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PubMed1994

Can bruits distinguish high-grade from moderate symptomatic carotid stenosis? The North American Symptomatic Carotid Endarterectomy Trial.

OBJECTIVE: To determine whether cervical bruits, alone or combined with other clinical characteristics, can distinguish high-grade (70% to 99%) carotid artery stenoses from less severe stenoses in patients with symptoms of cerebrovascular disease. DESIGN: Cross-sectional comparison of clinical observations with contemporaneous angiography. SETTING: The North American Symptomatic Carotid Endarterectomy Trial (NASCET), a multicenter randomized controlled trial of carotid endarterectomy. PATIENTS: All patients enrolled in the NASCET from its inception in 1988 to November 1991. RESULTS: A focal ipsilateral carotid bruit had a sensitivity of 63% and a specificity of 61% for high-grade stenosis and, when absent, only lowered the probability for high-grade stenosis from a pretest value of 52% to a post-test probability of 40%. When combined with four other clinical characteristics (an infarction on computed tomography of the head, a carotid ultrasound scan suggesting more than 90% stenosis, a transient ischemic attack rather than a minor stroke as a qualifying event, and a retinal rather than a hemispheric qualifying event), the predicted probabilities of high-grade stenosis ranged from a low of 18% (when none of the features was present) to a high of 94% (when all the features were present. CONCLUSIONS: Cervical bruits alone were not sufficiently predictive of high-grade symptomatic carotid stenosis to be useful in selecting patients for angiography; they were absent in over one third of patients with high-grade stenosis. When combined with other clinical variables, patients with high or low probabilities of 70% to 99% stenoses could be identified, but this prediction model still missed many individuals with high-grade stenosis, even in this training set of selected patients.

Angiography↗
PubMed1999

Carotid endarterectomy for non-hemispheric cerebrovascular symptoms: an unusual indication.

We report on an 80-year-old man who presented with non-hemispheric cerebrovascular symptoms in the form of daily multiple syncope. The left common carotid artery, its two main divisions, and the right vertebral artery were completely occluded. There was high-grade stenosis in the right carotid artery (82%) and left vertebral artery (60%). After excluding other causes of syncope such as postural hypotension, hypoglycaemia, cardiac arrhythymia, and epileptic seizure, a diagnosis of global ischaemia was made. The patient subsequently underwent carotid endarterectomy and the symptoms were relieved. This case represents an unusual indication for carotid endarterectomy.

Journal Article↗
PubMed1975

MYOCARDIAL INFARCTION FOLLOWING CAROTID ENDARTERECTOMY.

Myocardial infarction has been the major cause of mortality following operation for cerebrovascular insufficiency. In our institution, a clinical diagnosis of coronary artery disease was made in 37 of 125 (29.6%) consecutive male patients having carotid endarterectomy. Six of these 37 patients developed postoperative myocardial infarction. In contrast, none of the 88 patients without coronary artery disease developed myocardial infarction. A more recently treated group of 20 patients who had undergone carotid artery surgery and had previously undergone coronary artery bypass for angina did not develop postoperative myocardial infarction. These data suggest that in patients with both coronary artery and carotid artery disease, prior or concomitant coronary artery bypass should be considered. Myocardial infarction has been the leading cause of early and late death following operation for cerebrovascular insufficiency.(1) DeBakey(2) found operative mortality in patients having surgery for cerebrovascular insufficiency directly related to the incidence of coronary artery disease. An increased operative mortality due to reinfarction has been found in patients recovering from recent myocardial infarction.(3) Cooley(4) found that in patients having aortocoronary bypass there was no increased operative mortality 30 days after myocardial infarction and this may apply to patients having carotid endarterectomy. Subendocardial postoperative infarction associated with minor T wave changes and slight enzyme elevation had a better prognosis than did transmural infarction causing significant Q waves, sequential ST and T wave changes and marked enzyme elevations.(5) The purpose of this study was to document our experience with myocardial infarction in patients undergoing carotid artery operation for clinical coronary artery disease. Consideration of the role of saphenous vein bypass in those patients with coronary artery disease was the background for this review even though the evidence that myocardial infarction can be prevented with saphenous vein bypass operation is only preliminary at the present time.(6)

Journal Article↗
PubMed1989

Endarterectomy and external prosthetic grafting of the ascending and transverse aorta under hypothermic circulatory arrest.

A 78-year-old woman presented with acute pulmonary edema, a blood pressure of 250/160 mmHg, and a 4/6 diastolic murmur of probable aortic origin. Aortography revealed 4+ aortic regurgitation, left ventricular dysfunction, a right coronary artery with good distal run-off but complete proximal occlusion, a fusiform aneurysm of the ascending and transverse aorta (with a transverse dissection in the left anterolateral wall of the upper ascending aorta, but no evidence of intramural lumen), and milder, isolated dilatation of the descending thoracic aorta. Upon operation, on 8 September 1987, I discovered an incompetent aortic valve, advanced atherosclerosis in the ascending and transverse aorta, and a loose intimal flap--but no false lumen--in the upper ascending aorta. After valve replacement and construction of a vein graft to the distal right coronary artery, I decided against replacement of the diseased segment of the ascending and transverse aorta and chose, instead, aortic endarterectomy reinforced by external grafting, as a simpler, quicker, and safer procedure for this patient. Safety was further enhanced by use of profound hypothermia (16 degrees C) to induce total circulatory arrest during the brief period (15 minutes) required for endarterectomy of the arch and approximation of the flap. The patient was discharged 19 days after surgery and continues well and asymptomatic to the present, 21 months after surgery; her milder dilatation of the descending thoracic aorta, which was not treated, is stable and is being monitored.

Journal Article↗
PubMed1987

The geometry and mechanics of saphenous vein patch angioplasty after carotid endarterectomy.

To elucidate some of the mechanisms that may account for the potential advantages and disadvantages of saphenous vein patch angioplasty (VPA) after endarterectomy of the carotid artery, the author evaluated 50 VPAs with respect to geometry, blood-flow velocities, and wall mechanics. The mean internal carotid artery (ICA) diameter cephalad to the vein patch was 4.5 mm, whereas the mean diameter of the patched segment was 7.4 mm. The mean ratio between the cross-sectional area of the patched ICA and the cross-sectional area calculated as if the artery were nonpatched was 2.9. In the presence of restenosis sufficient to occlude the nonpatched artery, this ratio was decreased to 1.9 when the artery alone was stenosed and to 0.49 when both the artery and the vein patch were stenosed. The mean ratio between the peak blood-flow velocity distal to the patch and the blood-flow velocity in the patched segment was 3.4. These area and velocity ratios indicate that the wall shear stress in the patched segment was three to five times lower than that in the distal ICA. The normal stress in the circumferential vein patch wall was two to three times greater than that in veins used as bypass grafts at the same intraluminal pressure. In comparison to primary arteriotomy closure after carotid endarterectomy, VPA provides a partially endothelialized flow surface, a significantly greater cross-sectional area, and a relatively mild wall shear stress; all three of these factors may protect the artery against both hemodynamically significant restenosis and early post-operative thrombosis.

Journal Article↗
PubMed2006

[Coronary endarterectomy and bypass grafting without cardiopulmonary bypass for patients with diffused coronary artery disease].

OBJECTIVE: To review and summarize the early outcomes and clinical experience of coronary endarterectomy (CE) and bypass grafting without cardiopulmonary bypass for patients with diffused coronary artery disease. METHODS: From May 2003 to May 2005, 53 patients with diffused coronary artery disease underwent CE and bypass grafting without cardiopulmonary bypass. There were 41 males and 12 females aged from 55 to 79 (mean 64 +/- 7) years old. 72% patients (38/53) were in Canadian Cardiac Society (CCS) angina class III and IV. 49% (26/53) had history of myocardial infarction. Coronary angiogram revealed that 3 cases had double vessels disease and, other 50 cases had triple vessels disease with 9 left main stem disease. The left ventricular ejection fraction (LVEF) ranged from 0.26 to 0.65 (0.52 +/- 0.17). Seventy endarterectomies were performed in 53 patients totally which included 38 in left anterior descending artery (LAD), 8 in circumflex artery and 24 in right coronary artery. Five cases received on-lay venous patch after CE in LAD and then grafted by internal mammary artery (IMA) on the patch. There were 53 left IMAs, 2 radial arteries, others were great saphenous veins, the mean number of grafts was 3.8 +/- 1.1 with index of completeness of revascularization (ICR) 1.03 +/- 0.07. RESULTS: Intra-operative graft flow-meter was used to check the flow in the grafts before chest closure. There is no death in the group. Sixty-three (90%) out of 70 grafts after CE showed a satisfactory grafts flow intra-operatively. Two patients had peri-operative myocardial infarctions but neither had hemodynamic changes. All patients discharged uneventfully with mean hospital stay 9 days postoperatively. Forty-four patients had 6 to 29 months follow-up with no angina re-occurrence. Six patients had coronary angiogram 3 to 27 months postoperatively with all patent grafts to the CE coronaries. CONCLUSION: CE and bypass grafting without cardiopulmonary bypass is technically feasible and can be performed safely in patients with diffused coronary artery disease with increased completeness of myocardial revascularization.

Aged↗
PubMed1998

Carotid endarterectomy: current indications for surgery.

The study of carotid artery occlusive disease interventions can be divided clinically into the treatment of asymptomatic and symptomatic diseases. Clinical trials that have studied or are currently studying asymptomatic disease include: the Carotid Artery Stenosis with Asymptomatic Narrowing Operation Versus Aspirin study; the Mayo Asymptomatic Carotid Endarterectomy trial; Veterans Administration Cooperative Trial on Asymptomatic Carotid Stenosis; and the Asymptomatic Carotid Atherosclerosis Study. Trials for the treatment of symptomatic disease include: the North American Symptomatic Carotid Endarterectomy Trial; the European Carotid Surgery Trial; and the Veterans Administration Cooperative Study. In the earliest trials conducted to study asymptomatic disease medical therapy was slightly favored; on close scrutiny these studies were flawed and the findings appeared to be equivocal. The more scientific and appropriate trial, which was ended due to ethical concerns, revealed a clear advantage in patients who underwent surgery for greater than 60% stenosis and when the surgical center demonstrated less than 3% surgical risks. All trials studying symptomatic disease found a significant decrease in subsequent stroke when surgical intervention was performed. It is now judged that patients with greater than 50% stenosis receive significant benefit. In this paper the authors review the data from all of these studies. They also review data for special circumstances, such as critical stenosis and patients with symptomatic and asymptomatic Hollenhorst plaques. It is their opinion that these data have allowed surgeons to make much more educated decisions when considering the treatment of patients with carotid artery occlusive disease.

Journal Article↗
PubMed1995

[Arterial wall texture after uncomplicated endarterectomy].

Recanalisation of the carotid sinus is one of the most frequently performed vascular interventions; endarterectomy of the coronary arteries is an auxiliary measure accompanying aortocoronary bypass. Enucleation of the sclerotic plaque is followed by reconstruction of the intima and by rapid smoothing over of the "steps" along the side of the recanalised segment by proliferation of smooth muscle cells from the remaining media. The thinner the residual media, the thicker grows the neointima. Occasionally elastic lamellae reminiscent of a lamina elastica interna are formed close to the lumen. Moreover, in some cases renewed formation of the characteristic intimal spur (fibrotic ridge) is seen at the carotid sinus inlet, a sign of continued irregularity of blood flow postoperatively. In contrast, no focal lesions are generally observed in recanalised segments in the coronary arteries. New sclerotic pads that occur in the late phase bear a morphological resemblance to those in operated restenoses. The distribution of these pads is largely congruent with that of the sclerotic plaques in non-operated cervical arteries. Thus, even when recanalisation of the carotid sinus is uncomplicated, reparative processes are followed by the reformation of sclerotic pads, largely determined by haemodynamic factors. In the coronary arteries, concentric rather than focal sclerotic lesions predominate.

Arteriosclerosis↗
PubMed2005

Transcranial Doppler monitoring after carotid endarterectomy.

The objectives of this study were to evaluate the feasibility of transcranial Doppler (TCD) monitoring after carotid endarterectomy (CEA) and to investigate whether 1 hr of monitoring is sufficient to detect a clinically relevant change in the number of postoperative microemboli. We also evaluated the association of patient characteristics and procedure-related variables with the number of postoperative microemboli. One hundred and two patients were monitored during the second hour after CEA. The main outcome measure was the number of TCD-detected microemboli. The secondary outcome measure was a procedure-related cerebral complication graded according to the modified Rankin scale. The median number of microemboli during the second postoperative hour was two (interquartile ranges, 0.75-11) and decreased in most the patients during this time. Two patients had a relatively high and increasing number of microemboli and developed a minor stroke after a symptom-free interval. One patient developed a TIA intraoperatively. There was no significant association between patient characteristics and the use of a venous patch and the number of postoperative microemboli. Conversely, a statistically significant negative association was found between shunt use and the number of microemboli (p = 0.02). The majority of patients had no or a small and decreasing number of microemboli. One hour of monitoring appeared to be effective to select those patients in whom the number of microemboli did not spontaneously decrease and who may need additional medical treatment or surgical reexploration. The role of TCD-detected microemboli as a surrogate measure for the risk of stroke after CEA remains to be validated.

Aged↗
PubMed2002

Are there commonalities among audit tools used to measure carotid endarterectomy outcomes in New South Wales?

BACKGROUND: To prepare for a state-wide audit of carotid endarterectomy (CEA), we sought to ascertain pre-existing practices and identify common process and outcome measures among audits tools used by NSW vascular surgeons. METHOD: Telephone survey comprising five questions about CEA audit practices. RESULTS: Of 37 known vascular surgeons in NSW, all performed CEA and agreed to participate in our telephone survey (response rate 100%). All but one reported collecting CEA data (97%). Two thirds of these collected data prospectively. From those 19 surgeons (51%) who stated that they used standard tools for audit, we received five CEA-specific tools. Process measures common to all five were: side of CEA, date of operation, sex, past history of hypertension, history of diabetes, use of shunt, use of patch. There were only three outcome measures common to all five CEA-specific tools: postoperative transient ischaemic attack (TIA), postoperative stroke, and postoperative death. Data about outcomes beyond discharge were inconsistently collected. CONCLUSIONS: While most vascular surgeons in NSW report collecting information about CEA outcomes, not all do so prospectively. Only three outcomes (postoperative TIA, postoperative stroke and death) were common to all tools, inviting the development and use of a comprehensive and standard tool.

Endarterectomy, Carotid↗
PubMed2001

Durability of eversion carotid endarterectomy: comparison with primary closure and carotid patch angioplasty.

OBJECTIVES: Despite numerous studies in which various methods for arteriotomy closure after carotid endarterectomy (CEA) have been addressed, the optimum surgical technique to reduce complications and late carotid restenosis has yet to be firmly established. The purpose of this study was to prospectively compare the results of the eversion CEA technique with those of conventional CEA with either primary closure or carotid patch angioplasty, and to determine under clinical conditions whether eversion CEA influences the results and restenosis rate. PATIENTS AND METHODS: Over a 3-year period, 322 CEAs performed on 296 consecutive patients were concurrently evaluated. This study included 118 eversion CEAs, 97 CEAs with primary closure, and 107 CEAs with patch angioplasty. There were no differences in demographics, in surgical indications, or in the severity of carotid disease (not significant [NS]). The choice of CEA technique was not randomized because of technical considerations and surgeon preference. After entry into the protocol, no patients were excluded or withdrawn. Carotid restenosis was defined as a > 60% lumen reduction at the CEA site with established duplex ultrasonography criteria. RESULTS: The mean operative time for eversion CEA was 31 minutes, for CEA-primary closure it was 39 minutes, and for CEA-patch angioplasty it was 46 minutes (P <.01). The operative mortality rate for eversion CEA was 0.8% (1 patient), for CEA-primary closure it was 1.0% (1 patient), and for CEA-patch angioplasty it was 2.8% (3 patients) (NS). The postoperative stroke rate was 0.8% after eversion CEA, 1.0% after CEA-primary closure, and 2.8% after CEA-patch angioplasty (NS). The combined stroke and death rate in each group was thus 0.8% for eversion CEA (1 stroke-death), 1% for CEA with primary closure (1 stroke-death), and 5% for CEA with patch angioplasty (1 stroke-death, 2 fatal myocardial infarctions, and 2 nonfatal strokes) (NS). Transient ischemic attacks occurred in 2.5% after eversion CEA, in 5.2% after CEA-primary closure, and in 2.9% with CEA-patch angioplasty (NS). The mean clinical follow-up for all three groups was 23 months (range, 6-42 months) (NS). The restenosis rate was 1.7% after eversion CEA, 9.3% after CEA-primary closure, and 6.5% after CEA-patch angioplasty (P <.05). CONCLUSIONS: This prospective, nonrandomized clinical study indicates that eversion CEA is an effective surgical option comparable to conventional CEA with either primary arteriotomy closure or carotid patch angioplasty. No differences were found between eversion CEA and these more widely accepted CEA closure techniques with respect to operative morbidity and mortality. These data indicate, however, that eversion CEA has a lower restenosis rate than conventional CEA closure techniques and thus superior long-term durability.

Aged↗
PubMed2004

TCD-detected cerebral embolism in carotid endarterectomy versus angioplasty and stenting of the carotid bifurcation.

PURPOSE: In this article we will review some of the issues surrounding the relationship between TCD-detected emboli and brain function and architecture, both during conventional surgical carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS). MATERIAL AND METHODS: In both procedures, the cerebral embolic load was semi quantitatively assessed and associated with clinical outcome during the procedure and after a symptom free interval within 7 days. RESULTS: In CEA, particulate emboli that occurred during the wound closure stage were associated with intraoperative stroke and stroke related death, odds ratios [OR] 2.3 95% CI 1.2-4.4, p = 0.007. In CAS, showers of microemboli that appeared at postdilatation of the stent (OR 3.2, 95% CI 1.5-6.9, p = 0.002), particulate macroembolism (relative risk [RR] 10.2, 95% CI 5.9-17.3, p < 0.001), and massive air embolism (RR 10.2, 95%CI 5.8-17.7, p < 0.001) were associated with new transient and persistent cerebral deficits. CONCLUSION: In both CEA and CAS, recording of cerebral emboli by TCD ultrasonography provides insight in the pathogenesis of procedure related adverse cerebral outcome. In several centres TCD monitoring during CEA is now accepted as a clinically relevant tool that helps the surgeon to make the operation safer. In CAS more research is needed, particularly with respect to the impact of cerebral protection devices.

Aged↗
PubMed2006

Intrapatient comparison of restenosis between carotid artery angioplasty with stenting and carotid endarterectomy.

AIM: Comparison of restenosis in patients who underwent both carotid artery angioplasty with stenting (CAS) and contralateral carotid endarterectomy (CEA). METHODS: From our CAS data registry (1998-present) all patients with a history of contralateral CEA at any other time were selected (n = 63). Mean age was 70.6, SD = 6.8 for CAS and 68.2, SD = 6.1 for CEA and symptomatic carotid artery stenosis was present in 24% of patients pre-CAS and 40% pre-CEA. All CEAs were primary interventions, 19% of CAS were secondary to restenosis after previous ipsilateral CEA. All patients were followed up prospectively with duplex at 1 year (CAS: n = 58, CEA: n = 59), 2 years (CAS: n = 44, CEA: n = 53), 3 years (CAS: n = 27, CEA: n = 41), and every year thereafter. Within each patient we compared restenosis (>50%) between CAS and CEA procedures. RESULTS: After a follow-up of 28.7 months for CAS (SD = 16.9) and 54.4 months for CEA (SD = 39.5) the rate of = or > 50% restenosis for CAS vs CEA at 1, 2, and 3 years was 23% vs 10%; 31% vs 19%; and 34 vs 24%, respectively (log rank P = NS). CONCLUSIONS: Our intrapatient comparison of patients who underwent both CAS and contralateral CEA did not reveal significant difference in restenosis between both procedures.

Aged↗
PubMed2006

[Surgical treatment of chronic thromboembolic pulmonary hypertension with pulmonary endarterectomy].

Acute pulmonary embolism is the third most common cardiovascular disease in Italy with approximately 65 000 new cases a year. Appropriate medical therapy does not necessarily prevent evolution of acute pulmonary embolism into chronic thromboembolic pulmonary hypertension (CTEPH), which occurs in 0.1-4.0% of cases. In our country, there are approximately up to 2600 new CTEPH patients a year. CTEPH is a progressive and potentially lethal disease. Medical therapy is palliative and only surgery can modify its natural history. Pulmonary endarterectomy (PEA) is the treatment of choice and lung transplantation should be considered only when PEA is contraindicated. Currently, nearly 4000 PEAs have been performed worldwide. Approximately ten centers are able to carry out this intervention with excellent and permanent results. Solid experience and close multidisciplinary collaboration allow appropriate patient selection, rigorous surgical technique, and adequate postoperative management. All these aspects represent the key to the success in the treatment of CTEPH. After PEA, quality and expected length of life are similar to the age-matched general population and the only therapy required is oral anticoagulation.

Acute Disease↗
PubMed2006

Predicting medical and surgical complications of carotid endarterectomy: comparing the risk indexes.

BACKGROUND: Several generic cardiac risk assessment tools predict perioperative cardiac complications, but their ability to predict a broader range of medical, neurologic, and surgical complications is unknown. METHODS: A multicenter retrospective observational cohort study of 1998 patients undergoing carotid endarterectomy (CEA). Complications within 30 days of surgery were assessed by medical record review, including death or nonfatal stroke and cardiac, noncardiac medical, minor neurologic, and wound complications. Logistic regression and receiver operating characteristic curve analyses assessed the predictive abilities of the Goldman, Detsky, Revised Cardiac Risk, and American Society of Anesthesiologists indexes and of 2 CEA-specific risk models (the Halm and Tu scores). RESULTS: Death or stroke occurred in 3.2% of patients, cardiac complications in 4.0%, noncardiac medical complications in 3.2%, minor neurologic complications in 6.9%, and wound complications in 6.0%. All risk models (except the Tu score) significantly predicted cardiac complications equally well (P<.05). All 6 risk models were equivalent in predicting noncardiac medical complications. Only the Revised Cardiac Risk Index and the 2 CEA-specific risk models (Halm and Tu scores) predicted death or stroke and minor neurologic and wound complications. The Halm score was superior in predicting death or stroke compared with the Tu score and the Revised Cardiac Risk Index (area under the receiver operating characteristic curve, 0.72 vs 0.62 and 0.61, respectively; P<.05). Patients with cardiac, noncardiac medical, minor neurologic, or wound complications had 3- to 16-fold increased odds of death or stroke. CONCLUSION: The Halm score CEA-specific risk model and the generic Revised Cardiac Risk Index predicted a broad range of medical, neurologic, and surgical complications following CEA.

Aged↗
PubMed1984

Monitoring of somatosensory evoked responses during carotid endarterectomy.

During carotid endarterectomy (CEA), we monitored somatosensory evoked responses (SERs) ipsilaterally over the scalp following stimulation of the contralateral median nerve at the wrist. Thirty-eight CEAs in 36 patients were studied. Of the 10 CEAs performed with patients under general anesthesia, three involved marked changes in SERs, reversed by shunt insertion. The remaining 28 CEAs were done with patients under local anesthesia. The SERs remained stable during an average clamp time of 30 minutes in all except one patient, in whom SER changes developed within a minute of clamping; the changes were reversed by shunt placement. Four of the 38 CEAs required a shunt based on SER changes, although measurement of stump pressure (less than 50 mm Hg) would have indicated the necessity of a shunt in eight additional operations. We concluded that SERs are useful in signaling cerebral ischemia and the need for a shunt during CEA.

Aged↗
PubMed2002

Hospital and surgeon determinants of carotid endarterectomy outcomes.

BACKGROUND: Prior studies have found associations between surgeon and hospital case volumes and outcomes after carotid endarterectomy (CEA), but they have not simultaneously assessed the importance of a number of surgeon and hospital characteristics. OBJECTIVE: To simultaneously assess associations between hospital case volume, teaching status, clinical trial participation, and surgeon specialty and case volume and the outcome after CEA. DESIGN: Analysis of a large administrative data-base using logistic regression to correlate adverse outcomes after CEA with surgeon and hospital characteristics. SETTING AND PATIENTS: A Canadian administrative hospital discharge database of all patients undergoing CEA in fiscal years 1994 through 1997. MAIN OUTCOME MEASURES: In-hospital stroke and/or death. RESULTS: We found an inverse relationship between both hospital and surgeon case volumes and adverse outcomes. Teaching status had no association with outcome, but previous clinical trial participation predicted a better outcome. General surgeons fared worse than other specialists. Low-volume surgeons in low-volume hospitals had a relative risk of 3.5 for adverse outcomes compared with high-volume surgeons in high-volume hospitals. CONCLUSIONS: Several physician and hospital characteristics are determinants of outcome after CEA, but the negative effects of low hospital and surgeon case volumes, in particular, suggest that regionalization should be considered for CEA and that surgeons with low case volumes should not be performing CEA.

Aged↗
PubMed2002

A controlled prospective study of neuropsychological dysfunction following carotid endarterectomy.

BACKGROUND: Although subtle cognitive injury as revealed by neuropsychological testing occurs in a substantial number of patients following carotid endarterectomy (CEA), there is controversy about whether this finding is a result of the surgery or the anesthesia. OBJECTIVES: To examine the changes in neuropsychological test performance in patients following CEA vs a control group of patients older than 60 years following spine surgery, so as to determine whether neuropsychological dysfunction after CEA is a result of surgery or anesthesia. METHODS: Patients undergoing CEA (n = 80) and lumbar spine surgery (n = 25) were assessed with a battery of neuropsychological tests preoperatively and on postoperative days 1 and 30. The neuropsychological performance of patients in the control group was used to normalize performance for patients in the CEA group, by calculating z scores using the mean and SD of the change scores in the control group. Significant cognitive dysfunction was defined as performance that exceeded 2 SDs above the mean performance of patients in the control group. RESULTS: Postoperative days 1 and 30 total deficit scores were significantly worse in the CEA group compared with the controls. When individual test results were examined, the CEA group performed significantly worse than the controls on the Rey Complex Figure test and Halstead-Reitan Trails B on day 1, and on the Rey Complex Figure on day 30. Overall, cognitive dysfunction was seen in 22 patients (28%) in the CEA group on day 1 and in 11 (23%) of 48 patients on day 30. CONCLUSIONS: Subtle cognitive decline following CEA occurs and persists for at least several weeks after surgery. This decline was absent in a control group.

Aged↗