial strength to withstand torsional stresses at the knee joint, and RSFAE and distal vein bypass for limb salvage.

Aged↗