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The application of intraoperative sonography during carotid endarterectomy will give additional information in vascular diseases, in control of vascular anastomoses in localization of residual arterioma, intima flaps and instrumental damage. Intraoperative sonography is a new device for the vascular surgeon, and should be used to reduce the risk of early restenosis after carotid endarterectomy.
During a 12-month period of study, 265 patients (mean age 65 years) underwent a total of 314 carotid endarterectomies for the management of previous transient cerebral ischemia (39%), prior stroke (10%), or severe asymptomatic carotid stenosis (51%). Five patients (1.6%) died within 30 days of operation, but only three deaths (1%) were related to carotid reconstruction. Six patients (1.9%) experienced postoperative strokes, including 1.6% of those with previous transient ischemia, 9.7% of those with prior strokes (P less than 0.02), and 0.6% of those with asymptomatic carotid stenosis before operation. Digital subtraction angiography (DSA) was performed during the same hospital admission following 262 procedures in a group of 214 patients, including all patients who had postoperative neurologic complications. Seven of these operations were limited to external carotid endarterectomy. The internal carotid artery was entirely normal in 239 (94%) of the remaining 255 DSA studies. The external carotid artery was normal on 238 (93%) of 255 DSA examinations, but was occluded on 12 (4.7%). A focal intimal defect corresponding to the apical arteriotomy suture was found in nine internal carotid arteries (3.6%), but these lesions did not appear to be hemodynamically significant. The internal carotid artery contained over 30% stenosis in two patients (0.8%) and was occluded in five (1.9%). Two of these five patients had neurologic complications, but four others with operative strokes had normal angiograms. Asymptomatic postoperative thrombosis of the internal carotid artery was documented in only three patients (1.2%).
The major complications associated with shunting include embolization at the time of insertion and shunt thrombosis. Increased technical difficulty of performing the endarterectomy with an inlying shunt hs also contributed to lack of surgeon acceptance. These problems can be minimized by using a short, flexible shunt with a sidearm attachment. The shortness enables the shunt to lie within the vessel, while the flexibility enables manipulation of the shunt to optimize exposure of all segments of the vessel. The sidearm allows flushing of both limbs and helps prevent embolization while providing a means for rapid assessment of shunt patency. The technique provides a safe and simple method of shunting during carotid endarterectomy.
A single-channel EEG, analyzed in real time to produce a density spectral array (DSA) display was recorded during 111 carotid endarterectomies. A simple protocol that emphasized loss of high frequency activity was used to identify serious ischemic EEG events. In 70 patients (78 operations) with no preoperative neurologic deficits, new postoperative neurologic deficits appeared only in the seven patients who had ischemic EEG events that lasted 10 min or longer. The EEG was not predictive in the 31 patients (33 operations) who had preoperative neurologic deficits: one patient with no intraoperative change in EEG developed a new postoperative deficit, and one patient with EEG changes lasting 13 min had no demonstrable new deficit postoperatively. This EEG monitoring technique was simple and convenient to use, and appears to be predictive of gross neurologic outcome following carotid endarterectomy in patients without preoperative neurologic deficits.
Simultaneous coronary artery bypass and carotid endarterectomy were performed in 331 patients (mean age 61 years) at the Cleveland Clinic from 1973 through 1981. Of these, 195 (59%) had Functional Class III-IV angina pectoris, 308 (93%) had multiple-vessel coronary artery disease (CAD), 68 (21%) had over 50% stenosis of the left main coronary artery, and 185 (56%) had either segmental or diffuse impairment of left ventricular function. Asymptomatic carotid stenosis was documented in 173 patients (52%), and the remaining 158 had experienced either previous transient cerebral ischemia (38%) or completed strokes (10%). Single aorta-coronary grafts were placed in 59 patients (18%), double grafts in 131 (40%), and three or more grafts in 141 (42%). Nineteen patients (5.7%) died postoperatively in the hospital. Neurologic deficits occurred in 30 patients (9.0%) and produced permanent functional impairment in 15 (4.5%). Late results have been obtained for 312 operative survivors at a mean postoperative interval of 38 months. Thirty-eight patients (12%) have died, but the 5 year life-table survival rate of the study group was identical to that of the normal population aged 61 years. Significant differences in cumulative 5 year survival rates were identified among diabetic patients (p less than 0.025) and among those receiving single rather than double (p less than .005) or multiple (p less than .01) coronary grafts. Although 18 patients (5.8%) have had late strokes, only five (1.6%) of these strokes have involved the cerebral hemisphere on the same side as combined carotid endarterectomy.
A retrospective study was made of carotid endarterectomies performed at Royal Brisbane and Princess Alexandra Public Hospitals, the 2 major teaching hospitals in Brisbane, between 1st July 1973 and 30th June 1978. The case histories of the patients undergoing the procedure during the period were studied and the immediate mortality and morbidity associated with the procedure were determined. Records of 38 operations at Royal Brisbane Hospital were found. From these operations there were 3 deaths and 1 completed stroke, a major complication rate of 11%. From 83 operations at Princess Alexandra Hospital there was 1 death and 3 completed strokes, a major complication rate of 5%. Significant delays were noted from the time of referral to the hospitals to the time when endarterectomy was performed.
This report reviews the angiographic evaluation of 41 patients who underwent a carotid endarterectomy at Henry Ford Hospital. Postoperative angiograms were performed after 48 endarterectomies. Changes included the development of postoperative intimal flaps, common carotid stenosis, carotid occlusions, areas of corrugation, surface irregularities, and postendarterectomy dilatation. The development of dilatation, or the pantaloon effect, on the endarterectomized segment contributed to the limited use of angioplastic procedures. The benefits derived from a postoperative angiogram include the objective evaluation of the endarterectomized segment, the demonstration of a potentially complicating problem such as intimal flaps that could lead to restenosis, and recognition of the possible development of associated local problems. The procedure can be done with limited risks to the patients and in competent hands has low morbidity and mortality.
Real-time intraoperative angiosonography is a readily available and simple means of obtaining high-resolution imaging of the carotid vessels after endarterectomy. In an experience of 60 intraoperative scans, nine abnormalities (15%) were detected, or which 4 lesions were hemodynamically significant. Three of these abnormalities were in the external carotid artery, and one was in the common carotid artery. The detection of these defects, which usually were not obvious during palpation or inspection, enabled immediate reexploration and correction of the fault to be undertaken. The considerable advantages of the intraoperative method of scanning over the transcutaneous technique and operative angiography are discussed. Immediate intraoperative angiosonography is recommended for routine use after carotid endarterectomy.
Carotid endarterectomy performed with the patient conscious under regional anesthesia provides a unique opportunity to determine the time of onset of a neurologic deficit and in deduce a likely cause. If a trial period of carotid occlusion is tolerated without the development of a neurologic deficit (96% of our patients), operation may continue without indwelling shunt. Of the 345 patients who had elective carotid endarterectomies performed without shunt, neurologic deficits lasting longer than 24 hours developed in 6 patients (1.7%), and deficits resolving within 24 hours occurred in 15 patients (4.3%). The neurologic deficit developed during carotid dissection in 3 patients, during carotid occlusion in 1 patient, upon release of carotid occlusion in 2 patients, and in the first 5 postoperative days in 15 patients. Of the 15 postoperative deficits, 9 were transient ischemic attacks similar to preoperative episodes, 4 were strokes, and 2 were visual changes. Twenty of 21 deficits were thromboembolic, reperfusion phenomena or were related to hypotension. Only one (0.3% of 345 cases) could be attributed to cerebral anoxia. We believe comparison of raw stroke rates is not valid in comparing methods of cerebral protection, since most perioperative neurologic deficits are not attributable to hypoperfusion. Furthermore, trial carotid occlusion in the conscious patient is a satisfactory method for determining the need to use a shunt.
Our experiences with a patient who developed recurrent hemispheric transient ischemic attacks 3 1/2 years after ipsilateral carotid endarterectomy are described. Although repeat arteriography demonstrated smooth and unobstructed common and internal carotid arteries and a normal intracranial circulation, there was complete occlusion of the external carotid artery at its origin, which appeared as a stump or diverticulum at the origin of the internal carotid artery. This stump was filled with atherothrombotic debris and served as a source of emboli to the adjacent and patent internal carotid artery. Excision of the stump effected complete relief of the recurrent ischemic symptoms. The pernicious potential of an external carotid obstruction when adjacent to a patent internal carotid artery should be recognized. To prevent this avoidable complication of carotid endarterectomy, we recommend that the origin of the external carotid artery be treated with the same standards of technical perfection as those customarily applied to the internal and common carotid arteries during this procedure.
In conclusion, an extensive study comparing routinely shunted carotid endarterectomies with routinely non-shunted carotid endarterectomies, supports the findings of others that there is a higher morbidity and mortality rate in the non-shunted population when shunting is performed non-selectively and supports the hypothesis that this morbidity and mortality may be reduced to more acceptable levels if selective shunting is employed.
Cerebral protection during carotid endarterectomy is of critical importance. This study reviews our experience with continuous EEG monitoring under general anesthesia during carotid endarterectomy. This experience defines indications for intraluminal shunting based upon electroencephalographic criteria as well as defining the utility of EEG monitoring of both intraoperative anesthesia and the post operative course.
Intraoperative hypertension and continuous electroencephalographic (eeg) monitoring were used during 42 carotid endarterectomies performed on 37 patients from 1970 to 1978. Computer spectral analysis of a majority of the electroencephalograms was also performed. Under supplemented nitrous oxide general anesthesia, elevation of the mean arterial blood pressure to 20% above the individual's preoperative mean blood pressure resulted in reversal to normal of an ischemic EEG pattern in 19% of the patients. The authors discuss the benefit of this technique. they present guidelines for patient selection and analyse the data to help the surgeon decide whether to use shunt during carotid endarterectomy.
External carotid endarterectomy may be useful in the management of selected patients who have internal carotid occlusion, persistent neurologic symptoms and additional atheromatous ulceration or stenosis within the carotid bifurcation. The procedure should be associated with a low risk for intraoperative stroke and a reasonable likelihood for symptomatic improvement. If symptoms are not completely corrected by external carotid endarterectomy, superficial temporal artery-to-middle cerebral artery bypass may be performed with greater confidence in a successful hemodynamic result.
Recent clinical results support the conclusion that internal carotid endarterectomy not only serves as a prophylactic measure against catastrophic stroke, but may improve cognitive functioning as well. Improvement in cognitive testing after internal carotid endarterectomy has been amply substantiated in recent literature. 3, 4, 5, 8, This report illustrates that improvement in cerebral blood flow by any means is equally effective in improving cerebral function.
Results of 200 iliac endarterectomies performed in 174 atheromatous patients were as follows: 15% mortality, 97% immediate good results, patency in 86% after 5 and 83.5% after 10 years. Five year survival was 62%. Contralateral atheroma progression was not marked, operation was required at an early stage in 5% and secondarily in 10% of cases. Results depend mainly on the operative technique employed, which is discussed. Mortality is lower after endarterectomy than when bifemoral-aortic prostheses are inserted, because of the reduced risk of infection and better respiratory tolerance of the retroperitoneal approach. This method should, therefore, be given preference whenever possible.
Continuous electroencephalographic (EEG) monitoring has been generally accepted as the most sensitive detector of cerebral ischemia and need for an intraluminal shunt during carotid endarterectomy. More recently, internal carotid artery stump pressure has been proposed as a simpler and equally reliable indicator of possible inadequate cerebral perfusion. In this study, stump pressure measurements and EEG changes were compared in 80 carotid endarterectomies. The mean stump pressure for patients with ischemic EEG changes was 58 mm Hg, vs 66 mm Hg for those without EEG alterations (not statistically significant). Eleven of 17 patients with definite ischemic EEG changes had stump pressure greater than 59 mm Hg, a value generally equated with adequate cerebral perfusion. EEG interpretations and stump pressure predictions did not agree in 18 of 80 patients (22.5%). Stump pressure measurements should be used with caution as the sole monitor of cerebral ischemia and need for intraluminal shunting.
Exactly 5 years after carotid endarterectomy for transient ischemic attacks (TIAs), the neurologic status of each of 67 patients whose angiograms demonstrated a contralateral carotid artery, two of which were fatal. One of these patients suffered antecedent TIAs. Two of the 50 patients (4%) without contralateral carotid stenosis experienced symptoms referable to the contralateral carotid; one of the 50 (2%) suffered a CVA without antecedent TIAs; and one of the 50 (2%) experienced a single TIA. Patients with a demonstrable contralateral carotid stenosis were at greater risk of developing contralateral symptoms than those without a stenosis [14 of the 67 versus two of the 50 (P < 0.01)]. There was no correlation between the incidence of new symptoms and the degree of contralateral stenosis. The 3% (two of the 67) incidence of stroke without antecedent TIAs on follow-up in those patients with a contralateral carotid stenosis suggests the following guideline: patients with contralateral carotid stenosis suggests the following guideline: patients with contralateral carotid artery stenosis can be advised to undergo staged carotid endarterectomies if the surgeon's stroke and morbidity rate is less than 3%.