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At least 19 recordsLinked to original sources
PubMedDate not supplied

Laser endarterectomy: a comparison of thrombotic potential following CO2 laser vs surgical endarterectomy.

Although laser endarterectomy has recently been suggested as useful in the treatment of arteriosclerotic obstructions, the "in vivo" clotting effects have not been well delineated. In this study, the common carotid and femoral arteries of ten mongrel dogs were exposed, and alternating 1 cm segments of each artery were treated with surgical endarterectomy and low-powered CO2 laser endarterectomy. Segments were then harvested, and subjected to histologic examination and vascular prostacyclin synthesis determinations, as measured by 6-keto PFG1a radioimmunoassay. Gross examination and light and scanning electron microscopy showed increased platelet aggregation and more extensive damaging of the underlying media of the laser compared to the surgical segments. Six-keto PFG1a levels were significantly lower (p = 0.001) in the laser compared to surgical sites (mean 232 +/- 72 pg/mg vs 515 +/- 144 pg/mg), or controls (895 +/- 337 pg/mg). These findings suggest that laser endothelial evaporation leads to increased thrombotic potential in the early post-operative period in comparison to surgical endarterectomy.

6-Ketoprostaglandin F1 alpha↗
PubMed1988

Differences in reendothelialization after balloon catheter removal of endothelial cells, superficial endarterectomy, and deep endarterectomy.

The process of reendothelialization was studied in a deendothelialized 3 cm segment of the canine descending thoracic aorta from which peripheral endothelial cell ingrowth had been prevented by impervious prosthetic graft sleeves. Three preparations were studied: (1) removal of only the endothelial cells, accomplished by flow surface drying and balloon catheter denudation, (2) removal of the superficial portion of the nonvasal media, accomplished by endarterectomy to a depth of 200 to 300 micron, and (3) removal of the entire inner (nonvasal) media, accomplished by endarterectomy to a depth of 500 to 600 micron to reach the outer (vasal) media. A total of 44 specimens were studied after implantation periods of 7, 14, 28, and 56 days. In all cases endothelial cell ingrowth from the host aorta into the test specimen was prevented by the impervious graft sleeves. In the deep endarterectomy group there were scattered areas of reendothelialization at 1 week, extensive reendothelialization at 2 weeks, almost complete reendothelialization at 4 weeks, and confluence by 8 weeks. However, in the superficial endarterectomy group scanning electron microscopy showed scattered areas of factor VIII/von Willebrand factor (FVIII/vWF)-negative, endothelial-like cells at 4 weeks, whereas at 8 weeks most of the surface was covered by endothelial cells identified by FVIII/vWF. In those specimens subjected to balloon catheter removal of endothelial cells only, reendothelialization was not seen, even at 8 weeks.

Animals↗
PubMed1992

Results of a randomized controlled trial of carotid endarterectomy for asymptomatic carotid stenosis. Mayo Asymptomatic Carotid Endarterectomy Study Group.

We undertook a randomized controlled trial designed to compare the effects of carotid endarterectomy with medical treatment using low-dose aspirin in patients with asymptomatic carotid stenosis. During 30 months of recruitment, 71 randomized and 87 eligible nonrandomized patients participated in a follow-up protocol. The total ipsilateral perioperative stroke and death rate was 0% among randomized patients and 3% among nonrandomized patients, and the major stroke and death rate was 0% for both groups. Too few cerebral ischemic events occurred to judge the comparative effectiveness of carotid endarterectomy versus low-dose aspirin for asymptomatic carotid stenosis. The trial was terminated early because of a significantly higher number of myocardial infarctions and transient cerebral ischemic events in the surgical group than in the medical group. Most of the events were not temporally related to the surgical procedure, but there was evidence that these events could have related to the absence of aspirin use in the surgical group. These observations reinforce the appropriateness of the use of aspirin throughout the perioperative period and beyond (unless contraindications exist) in patients with asymptomatic carotid stenosis who undergo carotid endarterectomy.

Aged↗
PubMed1989

Effectiveness of carotid endarterectomy for asymptomatic carotid stenosis: design of a clinical trial. Mayo Asymptomatic Carotid Endarterectomy Study Group.

A clinical trial, as described in this report, has been designed to compare the effects of carotid endarterectomy and medical treatment with aspirin for prevention of transient ischemic attack, reversible ischemic neurologic deficit, and ischemic stroke in patients with asymptomatic pressure-significant carotid stenosis. A prospective randomized controlled trial design is being used, and selection of patients with asymptomatic pressure-significant carotid stenosis is based on the results of ocular pneumoplethysmography and either duplex ultrasound scanning or digital subtraction angiography. Patients are randomized to either surgical (carotid endarterectomy) or medical (aspirin, 80 mg/day) treatment, and follow-up assessment is accomplished by return visits and patient questionnaires. A total of 945 patient-years of follow-up will accumulated for each of the medical and surgical groups.

Aspirin↗
PubMed1986

Early and late results of coronary endarterectomy. Analysis of 3,369 patients.

The effectiveness of coronary revascularization has been questioned in patients with diffuse coronary disease. Over a 14 year period (1970 to 1984), 30,464 patients underwent surgical revascularization at our institution. Coronary artery bypass alone was done in 27,095 patients and was combined with coronary endarterectomy in 3,369 patients (12.4%). Analysis of preoperative variables revealed an increased incidence of male sex, diabetes mellitus, low ejection fraction (less than 30) and multiple vessel disease in patients requiring endarterectomy. The early results after revascularization indicated a small increase in surgical risk after endarterectomy. The 30 day mortality for bypass alone was 2.6% versus 4.4% for coronary endarterectomy (p less than 0.01). Multivariate analysis identified independent predictors of operative risk: ejection fraction less than 30%, reoperation, age, absence of hyperlipidemia, endarterectomy, and female sex. Early mortality was significantly increased by endarterectomy in the left anterior descending coronary artery (8.5%) compared to endarterectomy in arteries other than the left anterior descending (4.2%) (p less than 0.01). In a sample of 4,473 patients, myocardial complications were also found to be increased after coronary endarterectomy. The incidence of perioperative myocardial infarction in patients undergoing bypass alone was 2.6% versus 5.4% for patients undergoing bypass plus endarterectomy (p less than 0.01). Both fatal and nonfatal cardiac arrests increased (bypass alone, 1.7%; endarterectomy, 3.5%; p less than 0.01). This suggests the failure mode of unsuccessful endarterectomy. Early mortality after coronary endarterectomy decreased substantially from 1970-1976 (6.4%) to 1977-1984 (3.5%; p less than 0.01). Actuarial analysis at 5 years and longer has shown very little difference in the long-term survival rate (coronary bypass, 90%; coronary endarterectomy, 86%), freedom from angina (coronary artery bypass, 58%; coronary endarterectomy, 52%), and freedom from reoperation (coronary artery bypass, 97%; coronary endarterectomy, 98%). Despite the small increase in surgical risk, the early and late results support the selective application of coronary endarterectomy in patients with diffuse distal disease and demonstrate the beneficial long-term effects.

Actuarial Analysis↗
PubMed1992

Risk of prophylactic contralateral carotid endarterectomy.

Fifty-eight patients underwent a prophylactic contralateral carotid endarterectomy following an initial endarterectomy for symptomatic (38 patients) or asymptomatic (20 patients) carotid stenosis. No deaths occurred after either operation. Two (3.4%) minor neurologic deficits occurred after the initial operation and two (3.4%) major and two (3.4%) minor deficits occurred after the prophylactic contralateral carotid endarterectomy. Sixteen (28%) of the initial endarterectomies were associated with perioperative hyper- or hypotensive episodes compared to 35 (60%) of the prophylactic contralateral carotid endarterectomies (p less than 0.001). We did not document an increased risk of surgery in patients undergoing prophylactic contralateral carotid endarterectomy soon after the initial operation. All four neurologic events following a prophylactic contralateral carotid endarterectomy occurred when the operation was performed more than five weeks after the initial endarterectomy. The incidence of perioperative hyper- or hypotension was similar in patients undergoing prophylactic contralateral carotid endarterectomy less than or greater than five weeks after the first operation. Our results suggest that a prophylactic contralateral carotid endarterectomy may be associated with a higher incidence of neurologic complications and hyper- and hypotensive episodes than the initial carotid endarterectomy. Waiting more than five weeks to repair a contralateral asymptomatic carotid stenosis may not enhance the safety of the operation.

Adult↗
PubMed1992

Influence of coronary heart disease on morbidity and mortality after carotid endarterectomy: a population-based study in Olmsted County, Minnesota (1970-1988)

To evaluate the prognostic importance of coronary artery disease among patients undergoing carotid endarterectomy, 177 residents of Olmsted County, Minnesota who underwent carotid endarterectomy during the period 1970 through 1988 were followed up to July 1, 1989. Patients were stratified as to the presence (n = 64) or absence (n = 93) of overt coronary artery disease or prior myocardial revascularization (n = 20) at the time of endarterectomy. At 30 days after carotid endarterectomy, there were no significant differences between patients with or without coronary artery disease in the occurrence of death, myocardial infarction or stroke. Kaplan-Meier estimate of 8-year relative survival after carotid endarterectomy (assessed as a percent of survival in age- carotid endarterectomy (assessed as a percent of survival in age- and gender-matched control subjects) was 89% in those without and 75% in those with overt coronary artery disease. Of the 59 total deaths, 29 (49%) had a cardiac cause and 4 (7%) were due to stroke (p less than 0.0001). The cumulative incidence of a cardiac event at 8 years after carotid endarterectomy was greater in those with than in those without overt coronary artery disease (61% vs. 25%, p less than 0.0001). In multivariable analysis, uncorrected coronary artery disease and diabetes were the only independent predictors of subsequent cardiac events, whereas age was the only independent predictor of death. These population-based data suggest that carotid endarterectomy can be safely undertaken in patients with stable coronary artery disease. In long-term follow-up of these patients, coronary rather than cerebral vascular disease is the most frequent cause of morbidity and mortality. Thus, these data lend strong support to the concept of early identification and management of coronary artery disease in patients undergoing carotid endarterectomy.

Cohort Studies↗
PubMedDate not supplied

Improved results of carotid endarterectomy in patients with symptomatic coronary disease: an analysis of 1,546 consecutive carotid operations.

The significant risk of fatal myocardial infarction after carotid endarterectomy in patients with coronary disease long has been recognized. In 1,546 consecutive carotid endarterectomies performed in 1,238 patients over the last 10 years, angina pectoris was present in 17% (212/1,238) of patients; a further 32% (396/1,238) of patients were asymptomatic, but had a history of myocardial infarction. The perioperative mortality (30 day) in the 1,306 consecutive endarterectomies in 1,026 patients without symptomatic coronary artery disease was 1.5% (15/1,026 patients). Of the 212 patients with symptoms, 85 carotid endarterectomies were performed in 77 patients without prior coronary bypass operation with an operative mortality of 18.2% (14/77 patients). The remaining 135 patients had 155 carotid endarterectomies but were treated by either prior coronary artery bypass (84 patients) or simultaneous carotid endarterectomy and coronary artery bypass (51 patients) with an operative mortality of 3% (4/135 patients). The greatly improved survival in those patients with symptomatic coronary disease who had a coronary artery bypass prior to or at the same time as carotid endarterectomy, and the absence of permanent neurological deficit in the 51 of these 135 patients who had simultaneous carotid endarterectomy and coronary artery bypass suggests that significantly improved survival can be achieved after carotid endarterectomy in these high risk patients by the use of simultaneous coronary artery bypass surgery.

Adult↗
PubMedDate not supplied

Management of the external carotid artery during routine carotid endarterectomy.

This study analyzes the results of carotid endarterectomy with a uniform technique of external carotid artery management. Aggressive blind instrument and eversion endarterectomy of the distal external carotid and its branches above the superior thyroid artery was performed during 211 standard carotid endarterectomies. This technique allows isolated external carotid artery repair if necessary after re-establishing carotid blood flow. Of these, 196 (92.9%) had normal intraoperative continuous wave Doppler ultrasonography in the external carotid. The 15 (7.1%) abnormal external carotid arteries underwent isolated completion endarterectomy with or without patch reconstruction followed by a normal Doppler study. All 15 had normal external carotid artery duplex ultrasonography 3 to 6 months after endarterectomy. However, 2 of the 196 (1.04%) intraoperative ultrasound normal external carotids had significant residual or recurrent stenosis (no occlusions) 3 to 6 months after endarterectomy for an early external carotid residual or restenosis rate of 0.95% (2/211). This was significantly less (p less than 0.05) than the 5.2% (11/211) 3- to 6-month incidence of residual or recurrent external carotid stenosis (6) and occlusion (5) in 211 carotid endarterectomies in which the external carotid artery was managed in an arbitrary manner. This study supports aggressive eversion endarterectomy of the external carotid artery during standard carotid endarterectomy with isolated repair when indicated.

Carotid Artery, External↗
PubMed1989

[Coronary endarterectomy].

From July, 1984, to December, 1986, coronary bypass grafting was performed in 314 patients, 70 (22%) requiring coronary endarterectomy (RCA; 48 pts, LAD; 10 pts, LAD + RCA; 10 pts, Others; 2 pts). Coronary endarterectomy patients (END group) were younger and often with the risk factor of hyperlipidemia than non-endarterectomy patients (NON group). The over-all hospital mortality rate of END group was 7 per cent; perioperative myocardial infarction occurred in 7 per cent of patients. Early postoperative angiogram (4 weeks after the operation) was performed in 54 patients. The patency rate of RCA endarterectomy was 81.8 per cent, and that of LCA endarterectomy was 75 per cent. This result was poor compared with the patency rate of non-endarterectomy graft (86.6%). However without endarterectomy, with all likelihood the patency rate of those grafts would have been poorer. The results of right coronary endarterectomy are satisfactory and better than those of the left coronary artery system. This experience suggests that coronary endarterectomy is safe and an useful adjunct of saphenous vein bypass grafting procedures in the management of diffuse coronary disease, especially in RCA lesions.

Adult↗
PubMed1988

Percutaneous transluminal angioplasty following endarterectomy.

Prior to the introduction of percutaneous transluminal angioplasty (PTA), bypass grafting or endarterectomy was the treatment of choice for aortoiliofemoral atherosclerotic occlusive disease. Currently, PTA is a well-established procedure for the treatment of aortoiliofemoral atherosclerotic occlusive disease. PTA is as effective as, and safer than, surgery in these cases. Percutaneous transluminal angioplasty and endarterectomy cause similar trauma to the arterial wall, i.e., intimal denudation, plaque disruption and splitting, and medial disruption, splitting, and overstretching. Both PTA and endarterectomy heal in a similar manner, i.e., neointima formation and scarring. Both PTA and endarterectomy can be repeated. Therefore, PTA can be performed after endarterectomy or vice versa. Several patients with recurrent occlusive disease after endarterectomy have been safely treated with PTA. Our results obtained with PTA in patients who had a prior endarterectomy are comparable to the results obtained in patients who did not have a prior endarterectomy. No complications have been encountered. A previous endarterectomy does not preclude a subsequent PTA, or vice versa, in patients with recurrent occlusive disease.

Angioplasty, Balloon↗
PubMed1988

Operative and long-term results of staged contralateral carotid endarterectomy: a personal series.

The operative risks as well as the proper interval for patients undergoing staged contralateral carotid endarterectomies remain uncertain. The long-term incidence of stroke after bilateral carotid endarterectomy is also poorly documented. In this report the results of staged contralateral carotid endarterectomies performed by one surgeon in a consecutive series of 89 patients are analyzed. No deaths occurred after a first or contralateral carotid endarterectomy. Four (4%) neurologic deficits (three minor and one major) occurred after a first operation, whereas only one (1%) major neurologic deficit occurred after a contralateral carotid endarterectomy. Postendarterectomy hypertension was noted in 33 (37%) patients after a first operation, and in 62 (70%) patients after a contralateral carotid endarterectomy (p less than 0.00001). No correlation existed among the intervals between carotid operations and the incidence or duration of hypertension after a contralateral carotid endarterectomy. From our results we conclude that the staged contralateral carotid endarterectomy can be safely performed with a stroke-mortality rate approaching 1%. Postendarterectomy hypertension, although more frequent after the contralateral operation as compared with the first operation, has no correlation with the interval between procedures. After a staged bilateral carotid endarterectomy, only one (1%) patient experienced transient ischemic attack symptoms, but five (6%) patients suffered late stroke (four fatal).

Adult↗
PubMed1991

Unilateral iliofemoral occlusive disease: long-term results of the semi-closed endarterectomy with the ring-stripper.

Nowadays, fewer endarterectomies are performed for treatment of occlusive arterial disease; more often a bypass procedure is done. This study investigates whether the results of the semiclosed endarterectomy for unilateral iliofemoral occlusive disease indeed indicate a wider use of bypass procedures for such short obstructions. Ninety-four patients with an obstructed external iliac and common femoral artery, but with patent ipsilateral common iliac and contralateral iliac arteries, underwent 101 operations. Seven of these patients were operated on at a later stage for occlusive disease on the contralateral side. Ninety-three endarterectomies were performed, and an iliofemoral bypass graft was inserted eight times because an endarterectomy was not feasible. Sixty-two operations were performed for disabling claudication, and 39 operations were performed for limb-threatening ischemia. Eighty-five percent of the patients who underwent an endarterectomy for disabling claudication became asymptomatic. Eighty percent of the patients who underwent an endarterectomy for limb-threatening ischemia became asymptomatic or improved to claudication. After endarterectomy no deaths, false aneurysms, or infections occurred. The patency rates at 1, 5, and 10 years were 94%, 83%, and 65%, respectively. We conclude that the semiclosed endarterectomy with the ringstripper of a unilateral obstruction of one external iliac and common femoral artery can be performed with a low morbidity and without deaths and gives good long-term results.

Adult↗
PubMedDate not supplied

Platelet deposition at carotid endarterectomy sites in humans.

Following carotid endarterectomy, early postoperative thrombosis or late restenosis occurs in up to 20% of vessels. Both complications may be related to platelet mechanisms. To assess platelet deposition at endarterectomy sites, we injected indium-111 labelled platelets in 24 men less than 30 minutes after carotid endarterectomy, with subsequent imaging 24-96 hours later. To determine if deposition decreased over time, 12 patients had follow-up studies 0.5-24 months later. For comparison, 2 control groups were studied: 1) patients with noncarotid surgery (n = 6) and 2) normal young subjects without endarterectomy and without evidence of carotid disease (n = 12). Quantitative analysis was performed performed using a deposition index that compared activity in operated with unoperated sites in surgical patients or activity in the right with left carotid arteries in normal subjects. Patients with recent endarterectomy had a mean deposition index of 1.7 +/- 0.5 (range 1.2-3.5) compared with a similarly determined ratio of 1.1 +/- 0.1 in normal subjects and 1.2 +/- 0.1 in the surgical controls (both p less than or equal to 0.05 vs. acute endarterectomy). At follow-up after endarterectomy, the mean deposition index decreased to 1.0 +/- 0.1, documenting reduced platelet deposition over time. We conclude that the arterial injury of carotid endarterectomy results in early platelet deposition, which is no longer present in most patients who are studied late. These findings suggest a reduction in platelet thrombus formation with time and are compatible with reendothelialization of the endarterectomized surface. This model may be useful for the in vivo assessment of therapies designed to reduce platelet accumulation following endothelial injury in humans.

Aged↗
PubMed1988

Results of coronary artery endarterectomy and reconstruction.

Since 1978, 5005 patients have had coronary artery bypass operations: 50% had conventional grafts only (group A), 25.1% required one coronary artery endarterectomy (group B), and 24.9% required multiple endarterectomies (group C). Operative mortality and long-term survival were stratified within each group according to the presence of additional risk factors: severe left ventricular dysfunction, repeat operation, insulin-dependent diabetes mellitus, female sex, and age over 70 years. Operative mortality was 4.0% in group A patients, 6.3% in group B, and 10.4% in group C; it increased in each group as the number of risk factors increased. Mortality was higher in patients with a left coronary artery endarterectomy compared to those with a right coronary endarterectomy only when multiple risk factors were present. Perioperative myocardial infarction occurred in 5.6% of group A patients, 6.5% of group B, and 13.1% of group C patients. Early graft patency (940 patients, 18.8%) was 801 of 901 (88.9%) for endarterectomy grafts and 2939 of 3248 (90.5%) for conventional grafts. Late patency (over 1 year) in 288 symptomatic patients was 137 of 191 (71.1%) for endarterectomy grafts and 644 of 850 (75.8%) for conventional vein grafts. Long-term (5-year) actuarial survival rate was reduced in patients requiring endarterectomy. Current anginal status is available for 3011 of 3305 patients (91.1%): 28.9% of group A patients, 32.5% of group B, and 33.7% of group C patients have recurrent angina at an average follow-up of 58.3 months. The results of this study show increased operative mortality and morbidity in patients requiring coronary artery endarterectomy and reconstruction. However, the early results and particularly the late survival, clinical status, and continued graft patency justify this approach in patients with diffuse coronary artery disease, many of whom would otherwise be inoperable.

Adult↗