Surgical reconstruction of the internal carotid artery with contralateral occlusion without use of shunt

Between 1979 and 1989, 133 carotid artery reconstructions were performed in 130 patients with contralateral internal carotid artery occlusion. These 133 reconstructions represent 7.3% of 1815 revascularizations of the internal carotid artery for atheromatous lesions performed during the same period. There were 113 men (87%) and 17 women (13%) whose mean age was 64.8 years (range 38 to 83 years). Forty-two patients (32%) had coronary artery disease and 77 (59%) were hypertensive. Nineteen patients (14%) were asymptomatic; 16 (12%) had symptoms of isolated vertebrobasilar insufficiency; 19 (14%) had ipsilateral carotid symptoms (on the side of operation); 67 (51%) had contralateral symptoms (on the side of occlusion); and 12 (9%) had bilateral carotid symptoms. All procedures were performed under general anesthesia without the use of a shunt. Nine patients (6.8%) died in the postoperative period (eight of neurologic and one of respiratory causes). Twelve patients (9%) sustained a cerebral vascular accident (eight ipsilateral and four contralateral). Four of these cerebral vascular accidents were diagnosed upon awakening, the remaining eight occurred after an initial uneventful recovery. Combined neurologic mortality and morbidity was 9.8%. Patients with occlusive lesions of the contralateral carotid artery undergoing internal carotid artery reconstruction are at high risk for postoperative cerebral vascular accidents. It is in this group of patients that the various methods of monitoring and cerebral protection should be evaluated.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Reconstructive internal carotid artery surgery over forty years (October 20, 1951–1991)

The background and history of internal carotid reconstruction are presented. Highlights in the early development of this technique include the research of John Ramsay Hunt, Moniz, and Leriche, and the surgical techniques of Carrel and Guthrie. Miller Fisher published his extensive studies on cerebrovascular disease and carotid occlusion in 1951. Pioneering operations by Carrea and Molins in Argentina, Strully, Hurwitt, and Blankenberg in New York and DeBakey in Houston soon followed. DeBakey's technique became the standard technique for the surgical treatment of occlusive carotid lesions. Eastcott, Pickering and Rob published the first paper describing a carotid reconstruction inThe Lancet in 1954. Recently two large multicenter trials have reinforced the benefit of carotid surgery under proper indications and in experienced hands.     

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.

经颅多普勒超声预警颈动脉内膜切除术后脑高灌注综合征

目的 通过经颅多普勒超声(TCD)脑血流监测,探索预警颈动脉内膜切除术(CEA)后脑高灌注综合征(CHS)发生的新方法.方法 2009年8月至2011年12月进行CEA前瞻性临床试验.TCD共测量夹闭前、开放后、离室前血压稳定后3个时间点大脑中动脉收缩期血流速度.计算术中脑血流速度增加比例(VR1)和术后脑血流速度增加比例(VR2).通过计算灵敏度、特异度、阳性预测值、阴性预测值、受试者工作特征曲线(ROC)下面积分析VR1、VR2预警CHS的能力.结果 共76例病例入组.6例VR1＞ 100％,18例VR2＞ 100％.共10例患者被诊断为CHS,其中3例VR1＞100％,7例VR2＞ 100％.VR1和VR2预警CHS发生的ROC下面积分别为0.636和0.728.当VR1取切点100％时,其灵敏度为30％,特异度95％,阳性预测值和阴性预测值分别为50％和90％;当VR2取切点100％时,其灵敏度为70％,特异度83％,阳性预测值、阴性预测值分别为39％及95％,明显优于VR1.结论 血压稳定条件下增加监测离室前的脑血流变化对预警CEA术后CHS的发生十分有效,VR2＞ 100％能较好预测CHS的发生并排除阴性病例.     

颈动脉内膜剥脱术治疗颈动脉狭窄58例临床分析

目的 评估颈动脉内膜剥脱术治疗颅外颈动脉狭窄的疗效,并探讨经颅多普勒超声(transcranial Doppler,TCD)的价值. 方法回顾性分析2002年1月至2008年12月采用颈动脉内膜剥脱术治疗的58例颅外颈动脉狭窄的资料.40例伴有不同程度的脑缺血症状,18例无明显症状.颈动脉狭窄程度均在70%以上.41例行内膜剥脱后动脉单纯缝合,9例采用人工材料(涤纶)补片成形,8例行自体静脉补片成形.32例在TCD的监测下完成,26例没有采用TCD监测,28例则采用临时转流管. 结果手术成功率为100%,无死亡率.术前有腩缺血症状的40例患者中,术后大多数患者有不同程度的恢复.未采用TCD组患者5例(19.2%)术后出现脑血流过度灌注.采用TCD者未发现过度灌注的并发症.53例患者获随访,随访率为91.4%;随访时间为15～86个月,平均42.5个月.死亡5例.3例出现术后再狭窄(5.7%),其中2例接受颈动脉支架成形术,1例仍在观察随访中.结论 颈动脉内膜剥脱术治疗颅外颈动脉狭窄是一种安全、有效的措施;TCD监测对于转流管的选择提供重要依据,并对预防术后过度脑灌注具有指导作用.     

Significance of transcranial doppler CO2 reactivity measurements for the diagnosis of hemodynamically relevant carotid obstructions

Transcranial Doppler ultrasonography can be used to determine CO₂ reactivity in the large basal cerebral arteries. CO₂ reactivity is expressed as percentage increase of mean flow velocity above one volume percent of CO₂, using a reference value of 40 mmHg pCO₂ normalized autoregulatory reserve. A normalized autoregulatory value of 15 as the lower limit of the normal range clearly separates patients with internal carotid artery obstructions 70% from the control group. Stenoses of the ipsilateral internal carotid artery of 70% result in a significant decrease of normalized autoregulatory reserve in the middle cerebral artery, which can be normalized by removal of the upstream flow obstacle using a carotid thromboendarterectomy. The scatter of normalized autoregulatory values in severe internal carotid obstructions indicates the variability of collateral circulation. A retrospective comparison of normalized autoregulatory reserve and ipsilateral ischemic symptoms in the supply area of the internal carotid artery reveals a significant correlation between clinical symptoms and reduced normalized autoregulatory reserve.     

Surgical management of extracranial carotid artery aneurysms

Between 1982 and 1991 we performed eight operations on seven patients with carotid artery aneurysms. Their mean age was 52.8 years (range: 20–67 years). Five aneurysms were atherosclerotic, one was associated with Marfan's syndrome, and two were pseudoaneurysms, one occurring after Dacron patch angioplasty and the other due to tuberculosis. Seven aneurysms were treated electively; one patient underwent an emergency surgical procedure. In one case, the internal carotid artery was ligated. Seven operations were reconstructive. No intraluminal shunt was used. No perioperative deaths occurred. Regressive hemiparesis and ipsilateral Horner's syndrome developed in one patient. The follow-up period ranged from six months to nine and a half years. One patient died of myocardial infarction three months after surgery.     

The carotid endarterectomy: Experience with 260 cases and discussion of the indications

Summary During 1978 to 1989, 235 patients were operated upon with 260 procedures for cervical carotid endarterectomy. The patients were classified according to the presence or absence of ischaemic symptomatology, and for symptomatic patients, according to the reversibility or persistance of ischaemic symptoms. So the selection of patients was: reversible ischaemia 46%, stroke 29%, asymptomatic patients 25%. In the stroke group, no patient was operated on as an emergency, the endarterectomy was only performed after stabilization of the clinical state. Three subgroups were included in patients operated on for asymptomatic carotid stenosis: casual discovery 40%, treatment of the second carotid artery (previous endarterectomy for symptomatic contralateral stenosis) 34%, and treatment of the second carotid artery (previous ECIC by-pass for contralateral carotid occlusion) 26%. All patients were operated upon after angiographic exploration (femoral catheterisation in most cases), and after cerebral CT scan. The surgical technique included general anaesthesia, systematic shunting, endarterectomy after longitudinal arteriotomy, closure without patch. The operating microscope has been used since 1985.The surgical results were studied in terms of uneventful postoperative course (87%), reversible complications (8%) and long lasting complications (5%). The long lasting complications were of local origin (1%), of neurological origin (2%), of general origin (1%). Overall the operative outcome at 6 months was: return to previous clinical state 95%, neurological sequelae 2%, death 3%. In the patients operated on for asymptomatic carotid stenosis the overall outcome was: previous clinical state 97%, death 3%. The legitimacy of carotid endarterectomy procedure is discussed in relation to some recent pertinent literature.     

Carotid surgery without arteriography: Noninvasive selection of patients

All carotid noninvasive studies at our institution comprised of duplex scanning, spectral frequency analysis, and ocular-pneumoplethysmography-Gee supraorbital Doppler assessments from 1985–1987 were reviewed. Forty symptomatic and 104 asymptomatic internal carotid arteries, concomitantly studied noninvasively and arteriographically, were identified. All studies were rereviewed prospectively and in blinded fashion. Utilizing peak frequency—internal carotid artery >10 mHz and carotid index (Pf-ICA)/PF-common carotid) >5 as criteria for surgery, 39/40 symptomatic internal carotid arteries were considered appropriate for carotid endarterectomy by noninvasive study. All of these internal carotid arteries had arteriographic confirmation of >50% internal carotid artery stenosis; 22 of them met noninvasive criteria for surgery of peak systolic frequency-internal carotid artery 14 mHz, carotid index >7 and abnormal ocular-pneumoplethysmography-Gee supraorbital Doppler. All of these had arteriographic confirmation of >80% internal carotid artery stenosis. Eleven asymptomatic internal carotid arteries met spectral frequency criteria for carotid endarterectomy but had normal ocular-pneumoplethysomgraphy-Gee/supraorbital Doppler. Eight in this group had <80% stenosis on arteriographic exam. Carotid endarterectomy may be performed without prior arteriography, provided objective criteria are established in a reliable noninvasive lab and met by individual patients. Presented at the Annual Meeting of the Eastern Vascular Society, Southhampton, Bermuda, May 5, 1989.     

A tailored approach to operative repair of extracranial carotid aneurysms based on anatomic types and kinks

Background

To present outcomes following an operative approach of extracranial carotid artery aneurysm (ECAAs) based on anatomic types and associated kinks.

Methods

This study represents retrospective analysis of anatomic type based approach to operative repair of 84 patients with ECAA from 1994 to 2011, 28 (33.3%) with associated kinking. Patients were followed for neurological ischemic events, hematoma, cranial nerve injury, myocardial infarction, neurological, and overall mortality. The results are presented as early, within 30 days after the surgery, and long term during the follow-up.

Results

In the early postoperative period, there were no strokes or mortalities, cranial nerve injury rate was 2.4% while 1 patient had myocardial infarction (1.2%). During the follow-up, 4 patients (4.8%) had stroke, out of which 2 patients died (2.3%), while overall mortality was 4.6%. The average 5-year survival rate was 96 ± 3%.

Conclusion

Excellent outcomes can be obtained with surgical repair of ECAA, which should be tailored to the anatomic types and presence of kinks.     

Bilateral severe carotid stenosis or occlusion and computed tomographic scan positive hemispheric stroke with neurologic deficit: Immediate contralateral carotid endarterectomy

In the last 10 years, 13 patients presented with acute, hemispheric, computed tomographic scan-positive stroke; neurologic deficit; and bilateral carotid stenosis greater than 90% (N=9) or ipsilateral occlusion with contralateral stenosis greater than 90% (N=4). To improve ipsilateral flow without elevation of pressure to levels causing hemorrhagic infarction, all patients underwent carotid endarterectomy on the side contralateral to the hemispheric stroke from two to 10 days (average 6.6 days) from onset of symptoms. Those with fluctuating deficits stabilized to the initial fixed deficit and all 13 improved over the next six months. Four patients with ipsilateral internal carotid occlusion and one with ipsilateral severe siphon stenosis were discharged on antiplatelet therapy; of the remaining eight patients, seven underwent subsequent ipsilateral carotid endarterectomy from 42 to 111 days (average 58.4 days) from onset of symptoms. Mortality and stroke rate were 0. The four patients with internal carotid occlusion and the one with severe siphon stenosis filled both hemispheres from the contralateral carotid artery arteriographically in four and by oculoplethysmography in one. One patient demonstrated preferential flow from contralateral to the ipsilateral hemisphere, but not the reverse; one patient demonstrated pericallosal collaterals. Immediate endarterectomy of the severely diseased carotid artery contralateral to a hemisphere with a computed tomographic scan-positive stroke causing neurologic deficit resulting from a severe carotid stenosis is a safe treatment option and may be beneficial in those with fluctuating neurologic deficits.Presented at the New England Society for Vascular Surgery, September 14, 1990, Newport, Rhode Island.     

Vein patch rupture after carotid endarterectomy: A survey of the Western Vascular Society members

To determine the prevalence, demographics and morbidity of vein patch rupture, the authors polled members of the Western Vascular Society. Forty-eight surgeons (53% of the members) reported an experience with 23,873 carotid operations. A vein patch was used in 1,760 operations (7.4%), and rupture of the patch occurred in 13 patients (0.7%), 10 women and three men. Indications for the patch were a small artery in 10 patients and restenosis in three. Saphenous vein was used for all patches and was harvested from the ankle in 12 patients and from the groin in one patient. All ruptures occurred from a split in the vein patch. Hypertension was present in seven of the 13 patients. None of the ruptures were associated with infection. Two ruptures occurred on the first postoperative day, six on the second day, three on the third day, one on the eighth day, and one on the twenty-first day. Four patients died: airway obstruction (1), hemorrhagic cerebral infarction (1), and myocardial infarction (2) were the causes. Three had a stroke and survived, one had a retinal embolus, and five underwent reoperation without complication. Vein patch of the carotid artery is used infrequently by members of the Western Vascular Society. The incidence of rupture of the patch is low (0.7%), but when it occurs, there is significant mortality (30.7%), and morbidity (30.7%). Patients with a vein patch should be observed in the hospital for three days after endarterectomy because rupture demands immediate reoperation.Presented at the Western Vascular Society Meeting, Coronado, California, January 25–28, 1990.     

Direct and primary carotid endarterectomy for common carotid artery occlusion. Report of 2 cases

BACKGROUND: Cerebral ischemia associated with chronic CCA occlusion is a rare condition and raises strategic dilemma when the revascularization is needed. METHODS: Two patients with CCA occlusion presented with ischemic symptom associated with the affected side. Both patients underwent vascular reconstruction by direct carotid endarterectomy to achieve primary restoration of CCA to ICA flow. RESULTS: Successful reopening of the vessels was obtained in both patients without the evidence of postsurgical ischemic event. Follow-up MRA was obtained at later than 6 months after surgery, which demonstrated patent CCA-ICA in both patients. CONCLUSIONS: Direct carotid endarterectomy of the occluded CCA can be safely performed if the preoperative angiography suggest still patent vessels distal to carotid bifurcation and the substantial "back flow" is obtained from ICA during arteriotomy.     

Carotid endarterectomy plaques: Correlations of clinical and anatomic findings

To establish possible relationships between the structure of carotid plaque and neurologic symptoms, 187 consecutive endarterectomy specimens were studied prospectively. Each specimen was examined for gross and histopathological features. Intraplaque hemorrhage, although found infrequently, was closely correlated with the presence of symptoms. Plaque ulcerations were encountered more often when lesions were symptomatic. Calcifications were more frequently associated with asymptomatic lesions. Consistency of plaque was related to its morphological features (stenosis or ulceration) and symptoms. Soft plaques with predominant atheromatous grumous material and hemorrhage were associated more often with tightiy stenotic, ulcerated, and symptomatic lesions. Consistency of atherosclerotic carotid plaques should be assessed and considered as an important element in the therapeutic decision.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Inflow atherosclerotic disease localized to the common femoral artery: Treatment and outcome

Severe occlusive disease of the common femoral artery without significant aortoiliac disease is not common in our experience. Since 1978 we have operated upon 29 limbs in 22 patients (mean age 60) with localized common femoral artery disease. Indications for operation were claudication in 31% and impending limb loss in 69%. Operations included common femoral artery endarterectomy with patch angioplasty (19 limbs), patch angioplasty alone (two limbs), and common femoral artery endarterectomy without a patch (three limbs). Operative mortality was zero; there were nine wound complications, one patient had a myocardial infarction with early thrombosis. Symptomatic relief was obtained in 20 of 22 patients. All minor amputations healed. The mean postoperative ankle/brachial index increased to 0.67 from 0.49. Mean follow-up is 37 months (one–118 months); there have been 10 late deaths. Cumulative two and five year patency rates are 82% and 74%, limb salvage is 80% and 80%, respectively. Major amputations were required in five patients at two, two, 12, 23, and 68 months. Further inflow procedures were required in four patients: three aortobifemoral bypasses and one axillofemoral bypass. Although this disease has an uncommon inflow level, it is amenable to safe, durable, local procedures. Presented at the Midwestern Vascular Surgical Society Meeting, Chicago, Illinois, September 30, 1989     

The evolution of carotid and coronary artery disease after operation for carotid stenosis

We followed 278 consecutive patients undergoing carotid artery surgery between January 1985 and December 1989 using a computerized surveillance program file with automatic carotid and coronary artery follow-up investigations every six months. Combined postoperative neurologic mortality and morbidity was 1.7%. During the mean follow-up period of 30 months, 10 patients died, four due to myocardial infarction. Actuarial rates of survival and freedom from cerebral vascular accidents at 36 months were 94% and 95.8%, respectively. No fatalities due to cerebral vascular accidents occurred during follow-up. Eleven patients had myocardial infarction, an actuarial rate of 6% at 36 months: 18 patients experienced angina pectoris, while seven sustaned silent electrical myocardial ischemia. Findings on myocardial angioscintiscans and coronary artery arteriograms led to four aortocoronary bypasses and seven percutaneous coronary artery dilatations. Duplex scanning documented three asymptomatic carotid restenoses of 80%, which were operated upon, and 32 contralateral carotid artery stenoses ranging between 80% and 99%, 24 of which were asymptomatic. Twenty-eight patients underwent secondary contralateral carotid artery revascularization. No one with contralateral carotid artery stenosis < 80% experienced a carotid artery ischemic event. These results clearly show the value of cardiac and neurologic surveillance of patients operated on for carotid artery stenosis.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

同期颈动脉内膜切除术与冠状动脉搭桥术治疗颈动脉合并冠状动脉狭窄15例临床经验

目的评价同期联合行颈动脉内膜切除术（carotid endarterectomy,CEA）与冠状动脉搭桥术（coronary artery bypass grafting,CABG）治疗颈动脉与冠状动脉狭窄并存疾病的早期临床疗效。方法2000年1月至2006年8月对15例颈动脉与冠状动脉狭窄并存患者实施了同期CEA与CABG手术。男性12例,女性3例,年龄63～80岁,平均（70±6）岁。所有患者术前均行冠状动脉造影与颈动脉造影术明确诊断,其中冠状动脉左主干病变3例,2支血管病变2例,3支血管病变10例。手术先行CEA再行CABG 14例,1例患者先行CABG后行CEA,有5例患者在体外循环（CPB）下完成CABG,其余10例在非体外循环下行CABG;在行CEA时,所有患者均使用颈动脉转流管,所有患者均采用人工血管补片加宽颈动脉切口。结果本组无手术死亡,围手术期无心脑血管并发症发生,1例患者手术后1个月因右下肢动脉硬化闭塞症而行右下肢股-腘动脉人工血管搭桥术。术后随访3～24个月,患者无心绞痛,短暂性缺血性脑发作（TIA）或脑中风发生。结论同期行颈动脉内膜切除术与冠状动脉搭桥术治疗颈动脉与冠状动脉狭窄并存疾病方法可行,早期效果满意。     

An evaluation of color duplex scanning in the primary diagnosis and management of carotid body tumors

Carotid body tumors present a diagnostic challenge. Despite technologic diagnostic advances, misdiagnosis resulting in blind biopsy or exploration through a limited incision still occur. Color duplex scanning has recently been used to evaluate carotid body tumors in our institution. A characteristic feature of these tumors found with this modality is wide splaying of the carotid bifurcation by a hypervascular mass. Color duplex scanning is the noninvasive modality of choice for the primary diagnosis of carotid body tumors. Additionally, it may be of use in screening for familial carotid body tumors and sequential follow-up of nonoperatively managed tumors.Presented at the 16th Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1991, Boston, Massachusetts.