Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “ENDARTERECTOMY”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 163 records · Page 9Linked to original sources
PubMed1995

Safety and efficacy of transaortic renal endarterectomy as an adjunct to aortic surgery.

PURPOSE: A study was undertaken to assess the safety and efficacy of transaortic endarterectomy for orificial atherosclerotic renovascular disease (ASRD), particularly in conjunction with surgery for concomitant aortic disease. METHODS: Forty-three consecutive patients with ASRD treated with transaortic orificial eversion endarterectomy were studied retrospectively to identify surgical indications, technical features, operative morbidity and mortality rates, and efficacy. RESULTS: A total of 76 renal arteries underwent transaortic endarterectomy for hypertension (88% of patients) or serum creatinine of 1.5 mg/dl or greater (65% of patients), including two patients undergoing dialysis. Concomitant aortic surgery was performed in 39 patients for aneurysmal (n = 30) or occlusive (n = 9) disease. Two (2.6%) of 76 renal endarterectomies required intraoperative conversion to bypass because of poor flow, and three arteries (3.9%) were reimplanted or bypassed because of fragility of the renal orifice after endarterectomy. Thirty-day operative death occurred in two patients (4.7%), and major morbidity occurred in six (14.0%). Hypertension was cured or improved in 83% of patients with hypertension. Among patients with preoperative renal insufficiency, function was improved in 19%, with dialysis discontinued in one of two patients receiving dialysis, and function was worse in 23%, with one patient dependent on dialysis. CONCLUSION: Transaortic renal endarterectomy is an acceptably safe and effective adjunctive technique in selected patients with combined aortic disease and ASRD.

Aged↗
PubMed1997

Comparison of perioperative results obtained with carotid eversion endarterectomy and with conventional patch plasty.

After limited experience with eversion endarterectomy of the internal carotid artery, comparison has been made between perioperative results obtained with the eversion technique and with the conventional method. The perioperative results of 715 consecutive cases of patch plasty of the internal carotid artery performed between January 1986 and December 1990 were reviewed and compared with perioperative data of 739 consecutive cases of eversion endarterectomy, performed between January 1991 and December 1993. The duration of surgery was also recorded. Statistical analysis was carried out, using chi2 test, Fisher's Z test and Student's t-test. The postoperative stroke rate was 2.9% in the conventional endarterectomy group, and 0.95% in cases of eversion endarterectomy (P<0.01); the stroke mortality rates were 1.8% and 0.54% respectively (P<0.05). Overall mortality rate was 2.9% in the conventional group and 0.95% in the eversion group (P<0.01): combined morbidity and mortality rate was 4% versus 1.35% (P<0.001). A statistically significant difference was found in favour of the eversion method between the duration of surgery (90.9 min versus 52.8 min; P<0.005) and between the mean clamp time (34.9 min versus 22.4 min: P<0.005). On the basis of these results, it is concluded that eversion endarterectomy of the internal carotid artery is a safe and rapid technique and its immediate results were superior to those obtained after conventional endarterectomy and patch plasty.

Adult↗
PubMed1998

Hemodynamic instability following carotid endarterectomy does not affect early discharge.

Over the last few years, there has been increased emphasis on early discharge of patients following carotid endarterectomy in the United States. Recent studies have shown that short-stay hospitalization for carotid endarterectomy may be safe and cost-effective. However, this is not always possible because of reasons that are not clearly delineated. In order to optimize the early discharge of patients following carotid endarterectomy, an analysis of the causes of delayed discharges was performed in the present series. Since hemodynamic instability has been shown to be the most frequent complication following carotid endarterectomy, the authors investigated whether it was an important factor preventing early postoperative discharge. This study reviewed the data of 100 consecutive patients admitted for elective carotid endarterectomy. The incidence of post-carotid endarterectomy hemodynamic instability was 37% (n = 37), with hypertension occurring in 25 patients (68%) and hypotension occurring in 12 patients (32%). Hemodynamic instability tended to occur with the use of general anesthesia as compared with regional anesthesia. Hemodynamic instability did not correlate with pre-existent history of hypertension, nor with the type of drug used when general anesthesia was applied. All the patients were successfully treated either in the recovery room or in a monitored area. The average total length of stay was 1.65 days with 79% of the patients being discharged on the first postoperative day and 21% having delayed discharge ranging from 2 to 15 days (mean 4 days). The main reasons for delayed discharges were cardiac and urinary tract complications. Blood pressure instability accounted for only 2% of cases. Thus, these data show that hemodynamic instability does not significantly affect early discharge.

Aged↗
PubMed1999

The use of low-dose heparin is safe in carotid endarterectomy and avoids the use of protamine sulfate.

Controversy exists concerning the appropriate dose of heparin needed during carotid endarterectomy. Use of high-dose heparin (100 U/kg) during carotid endarterectomy may require the use of protamine to minimize perioperative bleeding complications. At the authors' institution the use of 30 U/kg heparin for arterial reconstruction has obviated the need for protamine. A retrospective study of carotid endarterectomies performed was undertaken. Patients undergoing combined procedures with carotid endarterectomy were excluded. A total of 420 carotid endarterectomies were performed in 330 patients. All received 3000 U of heparin or less during carotid endarterectomy. Non-fatal stroke and transient neurological deficits occurred in 0.48% and 1.9%, respectively. Mortality was 0.9%. Wounds were dry in 97%, swollen in 2.5% and bloody in 0.5%. No patient received protamine. Two patients were returned to the operating room for re-exploration because of hematoma. In conclusion, the use of protamine may be safely avoided with 30 U/kg heparin, and give acceptable stroke- and minimal complication rates.

Anticoagulants↗
PubMed1999

Microemboli detected by transcranial Doppler monitoring in patients during carotid angioplasty versus carotid endarterectomy.

UNLABELLED: Microemboli, as detected by transcranial Doppler monitoring, have been shown to be a potential cause of strokes after carotid endarterectomy. We retrospectively reviewed 105 patients who underwent transcranial Doppler monitoring during 112 procedures for the treatment of 115 carotid bifurcation stenoses: 40 by percutaneous angioplasty with stenting and 75 by carotid endarterectomy. In PTAS procedures (n = 40), there was a mean of 74.0 emboli per stenosis (range 0-398, P = 0.0001) with 4 neurologic events per patient (P = 0.08). In CEA procedures (n = 76), there was a mean of 8.8. emboli per stenosis (range 0-102, P= 0.0001) with 1 neurologic event per patient (P = 0.08). The post-procedural neurological events in the percutaneous angioplasty with stenting population included two strokes (5.6%) and two transient ischemia attacks (5.6%). Microemboli for each of these cases totalled 133, 17, 29 and 47 (with one shower), respectively. One postoperative carotid endarterectomy patient was noted to have a stroke (1.4%), with 48 microemboli noted during that procedure. The mean emboli rate for percutaneous angioplasty with stenting patients with neurological events was 59.0: without complications it was 85.1. The mean emboli rate for carotid endarterectomy patients without complications was 8.3. Three percutaneous angioplasty with stenting patients had no emboli (7.5%), whereas 29 carotid endarterectomy patients had no emboli (38.7%). CONCLUSION: The percutaneous angioplasty with stenting procedure is associated with more than eight times the rate of microemboli seen during carotid endarterectomy when evaluated with transcranial Doppler monitoring. Larger patient groups are needed to determine if this greater embolization rate has an associated risk of higher morbidity or mortality.

Adult↗
PubMed2000

Comparative results of staged and simultaneous bilateral carotid endarterectomy: a clinical study and surgical treatment.

OBJECTIVE: Bilateral carotid stenoses are actually managed by staged endarterectomy. The present study compares the results of the above surgical procedure with simultaneous bilateral carotid endarterectomy. METHODS: Sixty-four carotid endarterectomies were carried out on two groups of thirty-two patients with bilateral carotid stenoses. Fifteen patients (group A) were subjected to staged and 17 patients (group B) who were subjected to simultaneous bilateral carotid endarterectomies. RESULTS: The mortality rate was zero in both groups; no statistically significant difference was found concerning complications related to the heart, neurological deficit and postoperative hypertension. CONCLUSIONS: Simultaneous carotid endarterectomy is a challenging and technically demanding operation but with limited indications in strictly selected patients. The development of methods of more effective monitoring and protection of the cerebral cells might broaden the indications of such a surgical tactic in the future. Staged carotid endarterectomy, however, remains the method of choice for the management of bilateral carotid occlusive disease.

Adult↗
PubMed2000

Early carotid endarterectomy after stroke.

The authors sought to determine if patients with stroke and a high-grade carotid stenosis benefited from a delay before carotid endarterectomy. A retrospective study of 45 patients undergoing carotid endarterectomy after stroke is presented. The patients were divided into two groups: group I (early group, n = 20), composed of patients who had carotid endarterectomy less than 6 weeks after stroke, and group II (late group, n = 25), comprised of patients who had carotid endarterectomy more than 6 weeks after stroke. As assessed by cerebral angiography, 100% of patients in group I and 64% of patients in group II had carotid artery stenoses > 76% (P < 0.001). The median interval from stroke to carotid endarterectomy was 14 days in group I and 129 days in group II. There was no mortality in either group. No patients in either group demonstrated any neurological deterioration. The authors conclude that, in select patients, carotid endarterectomy may be done safely less than 6 weeks after stroke in order to avoid new events or carotid occlusion while awaiting surgery.

Aged↗
PubMed1984

[Early postoperative morphology of the carotid artery following endarterectomy: systematic prospective studies with a high resolution ultrasound real-time imaging system].

The ultrasonic morphology of the carotid artery following 55 endarterectomies in 50 patients was systematically studied using a high resolution ultrasound duplex system. The typical findings were: At the site of endarterectomy the new vessel wall showed: lack of the "sonographic tunica intima"; the thickness of the vessel wall was reduced with less pronounced ultrasonic structure compared with healthy subjects; the surface toward the lumen was less smooth; "ultrasonically soft" thrombotic layers with irregular surface, individual distribution (sometimes only spots) and thickness (0.5 to 4.0 mm) were seen in the majority of patients. The edge of the tunica intima was always visible in the common carotid (edge of endarterectomy), whereas in the internal carotid artery there was often an interference of the jaw. The change of caliber at the site of the edge of the tunica intima was dependant on the thickness of the "sonographic intima" as well as on the layer of the vessel wall in which endarterectomy was done. At the site of arterial clamping intramural haematomas, lesions of the tunica intima with thrombotic layers causing some stenosis were observed after 9 of 55 procedures. Vascular sutures were always visible as bright spots. A "normalisation" of the pulsatory motion of the vessel wall as well as "normalisation" of local flow patterns could be seen in dependence on the morphological "normalisation". The soft thrombotic layers of the new vessel wall were especially pronounced at sites of incomplete endarterectomy, in one case with change of the vessel geometry and in another case were the opposite carotid was operated on 3 days later. Obviously, a short phase of high instability of the endarterectomy site (3 days, development of the platelet-fibrin layer) is followed by a period of relative instability of the new vessel wall, which lasted for 4 to 8 weeks. In 5 patients with central neurological deficits following surgery, especially pronounced soft thrombotic layers of the new vessel wall including 2 complete occlusions and 1 near-occlusion were observed.

Aged↗
PubMed1990

Transaortic endarterectomy of renal visceral artery lesions in association with infrarenal aortic surgery.

The complexity of infrarenal aortic reconstruction increases when bypass grafts to revascularize associated renal and visceral arteries are needed. Lesions in these vessels, however, are usually limited to their aortic orifices and therefore are amenable to retroperitoneal transaortic endarterectomy. A combined infrarenal aortic reconstruction and transaortic endarterectomy of the renal/visceral vessels was used in 18 (16%) of 120 patients undergoing elective infrarenal aortic reconstruction over a 2-year-period. Transaortic endarterectomy was performed primarily for renal preservation in 11 patients with bilateral, high-grade renal artery stenoses and abnormal renal function (serum creatinine greater than or equal to 1.9 mg/dl). In seven patients transaortic endarterectomy was performed as a secondary procedure during the course of complex reconstruction of aneurysmal or occlusive aortic disease. Mean serum creatinine, which was elevated preoperatively in 14 (78%) patients (3.3 mg/dl), decreased significantly after the operation (2.0 mg/dl, p less than 0.01). A single death occurred in the 18 patients undergoing transaortic endarterectomy. Renal function preservation can be achieved by renal revascularization in patients with bilateral renal artery stenoses and decreased renal function. The retroperitoneal approach to aortic reconstruction and the use of transaortic endarterectomy allows correction of most renal/visceral vessel involvement in complex aortic revascularization procedures.

Aorta, Abdominal↗
PubMed2000

Intraoperative use of stents for the management of unacceptable distal internal carotid artery end points during carotid endarterectomy: short-term and midterm results.

PURPOSE: The management of unacceptable distal internal carotid artery (ICA) end points during carotid endarterectomy presents multiple dilemmas. The problem may be expeditiously solved by placement of an intraluminal stent, but reported clinical experience with this technique is limited. We retrospectively reviewed our experience with intraoperative stenting of the ICA for the correction of unacceptable distal ICA end points during carotid endarterectomy. We report our techniques and document the 30-day stroke morbidity-death rate and midterm outcomes of patients treated in this manner. METHOD: The records of 316 consecutive carotid endarterectomies performed by the authors from January 1997 through June 1999 were reviewed to identify those cases in which adjunctive intraoperative stenting of the distal ICA was used. For those patients treated with adjunctive ICA stents, we assessed technique, 30-day outcomes, and midterm outcomes. RESULTS: The 30-day combined stroke and death rate for the entire group of 316 carotid endarterectomies was 1.9%. Adjunctive distal ICA stents were used in 13 cases-4.1% of the total carotid endarterectomy group-for the correction of unacceptable distal ICA end points. All patients were male; the average age was 70 years. Stents were used in 11 patients because in each of these cases the surgeon recognized an unacceptable end point and desired to limit further distal anatomic exposures and/or ischemia times. Stents were used in two patients to correct unexpected defects identified on intraoperative completion ultrasound scan. No 30-day periprocedural deaths, strokes, or transient ischemic attacks were observed. Average postoperative length of stay was 1.8 days (range, 1-5 days). All patients have been followed up with serial carotid duplex scans, and one patient has been studied by means of angiography. No patients have died, and all remain in active clinical follow-up. Mean length of follow-up has been 15 months. No significant asymptomatic recurrences have been observed, but one patient experienced an isolated episode of amaurosis fugax without demonstrable restenosis at 8 months postoperatively. CONCLUSION: Our experience suggests that the adjunctive use of stents for the correction of unacceptable distal ICA end points during carotid endarterectomy is safe and provides acceptable short-term and midterm outcomes. Continued follow-up will be required before this technique can be considered a primary choice rather than an expeditious secondary alternative in this infrequent clinical circumstance.

Aged↗
PubMed2001

Folate supplementation inhibits intimal hyperplasia induced by a high-homocysteine diet in a rat carotid endarterectomy model.

OBJECTIVE: Hyperhomocysteinemia has been implicated as a causative factor in intimal hyperplasia development. The addition of dietary folate in a hyperhomocysteinemia, carotid endarterectomy rat model is postulated to decrease plasma homocysteine levels and, in turn, reduce post-carotid endarterectomy intimal hyperplasia. METHODS: Each rat was fed one of six diets: (1) lab chow with no folate (n = 7), (2) lab chow with 10 mg/kg folate added (n = 3), (3) lab chow with 25 mg/kg folate added (n = 3), (4) a homocysteine diet with no folate (n = 7), (5) a homocysteine diet with 10 mg/kg folate added (n = 5), or (6) homocysteine diet with 25 mg/kg folate added (n = 5). Each rat then underwent an open carotid endarterectomy. In 2 weeks, intimal hyperplasia in the carotid artery was measured. Plasma homocysteine and folate levels were measured. RESULTS: Plasma folate levels rose with folate administration. Plasma homocysteine in the lab chow group was 5.4 +/- 0.5 micromol/L and did not change with the addition of folate. In the homocysteine diet group, plasma homocysteine rose 10-fold over the lab chow group (51.9 +/- 6.5 vs 5.4 +/- 0.5, micromol/L, P <.0001). In the group fed a homocysteine diet with 10 mg/kg folate added, a significant decrease in plasma homocysteine was observed (17.5 +/- 8.5 vs 51.9 +/- 6.5, micromol/L, P =.0003). In the group fed a homocysteine diet with 25 mg/kg folate added, plasma homocysteine levels were further reduced to levels seen in the lab chow group (12.6 +/- 2.6 vs 5.4 +/- 0.5, micromol/L, P = not significant). The relationship between plasma folate and homocysteine was inverse (R = 0.39, P =.0036). Luminal stenosis due to intimal hyperplasia was minimal in lab chow groups and unaffected by folate. The homocysteine diet group demonstrated post-carotid endarterectomy luminal stenosis due to intimal hyperplasia (60.9% +/- 9.2%). In the group fed a homocysteine diet with 10 mg/kg folate added, intimal hyperplasia was reduced, compared with the homocysteine diet group (32.6% +/- 7.4% vs 60.9% +/- 9.2%, P =.009). In the group fed a homocysteine diet with 25 mg/kg folate added, intimal hyperplasia was reduced to lab chow group levels (10.8% +/- 0.8% vs 4.8% +/- 1.0%, P = not significant) and was reduced, compared with the group fed a homocysteine diet with 10 mg/kg folate added. CONCLUSION: The use of folate in this hyperhomocysteinemia carotid endarterectomy model and the resultant attenuation of plasma homocysteine elevation and intimal hyperplasia development lend strong support to homocysteine being an independent etiologic factor in post-carotid endarterectomy intimal hyperplasia.

Animals↗
PubMed2000

Carotid endarterectomy for women and men.

Carotid endarterectomy is the standard of care for people with severe symptomatic carotid stenosis. We analyzed population administrative data and clinical trial data to determine whether sex differences exist in the use and outcomes of this surgical procedure. We studied patients in Ontario who underwent carotid endarterectomy between 1982 and 1994 (n = 12,949) and patients with severe carotid stenosis who were enrolled in two randomized trials of endarterectomy (n = 1646). We compared the proportion of men and women who underwent carotid endarterectomy in each group, over time, and after adjustment for demographic factors. Men were twice as likely as women to receive carotid endarterectomy in the administrative analysis (65% versus 35%, p < 0.001) and in the clinical trial analysis (70% versus 30%, p < 0.001). The relatively lower use in women was consistent in every age group and in every year studied. Men in the administrative database were somewhat less likely than women to die or be institutionalized after surgery (5% versus 6%, p = 0.007). Men in the clinical trial database were also less likely than women to experience perioperative stroke or death, although the results were not statistically significant (6% versus 7%, p = 0.32). Patients who were assigned to surgical therapy, compared with those assigned to medical therapy, had a significant decrease in the risk of adverse events at 1 year, and the net benefit appeared similar in women and men. Carotid endarterectomy is performed relatively infrequently on women despite their similar lifetime burden of disease and similar short-term perioperative risks compared with men.

Age Distribution↗
PubMed1983

Routine electroencephalographic (EEG) monitoring during carotid endarterectomy.

Controversy continues concerning the advisability of routine shunting, no shunting, or selective shunting during carotid endarterectomy. Because of its reflection of the physiologic state of the end organ, the authors chose routine 18 lead EEG monitoring as a guide to selective shunting and as an indication of adequate shunt function during all carotid endarterectomies performed from December 1977 through July 1982. In that period, 200 patients underwent 219 endarterectomies under general anesthesia and EEG monitoring. Ischemic EEG changes at the time of carotid cross clamping suggested the need for intraluminal shunts in 16% of patients. Insertion of shunts restored the EEG pattern to normal in all instances, although in two patients, adjustment of the shunt was required to maintain this results. EEG changes requiring shunting occurred in 10% of patients with unilateral disease, in 27% of patients with bilateral disease, and in 42% of patients with unilateral stenosis and contralateral occlusion. Twenty-seven patients had small fixed neurologic deficits before operation. Surgery was not delayed in these individuals who demonstrated no increased requirement for shunts and no new postoperative neurologic deficits. In the group of 150 endarterectomies performed as separate procedures, there was one (0.7%) fixed neurologic deficit after operation, one transient deficit (0.7%), and one death (0.7%). Sixty-nine endarterectomies were performed simultaneously with open heart surgery and were associated with one fixed neurologic deficit (1.4%) and two transient deficits (2.9%). All four deaths in this group were attributable to the cardiac surgical procedures. These results indicate that selective shunting based on EEG monitoring permits the safe performance of carotid endarterectomy, even in patients considered to be at high risk for postoperative neurologic deficit.

Adult↗
PubMed2004

Carotid endarterectomy in octogenarians.

BACKGROUND: The role of carotid endarterectomy in octogenarians is unclear as this age group was not included in the major trials of carotid surgery. The aim of the present study was to determine the trends and early outcome of carotid endarterectomy performed in octogenarians at a single institution. METHODS: A retrospective review of all carotid endarterectomies performed between 1990 and 2001 was conducted as part of a clinical audit. Trends in procedure numbers, length of stay, age and early outcome were assessed. The results of octogenarians were analysed separately. RESULTS: Three hundred and fifty-nine carotid endarterectomies were performed in 329 patients including 33 octogenarians. The number of cases and the mean age of patients increased and length of stay decreased during the study period. There was a significant increase in the proportion of octogenarians undergoing carotid endarterectomy (P = 0.03) in the second half of the study period. The combined rate of stroke and death was higher in octogenarians compared with patients under 80 years old, but the difference was not statistically significant (8.8%vs 5.8%; P = 0.59). CONCLUSION: The mean age of patients and the proportion of octogenarians undergoing carotid endarterectomy has increased over the 12-year study period.

Age Factors↗
PubMedDate not supplied

Extensive endarterectomy, onlay patch, and internal mammary bypass of the left anterior descending coronary artery.

The incidence of diffuse disease requiring multiple endarterectomies is high among the Oriental population. The technique of LAD endarterectomy and reconstruction is difficult, and often it is a challenging problem. From June 1987 to September 1994, 2376 patients from seven countries underwent coronary artery bypass graft surgery, among whom 610 patients had endarterectomy. One hundred thirty-six patients underwent LAD endarterectomy, and among them, 69 had extensive endarterectomy. The LAD was reconstructed with IMA onlay patch in 41 patients and with saphenous vein onlay patch in 28 patients. Three patients had evidence of postoperative myocardial infarction and seven patients died in the postoperative period. Twelve patients were postoperatively restudied and in all of them, the graft to LAD was patent. Use of internal mammary artery onlay patch after endarterectomy is advantageous since it may be associated with higher long-term patency and low incidence of reoperation. To our knowledge, this has not been reported anywhere.

Adult↗
PubMed1998

Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis.

OBJECTIVE: To assess the value of carotid endarterectomy for prevention of stroke in patients with asymptomatic carotid stenosis. DESIGN: Systematic review and meta-analysis of randomised controlled trials in patients with asymptomatic carotid stenosis in which subjects were allocated to carotid endarterectomy or to medical treatment alone. SUBJECTS: Five trials enrolled 2440 patients with stenosis >/ 50%. MAIN OUTCOME MEASURES: Stroke ipsilateral to the stenosis, all strokes, and perioperative complications (stroke or death). RESULTS: In patients who underwent carotid endarterectomy (n=1215) there was a significant reduction in the odds of ipsilateral stroke plus perioperative stroke or death (odds ratio 0.62; 95% confidence interval 0.44 to 0.86), corresponding to a 2% absolute risk reduction over about 3.1 years. The prevalence of stroke in any location was also reduced (0.68; 0.51 to 0.9) in patients undergoing carotid endarterectomy. During the immediate postoperative period there was an increased prevalence of stroke or death among such patients (4.51; 2.36 to 8.64). CONCLUSION: Carotid endarterectomy in patients with asymptomatic carotid stenosis unequivocally reduces the incidence of ipsilateral stroke, though the absolute benefit is relatively small. Given the modest benefit of surgery for unselected patients with asymptomatic carotid artery stenosis carotid endarterectomy cannot be routinely recommended for these patients pending reliable identification of high risk subgroups, and medical management is a sensible alternative for most patients.

Aged↗
PubMed1999

Public health impact of carotid endarterectomy.

Despite the completion of several multi-center clinical trials comparing medical management and carotid endarterectomy, there is still controversy as to when carotid endarterectomy is appropriate. The volume of this surgery appears to be increasing. However, available performance data indicate that the surgical proficiency required for the clinical trials is not achieved uniformly in actual practice. Therefore, benefits of carotid endarterectomy, when considered from a public health perspective, are limited by the following: (1) endarterectomy is an expensive stroke prevention modality; (2) endarterectomy addresses the needs of only a relatively small subset of stroke patients, and (3) endarterectomy for asymptomatic patients, without clearer evidence that these individuals benefit, may decrease the cost-effectiveness of this surgical procedure.

Brain Ischemia↗
PubMed1995

Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association.

BACKGROUND AND PURPOSE: Indications for carotid endarterectomy have engendered considerable debate among experts and have resulted in publication of retrospective reviews, natural history studies, audits of community practice, position papers, expert opinion statements, and finally prospective randomized trials. The American Heart Association assembled a group of experts in a multidisciplinary consensus conference to develop this statement. METHODS: A conference was held July 16-18, 1993, in Park City, Utah, that included recognized experts in neurology, neurosurgery, vascular surgery, and healthcare planning. A program of critical topics was developed, and each expert presented a talk and provided the chairman with a summary statement. From these summary statements a document was developed and edited onsite to achieve consensus before final revision. RESULTS: The first section of this document reviews the natural history, methods of patient evaluation, options for medical management, results of surgical management, data from position statements, and results to date of prospective randomized trials for symptomatic and asymptomatic patients with carotid artery disease. The second section divides 96 potential indications for carotid endarterectomy, based on surgical risk, into four categories: (1) Proven: This is the strongest indication for carotid endarterectomy; data are supported by results of prospective contemporary randomized trials. (2) Acceptable but not proven: a good indication for operation; supported by promising but not scientifically certain data. (3) Uncertain: Data are insufficient to define the risk/benefit ratio. (4) Proven inappropriate: Current data are adequate to show that the risk of surgery outweighs any benefit. CONCLUSIONS: Indications for carotid endarterectomy in symptomatic good-risk patients with a surgeon whose surgical morbidity and mortality rate is less than 6% are as follows. (1) Proven: one or more TIAs in the past 6 months and carotid stenosis > or = 70% or mild stroke within 6 months and a carotid stenosis > or = 70%; (2) acceptable but not proven: TIAs within the past 6 months and a stenosis 50% to 69%, progressive stroke and a stenosis > or = 70%, mild or moderate stroke in the past 6 months and a stenosis 50% to 69%, or carotid endarterectomy ipsilateral to TIAs and a stenosis > or = 70% combined with required coronary artery bypass grafting; (3) uncertain: TIAs with a stenosis < 50%, mild stroke and stenosis < 50%, TIAs with a stenosis < 70% combined with coronary artery bypass grafting, or symptomatic, acute carotid thrombosis; (4) proven inappropriate: moderate stroke with stenosis < 50%, not on aspirin; single TIA, < 50% stenosis, not on aspirin; high-risk patient with multiple TIAs, not on aspirin, stenosis < 50%; high-risk patient, mild or moderate stroke, stenosis < 50%, not on aspirin; global ischemic symptoms with stenosis < 50%; acute dissection, asymptomatic on heparin. Indications for carotid endarterectomy in asymptomatic good-risk patients performed by a surgeon whose surgical morbidity and mortality rate is less than 3% are as follows. (1) Proven: none. As this statement went to press, the National Institute of Neurological Disorders and Stroke issued a clinical advisory stating that the Institute has halted the Asymptomatic Carotid Atherosclerosis Study (ACAS) because of a clear benefit in favor of surgery for patients with carotid stenosis > or = 60% as measured by diameter reduction. When the ACAS report is published, this indication will be recategorized as proven. (2) acceptable but not proven: stenosis > 75% by linear diameter; (3) uncertain: stenosis > 75% in a high-risk patient/surgeon (surgical morbidity and mortality rate > 3%), combined carotid/coronary operations, or ulcerative lesions without hemodynamically significant stenosis; (4) proven inappropriate: operations with a combined stroke morbidity and mortality > 5%.

Arterial Occlusive Diseases↗