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At least 1,549 records · Page 86Linked to original sources
PubMed1981

A prospective study of carotid endarterectomy with and without shunt.

The extent of cerebral protection necessary during carotid endarterectomy for ischemia is controversial. In 147 carotid endarterectomies, carotid backflow was estimated and, in later years, these clinical impressions were correlated with stump pressure. These estimates or values, modified particularly in early years by the extent of contralateral disease and (inversely) of ipsilateral occlusion, were used to determine the need for a shunt at the time of carotid clamping. Only 32 shunts were used, 12 because of poor back bleeding and 20 because of stump pressure below 50 mmHg. The patients who received shunts had no mortality or neurologic deficits. In 30 patients excluded by adequate stump pressure there was only a single minor and temporary monoparesis. In 85 patients excluded by apparently good back bleeding, there were two deaths (one due to stroke), a permanent 10 per cent neurologic deficit, and two postoperative thromboses salvageable by reoperation. Routine shunting would probably have prevented only the temporary monoparesis and the 10 per cent neurologic deficit. Meticulous technique and selective use of a shunt should give satisfactory results.

Adult↗
PubMed1995

Carotid endarterectomy: emerging indications.

Several randomized trials have recently reported on the benefit of carotid endarterectomy for symptomatic or asymptomatic patients. A positive benefit has been found for symptomatic patients with > or = 70% stenosis measured by angiogram with a particular formula and performed with high surgical skill. Symptomatic patients with < 70% stenosis continue to be randomized and followed. The answer for this group is expected in the next two years. The randomized trials of asymptomatic patients have not established the benefit for carotid endarterectomy clearly. The most recent trial shows the absolute risk reduction at 5 years is only 5.9% or less than 1.5% risk reduction per year. A fifth trial continues in Europe.

Carotid Stenosis↗
PubMed1993

An audit of trends and current practice of carotid endarterectomy in Edinburgh (1975-1990).

Changes in the patient population and trends in management were studied for 260 consecutive carotid endarterectomies performed during the periods 1975-1982 and 1983-1990. A 43% increase was observed in the number of operations (from 107 to 153), an 81% increase taking into account patients randomized to medical treatment in the European Carotid Surgery Trial. There were significant reductions in patients continuing to smoke (79 to 60%, P = 0.001), in those with systolic hypertension (21 to 11%, P = 0.018) and diastolic hypertension (26 to 12%, P = 0.002), and in those with asymptomatic carotid lesions (8 to 2%, P = 0.031). There were significant increases in the proportion of patients with strokes presenting with a residual neurological deficit (40 to 66%, P = 0.024), and in those with ocular symptoms (30 to 50%, P = 0.001) and with stenoses greater than 50% (58 to 71%, P = 0.018). This study suggests a trend for a higher risk population with more severe carotid disease. In the light of results of clinical trials, further evolution of patient selection is likely to occur and should be taken into account when evaluating the risk of carotid endarterectomy.

Adult↗
PubMed1995

The American Heart Association Consensus Statement on guidelines for carotid endarterectomy.

The process by which a multidisciplinary, expert panel arrived at a Consensus Statement concerning indications for carotid endarterectomy was reviewed. It is important to point out that this represents an interpretation of currently available data by the individual members of the Committee as it pertains to 96 specific potential indications for carotid endarterectomy. Clearly, as more data become available, it is likely that there will be changes in the opinion of the Committee members. Therefore, this represents a current status that will require a periodic update.

American Heart Association↗
PubMed1994

Carotid endarterectomy without a temporary indwelling shunt: results and analysis of back pressure measurements.

A consecutive series of 342 carotid endarterectomies for cerebrovascular insufficiency without a temporary indwelling shunt is presented. The series is clinically analysed regarding the incidence of postoperative neurological deficits and mortality and statistically analysed concerning factors that may be reliable in identifying patients at risk. A transient neurological deficit occurred in five patients (1.5%) and a permanent deficit in six (1.7%). The mortality rate was 1.5% (five patients). The combined postoperative stroke and mortality rate was 2.6%. There was no statistical difference in the incidence of neurological deficits relative to operative indication (symptom-free 2.7%; transient ischaemic attack 1.4%; prior stroke 2.4%), and to the condition of the contralateral internal carotid artery (normal 1.4%; stenosis 2.9%; total occlusion 0%); nor between patients with internal carotid artery back pressure measurements > 50 mmHg (1.2%), 25-50 mmHg (2.0%) and < 25 mmHg (3.8%). In conclusion, carotid endarterectomy without a shunt is a safe procedure with a low combined perioperative stroke and mortality rate.

Adult↗
PubMed1994

[A case of emergency carotid endarterectomy to cope with vertebrobasilar insufficiency].

This is a report of an emergency carotid endarterectomy preformed on a 59 year-old male. He had been suffering from TIA of vertebrobasilar insufficiency since 1 day prior to admission. Angiography revealed severe stenosis and ulceration of the left cervical carotid bifurcation and occlusion of the bilateral vertebral arteries. Six hours after angiography, he showed hemiparesis, decerebrated posture and consciousness disturbance. These neurological signs were considered to be derived from occlusion of the left carotid bifurcation and disappearance of the collateral circulation via the left posterior communicating artery. Emergency carotid endarterectomy was performed to prevent brain infarction of the anterior and posterior circulation. Postoperative angiography showed disappearance of the stenosis of the carotid bifurcation and the recanalization of the left vertebral artery, and of the atherosclerotic stenosis of the left intracranial vertebral artery. It was considered that the left vertebral artery had been occluded by growth of a local thrombosis at the left intracranial vertebral artery.

Arterial Occlusive Diseases↗
PubMed1994

[Endarterectomy of left coronary arteries. An angiographic follow-up study].

From January 1989 to December 1993, 25 patients underwent endarterectomy on the left coronary artery system. Eight of the patients had concurrent endarterectomy of the right coronary artery. The operative mortality consisted of one high-risk patient who died from an intraoperative myocardial infarction. Two patients developed non-fatal perioperative infarction. The follow-up period averaged 27 months (range 4-58 months). At follow-up one patient was lost for evaluation owing to unexpected sudden death, no patients had experienced myocardial infarction, 17 patients (74%) were free of angina, two patients were in NYHA class I and four in NYHA class II. All patients showed an improvement in relation to their preoperative condition. Two asymptomatic patients refused recatheterization, while 21 patients had a control angiographic study. 25 of 34 grafts to endarterectomized vessels were open (patency 74%) compared with 41 of 45 grafts to non-endarterectomized arteries (patency 91%). We find the angiographic and functional results acceptable and they should be acknowledged with reference to patients with diffuse distal coronary artery disease, many of whom would otherwise be considered inoperable.

Adult↗
PubMed1994

Carotid stenosis and carotid endarterectomy.

This review focuses on the natural history of symptomatic and asymptomatic carotid stenosis and on the risk/benefit ratio of carotid endarterectomy. Five randomized trials for symptomatic stenosis and four trials for asymptomatic carotid occlusive disease are reviewed. Carotid endarterectomy has been proved effective in reducing stroke risk in symptomatic 70-99% stenosis. Conclusive results are still pending for moderate symptomatic stenosis and the asymptomatic lesion. Surgical controversies and techniques are discussed. Algorithms for management of symptomatic and asymptomatic stenosis are offered.

Aging↗
PubMed1994

Synchronous carotid endarterectomy and myocardial revascularization.

BACKGROUND: The management of the coexisting extracranial carotid and coronary disease is still controversial. We reviewed our experience in synchronous operation for both diseases in Veterans General Hospital-Taipei. METHODS: From Jan. 1988 to Nov. 1992, the synchronous carotid endarterectomy and myocardial revascularization were performed in nine patients with the mean age of 66.6 +/- 11 years. Five had symptomatic extracranial vascular disease or stabilized neurological deficits, and four had asymptomatic carotid bruits. Four had bilateral hemodynamically significant carotid stenosis. NYHA functional class III-IV was noted in three patients. Triple-vessel coronary disease was documented in 6 patients including one with left main lesion more than 50%. Eight had previous or recent myocardial infarction and four had moderate to severe left ventricular dysfunction noted on left ventriculography. RESULTS: All nine patients received unilateral carotid endarterectomy and a mean number of 2.8 distal anastomosis. Operative number of 2.8 distal anastomosis. Operative mortality within 30 days was zero and morbidity was noted in two patients. One patient was CVA and the other one was perioperative myocardial infarction. Late mortality occurred in previous two patients with morbidity. Late morbidity was mainly due to cardiac rather than neurological problems. CONCLUSIONS: If long-term natural history of coronary or carotid artery disease could be actually altered by surgery, a systemic evaluation for possible multifocal atherosclerosis is mandatory. By following a proposed guideline, synchronous operation is appropriate for a subgroup of patients with coexisting carotid and coronary artery disease.

Aged↗
PubMedDate not supplied

[Indications for repairing the internal carotid artery after carotid endarterectomy].

From 1983 to 1989, a total of 182 patients with atherosclerotic stenosis of the internal carotid artery (ICA) were examined and operated on. They underwent 198 carotid endarterectomies (EAE). In the long-term postoperative period, Doppler sonography and spectral analysis of an ultra Doppler signal were used to study 143 patients. Depending on the type of endarterectomy, 2 groups of patients were identified (1) 61 who had after EAE a plastic bifurcation operation with transition to the ostium of the ICA by means of a flap from a fragment of a synthetic prosthesis, autovein or xeno-pericardium; (2) 82 underwent EAE without dilatation of ICA. The analysis of the results of the studies revealed that after carotid EAE, the incidence of restenoses was 18.2%, that of thromboses was 8.4%, the incidence of atherosclerotic restenoses depended on the method to close the arteriotomic ostium: when the dilating flap was used, it was 1.5%, in isolated carotid EAE without its use, it was 11.03%. The incidence of myointimal restenoses in patients undergone plasty or no plasty of ICA was virtually equal. In atherosclerotic restenosis, 18.2% developed a negative dynamics of cerebrovascular insufficiency, whereas in thromboses 25% did, myointimal restenoses ran without clinical signs. The low incidence of atherosclerotic restenosis in plasty of carotid bifurcation made it the method of choice. Taking into account the nature of myointimal hyperplasia and the absence of clinical signs it should be noted that repeated reconstruction in this restenosis is not indicated, while in atherosclerotic restenosis, reconstruction is indicated in the presence of clinical manifestations.

Angioplasty↗
PubMed1994

[Bilateral stenosis of the renal arteries: transaortic endarterectomy].

Transaortic renal endarterectomy with infra-renal aortic prosthetic graft may be used to treat combined aortic and renal atherosclerosis. We present herein the technics we used in seven patients, which represented 0.4% of our aortic revascularizations and 15% of our combined aortic and renal revascularizations. All these patients were hypertensive and four had a mild preoperative renal insufficiency. Post-operatively there were no death and the morbidity rate was 12%. Morphological assessment showed no renal or limb graft occlusion. During the follow-up there were three deaths, one limb graft occluded. All renal arteries remained patent with improvement of hypertension in 70% and stabilisation of the renal function in all. In carefully selected cases, transaortic renal endarterectomy is a safe and efficient method of treatment of combined aortic and renal atherosclerotic disease.

Anesthesia, General↗
PubMed1993

[Endarterectomy by division of the internal carotid artery].

The literature reports superior results with patch angioplasty compared to direct suture for the restoration of the carotid artery after endarterectomy through a longitudinal arteriotomy. With the technique presented here access to the arterial lumen is gained through an oblique division of the internal carotid at its origin. After endarterectomy this vessel is reanastomosed to its origin on the common carotid. This oblique suture does not induce any stenosis. This technique is easily reproducible. In a prospective randomized study, comparing its results to saphenous vein angioplasty, no significant difference was found on mortality, morbidity and recurrent stenosis. With this technique, the saphenous vein can be preserved for other vascular reconstructions.

Carotid Artery, Internal↗
PubMed1993

Eversion technique for carotid endarterectomy.

Since April 1991, we have used the eversion technique to perform carotid endarterectomy in 31 consecutive procedures. There were no operative deaths in the current series, and no neurologic complications have been observed. We believe this technique decreases the possibility of early and late restenosis and recommend it for patients requiring carotid endarterectomy.

Aged↗
PubMed1993

Magnetic resonance angiography and duplex imaging: noninvasive tests for selecting symptomatic carotid endarterectomy candidates.

BACKGROUND: This report describes our experience with the use of duplex imaging and magnetic resonance angiography (MRA) in the diagnosis and management of 70 patients with symptomatic carotid artery disease. Prospective evaluation of our first 30 patients showed that duplex imaging and MRA accurately correlated with conventional cerebral arteriograms (XRA) in patients with symptoms with greater than 70% ipsilateral carotid artery stenoses. In MRA versus XRA accuracy was 94%, sensitivity 100%, and specificity 93%. With duplex scanning versus XRA accuracy was 88%, sensitivity 93%, and specificity 93%. METHODS: We are now performing carotid endarterectomy on patients with symptoms without preoperative XRA when there is exact correlation between duplex imaging and MRA. Patients must have focal hemispheric symptoms, ipsilateral duplex peak systolic velocity greater than 2 m/sec, and high-quality MRA imaging of the carotid vessels. RESULTS: We have prospectively entered 40 patients for preoperative evaluation with duplex imaging and MRA. High-quality MRA and duplex studies were obtained in 35 patients (88%). XRA was required in the remaining five patients (12%) because of discrepancies between duplex scanning and MRA. Endarterectomy was performed without morbidity or death. Combined use of duplex scanning and MRA eliminated XRA in 35 cases and created a net savings of more than $125,000. CONCLUSIONS: Our experience suggests that preoperative XRA may not be necessary when duplex imaging and MRA confirm the presence of severe extracranial disease.

Carotid Arteries↗
PubMed1993

[The effect of carotid endarterectomy on the reserve capacity of cerebral blood flow velocity].

Cerebral blood flow velocity was measured by transcranial Doppler sonography at rest and during cerebral vasodilatation evoked with acetazolamide in 14 patients before and after carotid endarterectomy. Before surgery the vasoreactivity in the affected middle cerebral artery territories was reduced and abnormal (asymptomatic side: 35.9 +/- 25.6% [mean +/- SD; n = 14]; symptomatic side: 25.6 +/- 10.7%), but the difference between the two hemispheres was not significant however, vasoreactivity was normalized 5 days after surgery (asymptomatic side: 46.9 +/- 22.3% symptomatic side: 58.9 +/- 23%) (p < 0.001). The increase in cerebral reserve capacity and changes in Gosling's index of pulsatility correlated significantly in both hemispheres (p < 0.02). This findings indicate an improved perfusion reserve on the fifth day following carotid endarterectomy in patients with an internal carotid artery diameter reduction of at least 70%.

Blood Flow Velocity↗
PubMed1996

Routine ultrasound surveillance after carotid endarterectomy.

Ultrasounds (US) are employed in preoperative carotid disease diagnosis and in carotid endarterectomy (CEA) follow-up. The authors present their experience about postoperative modifications in CEA site with US evaluation with particular interest in restenosis. Clinical and instrumental examinations were performed at intervals 1, 3, 6, 12, and 24 months following surgery. Follow-up data were available on 189 CEAs. In 58 cases a primary closure was performed, whereas in the other 131 cases, a patch was applied. 15 restenosis (7.9%) were seen during the follow-up control period with 2 cases of haemodynamic restenosis (1%). Good results were recorded with PTFE patch angioplasty (restenosis 4.4%), instead of vein (restenosis 14.2%) and a biosynthetic material called Omniflow (restenosis 9.5%). A vein patch dilatation was encountered in 13 applications (30.9%). In conclusion the routine application of US after carotid endarterectomy allowed us to monitor the evolution of the repair processes and of the stenotic lesions from the very beginning.

Angiography↗
PubMed1996

[Surgical results of two cases of simultaneous carotid endarterectomy and coronary artery bypass grafting].

Reports on simultaneous revascularization operations for concomitant stenoses of the carotid and coronary arteries are many in Europe and America but few in Japan. Herein we report two cases of successful combined carotid endarterectomy and coronary artery bypass grafting. The first case was a 56-year-old male who had effort angina and a right carotid bruit with tinnitus. He was revealed to have severe stenosis of the right internal carotid artery as well as significant lesions of the right coronary artery. The second case was a 69-year-old male who had unstable angina and a left carotid bruit with a history of transient ischemic attack. Coronary angiography revealed three vessel disease and carotid digital subtraction angiography also revealed critical stenosis of the left internal carotid artery. In both cases, simultaneous carotid endarterectomy with an internal shunt and coronary artery bypass grafting were performed with a successful outcome. The use of internal shunt on reconstruction of the carotid artery was effective for protecting the brain.

Angina Pectoris↗
PubMed1995

[Carotid endarterectomy using cervical plexus block].

To evaluate the efficacy and level of patient satisfaction, as well as the incidence of neurological manifestations, hemodynamic changes and other perioperative complications of cervical plexus block. This was a prospective study of 52 patients undergoing carotid endarterectomy under superficial and deep cervical plexus block. The anesthetic technique was effective in all cases. Supplementation with local anesthetic was needed for 25% of the patients and none required general anesthesia. The technique was considered good by 92% of the patients, who stated that would accept the same technique in case of having to undergo surgery on the contralateral carotid artery. Hypertension was the hemodynamic change observed most often (in 30%) during surgery. No serious complications related to the anesthetic technique were observed, though transient dysphonia was the most frequently seen effect (in 36.5%). Eight (15.4%) patients showed neurological signs when the carotid was clamped, with symptoms resolving with placement of a shunt. Two deaths due to myocardial infarction occurred after surgery and 1 patient suffered a permanent cerebrovascular accident. Regional anesthesia with deep and superficial cervical plexus block during carotid endarterectomy allows for continuous evaluation of the patient's neurological status and facilitates the selective use of intraluminal shunt for the prevention of stroke accident during surgery. The technique is well-tolerated by patients, does not make surgery more difficult, does not give rise to serious complications and the incidence of local complications is low.

Aged↗