Results of carotid endarterectomy in patients with contralateral internal carotid artery occlusion from the Mid-America Vascular Study Group and the Society for Vascular Surgery Vascular Quality Initiative

ObjectiveCarotid endarterectomy (CEA) is among the most commonly performed vascular procedures. Some have suggested worse outcomes with contralateral internal carotid artery (ICA) occlusion. We compared patients with and patients without contralateral ICA occlusion using the Society for Vascular Surgery Vascular Quality Initiative database.MethodsDeidentified data were obtained from the Vascular Quality Initiative. Patients with prior ipsilateral or contralateral CEA, carotid stenting, combined CEA and coronary artery bypass graft, or <1-year follow-up were excluded, yielding 1737 patients with and 45,179 patients without contralateral ICA occlusion. Groups were compared with univariate tests, and differences identified in univariate testing were entered into multivariate models to identify independent predictors of outcomes and in particular whether contralateral ICA occlusion is an independent predictor of outcomes.ResultsPatients with contralateral ICA occlusion were younger and more likely to be smokers; they were more likely to have chronic obstructive pulmonary disease, preoperative neurologic symptoms (56% vs 47%), nonelective CEA (16% vs 13%), and shunt placement (75% vs 53%; all P < .001). The 30-day ipsilateral stroke risk was 1.3% with vs 0.7% without contralateral ICA occlusion (P = .004). The 30-day and 1-year survival estimates were 99.0% ± 0.5% and 94.1% ± 1.1% with vs 99.6% ± 0.1% and 96.0% ± 0.2% without contralateral ICA occlusion (log-rank, P < .001). Logistic regression analysis identified prior neurologic event (P = .046), nonelective surgery (P = .047), absence of coronary artery disease (P = .035), and preoperative angiotensin-converting enzyme inhibitor use (P = .029) to be associated with 30-day ipsilateral stroke risk, but contralateral ICA occlusion remained an independent predictor in that model (odds ratio, 2.29; P = .026). However, after adjustment for other factors (Cox proportional hazards), risk of ipsilateral stroke (including perioperative) during follow-up was not significantly greater with contralateral ICA occlusion (hazard ratio, 1.21; P = .32). Results comparing propensity score-matched cohorts mirrored those from the larger data set.ConclusionsThis study demonstrates likely clinically insignificant differences in early stroke or death in comparing CEA patients with and those without contralateral ICA occlusion. After adjustment for other factors, contralateral ICA occlusion was not associated with a greater risk of ipsilateral stroke (including perioperative) in longer follow-up. Mortality was greater with contralateral ICA occlusion, and this difference was more pronounced at 1 year despite younger age of the contralateral ICA occlusion group. CEA risk remains low even in the presence of contralateral ICA occlusion and appears to be explained at least in part by other factors. CEA should still be considered appropriate in the face of contralateral ICA occlusion.     

Management of internal carotid artery occlusion

Although attempts to restore patency of occluded internal carotid arteries are now rarely made, endarterectomy in the contralateral artery, external carotid endarterectomy and until recently EC/IC bypass have remained surgical options in the management of such patients. Over a four-year period at this institution 104 patients underwent carotid endarterectomy for stenosis. In this group the contralateral carotid was patent (Group A). Fifty-four patients with unilateral carotid artery occlusion underwent contralateral endarterectomy (Group B), 8 underwent ECA/ICA bypass (Group C) and 4 an ECA endarterectomy (Group D). No statistically significant difference was noted in perioperative stroke and death rates for Groups A and B were (1% and 1%) and (3.7% and 1.9%) respectively. One Group C patient died from perioperative stroke (12.5%). For late events the life table adjusted annual rates for stroke and mortality were similar, Group A (stroke 2.1% and death 5%), and Group B (stroke 1.6% and death 5%). In Group C stroke rate was 10% and death 3%. All four patients undergoing ECA endarterectomy were relieved of their symptoms. It is concluded that in patients with internal carotid artery occlusion TEA may be performed with perioperative morbidity and mortality rates comparable to those when the opposite carotid artery is patent. The late outcome for stroke compares favorably with the reported natural history of the disease and outcome for such patients treated medically in the Joint Study of Extracranial Occlusion and EC-IC Bypass Study. External carotid artery endarterectomy appears useful in the treatment of embolic events on the occluded side. ECA/ICA bypass does not appear to confer benefit.     

Carotid endarterectomy contralateral to carotid artery occlusion: analysis from a randomized study

BACKGROUND AND AIMS: Many studies have reported the benefits of carotid endarterectomy (CEA) contralateral to an occluded internal carotid artery (ICA), with varying results. This study analyzed perioperative and late outcomes in a recent trial in which patients were randomized to carotid eversion endarterectomy (CEE) or traditional CEA with patching (CEAP). PATIENTS AND METHODS: In 336 primary CEAs (310 patients) 68 were contralateral to an occluded ICA (group I). The remaining 268 CEAs served as control group (group II). All patients underwent clinical follow-up and duplex ultrasonography at 1, 6, and 12 months and every year thereafter. Endpoints of the study were early and late neurological events, and deaths. RESULTS: Group I had a significantly higher incidence of perioperative electroencephalic changes and need for shunting. The perioperative stroke rate in group I was almost three times as high as in group II, but the difference was not significant. Similarly, the perioperative minor neurological event and death rates, as with the cumulative stroke-free and survival rates at 1, 3, and 5 years, were comparable in the two groups. CONCLUSIONS: CEA contralateral to an occluded ICA can be implemented with perioperative stroke and mortality rates and late stroke-free and survival rates comparable to CEA with no contralateral ICA occlusion.     

Is Contralateral Carotid Artery Occlusion a Risk Factor for Carotid Endarterectomy?

Occlusion of the contralateral internal carotid artery (ICA) is considered to have a significant impact on the outcome of carotid endarterectomy (CEA). The purpose of this study was to review one center’s experience concerning CEA opposite an occluded ICA, to see whether results differed from those obtained in patients with patent contralateral ICA in terms of relevant neurologic complication rate (RNCR, fatal + disabling stroke), stroke-free rate, and survival rate. From January 1997 to December 2002, 1,381 patients underwent a total of 1,445 CEAs at the Department of Vascular Surgery of Padua University. Patients were divided into two groups: group A included 144 patients with occlusion of the contralateral ICA and group B consisted of 1,237 patients with a patent contralateral ICA. There was no postoperative mortality in patients of group A, while in group B, two patients died as a result of myocardial infarction and cardiac failure and one died as a direct result of perioperative stroke. Postoperative disabling strokes occurred in one (0.7%) patient in group A and 10 (0.8%) patients in group B (p > 0.5). At 72 months, there were no statistical differences between the two groups in terms of RNCR, stroke-free rate, and late death. Our results show that contralateral carotid occlusion does not reduce the safety of CEA. The efficacy in terms of RNCR, stroke-free rate, and late survival is no different in patients with contralateral carotid occlusion.     

Carotid endarterectomy with routine electroencephalography and selective shunting: Influence of contralateral internal carotid artery occlusion and utility in prevention of perioperative strokes

OBJECTIVE: Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, particularly in the face of contralateral internal carotid artery (ICA) occlusion. We examined the results of CEA with continuous electroencephalography in patients without and with contralateral ICA occlusion. DESIGN AND SETTING: We reviewed 564 primary CEAs with routine electroencephalography and general anesthesia performed between April 1, 1989, and March 31, 1999, in a community teaching medical center. Main outcome measures were perioperative stroke, temporary lateralizing neurologic deficit, and death. Shunts were placed primarily for significant electroencephalographic changes after carotid clamping but also selectively for contralateral ICA occlusion, prior stroke, or surgeon choice. CEA was performed for asymptomatic disease in 35% of cases. RESULTS: Significant electroencephalographic changes occurred in 16% versus 39% (P <.001) and shunts were placed in 13% versus 55% (P <.001) of patients with patent (n = 507) versus occluded contralateral ICA (n = 57), respectively. The fraction of CEAs with significant electroencephalographic changes during clamping was stable, but shunt use declined slightly over time as our confidence in electroencephalography increased. Patches were placed more often (86% versus 65%; P =.002), but other operative details were similar when the contralateral ICA was occluded. Five early (30 days) strokes (0.9%) and eight early temporary postoperative neurologic events (1.4%) occurred, all ipsilateral to CEA and all after the patient left the operating room with none in patients with contralateral ICA occlusion. Two perioperative deaths occurred, one in a patient without and one in a patient with contralateral ICA occlusion. Neither of these deaths was related to ipsilateral stroke. No increase in stroke rate with decreased shunt use over time was seen. CONCLUSION: Routine use of electroencephalography was associated with apparent complete elimination of intraoperative strokes and less than 1% risk of perioperative strokes. These observations appear to be true even in the face of contralateral ICA occlusion. Electroencephalography is a sensitive detector of cerebral ischemia and a valuable tool for determination of need for shunting during CEA. Surgeons should consider routine use of electroencephalography and selective shunting for significant electroencephalographic changes with clamping.     

Surgical therapy for the patient with internal carotid artery occlusion and contralateral stenosis

With demonstration of the failure of extracranial-intracranial (EC-IC) bypass to reduce the incidence of stroke in patients with internal carotid artery (ICA) occlusion, controversy continues regarding the best method of stroke prevention in these high-risk persons. One approach, endarterectomy of stenotic lesions of the contralateral carotid bifurcation, has been used for 145 patients with ICA occlusion during the past 25 years. Presenting symptoms included focal transient ischemic attacks (TIAs) in 62 patients, stroke (CVA) in 57, and nonfocal TIAs in 16. Ten patients were asymptomatic. Nine patients (6.2%) sustained perioperative strokes, only three of which were ipsilateral to the endarterectomy. There were three perioperative deaths (2.1%). During the follow-up period (mean 4 years) there were 13 new strokes (9.2%), four of which were fatal. These late results compare favorably with patients from the cooperative study of EC-IC bypass with occlusion of one ICA, whether they received surgical treatment or were managed nonoperatively. With the exception of select situations where an occluded ICA may be reopened, we conclude that the best current therapy for these patients is close observation of the nonoccluded ICA and endarterectomy once a stenotic lesion is encountered.     

Somatosensory evoked potential monitoring during carotid surgery

Controversy exists over the value of intraoperative monitoring and shunting in patients undergoing carotid endarterectomy. Although it is widely believed that contralateral carotid occlusion and previous stroke mandate intraoperative shunting, the susceptibility of these two groups of patients to cerebral ischemia during carotid artery endarterectomy is not well defined. Somatosensory evoked potentials (SSEPs) were monitored in 113 carotid artery endarterectomy patients. Of these, 32 (28.3%) had a previous stroke, 24 (21.2%) had a contralateral carotid occlusion and 33 (29.2%) were diabetic. There were no deaths and only one perioperative stroke (0.9%). Cerebral ischemia occurred in 14 patients (12.4%). Six of these patients had a contralateral carotid occlusion. Some 29 patients (25.7%) were shunted, including 10 with contralateral carotid occlusions that did not have major SSEP changes. In the latter half of the study, 14 patients with contralateral carotid occlusions were selectively shunted (six shunted, eight not shunted) with no neurological complications. Thirty-two patients with prior strokes were selectively shunted (nine shunted, 23 not shunted); of these, one shunted patient undergoing combined carotid artery endarterectomy and coronary artery bypass grafting had a perioperative stroke. Intraoperative monitoring with SSEPs accurately identifies cerebral ischemia secondary to carotid clamping as well as patients requiring shunts. With the use of intraoperative SSEP monitoring, selective shunting may be safely performed in patients with a contralateral carotid occlusion or a previous stroke.     

转流管在颈动脉内膜切除术中的应用(附11例报告)

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。     

The Vascular Quality Initiative 30-day stroke/death risk score calculator after transfemoral carotid artery stenting

ObjectiveCarotid artery stenting (CAS) was introduced as an alternative carotid revascularization procedure in patients deemed to be at high risk for carotid endarterectomy. Although techniques and selection criteria for patients have dramatically improved, CAS continues to have higher risk of stroke and death in comparison to carotid endarterectomy. Several risk factors are known to be associated with worse outcomes. Whereas knowledge of these independent factors is helpful, clinical decision-making is further refined when these are considered in aggregate. This study aimed to develop a score to predict the risk of stroke/death after transfemoral CAS (TFCAS).MethodsWe analyzed the Vascular Quality Initiative CAS data set from 2010 to 2018. Lesions due to trauma, dissection, or transcarotid artery stenting and cases performed without an embolic protection device were excluded. Univariable and multivariable logistic regression methods with bootstrapping (1000 repetitions) were used to identify predictors associated with 30-day stroke/death. Stepwise backward selection for variables was used to achieve model parsimony. A risk score was made by converting regression coefficients for each predictor to integers from which probability was calculated. Scores were grouped into simplified categories.ResultsWe identified 10,753 patients undergoing TFCAS during the study period with a combined 30-day stroke/death rate of 4.1%. On multivariable adjustment, independent predictors of 30-day stroke/death included age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.06; P < .001), nonwhite race (OR, 1.42; 95% CI, 1.16-1.74; P = .001), diabetes (OR,1.34; 95% CI, 1.08-1.67; P = .01), coronary artery disease (OR, 1.40; 95% CI, 1.13-1.73; P = .001), congestive heart failure (OR, 1.41; 95% CI, 1.07-1.85; P = .02), symptomatic status (OR, 2.11; 95% CI, 1.64-2.72; P < .001), and contralateral occlusion (OR, 1.64; 95% CI, 1.22-2.19; P = .001). On the other hand, preoperative use of statins (OR, 0.074; 95% CI, 0.59-0.93; P = .02) and dual antiplatelet therapy (P2Y₁₂ inhibitors and aspirin; OR, 0.46; 95% CI, 0.32-0.66; P < .001) were associated with a significant reduction in stroke/death after TFCAS. The model had a C statistic of 69.0%. The coefficients of these predictors were used to develop a risk score calculator that estimates the probability of 30-day stroke/death after TFCAS.ConclusionsIn an analysis of 10,753 patients undergoing TFCAS between 2010 and 2018, significant predictors of perioperative stroke or death included old age, nonwhite race, symptomatic status, diabetes, coronary artery disease, congestive heart failure, and contralateral occlusion in addition to perioperative dual antiplatelet therapy and statin use. These variables were used to develop a risk score calculator that estimates the probability of 30-day stroke/death after TFCAS. External validation of this tool in different populations of patients and data sets is warranted to evaluate its predictive performance.     

Outcome in Patients with Symptomatic Occlusion of the InternalCarotid Artery

OBJECTIVES: to assess whether the risk of recurrent ischaemic stroke in patients with symptomatic internal carotid artery (ICA) occlusion has changed over the past decades, to determine risk factors for the occurrence of ischaemic stroke and to assess the risk of endarterectomy (CEA) of a severe contralateral ICA stenosis. DESIGN: retrospective cohort study. PATIENTS AND METHODS: patients with symptomatic ICA occlusion were identified from duplex registry files between 1991 and 1995. Information was obtained on vascular risk factors, performance of CEA for a contralateral ICA stenosis and on recurrence of ischaemic stroke. The rate of complications occurring within 30 days after CEA of the contralateral ICA in patients with symptomatic ICA occlusion was compared with the risk of CEA in patients with asymptomatic ICA occlusion and severe contralateral ICA stenosis (symptomatic or asymptomatic). RESULTS: ninety-seven patients were identified. Mean follow-up time was 26 months. The annual risk of (non-)fatal stroke was 5.3% for all strokes (95% CI 2. 9%-9.6%) and 3.8% for ipsilateral stroke (95% CI 1.9%-7.7%). Hyperlipidaemia and severe stenosis of the contralateral ICA were independent risk factors. Twenty-two of 32 patients with a severe stenosis of the contralateral ICA underwent CEA, of which one patient died and three suffered a minor ischaemic stroke. The perioperative risk of CEA in the control group of 20 patients with asymptomatic contralateral ICA occlusion was 0% (0 of 20). CONCLUSIONS: outcome in patients with symptomatic ICA occlusion has not substantially improved over the years. CEA for severe stenosis of the contralateral ICA carried a relatively high risk in our series, but deserves to be studied in a controlled design.     

Outcome analysis of carotid artery occlusion

The outcome of carotid artery occlusion was studied through the retrospective identification of 115 affected patients. The majority were white (77%) males (61%) with multiple atherogenic risk factors and suffering ipsilateral stroke (57%). Those patients presenting with stroke were not distinguished by demographic features, risk factors, lipid profile, medical regimen, or subsequent mortality when compared with those without. Overall, 36 patients (31%) required contralateral carotid endarterectomy (CEA), with one (2.8%) perioperative stroke, whereas 4 (3%) underwent ipsilateral external CEA without incident. With 81% follow-up (mean 3.9 years), the overall mortality of the group was 46%; the annualized risk of ipsilateral stroke was 1.6%. This study documents a significant risk of stroke and contralateral occlusive disease with ipsilateral carotid artery occlusion, which cannot be reliably predicted by clinical criteria. Duplex surveillance is valuable, but flow velocity measurements alone may be misleading. Surgical endarterectomy can be performed with an acceptable rate of perioperative stroke.     

Treatment of recurrent cerebrovascular disease. Review of a 10-year experience.

OBJECTIVE: The authors determined whether carotid endarterectomy in patients with recurrent cerebrovascular disease poses a greater perioperative risk than for those individuals undergoing first-time carotid endarterectomy. SUMMARY BACKGROUND DATA: A percentage of patients undergoing carotid endarterectomy for atherosclerosis experience recurrent cerebrovascular disease. Reoperation may be difficult because of postoperative scarring of the soft tissues of the neck and the carotid artery itself. Such patients were believed to be at greater risk for perioperative morbidity than those undergoing first-time carotid endarterectomy. METHODS: To address this concern, the authors retrospectively reviewed their experience with 69 patients who underwent repeat carotid endarterectomies over a recent 10-year period of time. This subgroup represented 6.4% of 1072 total carotid endarterectomies performed during the same time period. The average extent of stenosis on the operated side was 81% and the time elapsed after previous endarterectomy averaged 83 months. Twelve patients (17.4%) had contralateral internal carotid occlusion, and 30 patients (43.5%) had undergone previous endarterectomies on the contralateral side. RESULTS: Complications within 30 days of operation included two deaths (2.9%) and one stroke (1.4%), for a combined stroke and death rate of 4.3%. Six patients developed cervical hematomas requiring drainage; one of these had rupture of a saphenous vein patch. No patient had a significant cranial nerve injury in the reoperative group, whereas 2.0% of patients undergoing first-time carotid endarterectomy had cranial nerve injuries. Overall, these results compared favorably with a combined stroke and death rate of 4.0% among 1003 patients who underwent first-time carotid endarterectomy during the same period. CONCLUSIONS: This review suggests that repeat carotid endarterectomy can be performed safely in individuals with severe recurrent carotid stenosis, with morbidity and mortality rates similar to those for patients undergoing first-time carotid endarterectomies. For this population, reoperative carotid endarterectomy represents a safe and important mechanism for the prevention of stroke.     

Value of preoperative EEG for carotid endarterectomy

Purpose: This study was designed to determine whether the preoperative, baseline electroencephalogram (EEG) can be used for intraoperative decision making during carotid endarterectomy, and to identify circumstances where the EEG can be eliminated. Methods: The charts of all patients undergoing carotid endartectomy at the authors' institution from June 1991 to May 1995 were reviewed to identify those patients that had adequate pre- and intraoperative EEG monitoring. EEGs during 331 carotid endartectomies in 303 patients were coded without knowledge of outcome; primary and secondary endpoints were EEG changes with clamping and clinical outcome, respectively. Results: The incidence of mortality and major neurological morbidity was 1.8%. Baseline-EEGs were abnormal in 105 patients (32%). Whereas baseline-EEG changes were highly predictive of EEG changes after anesthetic induction (P<.0001), they were not predictive of EEG changes with clamping or of clinical outcome. Prior stroke (CVA) predicted abnormal baseline-EEGs (P<.0001) and abnormal post-anesthetic EEGs (P<.0001) but did not predict changes with clamping or perioperative CVA. EEG changes with clamping occurred during 18% of operations; such changes were predicted only by contralateral occlusion (P<.0016) and EEG changes during a prior contralateral carotid endartectomy (P<.0001). The only variable that predicted an adverse neurological outcome was the presence of contralateral occlusion, which increased the likelihood of a perioperative neurological event seven-fold (P=.0038). Clinical outcomes in the 57 of 105 patients with abnormal baseline-EEGs and the 49 of 83 with prior CVA who were shunted were not different from those who were not. Conclusions: baseline-EEG is not of value for the prediction of adverse events during carotid endartectomy and can be eliminated. Because contralateral occlusion is highly predictive of changes with clamping, and patients undergoing a second carotid endartectomy will usually manifest EEG changes identical to those at the first, operative EEG monitoring can also be eliminated from both these circumstances. Finally, prior stroke does not lead to a higher incidence of clamp-induced EEG changes, and thus is not an indication for shunting in and of itself.     

Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions

Objective

The external carotid artery (ECA) is inadvertently occluded during carotid endarterectomy (CEA). The importance of ECA occlusion has been emphasized as a loss of extracranial to intracranial collaterals, a source of chronic embolization, or a site for extended thrombosis during wound closure. This study aimed to determine whether ECA occlusion that inadvertently developed during endarterectomy and that was eventually detected using blood flow measurement of the ECA after declamping of all carotid arteries is a risk factor for development of new postoperative ischemic lesions at declamping of the ECA and common carotid artery (CCA) while clamping the internal carotid artery (ICA). This study also aimed to determine whether intraoperative transcranial Doppler (TCD) monitoring predicts the risk for development of such lesions.

Causes of the Increased Stroke Rate after Carotid Endarterectomy in Patients with Previous Strokes

n = 183) were compared to those who were either asymptomatic or experienced only transient ischemic attacks (TIAs) preoperatively (n= 423). Of the 183 patients who had suffered preoperative strokes, eight patients who experienced perioperative strokes after endarterectomy were compared with 175 who successfully underwent surgery. Patients with a prior stroke had an increased perioperative stroke rate (4.4% versus 1.2%, p= 0.01). They had a significantly higher incidence of hypertension (62.6% versus 47.9%, p < 0.001), cardiac disease (54.7% versus 40.7%, p= 0.001), and positive smoking history (52% versus 40.6%, p= 0.01) than did the asymptomatic/TIA patients. The presence of contralateral total occlusion was also significantly increased (22% versus 10.3%, p < 0.001). Although not statistically significant due to the overall small number of patients who sustained perioperative strokes, the preoperative stroke patients who sustained perioperative strokes had a higher incidence of hypertension (87.5% versus 61.5%) and contralateral total occlusion (37.5% versus 21.3%) than did those who successfully underwent surgery. Patients with both a prior stroke and contralateral total occlusion had a 7.5% perioperative stroke rate. Patients with both a prior stroke and hypertension had a 6.1% perioperative stroke rate. The perioperative strokes in patients with prior strokes were not related to the severity of the prior stroke, the interval between the stroke and surgery, the use of a shunt, or the type of anesthesia employed. Patients who have sustained preoperative strokes have a higher incidence of significant medical illnesses and overall cerebrovascular disease. Hypertension and total occlusion of the contralateral carotid artery appear to be particularly poor prognostic indicators of outcome after endarterectomy in these patients. Patients who have sustained preoperative strokes may be more likely to display clinical neurologic symptoms in response to any form of cerebral ischemia. In this higher risk subgroup, intraoperative and surgeon-dependent factors appear to play less of a role.     

Carotid endarterectomy with contralateral carotid artery occlusion: is this a higher risk subgroup?

OBJECTIVE: to evaluate early and mid-term term results of carotid endarterectomy (CEA) in patient with and without contralateral carotid occlusion. METHODS: between 1996 and 1999, 1324 CEAs were performed. In 82 patients contralateral carotid artery occlusion was present (group I); 1242 patients had patent contralateral carotid (group II). All patients were operated under general anaesthesia, and selective shunting was based on somatosensory evoked potentials (SEPs). Ultrasonographic follow-up was performed at 1, 6 and 12 months and then once a year. Early results and follow-up data were analysed retrospectively. RESULTS: in group I there was a significantly higher incidence of SEPs reduction and shunt insertion; however, there were no differences in terms of perioperative complications. The cumulative stroke and death rate at 30 days in group 1 and group 2 were 2.4% vs 1.4% (p=n.s.), respectively. At a mean follow-up of 15 months there were no differences between the two groups in terms of cumulative symptom-free survival. CONCLUSIONS:the presence of contralateral carotid occlusion caused an increased use of shunt, but not in early complications rates.     

Surgical treatment of internal carotid artery occlusion

PURPOSE: Nonoperative treatment of recent internal carotid artery (ICA) occlusion is associated with increased recurrent stroke rates. We analyzed our results of carotid endarterectomy (CEA) for treatment of symptomatic recent ICA occlusion to evaluate its feasibility, safety, and outcomes. METHODS: From 1990 to 2002, all patients with transient ischemic attack (TIA), amaurosis fugax, and minor stroke underwent duplex ultrasound (US) scanning and arteriography to confirm the diagnosis of ICA occlusion. Within 2 weeks of symptom onset, patients underwent operative exploration with attempted CEA. ICA occlusion was detected at preoperative angiography and confirmed at surgery. Patients with extensive ICA plaque not amenable to endarterectomy underwent external CEA with ICA ligation. RESULTS: Over 12 years, 87 patients with symptomatic ICA occlusion underwent 90 operations for ICA exploration. In 30 patients (18 men, 12 women) with TIA (45%), amaurosis fugax (19%), or minor stroke (36%), CEA to treat ICA occlusion was technically successful. There was 1 postoperative stroke, 2 asymptomatic internal carotid occlusions, and no restenoses (mean follow-up, 26 months; range, 1-93 months). In 57 patients (37 men, 20 women) with TIA (41%), amaurosis fugax (27%), or stroke (32%) in whom CEA was unsuccessful, external CEA was performed. In this group there were no postoperative strokes, 2 asymptomatic external carotid artery occlusions, and 1 restenosis (>70%) (mean follow-up, 22 months; range, 1-73 months). There were no late strokes in either group. CONCLUSION: Operative exploration and endarterectomy to treat symptomatic ICA occlusion is feasible and safe. Patients with symptomatic ICA occlusion should be considered candidates for CEA.     

Cerebral blood flow in relation to contralateral carotid disease, an MRA and TCD study.

OBJECTIVE: to describe redistribution of cerebral blood flow in patients with severe internal carotid artery (ICA) stenoses in relation to contralateral ICA disease. METHODS: sixty-six patients scheduled for carotid endarterectomy (CEA) were grouped according to severity of contralateral stenosis (<30% [group I]; 30-69% [group II]; 70-99% [group III]; occlusion [group IV]. Transcranial Doppler (TCD) and magnetic resonance angiography (MRA) investigations were performed preoperatively. RESULTS: TCD demonstrated a reversed flow in the contralateral anterior cerebral artery (A(1)segment) and ophthalmic artery in three-quarters of group IV patients (p <0.0001). Group IV patients also exhibited decreased blood flow velocity in the contralateral middle cerebral artery (p =0.001). MRA showed increased ipsilateral ICA and basilar artery (BA) blood flow volumes (Q-flows) in group IV patients when compared to the other groups (p <0.001). No changes in total Q-flow (ICAs+BA) were found. CONCLUSIONS: in patients considered for CEA, the severity of the contralateral ICA disease is an important determinant of the pattern of blood flow redistribution through the anterior communicating pathway and ophthalmic artery. Significant flow redistribution through the posterior communicating pathway occurs especially in patients with contralateral ICA occlusion.     

Delayed postoperative nonembolic neurologic deficit after left internal carotid endarterectomy in presence of known contralateral carotid artery occlusion

Neurologic sequelae are known complications of carotid endarterectomy. The current overall perioperative stroke rate is 2-5% (1,2). The incidence of perioperative morbidity and mortality is increased in certain patient subgroups, including neurologically unstable patients and patients who have known contralateral common or internal carotid artery occlusion (3-9). We present the case of a patient who had known total right carotid artery occlusion and a known previous right cerebrovascular accident who sustained a contralateral deficit after a left internal carotid thromboendarterectomy with vein patch angioplasty.     

Carotid artery endarterectomy in patients with contralateral carotid artery occlusion: Perioperative hazards and late results

The aim of this study was to analyze and compare the perioperative hazards and late results of internal carotid endarterectomy (CEA) in patients with and without contralateral internal carotid artery occlusion. From March 1980 to April 1990, 375 consecutive patients underwent 439 CEAs at the First Department of Vascular Surgery of Padova Medical School. Patients were divided into two groups; group 1 (61 patients) had contralateral internal carotid artery occlusion and group 2 (314 patients) did not (378 CEAs, 64 bilateral). Indications for CEA were similar in both groups. The only significant difference in patient characteristics was a higher rate of previous stroke in group 1 (11% vs. 3%,p < 0.001). General anesthesia, continuous EEG monitoring, selective intraluminal shunt, and arteriotomy closure with a polytetrafluoroethylene patch (PTFE) were used routinely in both groups. An intraluminal shunt was inserted more frequently in group 1 than in group 2 (69% vs. 17%,p <0.001). Major perioperativestroke occurred in one patient in each group (1.7% vs. 0.31%, respectively; NS). Early fatal stroke rates were 0% and 0.95% in groups 1 and 2, respectively (NS). All patients had neurologic examinations and duplex scans every 6 months (range 6 to 118 months; mean 42 months). Kaplan-Meier survival curves were virtually identical in the two groups; the majority of deaths were caused by myocardial infarction and cancer. There were no stroke-related deaths in group 1 as compared with 8.2% in group 2 (NS). New neurologic symptoms appeared in 4.7% of patients in group 1 and 6% in group 2 (NS) whereas the late stroke rates were 0% and 3.1%, respectively (NS). Restenosis was observed in two and three patients in groups 1 and 2, respectively (NS). In conclusion, CEA for ulcerated or stenotic lesions of the internal carotid artery in patients with contralateral carotid occlusion is associated with very low early and long-term neurologic morbidity and mortality, similar to findings in patients who undergo CEA with a patent contralateral carotid artery.