Carotid endarterectomy without a shunt for symptomatic lesions associated with contralateral severe stenosis or occlusion

PURPOSE: The purpose of this study was to assess the adequacy of thiopental protection against ischemic cerebral damage in patients undergoing carotid endarterectomy for symptomatic stenosis greater than 70% in association with contralateral stenosis greater than 70% or contralateral occlusion. METHODS: All patients (n=259) with severe bilateral carotid disease who underwent carotid endarterectomy for symptomatic stenosis greater than 70% were extracted from the database of an ongoing prospective carotid surgery study. Large-dose thiopental sodium without shunting was used for cerebral protection during endarterectomy. Asymmetric electroencephalogram changes during the operation, carotid occlusion time, stroke onset, and neuropathologic outcomes were analyzed. RESULTS: Three contralateral strokes occurred in the series, producing a cerebral morbidity/mortality rate of 1.2% (major 0.4%, minor 0.8%). Transient morbidity was 1.9% made of two reversible ischemic neurologic deficits and three transient ischemic attacks. New asymmetric electroencephalography changes were seen in 49 (19% patients, one of whom had transient deficit. Average occlusion time was 35 minutes. All strokes occurred within 24 hours of the procedure. Patients with previous stroke and and systemic hypertension seemed at greatest risk, and the contralateral hemisphere was the area at greatest risk. All transient deficits were ipsilateral and related to technical complications rather failed protection. CONCLUSIONS: Thiopental cerebral protection eliminates strokes caused by complications of shunting, prevents ischemic stroke during carotid occlusion for periods up to 67 minutes (average 35 minutes), allows meticulous management of the operative site, may modify or minimize clinical neurologic deficit, and in our experience has rendered intraluminal shunting obsolete.     

Postoperative stroke and late neurologic complications after carotid endarterectomy

From 1969 through 1973, 335 consecutive patients (mean age, 60 years) underwent 390 carotid endarterectomies using hypercarbic general anesthesia and no carotid shunting. Early neurologic complications were most common among patients with previous neurologic symptoms and among those with subtotal stenosis or occlusion of the contralateral internal carotid artery. The introduction of routine carotid shunting without hypercarbia during a subsequent series of 626 procedures from 1974 through 1978 has been associated with significantly fewer operative strokes in comparable groups of patients. Complete follow-up information during a mean interval of 8.6 years is available for 95% of 325 operative survivors. Late completed strokes have occurred in 17% of patients but have involved the cerebral hemisphere on the side of previous carotid endarterectomy in only 7%. Of 93 operative survivors who had subtotal stenosis of the contralateral internal carotid artery, 45 underwent contralateral endarterectomy as an elective procedure and 48 did not. The late contralateral stroke rates for these two groups of patients were 4% and 16%, respectively, although these differences did not attain statistical significance. Forty-nine (78%) of 63 patients with contralateral internal carotid occlusion have had no late neurologic symptoms following unilateral carotid endarterectomy.     

Role of transcranial Doppler and stump pressure during carotid endarterectomy

BACKGROUND AND PURPOSE: The aim of our study was to clarify the pathophysiology of perioperative cerebral complications during carotid endarterectomy in our series. METHODS: By means of transcranial Doppler ultrasonography and stump pressure measurement, we monitored 112 patients who underwent carotid endarterectomy under general anesthesia for symptomatic or asymptomatic severe carotid stenosis. RESULTS: Of 18 patients who underwent carotid endarterectomy with intra-arterial shunt, 2 (11.1%) developed an ischemic stroke. Of the other 94 patients, one suffered a nucleocapsular hemorrhage and 5 had cerebral ischemic complications. In these 5 patients, the duration of clamping was significantly longer (mean +/- SD, 16.4 +/- 1.1 versus 12.7 +/- 2.6 minutes; P = .0019), and the decrease of middle cerebral artery mean velocity on clamping was significantly greater (mean +/- SD, 56.4 +/- 4.9% versus 28.8 +/- 20.2%; P = .0031), while stump pressure was not significantly different. Microembolic signals were recorded in 70 patients (62.5%) and were not associated with cerebral ischemic complications. The 7 patients who developed cerebral ischemic complications had a significantly higher percentage of stenosis in the contralateral internal carotid artery (mean +/- SD, 82.0 +/- 17.8% versus 29.3 +/- 36.4%; P = .0018). CONCLUSIONS: The results of our study suggest that the major complications of carotid endarterectomy may be due to hemodynamic factors. Stump pressure alone is not a reliable indicator of hemodynamic changes that predict cerebral ischemia. Particulate microembolism may cause more subtle changes in cerebral parenchyma, but further studies are needed to clarify this point.     

Radiation exposure of the population by roentgen diagnosis. II. The collective effective dosage of the population in former East Germany caused by 1987/1988 roentgen diagnosis

OBJECTIVES: To examine the relations between the development of neurologic events and the following variables: degree of stenosis of the contralateral carotid artery, prior neurologic symptoms and stump pressure of the ipsilateral internal carotid artery in patients undergoing carotid endarterectomy under regional anesthesia. PATIENTS AND METHODS: We undertook a prospective study of 92 patients undergoing carotid endarterectomy with a blockade of the superficial and deep cervical plexus. Neurological integrity was assessed and internal carotid artery stump pressure was monitored. Contralateral carotid artery stenosis and neurologic disease present before surgery were studied. RESULTS: Neurologic events developed when the carotid artery was clamped in 9.7% of patients. Mean stump pressure was significantly lower in symptomatic patients (43 +/- 11 mmHg) than in asymptomatic patients (74.6 +/- 24 mmHg) (p < 0.001). Neurologic symptoms developed during clamping of the carotid in 27.2% of the patients with stump pressure less than or equal to 50 mmHg, but in only 4.2% of those with stump pressure surpassing 50 mmHg. Stump pressure was significantly lower in patients with contralateral carotid stenosis. The incidence of neurologic events during clamping was unrelated to contralateral carotid condition, however. Likewise, neurologic symptoms before surgery was also unrelated. In six of the nine patients with neurologic events, internal carotid stump pressure was less than or equal to 50 mmHg, indicating that the sensitivity of this parameter to the development of neurologic events in our series was 66%. CONCLUSIONS: Although internal carotid artery stump pressure identifies a subset of patients likely to have a higher incidence of neurologic events during carotid artery clamping, it can not be considered the only criterion for placement of an intraluminal shunt to prevent such events. The state of the contralateral carotid artery and preexisting neurologic symptoms are not objective screening criteria for identifying patients at high risk of neurologic events during carotid clamping.     

Incidence, timing, and causes of cerebral ischemia during carotid endarterectomy with regional anesthesia

PURPOSE: Controversy exists regarding the best technique to identify cerebral ischemia during carotid endarterectomy (CEA). Regional anesthesia allows continuous evaluation of neurologic function and therefore can help determine the incidence, timing, and causes of cerebral ischemia. METHODS: The timing and clinical manifestations of any neurologic event during CEA and as long as 30 days afterward was determined by review of operative reports, hospital charts, and outpatient records of consecutive patients who underwent CEA under regional anesthesia over a 68-month period. RESULTS: Two hundred patients underwent CEA; indications were asymptomatic stenosis > 60% in 25%, transient ischemic attack with stenosis > 50% in 52%, and prior stroke with stenosis > 50% in 23%. Eight patients (4%) were converted to general anesthesia for non-ischemic reasons. Of the remaining 192 patients, 183 (95.5%) underwent the procedure with regional anesthesia and no shunt, 2% had cerebral ischemia and underwent shunt placement, and 2.5% had cerebral ischemia, were converted to general anesthesia, and underwent shunt placement. Cerebral ischemia developed in nine patients after carotid cross-clamping, manifested by loss of consciousness in four, confusion in two, dysarthria and confusion in one, and decreased contralateral motor strength in two. Immediate cerebral ischemia developed in four of the nine patients within 1 minute of cross-damping; all four underwent shunt placement. In five of the nine patients, cerebral ischemia occurred between 20 and 30 minutes after cross-clamping; all occurred during relative intraoperative hypotension (average reduction of 35 mm Hg in the systolic pressure). All awake patients in whom ischemic symptoms developed immediately regained and maintained normal neurologic function with shunt placement. Five of 26 patients (19%) with contralateral occlusion required a shunt; none had postoperative ischemia. The mean carotid cross-clamp time was 27 minutes. Postoperative (30 day) complications included a 0.5% stroke rate, a 0.5% rate of postoperative transient ischemic attack, a 0.5% rate of worsening of preexisting acute stroke, and a 0.5% rate of myocardial infarction (no deaths). Of the nine patients who had intraoperative ischemic changes, none had a postoperative neurologic deficit; the three patients who had postoperative neurologic changes had no intraoperative ischemic symptoms. CONCLUSIONS: CEA with regional anesthesia allows continuous neurologic monitoring and can be performed safely even when contralateral occlusion coexists; intraoperative shunting for ischemia is necessary in 4.5% of all cases and in 19% of patients with contralateral occlusion. Intraoperative ischemia was flow-related in our patients; it occurred early from ipsilateral carotid clamping and late from reduced collateral flow as a result of hypotension. Monitoring should be continued throughout cross-clamping to identify late cerebral ischemia. Postoperative cerebral ischemia is not associated with intraoperative ischemia, if corrected.     

Elective carotid artery stenting in the presence of contralateral occlusion

Significant carotid stenosis in the presence of an occluded contralateral artery has a poor prognosis with medical therapy alone. Carotid cross clamping during surgical endarterectomy results in critical flow reductions in patients with inadequate collateral flow, and represents a significant risk for procedural strokes. Carotid stenting is being evaluated as an alternative to endarterectomy. We describe the immediate and late outcome of a series of 26 patients treated with carotid stenting in the presence of contralateral carotid occlusion. The mean age of the patients in this group was 65 +/- 9 years, 23 (89%) were men and 10 (39%) were symptomatic from the vessel treated. The procedural success of carotid stenting in this group of patients was 96%. The mean diameter stenosis was reduced from 76 +/- 15% to 2.8 +/- 5%. There was 1 (3.8%) minor stroke in a patient who developed air embolism during baseline angiography. At late follow-up there was no neurologic event in any patient at a mean of 16 +/- 9.5 months after the procedure. Thus, carotid stenting of lesions with contralateral occlusion can be performed successfully with a low incidence of procedural neurologic complications and late stroke.     

Sites of recurrence and long-term results of redo surgery

OBJECTIVE: The authors determined whether carotid endarterectomy in patients with recurrent stenosis could provide durable stroke prevention with acceptable perioperative risk. SUMMARY BACKGROUND DATA: Balloon angioplasty and stenting are being advocated for recurrent stenosis because of the presumption that reoperation is unsafe with poor results. METHODS: The authors retrospectively reviewed their experience with 67 patients undergoing 74 operations for recurrent stenosis in a recent 11-year period. This represented 8.4% of 883 endarterectomies performed during the same period. RESULTS: At original operation, 55% had primary closure and 45% were patched. Reoperation was performed for amaurosis fugax and transient ischemic attack (45%), post-stroke (7%), global ischemia (10%), and asymptomatic severe occlusive disease (35%). Four patients (6%) undergoing simultaneous cardiac procedures were excluded from further analysis. Mean duration between primary and first redo operation was 78 months (range, 1-240 months). The 30-day combined mortality and stroke morbidity was 2.8%, evenly divided with 1.4% stroke and 1.4% mortality rates. Recurrent disease occurred predominantly (69%) in the previous endarterectomy site. Follow-up ranged from 1 to 162 months (mean, 48.2). Seventeen deaths occurred, of which 10 (59%) were cardiac. Two late ipsilateral neurologic events and four late contralateral events occurred. Two patients required third ipsilateral reoperation. Life-table analysis shows the ipsilateral stroke-free rate at 5 years to be 93.6% CONCLUSIONS: Recurrent stenosis occurs either proximal to or in the previous endarterectomy site in the majority of patients. Recurrent stenosis can be treated surgically with low morbidity and mortality and durable long-term stroke prevention. The presumption that results of redo carotid surgery are poor is disproved.     

Influence of projected complication rates on estimated appropriate use rates for carotid endarterectomy. Appropriateness Project Investigators. Academic Medical Center Consortium

OBJECTIVE: To examine specifically the influence of estimated perioperative mortality and stroke rate on the assessment of appropriateness of carotid endarterectomy. DATA SOURCES/STUDY SETTING: An expert panel convened to rate the appropriateness of a variety of potential indications for carotid endarterectomy based on various rates of perioperative complications. We then applied these ratings to the charts of 1,160 randomly selected patients who had carotid endarterectomy in one of the 12 participating academic medical centers. STUDY DESIGN: An expert panel evaluated indications for carotid endarterectomy using the modified Delphi approach. Charts of patients who received surgery were abstracted, and clinical indications for the procedure as well as perioperative complications were recorded. To examine the impact of surgical risk assessment on the rates of appropriateness, three different definitions of risk strata for combined perioperative death or stroke were used: Definition A, low risk < 3 percent; Definition B, low risk < 5 percent; and Definition C, low risk < 7 percent. PRINCIPAL FINDINGS: Overall hospital-specific mortality ranged from 0 percent to 4.0 percent and major complications, defined as death, stroke, intracranial hemorrhage, or myocardial infarction, varied from 2.0 percent to 11.1 percent. Most patients (72 percent) had surgery for transient ischemic attack or stroke; 24 percent of patients were asymptomatic. Most patients (82 percent) had surgery on the side of a high-grade stenosis (70-99 percent). When the thresholds for operative risk were placed at the values defined by the expert panel (Definition A), only 33.5 percent of 1,160 procedures were classified as "appropriate." When the definition of low risk was shifted upward, the proportion of cases categorized as appropriate increased to 58 percent and 81.5 percent for Definitions B and C, respectively. CONCLUSIONS: Despite the high proportion of procedures performed for symptomatic patients with a high degree of ipsilateral extracranial carotid artery stenosis and generally low rates of surgical complications at the participating institutions, the overall rate of "appropriateness" using a perioperative complication rate of < 3 percent was low. However, the rate of "appropriateness" was extremely sensitive to judgments about a single clinical feature, surgical risk. These data show that before applying such "appropriateness" ratings, it is crucial to perform sensitivity analyses in order to assess the stability of the results. Results that are robust to moderate in variation in surgical risk provide a much sounder basis for policy making than those that are not.     

Early results of combined carotid endarterectomy and coronary artery bypass grafting in patients with severe coronary and carotid artery disease

The management of patients with carotid artery disease who require coronary artery bypass grafting (CABG) remains controversial. Several published series from the USA (including one with prospective randomization) advocate a combined approach of carotid endarterectomy (CEA) followed immediately by coronary artery bypass surgery. However, experience of combined carotid endarterectomy and coronary bypass grafting has not been previously reported by a centre from the United Kingdom. Between 1986 and 1991 we performed this combined procedure on 18 patients who required myocardial revascularization and had co-existing severe (> 70%) carotid stenosis. Sixteen patients (89%) had angina and 11 patients (61%) had symptomatic carotid artery disease. The perioperative mortality was 5.5% and the ipsilateral perioperative stroke rate was 5.5%. These early results are encouraging and suggest that further evaluation of combined carotid endarterectomy and coronary artery bypass surgery is warranted.     

Routine carotid endarterectomy without a shunt, even in the presence of a contralateral occlusion

A 10-year prospective experience with routine non-shunting, even in the presence of a contralateral internal carotid artery occlusion, is reviewed. METHOD AND RESULTS: Carotid endarterectomy was performed without a shunt in 654 consecutive patients: group 1, 513 patients with contralateral stenosis of less than 79%: group 11, 74 patients with a greater than 80% contralateral stenosis; and group 111, 67 patients with a contralateral occlusion. Average cross-clamp time was 23 min. Neurological complications occurred within 30 days in 20 (3.0%) patients (10 strokes, seven transient ischemic attacks in group I, one transient ischemic attack in group II, and one stroke and one transient ischemic attack in group III). Immediate postoperative strokes, i.e. those five cases that could be implicated as caused by lack of a shunt, were rare (0.76%). There were five perioperative deaths (0.76%). CONCLUSION: Carotid endarterectomy may be performed safely without a shunt even in the presence of a contralateral occlusion. Age, sex, preoperative indication, anesthetic agent and contralateral stenosis were not associated with an increased risk of postoperative neurological deficit.     

Carotid endarterectomy under regional (conductive) anesthesia

Carotid endarterectomy is reliable in the prevention of strokes due to arteriosclerotic disease at the carotid bifurcation. This is a retrospective review of 314 carotid endarterectomies performed at the University Health Center of Pittsburgh. The objectives of the study were to determine if regional anesthesia was a safe technique for carotid endarterectomy and to determine whether the neurologic complications that occurred were embolic or ischemic in origin. In patients who were neurologically intact before operation, the perioperative mortality was 0.88% and the incidence of neurologic complications was 3.1%. This is comparable to the current literature. Observations of the awake patient suggested that half the neurologic deficits that occurred in this series were due to embolization rather than to cerebral ischemia. Further more, the incidence of non-neurologic complications under general anesthesia was 12.9%. Under regional anesthesia, the incidence of non-neurologic complications was 2.8%. The data supports carotid endarterectomy under regional block as safe and reliable method.     

Carotid endarterectomy with shortened hospital stay

OBJECTIVE: To review the outcome of a consecutive series of patients undergoing carotid endarterectomy with a focus on length of stay. DESIGN: Retrospective case review. SETTING: Six hundred-bed community hospital. PATIENTS: During a 40-month period, we performed 266 carotid endarterectomies. Ages of patients ranged from 49 to 91 years (mean, 71.2 years). Seventy-two percent were hypertensive, 55% were smokers, 24% were diabetic, and 22% had symptomatic heart disease. Indications for operation included asymptomatic stenosis in 48% of patients, transient ischemia attack in 23%, stroke in 24%, and nonhemispheric symptoms in 5%. OUTCOME MEASURES: Perioperative complications and conditions precluding early hospital discharge were noted. In patients discharged within 48 hours of operation, problems requiring readmission within 30 days were recorded. RESULTS: Five patients (1.9%) experienced perioperative strokes, of which three were permanent and two temporary. There was one perioperative death. Hospital stays ranged from 1 to 9 days (mean 1.7 days). Sixty-three percent of the patients were discharged within 24 hours and 88% within 48 hours of operation. Patients staying in the hospital more than 48 hours were significantly older (P = .008). Other factors did not correlate with length of stay. Readmission was required in five patients. CONCLUSIONS: Patients having an uneventful course following carotid endarterectomy may be safely discharged within 48 hours of operation. Complications occurring after this time are infrequent and often unpredictable. It is unlikely that lengthening patient stay would decrease or eliminate these complications.     

Surgical treatment of common carotid artery occlusion

Eight patients with common carotid artery (CCA) occlusion underwent bypass with saphenous vein to either the carotid bifurcation (five), the internal carotid artery (two), or the external carotid artery (one). Indications included ipsilateral transient ischemic attack (two), recent nondisabling hemispheric stroke (two), and transient nonhemispheric cerebral symptoms (two). Two asymptomatic patients with CCA occlusion and contralateral internal carotid stenosis underwent prophylactic revascularization prior to planned aortic surgery. There were no perioperative strokes, occlusions, or deaths. Late ipsilateral stroke occurred in two patients, and one patient had a single transient ischemic attack after 2 years. The four patients with preoperative transient cerebral ischemia experienced relief of their symptoms. Duplex ultrasound is an accurate screening modality for distal patency. Collateral filling of the internal or external carotid artery can usually be demonstrated after aortic arch or retrograde brachial contrast injection. End-to-end distal anastomosis after endarterectomy eliminates the original occlusive plaque as a potential source of emboli. The subclavian artery is preferred for inflow on the left. The CCA origin is easily accessible for inflow on the right. Bypass of the occluded CCA is safe and may be effective in relieving transient cerebral ischemic symptoms, although long-term ipsilateral neurologic sequelae may still occur.     

Local overexpression of thrombomodulin for in vivo prevention of arterial thrombosis in a rabbit model

Data from 213 cases of simultaneous carotid endarterectomy and coronary artery bypass grafting (CEN/CABG) were analyzed (1980-1996). There were 154 males (72.3%), and 59 females (27.7%), (mean age: 65. 6 years, range: 42-83). One hundred and thirty-two patients (62.0%) had angina, 58 (37.2%) had myocardial infarction, and 23 (10.8%) had congestive heart failure. Symptomatic cerebrovascular disease was present in 89 patients (41.7%). One hundred and twenty-two patients (57.2%) had three-vessel coronary artery disease, 41 (19.2%) had left main disease, and 27 (12.6%) had a low ejection fraction (ejection fraction /=75% diameter reduction) stenosis was present in 168 (78.8%) of the operated carotid arteries. The contralateral internal carotid artery was severely stenosed or occluded in 35 patients (16.4%). The hospital mortality rate was 5. 6% (12 patients). The cause of death was cardiac in ten patients (4. 6%), and neurologic in two (1%). Eleven patients (5.1%) developed a stroke postoperatively; eight strokes were ipsilateral to the operated artery, and six were permanent. Myocardial infarction occurred in five patients (2.3%). Independent predictors of early mortality were age >62 years, hypertension, and postoperative stroke (p < 0.05). Male sex was the only independent predictor of neurologic morbidity (p < 0.05). Late follow-up data were obtained for 163 (81.0%) patients (mean: 54.8 months, range: 1-168). Four (9. 3%) out of the 43 late deaths were attributed to strokes. There were three (1.8%) late ipsilateral strokes, and five (3.1%) contralateral strokes. The 5- and 10-year survival probabilities were 75 +/- 4%, and 52 +/- 6.9%. The freedom from late ipsilateral neurologic morbidity at 5 and 10 years were 97 +/- 1.7% and 90 +/- 4.0%, respectively. Taken together, the results indicate that combined carotid endarterectomy and coronary artery bypass grafting can be performed safely in this high-risk group of patients. Excellent long-term freedom from stroke can be expected.     

EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system

BACKGROUND: The aim of this article was to analyze the perioperative mortality and stroke risk rates and late benefits of carotid endarterectomy (CE) contralateral to an occluded internal carotid artery (ICA), on the basis of our surgical experience from July 1990 to June 1996. METHODS: In 57 (14.7%) of 336 patients undergoing 388 CEs, the contralateral ICA was occluded (group I). All operations were performed under general anesthesia with selective shunting based on electroencephalographic criteria. Shunting was used in 36 (63.1%) of 57 revascularizations in group I and 47 (14.2%) of 331 operations performed on the remaining 279 patients with patent contralateral ICAs (group II) (p < 0.001). RESULTS: Perioperative strokes occurred in two patients (3.5%) in group I and three patients (1%) in group II (difference not significant). The only perioperative death, which occurred in one patient (1.7%) in group I, was the result of a perioperative stroke; two patients (0.7%) in group II died within 30 days of operation (difference not significant). Life-table cumulative stroke-free rates at 1, 3, and 5 years were 95%, 95%, 95% in group I and 98.8%, 98.2%, and 98.2% in group II, respectively (p = 0.272). Life-table cumulative survival rates at 1, 3, and 5 years were 97.5%, 94.2%, and 78.1% in group I and 99.2%, 94.8%, and 71.7% in group II, respectively (p = 0.306). CONCLUSIONS: The results of this analysis indicate that CE contralateral to an occluded ICA can be performed with acceptable perioperative mortality and stroke risk rates and late stroke-free and survival rates comparable to those seen in patients without contralateral ICA occlusion who have undergone operation. Nevertheless, we think it is misleading to imply that the risks of operating on the two groups are the same. Moreover, because no late stroke-related death occurred in patients with contralateral ICA occlusion, it would appear that superior late stroke-free rates did not translate into a prolonged survival advantage.     

A surgical approach to coexistent coronary and carotid artery disease

OBJECTIVE: To assess the early results of combined coronary artery bypass graft surgery and carotid endarterectomy. DESIGN: Retrospective and ongoing analysis of patients who underwent combined coronary artery bypass graft surgery and carotid endarterectomy. SETTING: Cardiothoracic unit in a London teaching hospital. PATIENTS: From June 1987 to March 1995, 64 patients were identified. They were patients who were scheduled to have coronary artery bypass graft surgery or required urgent coronary revascularisation and who were found to have significant coexistent carotid disease. (Unilateral carotid stenosis > 70%, bilateral carotid stenosis > 50%, or unilateral carotid stenosis > 50% with contralateral occlusion.) INTERVENTIONS: Both procedures were performed during one anaesthesia: the carotid endarterectomy was performed first without cardiopulmonary bypass. After completion of carotid endarterectomy, coronary artery bypass graft surgery was performed. MAIN OUTCOME MEASURES: The incidence of stroke, transient ischaemic attack, and myocardial infarction in the early postoperative period was analysed. RESULTS: Myocardial revascularisation was successful in all 64 patients. There were no perioperative infarcts. In three patients (4.7%) a new neurological deficit developed postoperatively: two recovered fully before hospital discharge. CONCLUSIONS: Combined coronary artery bypass graft surgery and carotid endarterectomy were performed safely and with good results.     

Symptomatic recurrent carotid stenosis and aneurysmal degeneration after endarterectomy

BACKGROUND: Aneurysmal degeneration of a carotid reconstruction was not recognized until the patient, who was known to have recurrent carotid artery stenosis, had a thromboembolic stroke. This sequelae of carotid endarterectomy is a serious complication, associated with a high morbidity and mortality rate. This review was conducted to establish the risk of transient ischemic attack and stroke for patients found to have recurrent carotid stenosis associated with aneurysmal degeneration of the carotid artery after endarterectomy. METHODS: A case is reported, and 100 literature references of aneurysmal degeneration of the carotid artery after endarterectomy were reviewed. RESULTS: False aneurysm from anastomotic disruption was the most common presentation identified in the cases reviewed. Nineteen of the patients had a significant neurologic event; however, three (50%) of six patients with aneurysm and recurrent carotid artery stenosis had a transient ischemic attack or stroke. CONCLUSIONS: The incidence of neurologic symptoms is markedly increased when recurrent carotid artery stenosis is associated with carotid aneurysm. During postoperative surveillance after endarterectomy, the identification of recurrent carotid artery stenosis requires evaluation for aneurysmal degeneration of the carotid artery with duplex scanning. These patients are at significant risk for transient ischemic attack and stroke. This rare complication merits operative repair.     

Relationship between intraoperative color-flow duplex findings and early restenosis after carotid endarterectomy: a preliminary report

PURPOSE: This study was undertaken to examine the relationship between intraoperative color-flow duplex (CFD) findings and the development of restenosis in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-eight patients (43 male and 35 female; mean age, 65 years) underwent 86 CEAs (eight staged bilateral) and intraoperative CFD during a 31-month period. Three patients (three CEAs, 3%) underwent both CFD and a completion arteriographic scan. Patients were observed in a postoperative protocol using CFD surveillance. The follow-up interval ranged from 6 to 24 months (average, 12 months). RESULTS: After undergoing CEA, 10 patients (10 CEAs, 11%) had an abnormality detected by intraoperative CFD; one was confirmed with a completion arteriographic scan. These abnormalities consisted of elevated peak systolic velocities (PSV) with a mosaic color pattern suggesting turbulence seen in six CEAs, including one internal carotid artery (ICA) with abnormal hemodynamics and an unremarkable completion arteriogram. Intimal defects on B-mode were seen in another four CEAs. These carotid arteries were reexplored, defects (intimal flaps with platelet thrombus) were confirmed by direct examination, and all were repaired with or without a patch (six ICAs, three external carotid arteries, and one common carotid artery). No cerebrovascular events occurred in the perioperative period. No carotid restenosis (> or = 50% diameter reduction) was identified during follow-up of 43 patients (48 CEAs, 56%). Two patients had recurrent neurologic symptoms. CONCLUSION: Intraoperative CFD is an effective test for detecting flow abnormalities or intimal defects in patients undergoing CEA. Ensuring normal intraoperative hemodynamics after CEA may be a major factor associated with decreased incidence of perioperative cerebrovascular events and subsequent carotid artery restenosis.     

Unilateral internal carotid arterial occlusion: special considerations

Cases of patients with unilateral internal carotid arterial occlusion and contralateral internal carotid arterial stenosis are reviewed. Forty-two percent presented with a fixed neurological deficit. The deficit was referable to the side of occlusion in 92% and to the side of stenosis in 8%. Eleven percent had a neurological complication following carotid endarterectomy on the side of the stenotic lesion. The neurological complication was referable to the side of stenosis in 67% and to the side of occlusion in 33%. Patients have been followed for an average of 19 months and have not developed any additional TIA's or strokes in the followup period. There may be a role for an extracranial-intracranial bypass (ECIC) on the occluded side prior to an endarterectomy on the stenotic side if a poor collateral situation exists. An ECIC should be done in patients who remain symptomatic following carotid endarterectomy on the stenotic side. These data do not support doing ECIC in asymptomatic patients with unilateral carotid arterial occlusion.     

Carotid stenosis--is arteriography necessary in investigation and treatment

The present study was undertaken in order to evaluate whether arteriography changed the planned treatment (carotid endarterectomy) of patients with symptomatic carotid artery disease, who had been investigated primarily by ultrasound Duplex scanning. The material was comprised of 50 consecutive patients admitted for arteriography. All patients were symptomatic and were by ultrasound examination found to have lesions of the relevant internal carotid artery (ICA). In three cases arteriography was performed because ultrasound examination was inconclusive. Of the remaining 47 cases, arteriography only changed the planned treatment in three. In one case, arteriography showed a long stenosis continuing into the intracranial part of the ICA, which was not observed by ultrasound. In two cases of minor disease ultrasound overestimated the degree of stenosis. The study concludes that carotid endarterectomy may be performed based on ultrasound duplex scanning, without prior arteriography, if the degree of stenosis is 70% or greater and if the distal end of the stenosis is clearly extracranial.