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Objective: Total occlusion of the contralateral internal carotid artery has often been considered to be a predictor of poor outcome after carotid endarterectomy (CEA) of ipsilateral carotid stenosis. Data from both the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study have suggested this to be true. However, each of these trials had relatively few patients with contralateral occlusion in the surgical arms of the studies. Recently, advocates of carotid angioplasty and stenting have suggested that this technique may be preferable in patients with a contralateral occlusion because of the perceived poor outcome with surgery. The purpose of this study was to review a large series of CEAs performed in patients with contralateral occlusion to see whether results differed from patients with patent contralateral arteries and to determine whether the presence of preoperative symptoms was an important factor in outcome in these cases. Patients and Methods: A review was conducted of a prospectively compiled database of all primary CEAs performed at our institution from 1985 to 1999. Surgery was performed on 2420 patients, of whom 338 (14.0%) had contralateral total occlusion. Results: Patients with contralateral total occlusion were more likely to be symptomatic (65.7% versus 60.1%; P = .1), male (70.9% versus 58%; P < .001), and hypertensive (63.9% versus 58.4%; P = .07) with a positive smoking history (42.6% versus 31.4%; P < .001) than patients with patent contralateral carotid artery. No significant difference was seen in the rates of perioperative neurologic events between patients with contralateral occlusion (3.0%) and those without (2.1%; P = .34). Among the total of 913 asymptomatic patients, of whom 115 had contralateral occlusion, no difference was seen in the rate of perioperative neurologic events (1.8% for contralateral occlusion cases; 1.9% for cases without contralateral occlusion). Among the total of 1507 symptomatic patients, of whom 223 had contralateral occlusion, no significant difference was seen in the rate of perioperative neurologic events (3.7% for contralateral occlusion cases; 2.2% for cases without contralateral occlusion; P = .2). Conclusion: The presence of contralateral occlusion does not appear to increase the perioperative risk of CEA. Although the risk of CEA in symptomatic patients with contralateral occlusion may be slightly increased, this must be weighed against the risk with medical treatment alone. CEA can be performed safely in patients with contralateral occlusion, which should not necessarily be considered a high-risk condition for surgery in favor of angioplasty and stenting. (J Vasc Surg 2002;36:668-73.)

Objective: The ideal method of arterial reconstruction in operations for recurrent carotid disease after prior endarterectomy is unknown. The goal of this study was to review a series of carotid reoperations and to determine whether the surgical technique influenced the rate of perioperative stroke, late stroke, or secondary restenosis. Methods: A retrospective review was conducted of 82 carotid reoperations performed on 74 patients at our institution. Results: The patient population included 39 men (52.7%) and 35 women (47.3%), with a mean age of 67.5 years. The indications for redo surgery included transient ischemic attack or amaurosis fugax in 35.3% of the patients, stroke in 6.1%, and asymptomatic restenosis (>80%) in 58.5%. Patch angioplasty with or without redo endarterectomy was used in 47 cases (57.3%), with saphenous vein in 26 (31.7%), Dacron in 15 (18.3%), and polytetrafluoroethylene in 6 (7.3%). Interposition grafting was used in 35 cases (42.7%), with saphenous vein in 9 (11.0%), Dacron in 10 (12.2%), and polytetrafluoroethylene in 16 (19.5%). The perioperative complications included three strokes (3.7%). There was a trend toward increased perioperative neurologic complications with interposition grafting when compared with patch angioplasty (8.6% vs 2.1%), although this did not reach statistical significance. Long-term clinical follow-up was obtained in all cases with a mean duration of 35 months, with follow-up duplex scanning performed in 89.2%. The late failures of redo surgery included four significant secondary restenoses and five total occlusions. There was a trend towards improved long-term results with interposition grafting as opposed to patch angioplasty. However, the cases in which reconstruction was performed with a vein had a significantly higher rate of late failures (stroke, secondary recurrent stenosis, or occlusion) than those in which reconstruction was performed with any prosthetic material (26.7% vs 2.3%; P = .002 by Fisher exact test). Conclusion: The use of autologous material for redo carotid surgery in any configuration appears to significantly increase the rate of subsequent recurrent stenosis or total occlusion of the operated artery. The reason for this finding is unclear but may be related to both host and technical factors. Prosthetic material may be more durable in the long-term for redo carotid surgery. Interposition grafting for redo carotid surgery may increase the perioperative neurologic complication rate to some degree; however, this was not statistically significant in this series. Interposition grafting may be a more durable solution in long-term follow-up than redo endarterectomy and patch angioplasty. A longer follow-up period will be needed to confirm this conclusion. (J Vasc Surg 1999;29:72-81.)

It has been suggested that general anesthesia is the preferred method for reoperative carotid surgery for several reasons, including: the difficulty of the reoperative dissection; the disease may extend unusually high into the internal carotid artery; and the reconstruction required may be more complex than a typical endarterectomy. The purpose of this study is to show that reoperative carotid surgery can be performed safely under regional anesthesia. The records of 109 reoperative carotid operations performed on 96 patients over the past 25 years were reviewed. Procedures performed under regional anesthesia were compared to those performed under general anesthesia with respect to patient characteristics, intraoperative courses, and perioperative results. Regional anesthesia was utilized in 79 operations (72.5%); 30 operations were performed with general anesthesia (27.5%). The two patient groups were essentially equivalent with regard to atherosclerotic risk factors, preoperative neurologic symptoms, and the prevalence of contralateral total occlusion. The etiologies for recurrent disease included recurrent atherosclerosis (50.4%), intimal hyperplasia (30.3%), and vein patch aneurysm (9.2%). The methods of reconstruction employed included saphenous vein patch (47.7%), vein interposition graft (11.9%), prosthetic patch (20.2%), and prosthetic graft (20.2%). Perioperative strokes occurred in one case performed under regional anesthesia (1.3%), and in two cases under general anesthesia (6.6%); this difference was not statistically significant. Reoperative carotid artery surgery can be performed under regional anesthesia safely in the majority of instances. The aforementioned theoretical factors in favor of general anesthesia could also lead to technical difficulties with intraarterial shunt insertion. Having the patient awake, even if just long enough to prove that the patient will tolerate carotid artery clamping, might simplify many of these operations by avoiding shunt insertion. Regional anesthesia should therefore be considered an acceptable option in cases of reoperative carotid surgery.

Purpose: Although it has been widely accepted as the evidence supporting prophylactic carotid endarterectomy, aspects of the Asymptomatic Carotid Atherosclerosis Study have left unease among clinicians who must decide which individuals without symptoms should undergo surgery. Additional confusion has been created by the fact that the several large randomized trials investigating the efficacy of carotid endarterectomy have classified and analyzed different categories of carotid stenosis. In an effort to provide more information on the natural history of asymptomatic, moderate carotid artery stenosis (50% to 79%), we have reviewed data on approximately 500 arteries.Methods: Records of our vascular laboratory from 1990 to 1992 were reviewed. We identified 425 patients with asymptomatic, moderate carotid artery stenosis; 71 patients had bilateral stenoses in this category, resulting in 496 arteries for study.Results: The mean length of follow-up was 38 ± 18 months. New ipsilateral strokes occurred in 16 (3.8%) patients. New ipsilateral transient ischemic attacks occurred in 25 (5.9%) patients. Documented progression of stenosis occurred in 48 (17%) of the 282 arteries for which a repeat duplex examination was available. Arteries that progressed to >80% stenosis were significantly more likely to have caused strokes than those that remained in the 50% to 79% range (10.4% vs 2.1%, p < 0.02). Conversely, arteries that remained stable in the degree of stenosis were significantly more likely to have remained asymptomatic than those that progressed (92.7% vs 62.5%, p < 0.001). With life-table analysis the estimated cumulative ipsilateral stroke rate was 0.85% at 1 year, 3.6% at 3 years, and 5.4% at 5 years. The respective estimated cumulative transient ischemic attack rates were 1.9%, 5.5%, and 6.3%. The respective estimated cumulative rates for progression of stenosis were 4.9%, 16.7%, and 26.5%. Life-table comparison of ipsilateral stroke revealed a significantly higher cumulative rate among arteries that progressed in the degree of stenosis than among those that remained stable (p < 0.001).Conclusions: Based on the low rate of permanent neurologic events in these cases, prophylactic carotid endarterectomy for the asymptomatic, moderately stenotic internal carotid artery cannot currently be recommended. The only factor that appears to predict increased risk for future stroke is progression of stenosis. Careful follow-up with serial repeat duplex examinations must be performed in these patients. Until there are widely accepted duplex parameters that can provide all clinicians with accurate identification of arteries with narrowing corresponding to 60% stenosis as defined by the Asymptomatic Carotid Atherosclerosis Study, all surgeons will need to be aware of specifically how their noninvasive laboratories are deriving their results. For the many laboratories that continue to use the University of Washington criteria, 80% should remain the level above which prophylactic carotid endarterectomy is warranted. (J Vasc Surg 1997;25:423-31.)

Purpose: The optimal anesthetic for use during carotid endarterectomy is controversial. Advocates of regional anesthesia suggest that it may reduce the incidence of perioperative complications in addition to decreasing operative time and hospital costs. To determine whether the anesthetic method correlated with the outcome of the operation, a retrospective review of 3975 carotid operations performed over a 32-year period was performed.Methods: The records of all patients who underwent carotid endarterectomy at our institution from 1962 to 1994 were retrospectively reviewed. Operations performed with the patient under regional anesthesia were compared with those performed with the patient under general anesthesia with respect to preoperative risk factors and perioperative complications.Results: Regional anesthesia was used in 3382 operations (85.1%). There were no significant differences in the age, gender ratio, or the rates of concomitant medical illnesses between the two patient populations. The frequency of perioperative stroke in the series was 2.2%; that of myocardial infarction, 1.7%; and that of perioperative death, 1.5%. There were no statistically significant differences in the frequency of perioperative stroke, myocardial infarction, or death on the basis of anesthetic technique. A trend toward higher frequencies of perioperative stroke (3.2% vs 2.0%) and perioperative death (2.0% vs 1.4%) in the general anesthesia group was noted. In examining operative indications, however, there was a significant increase in the percentage of patients receiving general anesthesia who had sustained preoperative strokes when compared with the regional anesthesia patients (36.1% vs 26.4%; p < 0.01). There was also a statistically significant higher frequency of contralateral total occlusion in the general anesthesia group (21.8% vs 15.4%; p = 0.001). The trend toward increased perioperative strokes in the general anesthesia group may be explicable either by the above differences in the patient populations or by actual differences based on anesthetic technique that favor regional anesthesia.Conclusions: In a retrospective review of a large series of carotid operations, regional anesthesia was shown to be applicable to the vast majority of patients with good clinical outcome. Although the advantages over general anesthesia are perhaps small, the versatility and safety of the technique is sufficient reason for vascular surgeons to include it in their armamentarium of surgical skills. Considering that carotid endarterectomy is a procedure in which complication rates are exceedingly low, a rigidly controlled, prospective randomized trial may be required to accurately assess these differences. (J Vasc Surg 1996;24;946-56.)

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%, P0.001). 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%, P0.01). Comparison of the operative techniques showed more frequent placement of intra-arterial shunt (52.6% versus 29.4%, P0.001) and increased use of general anesthesia (20.0% versus 9.4%, P0.01) 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)

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.

Reluctance to use saphenous vein (SV) for patch closure of the carotid arteriotomy is due in part to the concern of vascular surgeons that the SV should be preserved for possible future coronary or lower extremity reconstruction. Even among those who favour vein patch closure of the arteriotomy for improved immediate and late results, an effort has been made to use the ankle portion of the SV, preserving the upper, larger segment for later surgery. Recent reports of rupture of the patches formed from ankle SV and a study showing a decrease in strength of the ankle segment of vein, raised the question of the importance of trying to preserve the proximal SV and the impact of use of this segment in those patients requiring secondary vascular procedures. We reviewed 134 consecutive carotid patients from 1981 who had proximal SV harvested for patch angioplasty. Of those 122 were available (mean 44.9 months). Thirteen had secondary vascular procedures. Adequate saphenous vein was available in twelve. We conclude from this study that (1) less than 15% of patients undergoing carotid surgery will require a secondary vascular surgery within 5 years and (2) harvesting SV from the thigh rarely compromises future revascularisation.

In order to maximize the efficacy of carotid endarterectomy (CEA), the rate of perioperative stroke must be kept to a minimum. A recent analysis of carotid surgery at our institution found that most perioperative strokes were due to technical errors resulting in thrombosis or embolization. From 1992 through 1997 we have performed nearly 1200 additional CEAs; the purpose of this study was to examine recent trends in the causes of perioperative stroke, with specific attention to differences in symptomatic and asymptomatic patients. The records of 1041 patients undergoing 1165 CEAs were reviewed from a prospectively compiled database. Analysis of these data showed that a history of preoperative stroke appears to increase the risk of perioperative stroke after CEA. Surgical factors associated with perioperative stroke include an inability to tolerate clamping, use of an intraarterial shunt, and having surgery performed under general anesthesia; these factors are clearly interrelated and only the use of intraarterial shunting remains a risk factor by multivariate analysis. Over half of all perioperative strokes (54%) appear to be caused by intraoperative or postoperative thrombosis and embolization. The patient requiring use of intraarterial shunting and/or with a preoperative stroke most likely has a significant watershed area of brain at increased risk of infarction. However, technical errors are still the most common cause of perioperative stroke in these high-risk patients. Such high-risk patients may manifest clinical stroke from small emboli that may be tolerated by asymptomatic clamp-tolerant patients. Technical precision and appropriate cerebral protection are particularly critical for successful outcomes in high-risk patients.

Objectives: Although the results of the Asymptomatic Carotid Atherosclerosis Study clearly demonstrated the benefit of surgical over medical management of severe carotid artery stenosis, the results for women in particular were less certain. This was to some extent because of the higher perioperative complication rate observed in the 281 women (3.6% vs 1.7% in men). The objective of this study was to review a large experience with carotid endarterectomy in female patients and to determine whether the perioperative results differed from those of male patients. Methods: A review was conducted of a prospectively compiled database on all carotid endarterectomies performed between 1982 and 1997. Operations performed in 991 female patients were compared with those performed in 1485 male patients. Results: Female patients had a significantly lower incidence of diabetes, coronary artery disease, and contralateral carotid artery occlusion than did male patients. Female patients had a significantly higher incidence of hypertension. There were no significant differences in the age, smoking history, anesthetic route, shunt use, or clamp tolerance between the two groups. Of 991 female patients, 659 (66.5%) had preoperative symptoms, whereas 332 (33.5%) cases were performed for asymptomatic stenosis. Among 1485 male patients, 1041 (70.1%) had symptoms, and 444 (29.9%) were symptom free before surgery. There were no significant differences noted in the perioperative stroke rates between men and women overall (2.3% vs 2.4%, P =.92), or when divided into symptomatic (2.5% vs 3.0%, P =.52) and asymptomatic (2.0% vs 1.2%, P =.55) cases. Conclusions: Carotid endarterectomy can be performed with equally low perioperative stroke rates in men and women in both symptomatic and asymptomatic cases. In this series, symptom-free female patients had the lowest overall stroke rate. The concerns of the Asymptomatic Carotid Atherosclerosis Study regarding the benefit of carotid endarterectomy in female patients should therefore not prevent clinicians from recommending and performing carotid endarterectomy in appropriately selected symptom-free female patients. (J Vasc Surg 2001;33:236-41.)

Patients who have sustained a preoperative stroke are at increased risk for perioperative stroke after carotid endarterectomy. At our institution this risk was recently shown to be increased two-to threefold. The purpose of this study was to investigate the reasons for the increased surgical risk in these patients. Records of 606 patients undergoing 704 consecutive carotid endarterectomies from 1988 through 1993 were reviewed. Patients who suffered preoperative 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%, p0.001), 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%, p0.001). 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.

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. (J VASC SURG 1994;19:206-16.)