Faculty Bibliography

Recent data from the North American Symptomatic Carotid Endarterectomy Trial revealed a 14.3% perioperative risk of stroke or death with carotid endarterectomy contralateral to a carotid artery occlusion. Since last reporting on this topic in the mid-1980s, the authors have reviewed 180 patients with occlusion of one internal carotid artery (ICA) and who underwent endarterectomy of the stenotic contralateral ICA operated from 1965 to 1984 (group A) compared with 135 operated on from 1985 to 1991. The two groups were similar with respect to age, sex, incidence of coronary artery disease, hypertension, diabetes and history of smoking, but group B had a significantly increased incidence of patients who were neurologically symptom-free before surgery (21.5% versus 7.8%, P < 0.001). The combined perioperative stroke or death rate for patients in group B was significantly lower than for those in group A (0.7% versus 6.7%, P < 0.01). Comparison of the operative techniques showed more frequent placement of intra-arterial shunt (52.6% versus 29.4%, P < 0.001) and increased use of general anesthesia (20.0% versus 9.4%, P < 0.01) in patients of group B. Analysis of the etiology of the complications, however, showed that shunting alone could not account for the improved results. Lower incidences of postoperative thrombosis, embolization and intracerebral hemorrhage were equally important.(ABSTRACT TRUNCATED AT 250 WORDS)

BACKGROUND: To investigate the possibility of gender bias in the cardiac management of patients who undergo peripheral vascular surgery, we examined the hospital data and outcomes for 350 adult men and 128 women who underwent vascular surgery from September 1987 to December 1991. METHODS AND RESULTS: There were no significant differences between the two groups in age at operation, incidence of standard risk factors for myocardial infarction, or incidence or duration of episodes of perioperative silent ischemia. Nevertheless, a significantly lower percentage of women than men had undergone prior coronary bypass procedures (6.3% and 17.1%, respectively; P < .01), an apparent example of gender bias. However, there was no significant difference in the incidence of perioperative myocardial infarction in women (3.9%) compared with men (4.0%). Furthermore, actuarial analysis showed that at 24 months after operation a significantly higher percentage of women (77.9%) had escaped late cardiac death and cardiac complications than men (71.9%; P < .05). CONCLUSIONS: These findings indicate that apparent gender bias in the preoperative cardiac management of this group of women who underwent vascular surgery may have had no detrimental effect on short- and long-term incidence of cardiac death and complications, and may represent sound clinical judgment rather than true bias. However, the possibility that female patients might have had even better short- and long-term cardiac results if they had undergone more preoperative cardiac revascularization cannot be discounted

We examined the operative risks and long-term results of carotid endarterectomy for asymptomatic patients in terms of stroke, death, and recurrent stenosis. The results of a nonrandomized study with a follow-up of 1 to 104 months (mean 46 months) is reported. A tertiary referral center served as the setting for this report. One hundred consecutive patients with severe but asymptomatic carotid artery stenosis out of a total of 514 patients undergoing carotid endarterectomy were entered into this study. The severity of carotid disease was determined by duplex scanning and confirmed arteriographically. No patients were lost to follow-up after surgery. Eighty-nine operations (77%) were done under cervical block anesthesia and all arteries were closed with saphenous vein patches. Life-table analysis showed that the stroke-free rate at 5 years was 96.3% with an ipsilateral stroke-free rate of 98.2%. The 5-year overall survival rate was 78.2% with a stroke-free survival rate of 75%. Carotid endarterectomy can be performed safely for asymptomatic patients believed to be at risk for stroke. The potential for early death due to myocardial disease, late stroke, and recurrent stenosis do not justify advising patients against undergoing prophylactic carotid endarterectomy for asymptomatic high-grade stenosis

PURPOSE: The purpose of this study was to examine the cause of perioperative stroke after carotid endarterectomy. METHODS: The records of 2365 patients undergoing 3062 carotid endarterectomies from 1965 through 1991 were reviewed. Sixty-six (2.2%) operations were associated with a perioperative stroke. The mechanism of stroke was determined in 63 of 66 cases. Patient risk factors and surgeon-dependent factors were analyzed. RESULTS: More than 20 different mechanisms of perioperative stroke were identified, but most could be grouped into broad categories of ischemia during carotid artery clamping (n = 10), postoperative thrombosis and embolism (n = 25), intracerebral hemorrhage (n = 12), strokes from other mechanisms associated with the surgery (n = 8), and stroke unrelated to the reconstructed artery (n = 8). Dividing the operative experience approximately into thirds, during the years 1965 to 1979, 1980 to 1985, and 1986 to 1991 the perioperative stroke rates were 2.7%, 2.2%, and 1.5%, respectively. This, in part, is associated with a better selection of patients (more symptom free, fewer with neurologic deficits). There has been a notable decrease in perioperative stroke caused by ischemia during clamping and intracerebral hemorrhage, but postoperative thrombosis and embolism remain the major cause of neurologic complications. CONCLUSIONS: Although patient selection seems to play a role, most perioperative strokes were due to technical errors made during carotid endarterectomy or reconstruction and were preventable

PURPOSE: We examined the perioperative course and long-term fate of individuals who required reoperation for recurrent carotid artery disease. METHODS: The records of 2289 patients undergoing 2961 consecutive operations during a 22-year period were reviewed. Forty-two patients (1.8%) who underwent reoperations were studied. Forty-seven redo carotid artery reconstructions were performed on these 42 patients for neurologic symptoms or asymptomatic high-grade stenosis. Long-term follow-up was obtained on 41 of 42 patients (mean 54 months; range 9 to 202 months). RESULTS: The forty-seven reoperations consisted of endarterectomy with patch angioplasty (n = 36), saphenous vein or polytetrafluoroethylene interposition graft (n = 7), or simply vein or polytetrafluoroethylene patch angioplasty (n = 4). There were no perioperative strokes or deaths. Three patients had perioperative transient ischemic attacks and two had cranial nerve injuries. The incidence of late failure after secondary surgery was 19.5% (8/41 patients). These failures consisted of one stroke, three transient ischemic attacks, and four asymptomatic occlusions. One tertiary carotid artery reconstruction was performed for a restenosis at the site of the secondary reconstruction. CONCLUSION: The factors responsible for the high incidence of late failures after secondary carotid artery reconstruction are unclear. Reoperation for recurrent carotid artery disease appears less durable than primary carotid endarterectomy. Close postoperative surveillance is recommended after carotid artery reoperation

In a previous study we have shown that perioperative monitoring for silent myocardial ischemia can noninvasively identify those patients undergoing peripheral vascular surgery who are at significantly increased risk for perioperative myocardial infarction. In the present study a group of 385 patients undergoing peripheral vascular surgery was studied long-term as well as short-term to determine whether perioperative monitoring for silent ischemia can identify those patients who are at significantly increased risk of late cardiac death or late cardiac complications as well as those patients at increased risk of perioperative myocardial infarction. All patients were monitored before, during, and after operation and were divided into two groups on the basis of results of monitoring: patients whose total duration of silent ischemia as a percentage of the total duration of perioperative monitoring was 1% or greater (group I, n = 120) and those for whom this value was less than 1% (group II, n = 265). Among patients in group I 13.3% (16 of 120) suffered a perioperative myocardial infarction in contrast to only 1.1% (3 of 265) patients in group II (p less than 0.001). Multivariate logistic regression analysis of preoperative and perioperative characteristics showed that the presence of a total perioperative percent time ischemic 1% or greater and age were the only significant predictors of perioperative myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

From a registry of 2406 carotid endarterectomies performed on 1818 patients over a 19-year period, 29 patients (1.6%) underwent reoperations for recurrent stenosis. Reoperations were performed for symptomatic stenosis for 23 and asymptomatic greater than 80% stenosis for six patients. Compared to the entire series, there was no difference in the incidence of restenosis for men and women. The pathologic findings were myointimal hyperplasia in 27%, atherosclerosis in 53%, thrombus with vessel dilatation in 17% and extrinsic scar in 3%. Redo endarterectomy with patch angioplasty was used for reconstruction in 27 patients and patch angioplasty alone in two. There were no operative deaths or strokes. Late follow-up (mean 50 months) revealed only one stroke and six other deaths. Although 21 (75%) were alive and stroke-free, follow-up studies suggest a high incidence (21%) of tertiary lesions among patients who have undergone redo endarterectomy for recurrent stenosis

Since 1964 we have performed 136 vertebral artery reconstructions representing 4% of all operations on extracranial cerebral arteries by our staff. Fifteen of our patients were under age 55 years and had symptoms of dizziness, bilateral visual disturbances, ataxia, presyncopal episodes, and occasionally localized extremity weakness. Dizziness, often severe and incapacitating, has been the most common and consistent symptom. The diagnosis of vertebral artery lesions was made using aortic arch four-vessel cerebral arteriography. Operations were performed for severely obstructing bilateral vertebral artery lesions and included only unilateral vertebral vein patch angioplasty with or without suture plication of the artery in 13 patients. Unilateral carotid vertebral bypass was performed in one patient and unilateral vertebral reimplantation to the carotid in another. Follow-up averaged 8.9 years, ranging from ten months to 20 years. Eleven of 15 patients have remained asymptomatic and without strokes. Recurrent dizziness was present in three, two of whom had vertebral arteriography showing patent vertebral reconstructions. Another had a stroke related to the anterior circulation in follow-up at nine years. Atherosclerotic obstruction of vertebral arteries does occur in patients in the preatherosclerotic age group. Even atypical symptoms suggestive of vertebrobasilar insufficiency may be associated with isolated correctable bilateral flow-impeding vertebral lesions. These symptoms warrant evaluation with cardiac neurological and cerebrovascular studies. Vertebral angioplasty relieves symptoms and the incidence of stroke during follow-up is low