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1.
OBJECTIVE: This study attempted to correlate neurologic changes in awake patients undergoing carotid endarterectomy (CEA) under cervical block anesthesia (CBA) with electroencephalography (EEG) and measurement of carotid artery stump pressure (SP). METHODS: Continuous EEG and SP monitoring was measured prospectively in 314 consecutive patients undergoing CEA between April 1, 2003, and July 30, 2006, under CBA. Indications for CEA were asymptomatic 70% to 99% internal carotid artery stenosis in 242 (77.1%), transient ischemic attacks (including transient monocular blindness) in 45 (14.3%), and prior stroke in 27 (8.6%). Mean common carotid artery pressure before clamping, mean SP after carotid clamping, and intraarterial pressure were continuously monitored in all patients. An indwelling shunt was placed when neurologic events (contralateral motor weakness, aphasia, loss of consciousness, or seizures) occurred, regardless of SP or EEG changes. RESULTS: Shunt placement was necessary because of neurologic changes in 10% (32/314) of all CEAs performed under CBA. Only 3 patients (1.4%) of 216 required shunt placement if SP was 50 mm Hg or more, vs 29 (29.6%) of 98 if SP was less than 50 mm Hg (P < .00001; sensitivity, 29.8%; specificity, 98.6%). In patients with SP of 40 mm Hg or more, 7 (2.6%) of 270 required shunt placement, vs 25 (56.8%) of 44 if SP was less than 40 mm Hg (P < .00001; sensitivity, 56.8%; specificity, 97.4%). Ischemic EEG changes were observed in 19 (59.4%) of 32 patients (false-negative rate, 40.6%) requiring shunt placement under CBA. Three patients had false-positive EEG results and did not require shunt placement (false-positive rate, 1.0%). The perioperative stroke/death rate was 4 (1.2%) in 314. All strokes occurred after surgery and were unrelated to cerebral ischemia or lack of shunt placement. CONCLUSIONS: Ten percent of patients required a shunt placement during CEA under CBA. Shunt placement was necessary in 56.8% of patients with SP less than 40 mm Hg. EEG identified cerebral ischemia in only 59.4% of patients needing shunt placement, with a false-positive rate of 1.0% and a false-negative rate of 40.6%. Both SP and EEG as a guide to shunt placement have poor sensitivity. Intraoperative monitoring of the awake patients under regional anesthesia (CBA) is the most sensitive and specific method to identify patients requiring shunt placement.  相似文献   

2.
Selective shunting with eversion carotid endarterectomy   总被引:2,自引:0,他引:2  
PURPOSE: The consensus is that eversion carotid endarterectomy (CEA) is a safe, effective, and durable surgical technique. Concern remains, however, regarding insertion of a shunt during the procedure. We studied the advisability of shunting with eversion CEA by comparing patients who underwent eversion CEA with and without shunting. METHODS: Over 9 years, 624 primary eversion CEAs were performed in 580 selected patients to treat symptomatic (n = 398, 63.8%) and asymptomatic (n = 226, 36.2%) carotid lesions. All eversion CEAs were performed by the same surgeon (E.B.), with the patient under deep general anesthesia, with continuous electroencephalographic (EEG) monitoring for selective shunting, based exclusively on EEG changes consistent with cerebral ischemia. A Pruitt-Inahara shunt was used in 43 eversion CEAs (6.9%). All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at 1, 6, and 12 months and once a year thereafter. Mean follow-up was 52 months (range, 3-91 months). The main end points were perioperative (30-day) stroke and death, and recurrent stenosis. RESULTS: No perioperative death occurred in this series. Overall, ischemic perioperative stroke occurred in 4 of 624 patients (0.6%). Two strokes were minor and two were major. Only one (major) stroke occurred in the group with shunt insertion (1 of 43, 2.3%; P = not significant); the everted internal carotid artery was patent. Long-term follow-up was performed in all living patients. There was no late recurrent stenosis (>50%), and one late asymptomatic occlusive event occurred in the group without shunt insertion. CONCLUSIONS: Shunt insertion can be safely performed during eversion CEA. Perioperative mortality and morbidity after eversion CEA are not statistically modified with shunting.  相似文献   

3.
OBJECTIVE: Various modalities are used for cerebral monitoring during carotid endarterectomy (CEA). The aim of this study was to evaluate whether transcranial cerebral oximetry (TCO) and carotid stump pressure (SP) are as accurate as electroencephalography (EEG) for monitoring cerebral ischaemia during carotid cross-clamping. METHODS: One hundred consecutive patients who underwent CEA were studied with continuous and simultaneous EEG and TCO. SP was measured for each patient. The percentage decrease of oxygenation on TCO was calculated during cross-clamping and surgery. EEG findings were used as the benchmark to detect cerebral ischaemia and were the indication for insertion of a temporary shunt. The relationship with TCO was observed in terms of percentage decrease in oxygenation. RESULTS: A total of 6 patients were shunted on the basis of their EEG changes. TCO changed more than 20% in these 6 patients, but an additional 12 patients had TCO changes with a normal EEG. This correlated with a decrease in blood pressure (BP) and was corrected by increasing the BP. The positive predictive values (PPVs) and negative predictive values (NPVs) for shunting based on TCO (as compared with EEG) were 33% and 100% respectively. Thirty-four patients had SP <50 mmHg, of whom 4 were shunted based on EEG changes. Two of 66 patients with SP >50 mmHg were shunted based on EEG changes. If a shunting policy had been based on a SP of 50 mmHg, 30 patients would have been shunted unnecessarily (PPV 12%), whereas the non-requirement for a shunt was predicted correctly in 64 of 66 patients (NPV 97%). There were 2 major strokes: 1 contralateral on day 3 in a patient with bilateral severe stenoses, and 1 ipsilateral in a nonshunted patient with normal EEG, TCO and SP >50 mmHg. CONCLUSION: Compared with EEG, TCO is a practical and non-invasive monitoring system with a high sensitivity (100%) but a low specificity. TCO is more sensitive to a drop in BP and responds earlier to these changes than EEG. SP should not be used as the sole predictor for shunting during CEA.  相似文献   

4.
Regional anesthesia (RA) is the gold standard of neuromonitoring during carotid endarterectomy (CEA). Recent data show that RA for CEA is associated with fewer postoperative complications. The aim of the present study was to assess hemodynamic stability and vasoactive drug use for CEA performed under RA versus general anesthesia (GA). All patients undergoing CEA from January 2005 to January 2006 were identified from our prospective database. Electronic and paper charts were reviewed. Intraoperative monitoring data were reviewed retrospectively. Hypotension was defined as systolic blood pressure (SBP) <100 mm Hg and deemed prolonged if it lasted more than 10 min. Hypertension was defined as SBP >160 mm Hg. BP variation was defined as the difference between the highest and lowest SBP, and bradycardia as heart rate (HR) below 60. The data were expressed as means +/- standard deviation. Seventy-two consecutive patients underwent CEA: 25 under RA and 47 under GA. There was no difference in preoperative HR and BP. Most patients had symptomatic severe carotid stenosis (80% in RA vs. 85% in GA, nonsignificant). Intraoperatively, RA was associated with less BP variation (60 +/- 27 vs. 78 +/- 22 mm Hg, p = 0.005), bradycardia (5% vs. 63%, p < 0.001), hypotension (20% vs. 70%, p < 0.01), and prolonged hypotension (0% vs. 23%, p = 0.009) and more hypertension (80% vs. 47%, p = 0.007). Vasopressor requirements were less frequent under RA (20% vs. 77%, p < 0.001). There was no significant difference between groups in hypotension or hypertension episodes seen in the postoperative recovery room. RA was associated with less hypotension and less vasopressor used during CEA compared to GA. The improved hemodynamic stability may account for the lower incidence of complications after CEA.  相似文献   

5.
Previous investigations appear to indicate that an ischemic EEG is not observed during carotid cross-clamping when the stump pressure is >/=60 mm Hg. In this report of 124 carotid endarterectomies (CEA) performed with selective shunting based on computerized EEG (CEEG), we compared the CEEG and this previously established critical stump pressure level of 60 mm Hg as methods of detecting cerebral ischemia during carotid clamping. A significant association between stump pressure and CEEG findings during clamping existed (p <0.05). Only 1 of 44 patients with a stump pressure >/=60 mm Hg received a shunt based on CEEG signs of cerebral ischemia. However, 62 of the remaining 80 patients did not receive a shunt and awoke neurologically intact despite a stump pressure <60 mm Hg. A highly significant association between the postoperative neurologic exam and the CEEG findings during carotid clamping was demonstrated (p <0.001). In contrast, for stump pressure, a correlation with the neurologic exam was not found. Compared to CEEG, these results appear to indicate that a critical stump pressure of 60 mm Hg is a sensitive but not specific indicator for the placement of a shunt selectively during CEA. The combined use of these two monitors should lead to reliable shunt selection, especially when stump pressure is <60 mm Hg.  相似文献   

6.
Bydon A  Thomas AJ  Seyfried D  Malik G 《Surgical neurology》2002,57(5):325-30; discussion 331-2
BACKGROUND: Controversy about the optimal method of performing a carotid endarterectomy (CEA) exists despite its widespread application and support from various randomized clinical trials. Many surgeons selectively or routinely use electroencephalography (EEG) monitoring as well as shunting when performing this operation. ETHODS: We conducted this retrospective study to assess the maximum carotid clamp time without shunting or EEG monitoring during a CEA without the development of neurological deficits in an already compromised cerebral circulation. RESULTS: Fifteen consecutive patients who underwent CEAs between 1988 and 1999 met our criteria of angiographically documented ipsilateral internal carotid artery (ICA) stenosis with contralateral ICA occlusion. The patient presentations included asymptomatic (14%), transient ischemic attack (TIA) (50%), and stroke (36%). All patients were operated under general anesthesia without shunting and only 4 patients underwent EEG monitoring. On angiography, all 15 patients had ipsilateral ICA stenosis (70-99%) and contralateral occlusion. In 54% of patients, the vertebral arteries (VAs) were both patent, while in 46% of patients only 1 VA was patent. Eighty-five percent of patients had at least 1 patent anterior communicating (Pcomm) artery, while 15% had nonvisualized Pcomm arteries bilaterally. Of the 15 patients, 14 had a patent anterior communicating artery. The mean clamp time of the CCA was 18.5 minutes (range 14-30 minutes). None of the 15 patients had new neurological changes immediately postoperatively or during the 6 weeks of follow-up. CONCLUSION: We propose that shunting may not be necessary during CEA for high-grade stenosis with contralateral ICA occlusion, presumably because of adequate distal small vessel collaterals.  相似文献   

7.
Cerebral oximetry is a simple method of measuring regional cerebral oxygen saturation (rSO(2)). One promising application is its use during carotid endarterectomy (CEA) to help minimize the risk of perioperative stroke. The authors used the INVOS-4100 cerebral oximeter at several steps during CEA to measure the effect of carotid clamping and shunting on rSO(2). The authors prospectively evaluated 42 consecutive CEAs in 40 patients. All had CEA under general anesthesia with the routine use of a Javid shunt. The INVOS-4100 oximeter was used to measure rSO(2) before clamping (t1), after clamping but before shunting (t2), 5 minutes after shunt insertion (t3), and after patch closure with reestablished flow (t4). The Wilcoxon signed-rank and rank-sum tests were used for analysis. Clamping of the internal carotid artery (t1 vs t2) resulted in a drop of ipsilateral rSO(2) by -12.3% (p < 0.001). Shunt insertion (t2 vs t3) increased rSO(2) by 10.9% (p < 0.001). Contralateral rSO(2) for the same time periods was insignificant. Patients with preoperative neurologic symptoms had a greater decrease in rSO(2) after clamping (-18.4%) compared with a decrease of -10.4% in asymptomatic patients (p = 0.037). Cerebral oximetry monitoring is simple and inexpensive. The study showed statistically significant changes in rSO(2) as a result of clamping and shunting of the carotid artery. Symptomatic patients had a greater drop in rSO(2).  相似文献   

8.
OBJECTIVE: Surgery for extracranial carotid artery disease has been challenged by carotid angioplasty stenting because the latter is less invasive and avoids surgical trauma. In fact, the magnitude of the perioperative stress response evoked by carotid endarterectomy (CEA) has never been evaluated. Our aim was to determine the degree of surgical trauma caused by CEA and to define differences related to the use of locoregional or general anesthesia. METHODS: We prospectively studied 113 consecutive CEAs performed on 109 patients admitted at a community institutional center. Patients were stratified for demographics and risk factors and operated on under locoregional (LA) or general anesthesia (GA) depending on both the surgeon preference and patient's compliance. Selective carotid shunting was performed for patients who manifested neurologic deficits under LA or had stump pressure values 120 minutes. Three patients experienced an intraoperative neurologic event and had higher post-CACC cortisol values as compared to asymptomatic patients. CONCLUSIONS: Intraoperative surgical stress was higher under LA and was blunted by carotid shunting under both LA and GA. Within 2 hours after surgery the anesthetic modality no longer had any impact on surgical trauma. The stress response to CEA, regardless of the type of anesthesia, was abolished within 24 hours. Intraoperative stress response, namely hypercortisolemia, directly correlated with subclinical and clinical cerebral hypoperfusion/ischemia during CACC. Hence, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events.  相似文献   

9.
BACKGROUND: Level 1 evidence supports carotid endarterectomy (CEA) as the standard treatment for severe (>70% lumen reduction) carotid stenosis in asymptomatic patients, though its safety and efficacy in high-risk patients remain controversial. Long-term survival and stroke-free survival after CEA may guide decisions concerning this procedure for asymptomatic patients, but this outcome has only been considered in few reports outside the large randomized trial setting. This study analyzed long-term survival and stroke-free survival after CEA and the impact of risk factors in a consecutive series of asymptomatic patients, including those with medical comorbidities and particular anatomical features believed to increase the perioperative morbidity and mortality of CEA. METHODS: For over 10 years, data were prospectively collected for all patients who underwent CEA for asymptomatic severe carotid disease at our institution. All CEAs performed by the same surgeon involved eversion technique, with patients under deep general anesthesia and continuous perioperative electroencephalographic (EEG) monitoring for selective shunting. All patients had neurological follow-up and duplex ultrasound at 1, 6, and 12 months, and yearly thereafter. A complete follow-up (mean, 6.1 years; range, 0.1 to 10.6 years) was obtained in 348 patients (93%) with an overall 365 CEAs (93%). Survival analyses were performed using Kaplan-Meier life tables. RESULTS: Among 374 patients undergoing 391 CEAs, there were no perioperative deaths or strokes. There were 17 (4.8%) late deaths, mainly cardiac-related (70%), and 2 (0.5%) non-fatal strokes. At 5 and 10 years, survival was 96.3% and 85.7%, and stroke-free survival was 95.6% and 84.8%, respectively. At multivariate analysis, diabetes mellitus (P = .002) and cardiac disease (P = .005) were independent predictors of a shorter long-term survival. CONCLUSIONS: Eversion CEA proved safe and effective in a series of patients with asymptomatic severe carotid disease representing the typical population of daily clinical practice. Although long-term results were extremely favorable, excellent stroke-free survival was not translated into a longer patient survival.  相似文献   

10.
A total of 289 carotid endarterectomies were performed in 204 patients. A decision to place a temporary shunt during carotid endarterectomy in this series was made entirely on the basis of intraoperative EEG monitoring. Retrospectively, the correlation between stump pressures and the results of intraoperative EEG monitoring in each case was determined. Evidence of ischemia developed in 6% of the total series on intraoperative EEG monitoring despite a stump pressure of greater than 50 mm Hg. The degree of disagreement between stump pressure and EEG varied according to clinical category in this series. In those endarterectomies performed for completed stroke, all cases requiring shunting had stump pressures less than 50 mm Hg. In those cases performed for symptoms of vertebral basilar insufficiency, however, 77% of the cases requiring an intraoperative shunt had stump pressures greater than 50 mm Hg. A review of the complication rate in the various study groups indicates that the use of intraoperative EEG is a safe indicator of cerebral ischemia during carotid endarterectomy regardless of stump pressure.  相似文献   

11.
OBJECTIVES: The aim of our study was to assess the influence of previous contralateral carotid endarterectomy (CEA) and of the timing of the procedures on cerebral clamping ischemia during the second operation in patients undergoing staged bilateral CEA. METHODS: We reviewed the 251 patients who presented with bilateral carotid stenosis of > or =70% at the time of the first admission and underwent staged bilateral CEA between January 2001 and December 2004. Surgery was performed under locoregional anesthesia. Cerebral perfusion was monitored with mental status and contralateral motor function evaluation in awake patients. Selective carotid shunting was performed for patients who manifested neurologic deficits. Univariate and multivariate analyses were performed for the variables of interest. RESULTS: Twenty-two patients (8.8%) required carotid shunting during the first procedure and 28 (11.1%) during the second one. Nine of the latter also had shunts during the first CEA, whereas 19 tolerated cross-clamping during the first operation. Among the patients who underwent contralateral CEA < or =30 days, 23 of 146 required carotid shunting; between 31 and 60 days, 4 of 73; and after 61 days, 1 of 32 (P = .023; univariate analysis). The chi2 for trend was statistically significant (P = .009). Patients operated on the second side < or =30 days had a nearly fourfold risk of shunting during the second procedure compared with patients operated on > or =31 days. The highest risk was observed in patients with a shunt during the first operation who underwent the second CEA < or =30 days. Multivariate analysis also identified the time intervals between CEAs and the need of shunting during the first procedure as independent risk factors (P = .042 and P < .001). CONCLUSIONS: These data show an increased incidence of cerebral clamping ischemia during contralateral endarterectomy performed < or =30 days; whereas after longer intervals between CEAs, the need for shunting is significantly reduced.  相似文献   

12.
A prospective series of carotid endarterectomies were performed with patients given local anesthesia in an attempt to determine the efficacy of intraoperative EEG monitoring and/or stump pressure measurements in predicting the need for carotid shunting. Carotid artery stump pressure was measured and EEG changes noted; however, neither low stump pressure nor EEG changes influenced the decision for shunt insertion. A shunt was only used if a neurologic deficit developed during carotid clamping. A total of 134 carotid endarterectomies were done in 121 patients. Sixty-six patients were men and 55 were women with ages ranging from 41 to 88 years. Indications included transient ischemic attacks in 57 (43%), prior stroke in 25 (19%), vertebrobasilar symptoms in nine (6%), and asymptomatic patients with high-grade stenosis, 43 (32%). Thirteen patients (9.7%) developed neurologic deficits following carotid clamping and had shunts inserted. All deficits cleared following shunt insertion. Nine of the 13 had EEG changes, but in four, EEGs were unchanged despite the occurrence of clear-cut neurologic changes. Stump pressure in the 13 patients ranged from 14 to 78 mm Hg. Ten were greater than 24 mm Hg and three were more than 50 mm Hg. In 121 operations no neurologic deficits occurred during carotid clamping and no shunts were inserted. In 13 of these operations, significant EEG changes were noted. Stump pressures in these 13 with EEG changes ranged from 15 to 120 mm Hg. In seven, stump pressure was greater than 50 mm Hg. There were no deaths in the series. Two (1.5%) temporary and one (0.7%) permanent postoperative deficits occurred.(ABSTRACT TRUNCATED AT 250 WORDS)  相似文献   

13.
Limited information on a correlation between carotid stump pressure and cerebral oximetry changes associated with cross-clamping of carotid vessels during carotid endarterectomy (CEA) prompted us to prospectively evaluate 38 consecutive CEAs in 37 patients. The authors used the INVOS-4100 cerebral oximeter to measure cerebral oximetry (cerebral oxygen saturation) before (t1) and after (t2) cross-clamping along with carotid stump pressure. All patients had CEA under general anesthesia with the routine use of a Javid shunt. Cross-clamping (t1 vs. t2) resulted in statistically significant changes (p < 0.0001) on the operated side of 6.03 units or a percent change of 9.2% when analyzed using the nonparametric signed-rank test. The nonoperated side had insignificant change (p = 0.71). Spearman correlation analysis revealed significant correlation (r = -0.63) between cerebral oximetry changes on the operated side and carotid stump pressure such that a larger change in cerebral oximetry due to cross-clamping was strongly and significantly correlated with lower carotid stump pressure. Using regression analysis, stump pressures of 25 and 50 mm Hg were predicted by cerebral oximetry changes of 28.5 or 8.8 units, respectively. This is equivalent to a percent change from baseline (t1) of 41.1% or 13.1%, respectively. Taken together, these findings suggest that cerebral oximetry can be used as an alternative to carotid stump pressure to provide noninvasive, inexpensive, and continuous real-time monitoring during CEA.  相似文献   

14.
OBJECTIVES: to compare stump pressure (SP) and transcranial Doppler (TCD) with neurologic monitoring during carotid endarterectomy (CEA). MATERIALS: one hundred and forty-seven CEAs performed under local anaesthesia. METHODS: neurologic monitoring and SP were performed in all cases, while mean velocity of the middle cerebral artery (mvMCA) by TCD was done in 140/147 (95%) cases. Shunts were applied in all cases on the basis of neurologic monitoring. The following haemodynamic criteria have been compared to neurologic monitoring: (a) <25 mmHg SP; (b) <50 mmHg SP; (c) < or =10 cm/s mvMCA after carotid occlusion; (d) > or =70 decrease of mvMCA after carotid occlusion. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for each haemodynamic criterion. RESULTS: shunt was used in 18/147 (12.2%) cases. With regards to <25 mmHg SP, < or =50 mmHg SP, < or =10 cm/s mvMCA after carotid occlusion, and > or =70 decrease of mvMCA after carotid occlusion, sensitivity resulted 33, 89, 80 and 80%, respectively. Specificity resulted 96, 82, 97 and 96%, respectively. Positive predictive value resulted 55, 41, 75 and 71%, respectively. Negative predictive value 91, 98, 98 and 98%, respectively. Accuracy resulted 88, 76, 89 and 94%, respectively. CONCLUSIONS: none of the haemodynamic criteria by SP and TCD resulted absolutely reliable in predicting the need for carotid shunt.  相似文献   

15.
《Journal of vascular surgery》2020,71(6):1964-1971
BackgroundAlthough the choice of anesthesia during carotid endarterectomy (CEA) does not seem to increase the risk of perioperative stroke, it might affect the outcomes of shunting during CEA. This study aims to evaluate whether the choice of anesthesia modifies the association between shunting and in-hospital stroke/death after CEA.MethodsWe retrospective reviewed all CEA cases performed between 2003 and 2017 in the Vascular Quality Initiative. Patients were divided into three groups: (1) no shunting during CEA (n = 29,227 [48.4%]), (2) routine shunting (n = 28,673 [47.5%]), and (3) selective shunting based on an intraoperative indication (n = 2499 [4.1%]). Multivariable logistic regression analysis was used to study the interaction between anesthesia (local anesthesia [LA]/regional anesthesia [RA] vs general anesthesia [GA]) and intraoperative shunting (no shunting vs routine and selective shunting) during CEA in predicting the risk of in-hospital stroke/death after CEA.ResultsThe final cohort included 60,399 patients. The majority of CEA cases (90.2%) were performed under GA. Of the study cohort, 29,227 (48.4%) underwent CEA without shunting, 28,673 patients (47.5%) had routine shunting, and the remaining (n = 2499 [4.1%]) were selectively shunted. The interaction between intraoperative shunting and anesthesia in predicting in-hospital stroke/death was statistically significant (P < .05). When CEA is performed under LA/GA, routine shunting was associated with 3.5 times the adjusted odds of in-hospital stroke/death after CEA (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.8-6.8; P < .001) compared with no shunting, whereas selective shunting was associated with 7.1 the odds (OR, 7.1; 95% CI, 3.5-14.7; P < .001). In contrast, under GA, there was no significant association between routine shunting and in-hospital stroke/death (OR, 1.2; 95% CI, 1.0-1.5; P = .12), whereas selective shunting was associated with 1.7 times the odds (OR, 1.7; 95% CI, 1.2-2.4; P < .01) compared with not performing shunting during CEA.ConclusionsThe use of LA/RA is associated with increased odds of stroke/death compared with GA when intraoperative shunting is performed. The effect of anesthesia is more pronounced in patients who develop clamp-related ischemia and undergo selective shunting. More controlled studies are needed to explain these findings and validate them.  相似文献   

16.
AIM: Comparison of restenosis in patients who underwent both carotid artery angioplasty with stenting (CAS) and contralateral carotid endarterectomy (CEA). METHODS: From our CAS data registry (1998-present) all patients with a history of contralateral CEA at any other time were selected (n = 63). Mean age was 70.6, SD = 6.8 for CAS and 68.2, SD = 6.1 for CEA and symptomatic carotid artery stenosis was present in 24% of patients pre-CAS and 40% pre-CEA. All CEAs were primary interventions, 19% of CAS were secondary to restenosis after previous ipsilateral CEA. All patients were followed up prospectively with duplex at 1 year (CAS: n = 58, CEA: n = 59), 2 years (CAS: n = 44, CEA: n = 53), 3 years (CAS: n = 27, CEA: n = 41), and every year thereafter. Within each patient we compared restenosis (>50%) between CAS and CEA procedures. RESULTS: After a follow-up of 28.7 months for CAS (SD = 16.9) and 54.4 months for CEA (SD = 39.5) the rate of = or > 50% restenosis for CAS vs CEA at 1, 2, and 3 years was 23% vs 10%; 31% vs 19%; and 34 vs 24%, respectively (log rank P = NS). CONCLUSIONS: Our intrapatient comparison of patients who underwent both CAS and contralateral CEA did not reveal significant difference in restenosis between both procedures.  相似文献   

17.
The aim of this study is to compare measurement of stump pressure (SP) and somatosensory evoked potentials (SSEP) made during carotid surgery as criteria upon which to base the decision whether or not to use a shunt. We included 288 patients who underwent for carotid surgery under general anaesthesia. We performed 247 endarterectomies with patch closure (85.7%), 25 carotid transsection with reimplantation (8.7%), and 16 carotid bypasses (5.6%). SSEP monitoring showed no modification in 225/288 patients (78.1%), moderate modification in 32/288 patients (11.1%), and severe modification in 31/288 patients (10.8%). Shunt was used if there was moderate or severe SSEP modification in response to carotid clamping, which represents 63 patients in our series. A shunt was used in 47/288 patients (16.3%). In 16 patients, despite SSEP modifications, the shunt was not used because these SSEP modifications occurred only in the last minutes of the procedure just before off clamping the carotid. The mean SP for all patients was 51 mm Hg. In the shunted patients, the mean SP was 33 mm Hg. Variation of SP was correlated with the SSEP modifications. There was just one perioperative stroke in this series (1/288 = 0.3%). We concluded that the threshold of SP below which shunting is indicated in our study was 44 mm Hg with 81% sensibility and 68% specificity.  相似文献   

18.
In 1971 this study was undertaken to determine optimal methods and guidelines for lowering the mortality and neurologic complication rates associated with carotid endarterectomy. Of 570 carotid endarterectomies, 481 (84%) were performed under local anesthesia to provide continuous neurologic monitoring and to permit operation on the very elderly and poor-risk patient. In 418 of these procedures carotid stump pressures (CSPs) were measured with patients awake to determine the level of back pressure sufficient for brain protection during operative occlusion. Selective shunting was necessary in 40 (8%) of these cases. Of 78 patients with a CSP of 0 to 25 mm Hg, only 39 (50%) required shunting. Only one patient with a pressure >25 mm Hg (29 mm Hg) needed a shunt. The CSP/brachial blood pressure (BBP) index was calculated for 410 procedures. Of 97 patients with a CSP of 0 to 30 mm Hg, only 31 required a shunt (CSP/BBP index 0.01 to 0.18). No shunt was necessary for an index >0.18. Patients with a contralateral occlusion or severe stenosis required a shunt six times more frequently than those with unilateral disease. For 570 procedures the overall mortality rate was 0.7% and the neurologic complication rate was 0.9%. When local anesthesia was used for 481 procedures, there was only one death (0.2%). For 74 asymptomatic lesions there were no deaths or stroke. Neurologic monitoring under local anesthesia and CSPs are reliable indicators for selective shunting. Multiple-risk factors influence the outcome of carotid endarterectomy, but most can be avoided. (J VASC SURG 1984;1:392-7.)  相似文献   

19.
转流管在颈动脉内膜切除术中的应用(附11例报告)   总被引:1,自引:0,他引:1  
目的:评价转流管在颈动脉内膜切除术中的所提供保护作用。方法:回顾性分析本科2002年10月以来11例施行颈动脉内膜切除术中使用转流管的经验,此11例病人全部合并对侧颈内动脉闭塞或重度狭窄,均在颈动脉转流管保护下完成手术。结果:术中、术后无死亡,且无中风等严重并发症发生。结论:在严格掌握适应证的前提下,颈动脉内膜切除术中使用转流管是安全的,对脑组织具有良好的保护作用。  相似文献   

20.
PURPOSE: Intraoperative duplex scanning (IDS) after carotid endarterectomy (CEA) has been shown to reliably identify major defects either by significant changes in peak systolic velocities or by B-mode imaging. To evaluate whether IDS could also predict postoperative strokes in technically flawless CEAs, we analyzed several hemodynamic parameters and correlated them with patient outcome. METHODS: From March 2000 to February 2001, 226 consecutive primary CEAs were performed in 208 patients (120 men). Of these, 153 lesions were asymptomatic. General anesthesia and synthetic carotid artery patches were used routinely. Intraluminal shunts were used when internal carotid artery (ICA) back-pressures were <50 mm Hg (35% of cases). IDS consisted of B-mode and color-flow imaging and spectral analyses of the common, external, and internal carotid arteries. Volume flows were measured three times, and the mean flow rate was used for this study. RESULTS: The first set of data was analyzed when the twenty-ninth patient had the second immediate postoperative stroke. It was noted that the two patients who had postoperative strokes had mean ICA volume flows (MICAVF) of 48 mL/min and 85 mL/min. Only two additional patients had MICAVF <100 mL/min. The remaining 25 cases had MICAVF ranging from 102 to 299 mL/min, with a mean of 165 +/- 57 mL/min (+/-SD) (P <.02). Although there was a significant correlation between MICAVF and ICA peak systolic velocity (P <.01), the latter was not found to be a significant predictor of postoperative stroke. Moreover, end-diastolic velocities, resistive index, ICA diameter, and ICA back-pressure also did not correlate with neurologic events. These findings led us to change our protocol for patients with MICAVF <100 mL/min. This included a repeat set of volume flow measurements after 15 to 20 minutes, withholding the reversal of heparin, and the liberal use of completion arteriography. Of the following 197 CEAs, 26 (13%) were found to have MICAVF <100 mL/min (range 55 to 99 mL/min; mean 79 +/- 18 mL/min). Of these, five had arteriography that documented spasm of the intracranial portion of the ICA in four and a small-diameter ICA (<2 mm) in one. Except for the five cases, the remaining 21 cases had MICAVF >100 mL/min (range 105 to 158 mL/min, mean 127 +/- 20 mL/min [+/-SD]) on repeat study. Four patients with persistent ICA low flow (70 to 99 mL/min) were treated with postoperative anticoagulation. One of the last 197 patients had a stroke caused by hyperperfusion syndrome 2 weeks after operation. Overall, six of 226 cases (2.7%) required revision on the basis of abnormal B-mode imaging results or peak systolic velocities >150 cm/s. There were two common carotid artery flaps, two ICA stenoses, one ICA flap, and one localized thrombus. All six were successfully revised and had repeat normal IDS study results, and none of these patients had a postoperative stroke. CONCLUSIONS: IDS is helpful in identifying residual lesions or defects that may contribute to postoperative neurologic deficits. MICAVF <100 mL/min are suggestive of spasm that could lead to thrombus formation and stroke, particularly in the presence of synthetic patches. We suggest that heparin reversal should not be used unless ICA flow rates are >100 mL/min. ICA spasm is short lived in most patients undergoing CEA.  相似文献   

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