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At least 1,621 records · Page 90Linked to original sources
PubMed2002

Carotid endarterectomy in elderly patients: low complication rate with overnight stay.

HYPOTHESIS: Elderly patients undergoing carotid endarterectomy (CEA) can have a low complication rate and a short hospital stay. DESIGN: In this case series, we compared CEA results from January 1, 1994, through December 31, 1998, in 2 different age groups: 71 to 80 years and 81 years and older. SETTING: A private vascular surgery practice. PATIENTS: We studied 271 patients who underwent 293 CEAs; 124 procedures were for patients in the 71- to 80-year-old age group, and 42 procedures were for patients aged 81 years and older. INTERVENTIONS: Classic CEA was performed on all patients. From 1994 through 1996, 179 operations were performed under general anesthesia with routine shunting. In 1997 and 1998, 114 operations were performed under locoregional anesthesia with selective shunting. MAIN OUTCOME MEASURES: Length of hospital stay and 30-day morbidity and mortality. RESULTS: The mortality rate for the entire series was 0.7% (2 of 293 patients). Major cardiac complications occurred in 3 patients (1.0%). Perioperative stroke occurred in 3 cases(1.0%); 2 strokes occurred in patients aged 71 to 80 years (2 [1.6%] of 124 patients), and 1 occurred in a patient aged 81 years or older (1 [2.4%] of 42 patients). Two additional patients developed reversible ischemic neurological deficits but were not in the elderly group (> or =81 years and older). The mean hospital stay was 1.5 days for patients aged 71 to 80 years and 1.2 days for patients aged 81 years and older. All outcome variables were statistically similar in both age groups. CONCLUSION: Octogenarians can undergo CEA with little morbidity and mortality and virtually an overnight hospital stay.

Age Factors↗
PubMed1975

Carotid endarterectomy for nonhemispheric transient ischemic attacks.

Fifty carotid endarterectomies were performed in 46 patients with nonhemispheric transient ischemic attacks. There was no mortality. Three patients had temporary strokes postoperatively. Ninety-five percent of the patients were improved and remained so at follow-up examination. Clinical improvement was not related to the presence or absence of vertebral or subclavian stenosis. In retrospect, the two patients who were unimproved had been improperly selected.

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PubMed1976

Simultaneous bilateral carotid endarterectomies.

Twelve patients with bilateral symptomatic lesions of internal carotid arteries have had bilateral carotid endarterectomy at single operations without complications. These were patients up to age 80 who had prior mycardial infarction, stroke with recovery, and hemispheric and nonhemispheric episodes. Neurologist's clearance and three- or four-vessel intracranial-extracranial angiography preceded all operations, which were performed with the patient under general anesthesia. Stump pressure measurements were the principal guideline of adequacy of collateral flow and predictor of safe outcome. The safety of this concept of bilateral operations during one anesthesia can eliminate uncertainties of sequence and timing, obviate delay and indecision, and avoid the hazards of a second anesthetic-operative experience.

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PubMed1977

Innominate artery endarterectomy. A 16-year experience.

Transsternal endarterectomy was performed in 34 of 37 patients with symptomatic atherosclerosis of the innominate artery, with a mortality of 6%. Thirty of the 32 survivors are asymptomatic at an average of 6.1 years postoperatively. Six of these patients who had ulcerated, nonstenotic atherosclerotic lesions have had complete cessation of preoperative transient ischemic attacks. Normal arterial patency has been maintained for follow-up periods varying from seven months to 16 years.

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PubMed1978

Early restenosis after carotid endarterectomy.

Restenosis within 24 months of carotid endarterectomy was discovered in 3.6% of 361 operations. The patients in this group of restenosis tended to be younger than the overall group. Hypertension and hyperlipidemia were also more frequent. Restenosis recurred within an average of 12.5 months of the first operation, with a range from five to 24 months. No surgical technical causes could be found. Restenosis is attributed to rapid, exuberant myointimal proliferation. This process is histologically distinct from the atherosclerotic plaque which is the cause of late restenosis. Reoperation on this group of patients with the fibrous myointimal proliferative type of lesion was difficult and was infrequently associated with improvement in the patients' signs and symptoms.

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PubMed1979

Hand-held toy squeaker during carotid endarterectomy in the awake patient.

A toy squeaker held by the patient in the contralateral hand is used to monitor cerebral circulation during carotid endarterectomy. Regional anesthesia--cervical plexus block--allowed the patient to cooperate and give useful information, especially during the crucial period of test clamping. In a series of 300 cases, during a period of five years, it was instrumental in avoiding brain damage in 6% of the cases.

Anesthesia, Conduction↗
PubMed1979

Carotid endarterectomy shunting. Effectiveness determined by operative ocular pneumoplethysmography.

The theoretical advantages and practical disadvantages of carotid endarterectomy shunting are well known. To assess shunt physiology, we performed operative ocular pneumoplethysmography on six patients before carotid clamping, during carotid clamping, during carotid shunting, and on completion of carotid repair. In each case the shunt functioned, at best, as a vessel with at least a 75% or greater cross-sectional area stenosis. However, in all cases it appreciably elevated the ipsilateral ophthalmic systolic pressure over that noted during carotid clamping. There is no question that carotid shunting provides a margin of safety during prolonged carotid clamping.

Blood Pressure↗
PubMed1979

Carotid endarterectomy in the presence of contralateral carotid occlusion: the role of EEG and intraluminal shunting.

Patients undergoing carotid endarterectomy in the presence of occlusion of the contralateral carotid artery appear at greater risk for operative-related stroke or death. We had experience with 37 such patients in a five-year period. Routine intraluminal shunting without EEG monitoring was used in nine patients. Twenty-eight patients had continuous EEG monitoring during surgery. Of this group, 12 patients required intraluminal shunting based on intraoperative EEG criteria. In the early postoperative period, there was one death, and there were no instances of new, fixed neurological deficits. Life table analysis shows that 80% of the patients are neurologically stable in the five-year follow-up period. Electroencephalographic monitoring proved valuable in the detection of patients requiring intraluminal shunting, in the occasional recognition of poorly functioning shunts, and in the determination of the importance of alterations in blood pressure or cardiac rhythm on cerebral blood flow.

Arterial Occlusive Diseases↗
PubMed1980

Recurrent transient ischemic attacks after carotid endarterectomy.

The postoperative courses of 113 patients undergoing 121 carotid endarterectomies between 1974 and 1979 were analyzed for recurrent transient ischemic attacks (TIAs). The TIAs were the indication for the original operation in all patients; 31 patients had a stable neurologic deficit prior to operation. Two patients sustained major strokes and three had nondisabling minor strokes. Three patients had late strokes. Recurrent TIAs occurred during follow-up in 28 patients, and these were classified into four distinct categories: (1) Ten patients had single TIAs in the distribution of the carotid artery operated on in the early postoperative days. (2) Four patients had late, repetitive TIAs related to the operated side. (3) Five patients had late TIAs in the distribution of the contralateral artery. (4) Nine patients had single or multiple TIAs owing to recurrent vertebrobasilar insufficiency. Close, long-term follow-up of postendarterectomy patients is recommended to locate those who will have surgically correctable lesions.

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PubMed1980

Postoperative occlusion after carotid endarterectomy.

Noninvasive testing (Doppler imaging and spectral analysis of carotid flow) was performed in 70 symptomatic patients who required unilateral carotid endarterectomy. Angiographic correlations were made with the noninvasive tests before surgery, and postoperatively hemodynamic changes were determined during a three-year follow-up period. Postoperative stenosis occurred in 9% (3% early and 6% late) of the patients. Clinical progression on the unoperated side (new symptoms or bruits) occurred in 15 patients. Ten of these 15 patients had significant hemodynamic progression of disease in the unoperated carotid as well. Clinically occult hemodynamic progression of disease on the unoperated side was detected by noninvasive testing in four of the cases. Neurological complications resulting from postoperative occlusion occurred in two cases.

Arterial Occlusive Diseases↗
PubMed1980

Carotid endarterectomy: an alternative approach.

Ninety-six consecutive carotid endarterectomies were carried out with each patient under regional anesthesia and with the routine use of an indwelling arterial shunt. When combined on a routine basis, the theoretical advantages derived from each technique become additive such that maximal cerebral protection afforded by the shunt is continuously monitored by an awake patient. The validity of this approach in a teaching setting is evidenced by a low (1%) mortality and morbidity and by an exceptional degree of patient compliance.

Anesthesia, Conduction↗
PubMed1982

Prophylactic carotid endarterectomy for asymptomatic bruit. A look at cardiac risk.

We assessed the influence of preoperative cardiac risk factors in 57 patients undergoing 70 prophylactic carotid endarterectomies (PCE) and found that: (1) 47 (83%) had at least one cardiac risk factor and (2) nine of 15 deaths occurring in the late follow-up period (40 to 120 months) were due to cardiac causes. Perioperatively, one patient sustained a mild stroke. Although the cumulative stroke-free occurrence rate was kept to less than 6% over the five-year period, cardiac morbidity and mortality greatly influenced the quality of life after PCE. Therefore, PCE is suggested only for patients who have minimal preoperative cardiac risk factors or for those patients whose cardiac risk factors can be improved by medical therapy.

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PubMed1982

Carotid artery stenosis following endarterectomy.

Duplex scanning and spectral analysis were used to detect carotid artery stenosis following 89 endarterectomies in 76 patients with a mean postoperative follow-up interval of 16 months. Operative arteriography was used in all cases to verify the technical result. Spectral changes indicating greater than 50%-diameter internal carotid stenosis were observed postoperatively in 32 of the 89 sides. Serial follow-up of 22 stenotic sides showed persistent stenosis in 12, regression of stenosis in nine, and internal carotid occlusion in one. The estimated overall incidence of persistent high-grade stenosis was 19%. Recurrent neurologic symptoms occurred in eight patients. This incidence of postoperative carotid stenosis is higher than estimates based on clinical criteria. The transient nature of some early postoperative stenosis is consistent with proliferation and regression of myointimal lesions in response to arterial injury.

Carotid Arteries↗
PubMed1983

Digital subtraction angiography and continuous-wave Doppler studies. Their use in postoperative study of patients with carotid endarterectomy.

Postoperative study of 40 patients who underwent carotid endarterectomy was performed using digital subtraction angiography (DSA) and transcutaneous continuous-wave Doppler (CWD) studies. The two techniques were comparable in defining recurrent stenosis in the reconstructed carotid arteries and progressive disease in the contralateral carotid artery. Digital subtraction angiography appeared to be more sensitive than the CWD method in detecting minor progression of carotid disease. Our data suggested that CWD and DSA have comparable ability to identify significant (greater than 50%) carotid artery stenosis in this group of patients. However, DSA provided more detailed imaging of the carotid system and may give enough information about progression of carotid disease to avoid preoperative arteriography in some patients.

Angiography↗
PubMed1985

Correlation of B-mode ultrasound imaging and arteriography with pathologic findings at carotid endarterectomy.

Presently most noninvasive methods for assessing extracranial carotid disease have relied on hemodynamic change associated with significant stenosis. Recent evidence has suggested that both ulceration and/or plaque hemorrhage may frequently play an important role in the pathophysiology of carotid disease. To assess the ability of B-mode ultrasound to provide this anatomic information, in a prospective blinded manner we compared B-mode ultrasound and selective four-vessel arteriography to pathologic specimens obtained at the time of 89 carotid endarterectomies. The presence of ulceration, plaque characteristics (particularly hemorrhage), and luminal diameter were described for each modality. While arteriography detected only 16 of 27 ulcerations (sensitivity, 59%), B-mode ultrasound had a greater sensitivity (24/27, 89%). Both modalities had comparable specificities (arteriography, 73%; B-mode ultrasound, 87%). Moreover, B-mode ultrasound was highly sensitive for demonstrating plaque hemorrhage (27/29, 93%), as well as being quite specific (84%). Assessment of luminal reduction by B-mode ultrasound improved with technologist/interpreter experience and was significantly improved by adding real-time spectral analysis. Because of B-mode ultrasound's sensitivity for imaging ulceration and plaque hemorrhage, it offers significant advantages for the noninvasive detection of extracranial carotid disease.

Arterial Occlusive Diseases↗
PubMed1985

Management of acute postoperative thrombosis following carotid endarterectomy.

We reviewed 326 carotid endarterectomies performed from 1960 through 1981 and encountered five instances of acute postoperative thrombosis. Clinical decompensation occurs with the acute onset of severe neurologic deficits, most characteristically dense hemiplegias contralateral to the side that has been operated on. These deficits developed between two and 72 hours postoperatively. Prompt reoperation with thrombectomy and reestablishment of carotid flow within two hours from the onset of the neurologic deficit was performed on four patients with complete resolution of the deficits in three patients. The fourth patient recovered from a severe hemiplegia but retained a slight residual weakness of the hand. The one patient whose condition did not improve underwent thrombectomy more than 24 hours after the onset of her deficit. Time-consuming diagnostic procedures are not warranted as the success of reoperation depends on rapid reestablishment of cerebral flow.

Acute Disease↗
PubMed1986

Predicting cerebral ischemia during carotid endarterectomy.

We reviewed 86 consecutive patients undergoing elective carotid endarterectomy to determine whether preoperative clinical and angiographic data could be used to predict the risk of intraoperative cerebral ischemia during carotid occlusion. Electroencephalographic (EEG) monitoring with on-line Berg-Fourier transformation was carried out in all patients. A total of 32 patients (37.2%) underwent intraoperative shunting. Of these, 13 had no EEG changes but underwent shunting because of the surgeon's preference, while 19 patients underwent shunting because of EEG changes consistent with cerebral ischemia. There was one permanent (1.2%) and one transient (1.2%) neurologic deficit. Angiographic findings, clinical histories, and intraoperative EEGs were retrospectively reviewed to determine which risk factors best predicted the occurrence of intraoperative cerebral ischemia. Stroke within six weeks increased the risk of intraoperative cerebral ischemia 20-fold. Intracranial disease and contralateral carotid stenosis increased the risk of ischemia 17-fold and 16-fold, respectively. Statistical summation of all risk factors yielded a probability equation for EEG change that accurately quantitated pre-operative risk. Prospective application of this probability equation may simplify operative decision making if EEG monitoring is not available.

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PubMed1986

Noninvasive conjunctival oxygen monitoring during carotid endarterectomy.

Conjunctival oxygen tension (PcjO2) was measured continuously during carotid endarterectomy in 15 patients to evaluate its sensitivity in patients receiving shunts. These studies suggest that PcjO2 tracks brain perfusion during periods of carotid artery occlusion. Reduced PcjO2 was clearly demonstrated with systemic hypotension, carotid artery clamping, and carotid shunt obstruction and clamping. Monitoring of PcjO2 is noninvasive, easy to perform, offers no danger to the patient, and allows real-time assessment of the local tissue perfusion. It provides valuable information on the effectiveness of carotid oxygen transport and, in conjunction with arterial blood gas values, expresses carotid artery perfusion relative to systemic oxygen transport. Further investigations using the PcjO2 sensor may define criteria for intraoperative carotid arterial shunting in patients with tenuous cerebral perfusion, and for prompt intervention in patients with deteriorating perfusion prior to the onset of life-threatening cerebral ischemia.

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