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PubMed1997

Effect of the Asymptomatic Carotid Atherosclerosis Study on carotid endarterectomy in Veterans Affairs medical centers.

OBJECTIVE: To examine the effect of the Asymptomatic Carotid Atherosclerosis Study on the volume of carotid endarterectomies (CEAs) performed in Veterans Affairs medical centers. DESIGN: The data were retrospectively extracted from the Veterans Affairs Patient Treatment File for all patients undergoing CEA using the International Classification of Diseases, Ninth Revision, Clinical Modification procedural code 38.12. Data were classified into patient management categories to identify complications and to quantify the severity of illnesses and comorbidities. SETTING: All 172 US Veterans Affairs medical centers. PATIENTS: Veterans undergoing CEA during fiscal years 1993 through 1995. MAIN OUTCOME MEASURES: Procedural volume, mortality, and morbidity. RESULTS: There was a 43.4% increase in the volume of CEAs performed in fiscal year 1995 despite a 4.6% decrease in the served inpatients and an 8.8% decrease in the inpatient surgical procedures. The monthly volume of CEAs increased (P < .001, r2 = 0.78) at the onset of the fiscal year (October 1994) immediately after the Asymptomatic Carotid Atherosclerosis Study clinical advisory. The volume of CEAs increased in every region of the country for all nonpsychiatric hospital classifications and for almost every surgeon subspecialty. Despite the increased volume, the operative mortality rate, the International Classification of Diseases, Ninth Revision, Clinical Modification--and patient management categories--based complication rates, and the patients' comorbidity and severity of illness indexes all remained unchanged. CONCLUSION: The dramatic increase in CEAs following the Asymptomatic Carotid Atherosclerosis Study clinical advisory suggests that the conclusions of the trial have been accepted by the medical community throughout the Veterans Affairs medical centers.

Adult↗
PubMed1980

Convulsions after carotid endarterectomy.

Convulsions have not been emphasized as a possible complication of carotid endarterectomy. We describe here three patients in whom seizures with a focal component developed postoperatively. We suspect that the convulsions were secondary to a cerebral embolus arising from the operative site. An unstable preoperative neurological status is not a prerequisite for this complication.

Aged↗
PubMed2005

Carotid endarterectomy for asymptomatic carotid stenosis.

BACKGROUND: Carotid endarterectomy (CEA) is of proven benefit in recently-symptomatic patients with severe carotid stenosis. Its role in asymptomatic stenosis is still debated. The Asymptomatic Carotid Surgery Trial (ACST) more than doubled the number of patients randomised to CEA trials. This revised review incorporates the recently published ACST results. OBJECTIVES: Our objective was to determine the effects of CEA for patients with asymptomatic carotid stenosis. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (searched May 2004), MEDLINE (1966 to May 2004), EMBASE (1980 to June 2004), Current Contents (1995 to January 1997), and reference lists of relevant articles. We contacted researchers in the field to identify additional published and unpublished studies. SELECTION CRITERIA: All completed randomised trials comparing CEA to medical treatment in patients with asymptomatic carotid stenosis. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data and assessed trial quality. Attempts were made to contact investigators to obtain missing information. MAIN RESULTS: Three trials with a total of 5223 patients were included. In these trials, the overall net excess of operation-related perioperative stroke or death was 2.9%. For the primary outcome of perioperative stroke or death or any subsequent stroke, patients undergoing CEA fared better than those treated medically (relative risk (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83). Similarly, for the outcome of perioperative stroke or death or subsequent ipsilateral stroke, there was benefit for the surgical group (RR 0.71, 95% CI 0.55 to 0.90). For the outcome of any stroke or death, there was a non-significant trend towards fewer events in the surgical group (RR 0.92, 95% CI 0.83 to 1.02). Subgroup analyses were performed for the outcome of perioperative stroke or death or subsequent carotid stroke. CEA appeared more beneficial in men than in women and more beneficial in younger patients than in older patients although the data for age effect were inconclusive. There was no statistically significant difference between the treatment effect estimates in patients with different grades of stenosis but the data were insufficient. AUTHORS' CONCLUSIONS: Despite about a 3% perioperative stroke or death rate, CEA for asymptomatic carotid stenosis reduces the risk of ipsilateral stroke, and any stroke, by approximately 30% over three years. However, the absolute risk reduction is small (approximately 1% per annum over the first few years of follow up in the two largest and most recent trials) but it could be higher with longer follow up.

Carotid Stenosis↗
PubMed2001

Dextran reduces embolic signals after carotid endarterectomy.

One hundred fifty patients undergoing carotid endarterectomy were randomly assigned to receive intravenous 10% dextran 40 or placebo. Transcranial Doppler monitoring of the ipsilateral middle cerebral artery 0 to 1 hour postoperatively detected embolic signals in 57% of placebo and 42% of dextran patients, with overall embolic signal counts 46% less for dextran (p = 0.052). Two to 3 hours postoperatively, embolic signals were present in 45% of placebo and 27% of dextran patients, with embolic signal counts 64% less for dextran (p = 0.040). We conclude that dextran reduces embolic signals within 3 hours of CEA.

Aged↗
PubMed1982

Progression of carotid disease after endarterectomy: a Doppler ultrasound study.

The clinical prognosis and evolution of carotid lesions after unilateral endarterectomy were determined in 64 patients examined 1 to 13 years after surgery (mean observation period, 6 years). Surgery mainly was confined to symptomatic patients with a stenosis only on the appropriate side. Average annual stroke rate was 1.6% on the operated and 0.8% on the nonoperated side. Direct Doppler examination at follow-up revealed a recurrent stenosis (greater than or equal to 50%) or occlusion in 36% of the operated carotid arteries, not significantly different from the proportion of progressive carotid lesions on the nonoperated side (27%). In total, 43.8% of the patients had developed new lesions in one or both carotid arteries, as compared to previous angiographic findings. About 30% of the progressive lesions were associated with symptoms of transient ischemic attacks or stroke, as opposed to 5.5% of vessels without progression of lesions (p less than 0.001). The incidence of recurrent stenosis on the operated side is considerably higher than that previously reported for symptomatic recurrent stenosis, but may represent the natural course of carotid disease in this population, in which carotid surgery thus should not be regarded as definitive treatment.

Adult↗
PubMed1986

The value of intraoperative EEG monitoring during carotid endarterectomy.

Since controversy continues concerning the value of routine electroencephalographic (EEG) monitoring and selective carotid bypass shunting, we reviewed the neurological morbidity and mortality following elective carotid endarterectomy in 172 patients with symptomatic carotid occlusive disease. The use of EEG monitoring and selective shunting was associated with a reduction in the frequency of carotid shunts (49 to 12%) and a decline in combined major neurological morbidity and mortality (2.3 to 1.1%). We conclude that the routine use of intraoperative EEG monitoring is a valuable procedure, particularly in patients at high risk for perioperative neurological complications.

Aged↗
PubMed1997

Pupil-involving third-nerve palsy and carotid stenosis: rapid recovery following endarterectomy.

We report a patient who presented with a painful pupil-involving third-nerve palsy. Cerebral angiography revealed a high-grade stenosis of the ipsilateral internal carotid artery with a 4-cm intraluminal thrombus. Following emergent carotid endarterectomy, the patient's partial third-nerve palsy resolved in 1 hour. A pupil-involving third-nerve palsy may be an unusual presentation of impending carotid occlusion.

Carotid Stenosis↗
PubMed1977

The finding of thrombus at carotid endarterectomy and its relationship to the timing of surgery.

The clinical, angiographical, operative and histological records of 52 patients undergoing carotid endarterectomy for transient cerebral ischaemic attacks were reviewed. Thrombus or other friable material was present in 66 per cent of the 24 patients operated upon within 4 weeks of a clinical attack, but in only 21 per cent of the 28 patients in whom the time interval was longer. The data favour an embolic explanation for the clinical episodes and further suggest that thrombus formation on atheromatous stenosis and ulceration is intermittent.

Adult↗
PubMed1986

Monitoring middle cerebral artery blood velocity during carotid endarterectomy.

Transcranial pulsed Doppler ultrasound and spectral analysis were used to monitor blood velocities in the middle cerebral artery of nineteen patients (mean age 61 +/- 9 years) during carotid endarterectomy. A Javid shunt was used in all patients. The intensity weighted mean Doppler frequency for each spectral sweep (at 5 ms intervals) was time-averaged over the cardiac cycle to obtain a mean value for blood velocity in the middle cerebral artery. The range of such values found in the 19 patients was: 12-38 cm s-1 after anaesthesia (baseline); 12-69 cm s-1 during diathermy; 0-30 cm s-1 during carotid clamping; 16-32 cm s-1 during shunting and 18-60 cm s-1 in the recovery room. The average change in middle cerebral artery blood velocity from baseline values showed significant increases during diathermy (P less than 0.005), shunting (P less than 0.05) and in the recovery room (P less than 0.005). Clamping of the internal carotid artery showed a significant decrease in middle cerebral artery blood velocities of all patients (P less than 0.005), three of whom showed no flow in the middle cerebral artery during clamping. Abnormally high amplitude Doppler signals at the commencement of shunting were detected in 17 of the 19 patients. Such Doppler signals are consistent with turbulent blood flow or the introduction of micro-air bubbles by the shunt. Backbleeding in the internal carotid artery before insertion of the shunt was associated with diminished flow in the ipsilateral middle cerebral artery of ten patients, oscillatory forward/reverse flow in three patients and cessation of flow in the remaining six patients.

Adult↗
PubMed1990

Impact of duplex scanning on carotid endarterectomy.

Duplex ultrasound permits safe and accurate assessment of the extracranial vasculature. This paper reports the change in patterns of referral to a specialized vascular unit following its introduction; increased referrals were seen in all specialties except neurology. A widely available and reliable duplex service has revealed more extracranial vascular disease than was previously recognized, and has increased referrals for carotid endarterectomy, thereby increasing surgical workload.

Adult↗
PubMed1991

Transcranial Doppler monitoring during carotid endarterectomy.

Transcranial Doppler monitoring of the middle cerebral artery blood flow velocity was used as an adjunct to routine methods of cerebral monitoring in a prospective study of 30 consecutive patients undergoing carotid endarterectomy to investigate whether transcranial Doppler monitoring provided information influencing operative technique. Application of carotid clamps caused a significant fall in middle cerebral artery velocity and there was a linear relationship between middle cerebral artery velocity and internal carotid artery stump pressure. Assuming a stump pressure of less than 50 mmHg to be an indication for shunting, this would correspond to a systolic middle cerebral artery velocity of less than 42 cm/s and a mean velocity of less than 30 cm/s. Transcranial Doppler monitoring immediately identified problems with shunt function and demonstrated a higher frequency of intraoperative embolization than had been anticipated, particularly after shunt insertion and final restoration of flow. With revision of operative technique this phenomenon is rarely encountered now. Two of the 30 patients exhibited a minor neurological deficit on recovery of consciousness, and transcranial Doppler monitoring was able to identify the probable underlying cause in both cases. Unnecessary and potentially hazardous re-exploration was avoided. In the absence of transcranial Doppler monitoring the neurological deficit in one of the patients might have been much worse.

Blood Flow Velocity↗
PubMed1993

Randomized controlled trial of patch angioplasty for carotid endarterectomy. The Joint Vascular Research Group.

A randomized controlled trial was performed to evaluate patch angioplasty for patients undergoing carotid endarterectomy. There were 213 patient episodes affecting 148 men and 65 women, with 109 allocated to patch angioplasty. Following surgery six patients suffered transient ischaemic attacks but these did not delay discharge from hospital. Six individuals (four patched operations, two not patched) required re-exploration for postoperative haemorrhage and eight (two patched procedures, six not) had potentially serious neurological problems after operation. Of these eight patients, four (none receiving patch angioplasty) underwent re-exploration and in each case a clot was removed and a patch inserted; three of the four made a good long-term recovery. The other four patients suffered completed strokes from which one died. Two further patients (one patched procedure, one not) died after operation from myocardial events, giving an overall 30-day stroke or mortality rate of 2.8 per cent. Objective follow-up assessment with duplex scanning at 1 year was completed by 94.8 per cent of patients; significantly more vessel restenoses and occlusions were observed in those not receiving patches (P < 0.01). Patch angioplasty reduces the number of immediate postoperative complications, and significantly lowers vessel restenosis and occlusion rates at 1 year after operation.

Aged↗
PubMed1994

Diagnosis of intracranial occlusive disease before carotid endarterectomy: preliminary experience with transcranial colour-flow Doppler ultrasonography.

Transcranial colour-coded Doppler ultrasonography allows both imaging and simultaneous haemodynamic investigation of the basal cerebral arteries. Four of 16 patients undergoing carotid endarterectomy were found to have intracerebral artery stenotic disease by use of this technique. Discrete stenotic segments were recognized by their markedly raised blood flow velocities with damping of the spectral Doppler waveform distally. Colour-coded transcranial Doppler ultrasonography used in conjunction with extracranial duplex imaging might provide an effective and safe alternative to angiography.

Aged↗
PubMed1994

Clinical relevance of intraoperative embolization detected by transcranial Doppler ultrasonography during carotid endarterectomy: a prospective study of 100 patients.

A study was performed to investigate the clinical significance of microembolization detected by transcranial Doppler ultrasonography (TCD) by determining the quantity and character of emboli and correlating these with neurological and psychometric outcome, fundoscopy, automated visual field testing and computed tomographic brain scans in 100 consecutive patients undergoing carotid endarterectomy. Embolization was detected in 92 per cent of successfully monitored operations. Most emboli were characteristic of air and not associated with adverse clinical outcome. However, more than ten particulate emboli during initial carotid dissection correlated with a significant deterioration in postoperative cognitive function. A relationship between persistent particulate embolization in the immediate postoperative period, and both incipient carotid artery thrombosis and the development of major neurological deficits was observed. Immediate intervention, based on TCD evidence of embolization, has the potential to avert neurological deficits resulting from particulate embolization.

Aged↗
PubMed1995

Fate of the non-operated carotid artery after contralateral endarterectomy.

The long-term fate of the non-operated internal carotid artery (ICA) in 219 patients undergoing contralateral carotid endarterectomy was studied; 151 patients underwent serial postoperative imaging of the vessel. Cumulative freedom from stroke in the non-operated hemisphere was 99, 96 and 86 per cent at 1, 5 and 10 years respectively, giving a mean incidence of stroke of 1 per cent per annum. Only one stroke was preceded by a transient ischaemic attack and no stroke was associated with severe (70 per cent or greater) stenosis of the ICA. Ten patients (7 per cent) with initially mild or moderate disease of the non-operated ICA progressed to severe stenosis during follow-up, but only three became symptomatic and, in each case, the onset of symptoms preceded recognition of disease progression. The long-term risk of stroke in the non-operated ICA territory is very small. Of practical importance is that none of the observed strokes could have been prevented by postoperative surveillance of this type.

Carotid Artery Diseases↗
PubMed1996

Surveillance imaging of the operated artery does not alter clinical outcome following carotid endarterectomy.

Clinical outcome was studied in 243 patients undergoing 260 carotid endarterectomies; 166 of these patients underwent serial postoperative surveillance imaging. Including perioperative events, cumulative freedom from ipsilateral stroke was 86 and 82 per cent at 5 and 10 years respectively; the mean incidence of ipsilateral stroke was 1.8 per cent per annum. Twenty patients (8 per cent) suffered cerebral ischaemic events in the hemisphere of the operated side during follow-up: eight transient ischaemic attacks (TIA) and 12 strokes (only two preceded by TIA). Two symptomatic patients were found to have occluded the operated artery but the remainder had no evidence of significant recurrent disease. Cumulative freedom from occlusion or severe (greater than 70 per cent) recurrent stenosis was 87 and 78 per cent at 5 and 10 years respectively; the mean incidence of recurrence of significant disease was 2.2 per cent per annum. No revisional surgery was performed on the operated arteries. In its current format, neither clinical nor surveillance imaging could have prevented any of the strokes observed during follow-up.

Angiography, Digital Subtraction↗
PubMed1996

Prospective study of carotid endarterectomy and contralateral carotid occlusion.

A total of 700 patients who had carotid endarterectomy (CEA) in the UK and Ireland during a 6-month interval between March and August 1994 were studied prospectively. Some 108 patients (15.4 per cent) had a contralateral internal carotid artery occlusion. Previous reports have shown an associated stroke rate of about 10 per cent in these patients. This study assessed complications and outcome for patients undergoing CEA with contralateral internal carotid artery occlusion compared with those without. The indications for surgery were comparable between the two groups although the patients with occlusion had a slightly higher incidence of arrhythmia and stroke. Intraoperative shunts were used in a significantly higher proportion of those with occlusion (83.3 versus 64.7 per cent, P = 0.0001). The combined death and stroke rate for patients with occlusion was 5.6 per cent compared with 2.4 per cent for the remainder (P not significant). On the basis of the present data, CEA with a contralateral carotid artery occlusion carries only a slight increase in the rate of postoperative stroke and death. This increase was not statistically significant and is lower than that reported previously.

Carotid Artery, Internal↗
PubMed2003

Eversion endarterectomy complicating radial artery access for left heart catheterization.

The use of the radial artery for arterial access for left heart catheterization is gaining popularity. We report the first case of traumatic eversion endarterectomy following the removal of the arterial sheath after the cannulation of the radial artery. The patient has no long-term vascular compromise of the limb and did not require surgical intervention.

Aged↗