Faculty Bibliography

Consecutive patients who successfully underwent carotid endarterectomy (C) between 1970 and 1975 were followed during a 5-year period (mean follow-up 4.3 years). The patients were divided into three groups. Group I comprised 146 patients who had unilateral CE with a patent, nonstenotic contralateral carotid artery. Group II included 45 patients who underwent unilateral CE but whose contralateral internal carotid artery was found to be totally occluded. Group III consisted of 86 patients who underwent bilateral CE. There was no significant difference between the groups with respect to age, sex, neurologic status, or associated diseases, and all were maintained on antiplatelet medications for surgery. During the follow-up period a total of 22 of the 277 patients had a new hemispheric stroke; four others became comatose and died, presumably of stroke. Among the group I patients, 17 had new strokes, only six of which involved the hemisphere ipsilateral to the CE. Five later strokes occurred in group II, one ipsilateral to the CE. Four patients in group III had new strokes. The cumulative stroke rates at 5 years by the life-table method were 17.6% for group I, 16.4% for group II, and 5.6% for group III. The difference between group I and III was significant (P less than 0.05). The results suggest that patients undergoing unilateral CE should have close postoperative monitoring of the contralateral vessel

We performed 956 carotid endarterectomies in 661 conscious patients who were under cervical block anesthesia and in whom the stroke rate was 2.5%. They were analyzed to determine the mechanisms of strokes and the risk factor for perioperative stroke. Twenty-three patients with perioperative strokes, regardless of severity, were analyzed as to the mechanism of cause. One half were due to technical problems, one quarter to intraoperative embolization, one sixth to intracerebral hemorrhage, and the remainder were not directly related to the operative procedures. Perioperative stroke rate varied by group from 0.6% to 28.4%, highest when the contralateral carotid was occluded, where there was a preoperative persistent neurologic deficit, and when the patient failed to tolerate carotid clamping. Regional block monitoring was accurate and no stroke could be ascribed to anesthetic technique. Standard reporting techniques should be used in classifying patients into appropriate risk groups to permit meaningful comparisons among groups using different techniques for cerebral protection

Fifty-eight patients underwent unilateral vertebral arterial reconstructions over a 16-year period. Thirty-four underwent carotid operations as well. The first 18 patients underwent vertebral arterial reconstructions in conjunction with carotid endarterectomy as mandated in the Joint Study of Extracranial Arterial Occlusion as a Cause of Stoke. The next 40 underwent vertebral procedures for either brain stem symptoms alone, or for combined cerebral cortical and stem symptoms for specific indications after flow-obstructing carotid lesions had been corrected, but symptoms failed to subside. The surgical procedure consisted of subclavian-vertebral angioplasty except in one patient who underwent a subclavian distal-vertebral bypass graft to the level of the second cervical vertebral body. Syncopal episodes occurred as a major symptom in 16 and was controlled by either carotid and vertebral or vertebral artery operation alone except in four who also required cardiac pacemakers and one who needed correction of aortic stenosis. The long-term follow-up reveals that the stroke rate per average year for the first 14 years of follow-up was 1.2% per patient year with only five strokes having occurred in 410 patient years of follow-up and 70% of the patients having sustained no new neurologic episodes at the fourteenth year. Survival, however, was 45% at the fourteenth year with most deaths caused by myocardial infarction. The surgical procedure of vertebral angioplasty is indicated when bilateral vertebral arterial flow-obstructing lesions are found in patients with brain stem ischemia including drop attacks and syncopal episodes if flow-obstructing carotid lesions have been corrected and symptoms persist. The surgical procedure can be performed with a high degree of safety. The differential diagnosis of drop attacks and syncope in this age group should include, in addition to vertebrobasilar arterial insufficiency, transient cardiac arrhythmias, aortic stenosis, and convulsive disorders

The innervation of lower limb epineurial arterioles, specimens of which were obtained from six patients in the sympathectomy and from six patients in the nonsympathectomy diabetic groups at amputation for ischemic peripheral vascular disease, was compared by quantitative ultrastructural methods. Results demonstrated no statistically significant difference in the number of vasomotor axons present, the average axon to smooth muscle cell distance or the axon distribution pattern in the adventitia between the two diabetic groups of patients. A previous investigation has established that innervation of these arterioles is significantly reduced in patients with diabetes having end-stage ischemia of the lower limb when compared with similar patients without diabetes. The present results demonstrate that surgical lumbar sympathectomy does not significantly further reduce the already severely diminished number of vasomotor nerves in some diabetic arterioles. This observation offers a possible explanation for the poorer success rate of those with diabetes compared with those without diabetes in avoiding amputation of the limb after lumbar sympathectomy

The results of 93 consecutive lumbar sympathectomies performed over a five year period upon 54 patients with diabetes and 39 without diabetes were compared in terms of subsequent amputation using life table analysis methods. Cumulative success rates for avoiding amputation were significantly lower in those with diabetes as compared with rates for those without diabetes at five years and at most shorter six month intervals. Although there are a number of possible explanations for this difference, an important contributing factor may be the prior spontaneous denervation of diabetic blood vessels. The results demonstrate that better predictive indexes for lumbar sympathectomy are needed

The relationship between focal neurologic symptoms, carotid artery stenosis, and cervical bruits was studied in 495 patients. Among the 990 carotid arteries, 562 (57%) were considered to be symptomatic and 505 (51%) were associated with bruit. There was a linear relationship between the degree of stenosis and symptoms. Of the highly stenotic vessels (80% to 99% narrowing), 253 of 350 (72%) were symptomatic; 85 of 104 (82%) occluded vessels were symptomatic. There was a linear relationship between the occurrence of cervical bruit and degree of stenosis, up to but not including total occlusion. The relationship between bruits and focal neurologic symptoms was less direct. Among 562 symptomatic arteries, 297 (53%) had a bruit and 265 (47%) did not. In symptomatic patients, the absence of a cervical bruit should not delay a workup for extracranial vascular disease

Semiclosed femoral popliteal endarterectomy, herein described as extending from groin to knee and performed with an arterial stripper, has proved to be a satisfactory alternative to revascularization of comparable occluded segments of thigh arteries employing autologous saphenous vein. Cumulative patency of 95.7% in all groups initially decreases to 59.6% in claudicators at 5 years and 30.6% in those who had surgery for limb salvage, whereas the limb salvage rate exceeds patency rate, being 62.9% at 5 years