Bilateral Carotid Endarterectomy Research Articles

Bilateral carotid endarterectomy during the same hospital admission

The efficacy of carotid endarterectomy for the prevention of strokes has been well demonstrated in recent multicenter randomized trials. However, patients presenting with bilateral significant disease pose a difficult problem to the vascular surgeon. Currently, bilateral carotid endarterectomies are staged at varying intervals between operations, with the surgeon and patient weighing the risks of waiting for surgery versus the risks of having both procedures done within a shortened interval. There are few data and no consensus on the optimal time interval between these operations. In order to evaluate the timing of carotid endarterectomies in patients with severe bilateral disease, the authors reviewed their experience with patients who had bilateral procedures performed during one hospitalization. Over the past 5 years, they have performed 204 such carotid endarterectomies in 102 patients. Cervical block anesthesia was used in 99% ( 201 204 ) of these procedures. All patients either had symptomatic disease, >60% stenosis or severe ulcerative plaque as defined by duplex scan and/or preoperative angiography. Symptomatic stenoses were the operative indications in 39% ( 80 204 ) of the patients; the remaining 61% ( 124 204 ) were symptom-free. The majority of patients (80%; 164 204 ) had their second procedure performed within 2 days of their first operation. There was one operative mortality and only one permanent neurologic defect in this group for a combined stroke mortality rate of 1%. Three patients (1.5%) had transient neurologic deficits postoperatively which completely resolved by discharge. These data show that bilateral carotid endarterectomies can be performed safely and effectively during one hospital admission with a short interprocedural interval and without an increase in mortality or morbidity. Copyright © 1996 The International Society for Cardiovascular Surgery.

Feasibility and safety of 1-day postoperative hospitalization for carotid endarterectomy.

To determine whether 1-day postoperative hospitalization after carotid endarterectomy is safe and the degree to which this can be achieved. Consecutive sample series of all carotid endarterectomies performed by a single surgical group. A single tertiary-care hospital. All who underwent carotid endarterectomy. Patients with procedures combined with coronary revascularization and patients undergoing the first part of a staged bilateral carotid endarterectomy performed in 1 hospitalization were excluded. In December 1993, a fast-track protocol was initiated, aiming for a 1-day stay after carotid endarterectomy without admission to an intensive care unit (ICU). Before this date, postoperative care included obligatory monitoring for at least 1 night in an ICU. Length of stay, admission to and stay in the ICU, complications, and hospital readmission rate. Over a 21-month period, 152 patients had 163 carotid endarterectomies. Of these, 124 were elective and 39 urgent (patients with a critical stenosis). Indications were stroke (n = 14 [8.6%]), transient ischemic attack (n = 50 [30.7%]), amaurosis fugax (n = 36 [22.1%]), and asymptomatic stenosis (n = 63 [38.7%]). General anesthesia was used for 159 procedures, cervical block for 4. Mean operation time was 2.6 hours. Postoperative stay was 1 day for 82 procedures (50%), 2 days for 49 procedures (30%), 3 days for 12 procedures (7%), and longer for 20 procedures (12%). In the last half of the study, 61% of patients (50/82) were discharged on postoperative day 1 and 87% (71/82) by postoperative day 2. One hundred three patients went to a surgical floor postoperatively. Overall, 60 patients went to the ICU, but only 18 (22%) of the last 82 procedures required ICU admission. The total stay averaged 3.8 days. Twenty-one patients (13%) experienced complications, including 3 deaths within 30 days and 5 neurological deficits. There were 14 early readmissions, but none was attributable to discharge on the first or second postoperative day. Early discharge home after carotid endarterectomy is safe and efficacious, and obligatory admission to an ICU is not necessary. At least 60% of patients who undergo carotid endarterectomy can have a postoperative stay of 1 day, and more than 80% can be discharged by postoperative day 2. A short postoperative stay is not associated with a significant risk of readmission for complications.

Local Infusion of FGF-Saporin Reduces Intimal Hyperplasia

The recent conjugation of the potent ribosome-inactivating protein saporin (SAP) with basic fibroblast growth factor (FGF2) to form recombinant (r)FGF2–SAP permits increased selectivity of this mitoxin for cells exhibiting upregulated FGF receptors. Systemic administration of rFGF-SAP in therapeutic doses, however, may be associated with significant liver toxicity. In this blinded study, we used a local boundary layer infusion approach to increase local drug concentration while minimizing the risk of side effects. Six dogs underwent bilateral carotid endarterectomies. Expanded polytetrafluoroethylene infusion devices, blindly primed with rFGF2–SAP to one artery or vehicle to the contralateral vessel, were anastomosed proximal to the injured segments so that each animal served as its own control. rFGF2–SAP (2 μg/kg/day) or vehicle (5 μl/hr) was continuously delivered for 14 days from an osmotic reservoir, through the wall of the graft infusion device. Euthanasia was carried out at 14 days and the processed arteries were blindly analyzed for intimal thickening and cellular proliferation. All dogs survived until sacrifice with no clinical side effects. Liver function tests at euthanasia were not significantly altered when compared to baseline values. Intimal area in rFGF2–SAP-treated vessels averaged 0.31 ± 0.10 mm2versus 0.57 ± 0.24 mm2in the control segments (P= 0.02), a relative reduction of 46%. Cell proliferation, however, was not significantly different at 14 days postendarterectomy (2.40 ± 1.31% vs 2.39 ± 0.45%). From this study it can be concluded that locally delivered rFGF2-SAP reduces intimal hyperplasia and that the boundary layer infusion strategy is an effective means for delivering high local drug concentration while minimizing systemic drug effects.

両側頸動脈内膜剥離術施行例の検討

両側CEA症例の手術成績,合併症対第について検討したので報告する.当科で施行した230症例,252 CEAのうら,20例(8.7%)が両側CEA施行例であった.初回CEAのmortalityとmorbidityは併せて0%であった.反対側CEAまでの間隔は平均9.2カ目(2〜33カ目)であった.反対側CEAのmortalityは1/20例(5.0%),morbidityも1/20例(5.0%)であった.この2例の悪化例の原因はいずれも術翌日に出現した喉頭浮腫あるいは下位脳神経麻庫による呼吸障害であった.その他の症例は全例ADL 1で退院し,平均60.7カ目のfollow-upで2例が心不全で死亡したが,脳虚血発作を起こした症例はなかった.両側のCEA施行例の第2回目のCEAの術直後の成績は,片側CEA施行例の手術成績に比し劣るものであったが,長期予後でみると,両側手術により脳虚血は高い確率で予防できていると考えられた.

Bilateral carotid endarterectomy during the same hospital admission

Bilateral carotid endarterectomy during the same hospital admission

Hypertensive Encephalopathy After Bilateral Carotid Endarterectomy

Hypertension occurs frequently after carotid endarterectomy and may lead to cerebral vascular complications and myocardial infarction. Its pathophysiology has recently been related to surgically induced damage of carotid baroreceptors. A 45-year-old normotensive man with no history of epilepsy was admitted 3 weeks after bilateral carotid endarterectomy for severe repetitive paroxysmal headaches, vomiting, and agitation that were closely associated with attacks of marked hypertension. During one of these attacks, he had a grand mal seizure. Plasma catecholamine levels during hypertensive attacks were highly elevated despite the absence of pheochromocytoma, reflecting abnormalities in baroreceptor sensitivity that lead to unrestrained activation of the central sympathetic nervous system. Heart rate response to Valsalva maneuver showed suppression of the usual tachycardia, indicating baroreceptor reflex insensitivity. We report the first case of hypertensive encephalopathy associated with baroreflex failure syndrome after bilateral carotid endarterectomy. The role of blood pressure monitoring may be critical in revealing carotid baroreceptor insensitivity in such clinical settings.

Postoperative Tracheal Extubation

Postoperative Tracheal Extubation

Postoperative Tracheal Extubation

Postoperative Tracheal Extubation

Carotid endarterectomy can be safely performed with acceptable mortality and morbidity in patients requiring coronary artery bypass grafts

Patients undergoing the placement of coronary artery bypass grafts (CABG) with hemodynamically significant carotid artery lesions pose a difficult problem for both cardiac and vascular surgeons. Despite numerous studies, there has been no consensus of opinion as to the proper management of these patients. In numerous series, the combined mortality and perioperative stroke rates in concomitant carotid endarterectomy and CABG procedures have ranged from 8% to 40%. This has made many surgeons consider staging these procedures. Retrospective analysis of patients undergoing combined carotid endarterectomies and CABG from 1980 to 1993 were reviewed. Two hundred six procedures were performed in 189 patients. Seventeen patients had bilateral carotid endarterectomy performed with CABG. The average age of our patient population was 66 years, with 123 being male and 66 being female. Seventy-five percent of the patients were asymptomatic with the remainder having transient ischemic attacks, amaurosis fugax, or prior stroke. Operative mortality was 2%, with three of four patients dying of cardiac failure and one of a stroke. A temporary neurologic deficit was seen in 2% of patients, and a permanent neurologic deficit was seen in 2 of 206, or 1%. Thirty shunts were used in this series, mostly in patients with contralateral carotid occlusion. All procedures were performed under general anesthesia with full invasive monitoring. One patient was re-explored for bleeding, and one patient had a temporary hypoglossal palsy. A total of 203 cases had the arteriotomies closed primarily, and 3 required patches. In our experience, simultaneous carotid endarterectomy and CABG can be performed with an acceptable mortality and morbidity and does not appear to put the patient at an increased risk. Staging of these procedures may not be necessary in most cases.

Ambulatory blood pressure profile after carotid endarterectomy in patients with ischaemic arterial disease

To assess the circadian blood pressure profile observed 3 months after endarterectomy. Twenty-five patients undergoing unilateral or bilateral carotid endarterectomy were compared with a control population of 20 patients, matched for age, sex, weight and drug therapy. Casual mean blood pressure measured by mercury sphygmomanometry was similar in both groups. Non-invasive ambulatory blood pressure monitoring showed that, whereas mean arterial pressure was identical in both groups, the group undergoing surgery had a significant increase in pulse pressure and its variability over 24 h. Such abnormalities predominated during the nocturnal period, in which the reduction in systolic blood pressure was less pronounced in the operated group than in controls. For all parameters there was no significant difference between subjects with unilateral or bilateral endarterectomy. This study provides evidence that patients with carotid endarterectomy were characterized in the long term by an increase in the pulsatile component of blood pressure and its variability, in association with a disturbance in the physiological circadian rhythm. Such findings were not identified using casual blood pressure measurements.

Incidence of Bilateral Intraplaque Hemorrhage in Carotid Artery Disease

Stroke is an important source of morbidity and mortality in the USA. Carotid occlusive disease is associated with most cerebrovascular accidents, and carotid artery intraplaque hemorrhage is particularly important in the pathogenesis of cerebral ischemic symptoms. The authors' experience with intraplaque hemorrhage in patients undergoing bilateral carotid endarterectomy was reviewed to determine whether unilateral intraplaque hemorrhage is predictive of the condition occurring on the contralateral side. Forty-seven patients underwent staged bilateral carotid endarterectomy performed by one vascular surgeon. Each plaque was reviewed by a pathologist for the presence of intraplaque hemorrhage. Of these patients, 33 demonstrated intraplaque hemorrhage on the side of initial endarterectomy; 27 of these 33 (82%) had bilateral hemorrhage. It was concluded that intraplaque hemorrhage in the initially operated carotid atheroma is highly predictive of the condition occurring in the contralateral atheroma. Furthermore, aggressive follow-up in this patient population may be warranted.

Hypoxic ventilatory response and carotid endarterectomy

Carotid endarterectomy is reported to abolish hypoxic ventilatory responsiveness. This effect is thought to be due to denervation or destruction of the carotid bodies by surgical exposure. The technique of carotid endarterectomy, however, does not require the sacrifice of these structures. Six patients who had bilateral carotid endarterectomy with careful preservation of the carotid bodies and their innervation were studied pre- and postoperatively with respect to hypoxic ventilatory responsiveness and the latter was taken as a measure of chemoreceptor activity. Five patients showed a weak or absent response to hypoxia before surgery. In four of these there was a significant increase in reactivity after the procedure (p less than 0.01 in one case, p less than 0.05 in three others). The fifth patient had a non-significant increase and the sixth had a normal response before and after surgery. Thus, loss of chemoreceptor function after bilateral carotid endarterectomy was not observed in this group of patients with preserved carotid bodies. The low ventilatory hypoxic sensitivity before surgery and its occasional increase after removal of the plaque suggests that atherosclerosis might well impair the microscopic blood supply to the carotid bodies, inducing sensor dysfunction but this hypothesis requires further investigation.

Reversible basilar artery blood flow in subclavian steal syndrome

Transcranial Doppler ultrasound examination of intracranial vertebral and basilar arteries was performed on a 61-year-old man who presented with symptoms of amaurosis fugax and subclavian steal syndrome. During arm exercise, flow in the basilar artery reversed direction from cephalad to caudal, coincident with symptoms of vertebrobasilar insufficiency. Following bilateral carotid endarterectomies, exercise-induced reverse flow velocities in the basilar artery were markedly increased, and the patient remained asymptomatic. These findings suggest that collateral flow from the anterior cerebral circulation may play an important role in the pathogenesis of brainstem ischemia in subclavian steal syndrome and that transcranial Doppler may identify a subgroup of patients who will benefit from procedures to augment cerebral blood flow.

Chemoreceptor injury as probable cause of respiratory depression after a simultaneous, bilateral carotid endarterectomy

TOUNG, THOMAS J. K. MD; SIEBER, FREDERICK E. MD; GRAYSON, ROGER F. MD; DERRER, STEPHEN A. MD Author Information

Ventilatory effects of hypoxia and adenosine infusion in patients after bilateral carotid endarterectomy

1. We have studied the carotid body contribution to hypoxic respiratory drive, using a hypoxic/hyperoxic switching technique, and the ventilatory response to intravenous infusion of adenosine, a recently described respiratory stimulant, in five patients with bilateral carotid endarterectomy. 2. The contribution made by the carotid bodies to total ventilatory drive during hypoxia varied from 2.5% to 45.9%. 3. The ventilatory response to adenosine infusion varied from a 7% decrease to a 25% increase in ventilation. 4. Those patients with intact hypoxic ventilatory drive showed respiratory stimulation, whereas of the two patients with attenuated chemoreflexes, one showed no stimulation and the other depression of ventilation in response to adenosine infusion. 5. We conclude that adenosine exerts its respiratory stimulant effect via an action on the peripheral chemoreceptors. This may coexist with a centrally mediated respiratory depression that is masked when the carotid bodies are intact.

Vocal Cord Paralysis Following Carotid Endarterectomy: The Paradox of Return of Function

In a series of 411 consecutive carotid endarterectomies 29 patients were identified with vocal cord paralysis. All patients were symptomatic, although in many these symptoms were subtle and rapidly resolved. There was a statistically significant predominance of left-sided paralysis. Excluding three patients who died during the initial year of follow-up return of normal voice was noted in 22 patients, but complete return of vocal cord function was present in only 15. Apposition of the contralateral vocal cord against a paralyzed vocal cord allowed for production of normal voice in five patients. Less than 1% of patients remained with symptoms at one year following endarterectomy. We conclude that vocal cord paralysis is a common complication of carotid endarterectomy; the voice becomes an unreliable guide as to its resolution. We recommend laryngoscopic examination of all patients who undergo bilateral carotid endarterectomy.

Bilateral Carotid Endarterectomy: Impact of Staging on Early Results

Successive bilateral carotid endarterectomies were performed in 323 pa tients ; 193 (60%) had both sides operated on within fourteen days during the same hospitalization (Group I), and 130 (40%) were discharged after the first operation and readmitted for contralateral carotid endarterectomy more than two weeks later (Group II). High-risk patients who were older and sicker com prised the majority in Group II. Otherwise no attempt had been made to be selective based on preconceived criteria. There were 4 deaths (2.1 %) in Group I, and 1 death (0.7%) in Group II. Permanent neurologic complications occurred in 10 (5.2%) Group I patients and 8 (6.1%) Group II patients. Transient neuro logic complications were found in 8 (4.1%) of patients in Group I and 14 (10.8%) in Group II. No patients in Group II suffered any neurologic compro mise because of the waiting period between operations. A history of hyperten sion or previous cerebral infarction was found to place patients at increased risk for the development of permanent neurologic complications. Postoperative hy pertension after the second endarterectomy was greater in Group I than in Group II patients. Observations from this retrospective review support the concept that staging of bilateral carotid endarterectomies in two hospitalizations allows elderly, sicker patients to be operated on as safely as younger, otherwise healthy individ uals. The indications for staging bilateral carotid endarterectomies in separate hospitalizations should be liberalized in order to minimize complications.

Carotid Body Resection for COPD?

Bilateral carotid body denervation or resection (glomectomy) has been performed in three contexts over the past 35 years: 1) in the 1950s, Nakayama in Tokyo used glomectomy to treat childhood asthma.1 While many subjects were apparently relieved, the procedure was terminated after two of the youngsters died while attempting long underwater swims. Some of these patients were studied 30 years later and found still to be unresponsive to hypoxia.2 2) Bilateral carotid endarterectomy for arteriosclerotic occlusive disease was shown by Wade et al3 to result in carotid body denervation in most patients, with a resulting permanent 6 mm Hg rise of PCO2.

Asymptomatic carotid artery stenosis on the side contralateral to endarterectomy: A comparison between patients with and those without operation

From May 1974 to October 1983, 82 patients with severe bilateral carotid disease had unilateral carotid endarterectomy (CE) on the symptomatic side (group I). The carotid artery contralateral to the endarterectomy was severely stenosed (lumen diameter reduction 51% up to 99%) and it was not repaired for different reasons. Group I patients were compared with 78 patients who had bilateral CE (group II), matched with group I for associated diseases, operative indication, and angiographic findings. In this analysis, only neurologic deficits referable to the contralateral hemisphere were considered. There was a higher incidence of later neurologic deficits in the group I patients; however, this difference was not statistically significant. In group I, the occurrence of late neurologic deficits was statistically correlated to (1) severity of stenosis, (2) presence of large compound ulceration, and (3) history of previous stroke. Stepwise logistic regression analysis identified two groups of patients at higher risk for late neurologic deficits (1) patients with stenosis 75% or greater and large ulceration and (2) patients with stenosis 75% or greater and previous stroke. CE on the asymptomatic contralateral side should be considered in selected patients at high risk for late neurologic events at a surgical center with an established low incidence of perioperative complications. A nonoperative policy with careful follow-up is warranted in the remaining cases.

The Long-Term Effects of Bilateral Carotid Endarterectomy (BCE) on Hypoxic Chemosensitivity

The Long-Term Effects of Bilateral Carotid Endarterectomy (BCE) on Hypoxic Chemosensitivity