Eversion carotid endarterectomy without shunt: concerning 1385 consecutive cases
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Abstract:
The aim of this study was to evaluate the perioperative results of eversion carotid endarterectomy (e-CEA) without shunt at 30 days.From January 2004 to December 2013, 1385 e-CEAs were performed in 981 men and 404 women, for 268 hemispheric, 55 ocular and 12 oculopyramidal symptoms of carotid stenosis. The average age was 71.1 years. The contralateral internal carotid artery (ICA) was occluded in 77 cases. All e-CEAs were performed using Vanmaele technique, with blood pressure monitoring and under general anesthesia except in two cases (locoregional anesthesia alone). The need for application of an intra-arterial shunt was evaluated using visual quantification of adequate retrograde ICA pressure based on the quality of back-bleeding from the ICA. If well pulsatile, a shunt was not required. Otherwise, the systolic blood pressure was increased until a good quality ICA back-flow was obtained.Freedom from intra-arterial shunt placement was 100% as a result of estimation and augmentation of arterial perfusion to demonstrate pulsatile perfusion by retrograde ICA filling. A peroperative angiography was performed in 910 cases. All surgical sites were evaluated postoperatively by Duplex imaging. The overall stroke and death rate was 1.3%. Nine (0.7%) patients died perioperatively. The 24 (1.7%) non-fatal neurologic events were ipsilateral: 6 (0.4%) disabling and 9 (0.6%) regressive stroke, 3 (0.2%) permanent and 1 (0.1%) transient ocular ischemia, and 5 (0.4%) transient ischemic attacks. Three (0.2%) patients had a perioperative myocardial infarction. Eleven compressive neck hematomas (0.8%) were reoperated in emergency.E-CEA can be performed safely, as a routine technique, based on the surgeon's evaluation of arterial back-bleeding and an increase in ipsilateral arterial perfusion with standard anesthetic procedures. Also e-CEA may be considered a cost effective method of reducing the frequency of intra-arterial shunt placement and adjuncts used to assess adequate cerebral perfusion of the ipsilateral carotid artery during e-CEA.Keywords:
Pulsatile flow
Stroke
Endarterectomy
Endarterectomy
Interventional radiology
Stroke
Neuroradiology
Carotid artery disease
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Carotid endarterectomy (CEA) is a widespread and safe procedure associated with very little risk. Only at our hospital surgeons perform nearly 1000 of these surgeries annually, with serious complications occurring extremely rarely[1]. Cerebral ischemic events due to external carotid artery (ECA) thrombosis following a successful internal carotid artery (ICA) endarterectomy is one of such complications. We present a case of ECA thrombosis, following ICA endarterectomy that caused ischemic events.
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Occlusion or severe stenosis, with a reduction in the diameter of more than 70% of the extracranial arteries may lead to hpoperfusion of the brain with an increased risk of cerebral infarction. The aim of this study was to investigate whether endarterectomy of stenosed internal carotid arteries leads to alternations in cerebral metabolism in regions in which no infarcts were visible with magnetic resonance imaging (MRI). We studied 10 healthy control subjects and 20 patients with transient or nondisabling cerebral ischemia with MRI and 1H magnetic resonance spectroscopic imaging. All patients underwent carotid endarterectomy. Patients were examined 1 week before and 3-6 months after carotid endarterectomy. The N-acetyl aspartate (NAA)/choline ratio in the symptomatic hemisphere before endarterectomy (2.29 +/- 0.42) was significantly (p < 0.001) lower than for control subjects (3.18 +/- 0.32). In five of the patients lactate was detected preoperatively in regions that were not infarcted. The NAA/choline ratio in the symptomatic hemisphere of these five patients did not increase significantly after endarterectomy (1.99 +/- 0.22 vs. 2.23 +/- 0.48). The NAA/choline ratio in patients without lactate preoperatively increased significantly (p < 0.01) after endarterectomy to a normal level (from 2.39 +/- 0.42 to 2.92 +/- 0.52). These results indicate that the presence of cerebral lactate may predict whether the NAA/choline ratio increases after carotid endarterectomy.
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Endarterectomy
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BACKGROUND AND PURPOSE: Current indications for carotid endarterectomy are determined by balancing the relative risks of surgery with the benefits of reduced risk of subsequent stroke. Our purpose was to use MR perfusion imaging to assess patients being considered for carotid endarterectomy and to monitor sequential changes in MR perfusion characteristics after surgery. In particular, we wished to determine whether this technique could be used to detect changes that might be related to post‐ carotid endarterectomy hyperemia. METHODS: We used a single-section gradient-recalled echo sequence to investigate 14 patients being examined before possible surgery for carotid artery disease. In the 12 patients in whom carotid endarterectomy was performed, sequential studies were performed 3 to 5 days after surgery and at 3 months. Analysis of bolus-arrival-time (BAT) images was performed. RESULTS: Significant delays in preoperative BAT images of 0.89 seconds (range, 0.05 to 3.22 seconds) were apparent between hemispheres. Excluding the two patients with contralateral internal carotid artery (ICA) occlusion, early arrival, possibly indicating postoperative hyperemia, was seen in five patients immediately after carotid endarterectomy but resolved within 3 to 5 months after surgery. CONCLUSION: MR perfusion imaging shows differences in BAT between hemispheres in patients with ICA stenosis. Changes in perfusion characteristics after carotid endarterectomy are complex, and early BAT on the operative side can occur soon after endarterectomy in over half those patients without an occluded contralateral vessel. The significance of these findings with regard to patient outcome and risk of postoperative hyperemia requires further investigation.
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Aims: Selective endarterectomy is described as extraction of atheromatous plaque through an arteriotomy made starting from common carotid artery (CCA) and extending to external carotid artery (ECA). The aim of this study was to report the initial experience selective endarterectomy technique at our department.
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Endarterectomy
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Carotid Artery Dissection
Carotid bifurcation
Endarterectomy
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