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PubMed1994

Carotid endarterectomy without arteriography: the preeminent role of the vascular laboratory.

The classic workup of patients considered for carotid endarterectomy (CE) has included contrast arteriography to delineate the nature and extent of the arterial pathology. Noninvasive testing (NIT) consisting of duplex scanning plus sound spectrum analysis is an alternative method for accurately evaluating the carotid bifurcation. The accuracy of our laboratory in comparing NIT to contrast arteriography has been established by use of the guidelines suggested by the Intersocietal Commission for the Accreditation of Vascular Laboratories. Forty-two patients underwent CE based on NIT alone. Seventeen had hemispheric transient ischemic attacks or minor strokes, six had amaurosis fugax, three had nonspecific symptoms, and 16 were asymptomatic. NIT identified a severe stenosis that was limited to the carotid bifurcation; the internal carotid artery distal to the bulb was normal. The predicted stenotic atherosclerotic lesion was confirmed at operation in all patients. One patient had a high bifurcation that required an extension of the original incision. Of three undiagnosed kinked distal internal carotid arteries found at operation, only one required surgical correction. No transient ischemic attacks, strokes, or deaths occurred postoperatively. CE can be performed in selected patients based on NIT alone, obviating the mortality, morbidity, and cost of arteriography. This algorithm demands that the NIT is unequivocal and the accuracy of the testing laboratory is established and maintained according to published standards.

Arteriosclerosis↗
PubMed1991

Carotid endarterectomy plaques: correlations of clinical and anatomic findings.

To establish possible relationships between the structure of carotid plaque and neurologic symptoms, 187 consecutive endarterectomy specimens were studied prospectively. Each specimen was examined for gross and histopathological features. Intraplaque hemorrhage, although found infrequently, was closely correlated with the presence of symptoms. Plaque ulcerations were encountered more often when lesions were symptomatic. Calcifications were more frequently associated with asymptomatic lesions. Consistency of plaque was related to its morphological features (stenosis or ulceration) and symptoms. Soft plaques with predominant atheromatous grumous material and hemorrhage were associated more often with tightly stenotic, ulcerated, and symptomatic lesions. Consistency of atherosclerotic carotid plaques should be assessed and considered as an important element in the therapeutic decision.

Aged↗
PubMed1991

Vein patch rupture after carotid endarterectomy: a survey of the Western Vascular Society members.

To determine the prevalence, demographics and morbidity of vein patch rupture, the authors polled members of the Western Vascular Society. Forty-eight surgeons (53% of the members) reported an experience with 23,873 carotid operations. A vein patch was used in 1,760 operations (7.4%), and rupture of the patch occurred in 13 patients (0.7%), 10 women and three men. Indications for the patch were a small artery in 10 patients and restenosis in three. Saphenous vein was used for all patches and was harvested from the ankle in 12 patients and from the groin in one patient. All ruptures occurred from a split in the vein patch. Hypertension was present in seven of the 13 patients. None of the ruptures were associated with infection. Two ruptures occurred on the first postoperative day, six on the second day, three on the third day, one on the eighth day, and one on the twenty-first day. Four patients died: airway obstruction (1), hemorrhagic cerebral infarction (1), and myocardial infarction (2) were the causes. Three had a stroke and survived, one had a retinal embolus, and five underwent reoperation without complication. Vein patch of the carotid artery is used infrequently by members of the Western Vascular Society. The incidence of rupture of the patch is low (0.7%), but when it occurs, there is significant mortality (30.7%), and morbidity (30.7%). Patients with a vein patch should be observed in the hospital for three days after endarterectomy because rupture demands immediate reoperation.

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PubMed1994

Carotid artery endarterectomy in patients with contralateral carotid artery occlusion: perioperative hazards and late results.

The aim of this study was to analyze and compare the perioperative hazards and late results of internal carotid endarterectomy (CEA) in patients with and without contralateral internal carotid artery occlusion. From March 1980 to April 1990, 375 consecutive patients underwent 439 CEAs at the First Department of Vascular Surgery of Padova Medical School. Patients were divided into two groups; group 1 (61 patients) had contralateral internal carotid artery occlusion and group 2 (314 patients) did not (378 CEAs, 64 bilateral). Indications for CEA were similar in both groups. The only significant difference in patient characteristics was a higher rate of previous stroke in group 1 (11% vs. 3%, p < 0.001). General anesthesia, continuous EEG monitoring, selective intraluminal shunt, and arteriotomy closure with a polytetrafluoroethylene patch (PTFE) were used routinely in both groups. An intraluminal shunt was inserted more frequently in group 1 than in group 2 (69% vs. 17%, p < 0.001). Major perioperative stroke occurred in one patient in each group (1.7% vs. 0.31%, respectively; NS). Early fatal stroke rates were 0% and 0.95% in groups 1 and 2, respectively (NS). All patients had neurologic examinations and duplex scans every 6 months (range 6 to 118 months; mean 42 months). Kaplan-Meier survival curves were virtually identical in the two groups; the majority of deaths were caused by myocardial infarction and cancer. There were no stroke-related deaths in group 1 as compared with 8.2% in group 2 (NS). New neurologic symptoms appeared in 4.7% of patients in group 1 and 6% in group 2 (NS) whereas the late stroke rates were 0% and 3.1%, respectively (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1995

Selective use of the intensive care unit following carotid endarterectomy.

The purpose of this study was to develop criteria by which selected patients can be observed solely on the ward following carotid endarterectomy (CEA). One hundred consecutive CEA patients were retrospectively reviewed. Preoperative medical conditions were identified, and the postanesthesia recovery room course was reviewed in an attempt to predict the need for intensive care unit (ICU) level care. Forty-four of our 100 patients developed perioperative complications or conditions that required some intervention. Conditions included hypertension in 23, hypotension in nine, arrhythmias in six, and myocardial ischemia in two. Complications included nonfatal cerebrovascular accident (CVA) in one, fatal CVA in one, and postoperative bleeding in two. Sixteen patients required ICU level intervention (hypertension in five, hypotension in five, arrhythmias in two, nonfatal CVA in one, fatal CVA in one, and postoperative bleeding in two. Fifteen of the 16 were identified in the recovery room. Fifty-three patients had a medical history of significant hypertension (42), cardiac disease (27), and/or recent CVA (seven). Thirty-six (68%) of these patients required perioperative intervention in some form; 12 (23%) required ICU level therapy. Eight of 47 (17%) patients without a significant medical history required intervention; only four (9%) required ICU level care. All eight patients were identified in recovery. Only 16 of 100 CEA patients required ICU level care. Fifteen of 16 were identified in recovery. Certain patients identified in the recovery room can be followed safely in a less intense and costly setting.

Adult↗
PubMed1992

Prevention of ischemic stroke: the role of carotid endarterectomy in symptomatic patients.

Carotid endarterectomy (CE) has recently been proved to be beneficial in symptomatic patients with severe (70-99%) appropriate carotid stenosis. After discussing the historical evolution of CE as a possible preventive treatment of ischemic stroke, we review the results of North American and European trials in order to give practical information for the management of cerebrovascular patients.

Brain Ischemia↗
PubMed1989

Considerations after intraoperative monitoring of somatosensory evoked potentials during carotid endarterectomy.

Somatosensory evoked potentials (SEPs) following median nerve stimulation were used to monitor cerebral function during 26 carotid endarterectomies. The patients with minor SEP variations had no neurological deficits on regaining consciousness while the one with more serious SEP variations had a transient deficit. The method thus seems useful in the early detection of ischemic brain impairment.

Aged↗
PubMed1989

Pharyngeal function after carotid endarterectomy.

Neurologic deficiencies, with special reference to pharyngeal function, were studied prospectively in 12 patients before and after they underwent carotid endarterectomy. Pharyngeal function was monitored with cineradiography. Five patients developed pharyngeal dysfunction: defective closure of the laryngeal vestibule, epiglottic dysmotility, and pharyngeal constrictor paresis 1 week postoperatively. In 2 patients this dysfunction remained, while in 3 it had resolved 4 weeks after the operation. Pharyngeal dysfunction was more common in patients with preoperative minor stroke and a temporary perioperative carotid shunt and in patients with a long operation time. The registered transient pharyngeal dysfunction may be due to manipulation of the cervical structures including the vagus nerve and the pharynx or due to cerebrovascular damage during the operation. Our findings support careful monitoring of postoperative oral finding in patients at risk.

Adult↗
PubMed1978

A new surgical approach to extensive arterial occlusion of lower extremity--femoro-popliteal open endarterectomy with arteriovenous shunt.

A revascularized surgery for extensive arterial occlusive lesions of the lower extremities, namely open endarterectomy of the occluded femoro-popliteal artery with arteriovenous shunt, was devised. The procedure is specially indicated to the extensive arterial occlusion of the lower extremity for which the conventional reconstructive vascular surgery is not applicable. The patency of the reconstructed femoro-popliteal arteries are ensured by virture of an arteriovenous shunt and newly developed collaterals from the reopened genicular network is expected to provide effective blood flow to peripheral parts. From 1967 to 1975, this procedure was applied to 59 extremities in 53 patients, all of whom had extensive arterial occlusion from the femoral artery to the periphery with impending ulcer and severe rest pain. Fourty-five out of 59 extremities had remarkable improvement of the ischemic symptoms and signs at the time of discharge. Long-term effectiveness was shown in 34 out of 59 extremities or 58 per cent.

Arterial Occlusive Diseases↗
PubMed1995

Haemodynamic instability and myocardial ischaemia during carotid endarterectomy: a comparison of propofol and isoflurane.

The purpose of this study was to compare two anaesthetic protocols for haemodynamic instability (heart rate (HR) or mean arterial pressure (MAP) < 80 or > 120% of ward baseline values) measured at one-minute intervals during carotid endarterectomy (CEA). One group received propofol/alfentanil (Group Prop; n = 14) and the other isoflurane/alfentanil (Group Iso; n = 13). Periods of haemodynamic instability were correlated to episodes of myocardial ischaemia as assessed by Holter monitoring (begun the evening before surgery and ceasing the morning of the first postoperative day). In Group Prop, anaesthesia was induced with alfentanil 30 micrograms.kg-1 i.v., propofol up to 1.5 mg.kg-1 and vecuronium 0.15 mg.kg-1, and maintained with infusions of propofol at 3-12 mg.kg-1.hr-1 and alfentanil at 30 micrograms.kg-1.hr-1. In Group Iso, anaesthesia was induced with alfentanil and vecuronium as above, thiopentone up to 4 mg.kg-1 and maintained with isoflurane and alfentanil infusion. Phenylephrine was infused to support MAP at 110 +/- 10% of ward values during cross-clamp of the internal carotid artery (ICA) in both groups. Emergence hypertension and/or tachycardia was treated with labetalol, diazoxide or propranolol. Myocardial ischaemia was defined as ST-segment depression of > or = 1 mm (60 msec past the J-point) persisting for > or = one minute. For the entire anaesthetic course (induction to post-emergence), there was no difference between groups for either duration or magnitude outside the < 80 or > 120% range for HR or MAP. However, when the period of emergence from anaesthesia (reversal of neuromuscular blockade to post-extubation) was assessed, more patients were hypertensive (P = 0.004) and required vasodilator therapy in Group Iso (10/13 vs 5/14; P = 0.038 Fisher's Exact Test). The mean dose of labetalol was greater in Group Iso (P = 0.035). No patient demonstrated myocardial ischaemia during ICA cross-clamp. On emergence, 6/13 patients in Group Iso demonstrated myocardial ischaemia compared with 1/14 in Group Prop (P = 0.029). Therefore, supporting the blood pressure with phenylephrine, during the period of ICA cross-clamping, appears to be safe as we did not observe any myocardial ischaemia at this time. During emergence from anaesthesia, haemodynamic instability was associated with myocardial ischaemia. Under these specific experimental conditions, with emergence, hypertension and myocardial ischaemia were more prevalent with more frequent pharmacological interventions in patients receiving isoflurane.

Aged↗
PubMed1983

Thiopental bolus during carotid endarterectomy-rational drug therapy?

Ten studies were performed to examine the time course of arterial and venous thiopental concentrations following the administration of thiopental (4 mg X kg-1 over 3 min) for cerebral protection during carotid occlusion in nine patients undergoing elective carotid endarterectomy; in five patients the time course of EEG change was also studied. The arterial and venous thiopental concentrations were similar with no evidence of a sustained arterial-venous gradient. The average arterial concentration was 20.1 microgram X ml-1 +/- 10 (SD) at 2 min after thiopental, and fell rapidly to 13.0 micrograms X ml-1 +/- 3.2 at 5 min, 10.7 micrograms X ml-1 +/- 4.4 at 10 min and 6.2 micrograms X ml-1 at 30 min. After thiopental the EEG record showed an increase in delta activity and in four patients a burst suppression pattern was seen. The duration of burst suppression activity was variable (130 to 367 seconds) but in all instances cortical activity had returned to the pre-thiopental level by five to ten minutes. Thus concentrations of thiopental of 10-30 micrograms X ml-1 were associated with EEG burst suppression and both were seen only within the first five minutes after drug administration. In contrast the carotid artery was occluded for considerably longer (26 +/- 4) minutes. We conclude that, since there was no sustained arterial-venous gradient, either arterial or venous concentrations are adequate for the study of thiopental pharmacokinetics.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Cervical plexus anesthesia for carotid endarterectomy: comparison of ropivacaine and mepivacaine.

PURPOSE: To evaluate the effectiveness of cervical plexus block performed with ropivacaine 0.75% or 1%, or mepivacaine 2%. METHODS: In a prospective, randomized, double-blind study, 60 patients received deep cervical plexus block with 0.2 ml x kg(-1) divided among C2-C4 injections using ropivacaine 0.75% and 1% or mepivacaine 2%. A blinded observer recorded loss of pin-prick sensation every minute in the C2-C4 dermatomes until readiness for surgery. Then, a superficial cervical block was performed with 0.15 ml x kg(-1) lidocaine 1%. The need for intraoperative supplemental analgesia and degree of pain and time of first postoperative pain medication were also recorded. RESULTS: General anesthesia was not required to complete surgery in any case. No differences in the need for intraoperative supplemental analgesia was observed (7, 6, and 9 patients with ropivacaine 0.75% and 1% or mepivacaine 2%, respectively). Readiness to surgery required 15 (10-25) min with ropivacaine 0.75%, 18 (8-20) min with ropivacaine 1%, and 15 (5-20) min with mepivacaine 2% (P = NS); while patients asked for first postoperative pain medication after 10 (4-13) hr and 9 (6.5 - 11) hr with ropivacaine 0.75% and 1% compared with 5 (0-8) hr with mepivacaine 2% (P<0.05). CONCLUSION: Ropivacaine 0.75% or 1% are appropriate choices when performing cervical plexus anesthesia for carotid endarterectomy, providing nerve block characteristics similar to those of mepivacaine 2%, but with the advantage of longer postoperative pain relief.

Aged↗
PubMed1997

Comparison of cerebral oximeter and evoked potential monitoring in carotid endarterectomy.

PURPOSE: To assess the cerebral oximeter, which measures regional oxygen saturation (rSO2) continuously and noninvasively, as a cerebral monitor during carotid endarterectomy (CEA). The rSO2 was compared with Somatosensory Evoked Potentials (SSEPs) as an indicator for shunting and as a predictor of postoperative neurological deficits. METHODS: Seventy-two consenting patients undergoing CEA with general anaesthesia were studied. Normocarbia, normothermia and normotension were maintained. Cerebral monitoring consisted of bilateral median nerve SSEPs and the INVOS 3100 cerebral oximeter with the sensor pad placed on the ipsilateral forehead. Decreases in SSEP amplitude of 50% and in rSO2 of 10% were considered clinically significant. Neurological assessment was performed at emergence from anaesthesia, 24 hr postoperatively and at discharge. The rSO2 changes were compared with SSEP changes and with neurological deficits. Statistical analysis was with chi square and analysis of variance P < 0.05 was considered significant. RESULTS: During carotid artery clamping, rSO2 decreased from 72 +/- 8% to 68 +/- 9% and mean arterial blood pressure increased from 92 +/- 14 mmHg to 98 +/- 14 mmHg. In four patients, the carotid artery was shunted because of SSEP changes after cross-clamping. Five patients had > or = 10% decreases in rSO2 following clamp application. Changes in both SSEP and rSO2 occurred in two patients. Three of the four shunted patients had transient postoperative neurological deficits. One patients had a transient deficit without changes in either monitor. There were no persistent postoperative deficits. Compared with SSEPs, rSO2 had a sensitivity of 50% and a specificity of 96%. CONCLUSION: Clinical experience with this evolving technology is ongoing. Its role in neurovascular procedures has yet to be established.

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PubMed2006

Case report: Aggressive blood pressure management for carotid endarterectomy hyperperfusion syndrome.

PURPOSE: Cerebral hyperperfusion syndrome (CHS) is a rare but potentially devastating complication following cerebral revascularization. Management of CHS requires aggressive blood pressure control to prevent stroke and intracerebral hemorrhage. This case report documents a severe case of CHS, and outlines a successful outcome associated with aggressive blood pressure control. CLINICAL FEATURES: A 67-yr-old gentleman, nine days post left carotid endarterectomy, required tracheal intubation and intensive care unit admission following seizures and acute right-sided weakness. A computed tomography scan and magnetic resonance imaging revealed significant vasogenic edema in the left middle cerebral artery territory, without evidence of infarction. The history and radiographic findings suggested CHS. As such, a systolic blood pressure target was set at 90-140 mmHg. This blood pressure parameter was lower than typically targeted following acute ischemic or hemorrhagic stroke. Rapid clinical improvements were seen by day five, and tight blood pressure control was maintained throughout. Repeat computed tomography and magnetic resonance imaging revealed improved edema and no evidence of infarct or hemorrhage. CONCLUSION: Cerebral hyperperfusion syndrome is believed to occur following restoration of blood flow to a brain with impaired autoregulation due to chronic hypoperfusion. Massive brain edema and hemorrhage can result from higher pressures. Clinicians should be aware of this potential complication following cerebral revascularization procedures, and the importance of establishing blood pressure targets which are considerably lower than for other patients with similar clinical presentations.

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PubMed2004

[Open therapy of carotid stenosis by endarterectomy].

Carotid endarterectomy is a routine procedure in vascular surgery. Besides clinical symptoms and the degree of stenosis, indication for surgery is influenced by the perioperative complication rate. This depends on stroke and the mortality rate and should not exceed 6% in symptomatic, high-grade stenosis, according to the Stroke Council of the American Heart Association. Techniques of carotid disobliteration include the conventional open thrombendarterectomy by means of a longitudinal arteriotomy and the eversion technique. In the former, closure by direct suture or patch plasty are possible. Different methods for cerebral protection during the clamping time exist, of which shunt protection is the most common. The various operative techniques are described and critically discussed.

Carotid Artery, Internal↗
PubMed2005

[Early transfer from intensive care does not influence clinical results of carotid endarterectomy].

The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.

Adult↗
PubMed1998

Carotid endarterectomy and simultaneous percutaneous transluminal angioplasty for tandem internal carotid stenoses.

We treated three patients with tandem internal carotid stenoses in single procedures including carotid endarterectomy (CEA) for the proximal stenosis and percutaneous transluminal angioplasty (PTA) for the distal stenosis. We devised a Y-shaped shunt tube for the CEA, through which a balloon catheter was introduced to perform PTA guided by mobile digital subtraction angiography. No cerebrovascular events occurred during follow-up. Our approach avoids the risk of a second procedure while effectively treating tandem stenoses.

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