Carotid Endarterectomy: Results in 100 Patients William P. Cornell, M.D.
ABSTRACT One hundred twenty-two carotid endarterectomies were done in 100 patients in various clinical states of occlusive disease (4 with asymptomatic bruit, 61 with transient ischemia attacks, 35 following stroke) with an overall operative mortality of 3.27%. The 4 deaths all occurred among patients who had existing deficits when operated on. Among 82 operations done for transient ischemia or asymptomatic bruit there were no deaths; 2 transient but no permanent deficits resulted. Surgical management is described. During long-term follow-up, 3 patients in the transient ischemia group acquired deficits (4.6%), but no strokes occurred among the patients with asymptomatic bruits. Six cerebral deaths are reported (both early and late); 5 of them occurred among poststroke patients and the sixth was related to an unoperated, diseased carotid artery.
Carotid endarterectomy has become increasingly more acceptable to clinicians in the treatment of cerebrovascular insufficiency. Indications for as well as contraindications to operative management have become more precisely defined [l, 2,4, 9, 17, 191, and the results to be expected are generally well known. Numerous large series have been reported recently in which mortality is less than 3% and the incidence of postoperative neurological deficit is less than 4% [12,14,16]. This article is a report of 100 consecutive patients treated for cerebrovascular insufficiency. The study period spans the ten years from July, 1966, to May, 1976. Materials and Methods
During a ten-year period 122 carotid endarterectomies were carried out on 100 private patients. Fifty-seven were men and 43 were women. The median age was 65 years. The men ranged in age
Accepted for publication May 19, 1977.
I wish to thank Bette Clemons, R.N., for her valuable technical assistance.
Address reprint requests to Dr. Cornell, 926 E McDowell Rd, Suite 32, Phoenix, A2 85006. 122
from 40 to 78 years with an average of 63.4 years; among women the ages ranged from 46 to 84 with an average of 64.9 years. All patients had major disease of the internal carotid artery, primarily from arteriosclerosis. (There were 3 cases of carotid kink syndrome and 1of congenital carotid stenosis.) Many of these patients had more than one unrelated disease; associated diseases are shown in Table 1. All patients were studied by arteriography, which demonstrated the arteriosclerotic lesions. Early in the series the studies were done by direct injection into the carotid artery; in subsequent years, however, arteriography has been done entirely through the transfemoral route with selective injection of the carotid, innominate, and subclavian arteries, which usually demonstrated both carotid and both vertebral arteries. We consider it essential to view not only the carotid but also the vertebral arteries and have found this technique to be the most successful, with the fewest complications. At present most of our arteriographic procedures are done by the radiology department. All patients with arteriosclerotic disease underwent endarterectomy. Three patients were treated with endarterectomy plus an onlay patch of Dacron velour. In these patients the disease extended up into the base of the skull and, in 1of them, resulted in postoperative thrombosis with death. The other 2 patients were treated by "tacking" the intima down and utilizing an onlay patch; these were the only cases in which an onlay patch was used in the series. Bilateral procedures, when indicated, were usually staged seven to ten days apart. However, patients were frequently discharged home for readmission in four to six weeks. Twentyone patients underwent bilateral endarterectomy. Resection of a portion of the internal carotid artery with end-to-end anastomosis was done in 3 patients for carotid kink syndrome. All operations were done under general anesthesia with electrocardiographic and electroencephalographic monitoring.
0003-4975/78/0025-0206$01.25@ 1978 by T h e Society of Thoracic Surgeons
123
Cornell: Carotid Endarterectomy
Table 1. Associated Diseases
Disease
Nunn's
This Seriesa
Series [12]"
20%
17% 50% 41% 46%
~~
Diabetes Hypertension Arteriosclerotic heart disease Peripheral vascular disease
40% 44%
30%
"Approximatelythe same percent of patients had associated disease in each series.
Surgical Techitique Several technical points are worth emphasizing. 1. Great efforts were made to maintain each patient's blood pressure at a normal level for that patient. Hypertension both during operation and afterward was considered extremely hazardous and was treated with an infusion of Arfonad to maintain blood pressure at a normal level for the particular patient. 2. The artery was manipulated very gently to prevent dislodging of intraluminal debris and cerebral embolization with production of neurological deficits. 3. A Javid shunt was used in all instances of partial occlusion. I am familiar with the arguments put forth in favor of performing this procedure without a shunt; however, I believe that the routine use of an internal shunt, when done properly, affords the patient the greatest cerebral protection during the operation [3]. Hypercapnia was not used in any pa tien t.
Following dissection of the common, internal, and external carotid arteries, the patient was heparinized and a vertical arteriotomy was made, starting in the common carotid artery and extending up through the plaque and into the internal carotid. The Javid shunt was first inserted in the internal carotid artery and filled with blood, then it was passed into the common carotid, with care being taken to avoid introducing air or debris into the system. Total interruption of flow through the artery usually lasted less than two minutes. Following this maneuver, an endarterectomy could be carefully and completely performed without haste. It was also considered important that the plaque be adequately
removed from the external carotid artery, as this can be a source of major cerebral flow. In most cases the intimal plaque came away cleanly with a tapered end from the internal carotid artery. The shunt was removed before the last few sutures were placed, and again the total arterial occlusion time was usually less than two minutes. The sutures used for closing the arteriotomy were 5-0 or 6-0 Prolene. The patient was then given protamine sulfate to reverse the effects of the heparin. Following the patient's return to the recovery room and intensive care unit, particular care was given to maintaining the blood pressure at a normal level for the particular individual. During the last two years of the study period, all patients had a radial artery catheter inserted for blood pressure monitoring with an oscilloscope. The patients were kept in the intensive care unit overnight and were usually discharged home 48 to 72 hours postoperatively.
Classification of Patients The classification used in this group of patients (Table 2) was the same as that described by Thompson [16], which can be summarized as follows. ASYMPTOMATIC BRUIT. This group of patients was seen because of a carotid bruit detected in the neck. These individuals were neurologically asymptomatic and subsequently underwent arteriography, which showed major occlusive carotid plaques. This series included 4 patients with asymptomatic bruit. TRANSIENT CEREBRAL ISCHEMIA. This is a group of patients who had focal transient ischemic attacks (TIA) without permanent neurological deficit. The attacks last from a few seconds up to several hours, but there was no residual neurological deficit after 24 hours. The attacks sometimes appeared as lateralizing signs with aphasia, dysphasia, amaurosis fugax, or hemiparesis and hemiplegia. They could also show nonlateralizing symptoms, including bilateral visual field defects, double vision, dizziness, staggering gait, headache, confusion, and personality changes. Sixty-two patients in this series had TIA. CHRONIC CEREBRAL ISCHEMIA. This category is more difficult to define. These patients sometimes experienced loss of memory, im-
124 The Annals of Thoracic Surgery
Vol 25 No 2
February 1978
Table 2 . lndications for Operation by Clinical Classification
Group Asymptomatic bruit Transient ischemic attacks Poststroke, stable Acute stroke, or emergency
No. of
No. of
(N = 100)
Patients
4 61 28 7
paired mentation, or gradual mental deterioration. Frequently they were described by their families as having undergone a personality change or as having become quite difficult to live with. Thompson found them difficult to classify and called them patients who cannot be placed in any other clinical category. They constituted only a small portion of his 1970 series (2.8% of nearly 600 patients [16]). These patients with chronic cerebral ischemia, however, occasionally experienced dramatic improvement in their symptoms postoperatively. FRANK STROKE. The category of frank stroke included all patients with some neurological deficit at the time of operation, whether the stroke was stable, improving, or worsening. Their condition ranged from mild deficit to complete hemiplegia and aphasia. This series included 35 patients who had had previous strokes.
Results One hundred patients underwent 122 carotid endarterectomies with an overall operative mortality of 3.27%. The 4 deaths occurred among patients in the stroke group-those who had had preexisting neurological deficits when operated on-whereas 82 operations were performed in 65 patients for TIA or asymptomatic bruit with no mortality. The 4 operative deaths included 2 from myocardial infarction and 2 from acute cerebral infarction. Among the 96 surviving patients there were 2 with mild, permanent neurological deficits. Three had transient deficits, all mild, which included arm weakness, facial fold flattening, and lip paralysis. N o patient in either the asymptomatic bruit group or the TIA group acquired a permanent deficit. This compares favorably with results reported in other series [9, 13, 191.
Operations (N = 122)
Percentage of Series
5 77 33 7
4 63 27 6
Five patients showed signs of hypoglossal nerve trauma; all regained normal function within three months. Nonfatal cardiac complications occurred in 9 patients, and hospital discharge was delayed by arrhythmia 7 times; 1 of these patients required a temporary cardiac pacemaker. Two patients had fatal coronary occlusions; 1 patient suffered a cardiac arrest and was successfully resuscitated without neurological impairment. One patient in the poststroke group developed iliovenous thrombosis, which was treated nonsurgically. No patient has developed an aneurysm at the site of the arteriotomy closure. There have been no wound infections, and no patient has required reoperation for bleeding. The 4 patients who had asymptomatic bruits were free of symptoms one month postoperatively. One of the 4 experienced a brief episode of mild arm weakness on the second postoperative day. No permanent neurological deficits or deaths occurred in this group. One reoperation was performed for recurrent stenosis in a woman of 84 years who was asymptomatic for three years following her original operation. Because of the recurrence of symptoms, arteriography was done and demonstrated a recurrent stenotic lesion. She was successfully operated on with relief of symptoms. This was the only reoperation in the entire series. The longest follow-up has been seven years. Among the 94 survivors followed longer than 30 days, 18 patients (19'/0) were followed for less than one year; the average length of follow-up was 32.3 months. Of the original 100 patients, 71 were known to be alive at the conclusion of the study. A total of 25 deaths were confirmed, 4 early and 21 late (Table 3). Among the late deaths, 4 of the 21 were from cerebral causes, bringing the total to 6 cerebral deaths for the
125
Cornell: Carotid Endarterectomy
Table 3 . Known Causes of Death in the Series Cause ~
Time of
Death
Operative Late
Total
No. of
Pa tien ts
Cerebral
Cardiac
Cancer
Renal Failure
4
2
0
4
2 12
0
19”
2
1
23
6
14
2
1
=Two additional deaths occurred 4 and 36 months postoperatively, cause unknown.
study, 19% of 102 patients developed frank stroke (usually without prior TIA) from two days to four years following detection of a bruit. I agree with Javid and associates [lo] that when there are no medical contraindications to operating, patients with an asymptomatic bruit should undergo diagnostic radiography and be treated surgically [19]. The neurological deficit and mortality rates in this group should approach zero. In this study, all 4 operated patients with asymptomatic bruits are alive. None has suffered a stroke or developed cerebral ischemic symptoms during the four to five years since carotid endarterectomy was carried out. Among the 61 patients in the TIA group there were no deaths and only 2 temporary neurological deficits, both of which were mild and cleared. Sixty (98%) of the TIA patients were normal or asymptomatic in the early follow-up period. One patient with bilateral carotid lesions developed hemiplegia between staged operations; the paralysis was related to the unoperated carotid artery, and the residual neurological deficit cleared after the second procedure, with full recovery. In the poststroke group, 40 operations were carried out in 35 patients and resulted in 4 Comment fatalities, 2 of cardiac and 2 of cerebral cause. There is still some disagreement as to both sig- Four operative survivors developed new neuronificance of the finding of a mid carotid bruit logical deficits, 2 transient and 2 permanent. In and operative indications among asymptomatic 27 of the 35 patients with preexisting deficits, patients [19]. Waiting for symptoms to appear the impairment had improved or entirely can be extremely hazardous. If a stenotic carotid cleared by 30 days postoperatively (Table 3). Several points evident from this study should artery undergoes acute total occlusion, the result can be a stroke with death. Various studies have be emphasized. Carotid endarterectomy is a safe shown that among patients with asymptomatic and effective procedure for preventing or relievbruit followed up to ten years, more than half ing severe neurological problems. The best rewill develop either TIA or frank stroke that may sults are obtained in patients with asymptomwell result in death [2, 17, 201. In one control atic bruit orTIA, but much benefit can be offered
entire series, both early and late. Five of these 6 deaths occurred in the stroke group; the sixth death related to a contralateral unoperated carotid artery. Twenty-three patients in the stroke group were alive at the conclusion of this study; 3 were judged neurologically worse, having deteriorated. The remaining 20 survivors (86.9%) were either functionally normal, stable, or improved following operation. In the combined TIA and asymptomatic bruit groups, 63 (95%) of the 65 patients were demonstrably helped by carotid endarterectomy. As for stroke incidence, Thompson has reported that 5% of 210 patients with asymptomatic bruit or TIA followed up to thirteen years after endarterectomy developed strokes [181. Here, among comparable patients followed up to eight years, 3 of 64 developed a neurological deficit related to the operated artery (4.6% frequency). In each instance the impairment was permanent; all deficits were mild. None of the patients with asymptomatic bruit have died or have developed strokes or symptoms of cerebral ischemia in the four to five years since their operation.
126 The Annals of Thoracic Surgery Vol 25 No 2 February 1978
t h e patient with a stable stroke. In addition to the relief of disabling symptoms, the goal of endarterectomy is stroke prevention. The operation must be accomplished so as not to produce new neurological deficits or worsen preexisting ones. I agree with numerous other authors that surgery is generally contraindicated in patients with acute profound o r progressive stroke [l, 2, 4, 5, 9, 111. A careful a n d accurate history was considered responsible for detecting numerous patients with ulcerative carotid lesions who had a variety of symptoms when first seen. Quite often, patients with mild symptoms of ischemia were found to have severe ulcerative lesions in one or both carotid arteries. Surgical technique was thought to be particularly important. I value the use of a standardized procedure featuring introduction of a n internal s h u n t a n d preventing hypertension while maintaining normotension. Arteriography was the most useful diagnostic tool i n evaluating this group of patients, and four-vessel selective arteriograms taken by t h e transfemoral route were utilized most often. Experience with older age groups has taught us to extend indications for arteriography to elderly people whose major presenting symptom is described clinically as ”senility.” Both angiographic findings a n d operative outcome have been encouraging. Evidence of improved mentation by IQ testing postoperatively has been documented i n the literature [6, 73. I have been impressed with the fact that often at operation an ulcerative lesion has proved to be much more severe than the arteriograms had indicated, an observation supported by others [ 8 ] . W e have considered it essential to include intracranial a n d cervical studies to rule o u t the presence of atherosclerosis or intracranial lesions, including neoplasm a n d aneurysm. It should be noted that arteriosclerotic lesions above the level of t h e carotid bifurcation were uncommon in this series, indicating that the majority of cerebrovascular symptoms originate in the cervical vessels, where they frequently lend themselves to surgical treatment.
2. Edwards WS: Present status of carotid surgery in stroke prevention. Am Surg 40:164, 1974 3. Engell HC: Studies in cerebral circulation. Bull Am Coll Surg 58:7, 1973 4. Fields WS: Selection of stroke patients for arterial reconstructive surgery. Am J Surg 125:527, 1973 5. Grindal AB, Toole JF: Surgical treatment of carotid and vertebral artery disease: an updating in 1974. Ann Intern Med 81:647, 1974 6. Haynes: in discussion of Ford JJ, Baker WH, Ehrenhaft JL: Carotid endarterectomy for nonhemispheric transient ischemia attacks. Arch Surg 110:1317, 1975 7. Home DJ, Royale JP: Cognitive changes after carotid endarterectomy. Med J Aust 1:316, 1974 8. Houser, OW, Sundt Th4, Holman CB, et al: Atherosclerotic disease of the carotid artery: a correlation of angiographic, clinical and surgical findings. J Neurosurg 41:321, 1974 9. Hughes RK: Carotid endarterectomy. Ann Thorac Surg 16:635, 1973 10. Javid H, Ostermiller WE, Hongesh JW, et al: Carotid endarterectomy for asymptomatic patients. Arch Surg 102:389, 1971 11. Najafi H, Javid H, Dye WS, et al: Emergency carotid endarterectomy: surgical results and indications. Arch Surg 103:610, 1971 12. Nunn DB: Carotid endarterectomy: an analysis of 234 operative cases. Ann Surg 182:733, 1975 13. Nunn DB: Carotid endarterectomy in the treatment of transient cerebral ischemia. J Florida Med Assoc 62:26, 1975 14. Rich NM, Hobson RW: Carotid endarterectomy under regional anesthesia. Am Surg 41:253, 1975 15. Thompson JE: Endarterectomy of the totally occluded carotid artery for stroke: results in 100 operations. Arch Surg 95:791, 1967 16. Thompson JE: Carotid endarterectomy for cerebrovascular insufficiency: long term results in 592 patients followed up to thirteen years. Ann Surg 172:663, 1970 17. Thompson JE: The development of carotid surgery. Arch Surg 107:643, 1973 18. Thompson JE, in discussion of DeWeese JA, Rob CG, Satron R, et al: Results of carotid endarterectomies for transient ischemia attacks five years later. Ann Surg 178:263, 1973 19. Thompson JE: Management of asymptomatic carotid bruits. Am Surg 42:77, 1976 20. Yashon D, Jane JA, Javid H: Long term results of carotid bifurcation endarterectomy. Surg Gynecol Obstet 122:517, 1966
Editor’s Note The author reports excellent results in a relatively References small series of patients cared for by him personally. 1. Clauss RH, Sanoudos GM, Ray JF 111, et al: Carotid While no new ideas or techniques are presented, the endarterectomy for cerebrovascular ischemia (col- well-documented series shows that good results can lective review). Surg Gynecol Obstet 136:993, be obtained in the community hospital by a careful surgeon. 1973
ABSTRACT One hundred twenty-two carotid endarterectomies were done in 100 patients in various clinical states of occlusive disease (4 with asymptomatic bruit, 61 with transient ischemia attacks, 35 following stroke) with an overall operative mortality of 3.27%. The 4 deaths all occurred among patients who had existing deficits when operated on. Among 82 operations done for transient ischemia or asymptomatic bruit there were no deaths; 2 transient but no permanent deficits resulted. Surgical management is described. During long-term follow-up, 3 patients in the transient ischemia group acquired deficits (4.6%), but no strokes occurred among the patients with asymptomatic bruits. Six cerebral deaths are reported (both early and late); 5 of them occurred among poststroke patients and the sixth was related to an unoperated, diseased carotid artery.
Carotid endarterectomy has become increasingly more acceptable to clinicians in the treatment of cerebrovascular insufficiency. Indications for as well as contraindications to operative management have become more precisely defined [l, 2,4, 9, 17, 191, and the results to be expected are generally well known. Numerous large series have been reported recently in which mortality is less than 3% and the incidence of postoperative neurological deficit is less than 4% [12,14,16]. This article is a report of 100 consecutive patients treated for cerebrovascular insufficiency. The study period spans the ten years from July, 1966, to May, 1976. Materials and Methods
During a ten-year period 122 carotid endarterectomies were carried out on 100 private patients. Fifty-seven were men and 43 were women. The median age was 65 years. The men ranged in age
Accepted for publication May 19, 1977.
I wish to thank Bette Clemons, R.N., for her valuable technical assistance.
Address reprint requests to Dr. Cornell, 926 E McDowell Rd, Suite 32, Phoenix, A2 85006. 122
from 40 to 78 years with an average of 63.4 years; among women the ages ranged from 46 to 84 with an average of 64.9 years. All patients had major disease of the internal carotid artery, primarily from arteriosclerosis. (There were 3 cases of carotid kink syndrome and 1of congenital carotid stenosis.) Many of these patients had more than one unrelated disease; associated diseases are shown in Table 1. All patients were studied by arteriography, which demonstrated the arteriosclerotic lesions. Early in the series the studies were done by direct injection into the carotid artery; in subsequent years, however, arteriography has been done entirely through the transfemoral route with selective injection of the carotid, innominate, and subclavian arteries, which usually demonstrated both carotid and both vertebral arteries. We consider it essential to view not only the carotid but also the vertebral arteries and have found this technique to be the most successful, with the fewest complications. At present most of our arteriographic procedures are done by the radiology department. All patients with arteriosclerotic disease underwent endarterectomy. Three patients were treated with endarterectomy plus an onlay patch of Dacron velour. In these patients the disease extended up into the base of the skull and, in 1of them, resulted in postoperative thrombosis with death. The other 2 patients were treated by "tacking" the intima down and utilizing an onlay patch; these were the only cases in which an onlay patch was used in the series. Bilateral procedures, when indicated, were usually staged seven to ten days apart. However, patients were frequently discharged home for readmission in four to six weeks. Twentyone patients underwent bilateral endarterectomy. Resection of a portion of the internal carotid artery with end-to-end anastomosis was done in 3 patients for carotid kink syndrome. All operations were done under general anesthesia with electrocardiographic and electroencephalographic monitoring.
0003-4975/78/0025-0206$01.25@ 1978 by T h e Society of Thoracic Surgeons
123
Cornell: Carotid Endarterectomy
Table 1. Associated Diseases
Disease
Nunn's
This Seriesa
Series [12]"
20%
17% 50% 41% 46%
~~
Diabetes Hypertension Arteriosclerotic heart disease Peripheral vascular disease
40% 44%
30%
"Approximatelythe same percent of patients had associated disease in each series.
Surgical Techitique Several technical points are worth emphasizing. 1. Great efforts were made to maintain each patient's blood pressure at a normal level for that patient. Hypertension both during operation and afterward was considered extremely hazardous and was treated with an infusion of Arfonad to maintain blood pressure at a normal level for the particular patient. 2. The artery was manipulated very gently to prevent dislodging of intraluminal debris and cerebral embolization with production of neurological deficits. 3. A Javid shunt was used in all instances of partial occlusion. I am familiar with the arguments put forth in favor of performing this procedure without a shunt; however, I believe that the routine use of an internal shunt, when done properly, affords the patient the greatest cerebral protection during the operation [3]. Hypercapnia was not used in any pa tien t.
Following dissection of the common, internal, and external carotid arteries, the patient was heparinized and a vertical arteriotomy was made, starting in the common carotid artery and extending up through the plaque and into the internal carotid. The Javid shunt was first inserted in the internal carotid artery and filled with blood, then it was passed into the common carotid, with care being taken to avoid introducing air or debris into the system. Total interruption of flow through the artery usually lasted less than two minutes. Following this maneuver, an endarterectomy could be carefully and completely performed without haste. It was also considered important that the plaque be adequately
removed from the external carotid artery, as this can be a source of major cerebral flow. In most cases the intimal plaque came away cleanly with a tapered end from the internal carotid artery. The shunt was removed before the last few sutures were placed, and again the total arterial occlusion time was usually less than two minutes. The sutures used for closing the arteriotomy were 5-0 or 6-0 Prolene. The patient was then given protamine sulfate to reverse the effects of the heparin. Following the patient's return to the recovery room and intensive care unit, particular care was given to maintaining the blood pressure at a normal level for the particular individual. During the last two years of the study period, all patients had a radial artery catheter inserted for blood pressure monitoring with an oscilloscope. The patients were kept in the intensive care unit overnight and were usually discharged home 48 to 72 hours postoperatively.
Classification of Patients The classification used in this group of patients (Table 2) was the same as that described by Thompson [16], which can be summarized as follows. ASYMPTOMATIC BRUIT. This group of patients was seen because of a carotid bruit detected in the neck. These individuals were neurologically asymptomatic and subsequently underwent arteriography, which showed major occlusive carotid plaques. This series included 4 patients with asymptomatic bruit. TRANSIENT CEREBRAL ISCHEMIA. This is a group of patients who had focal transient ischemic attacks (TIA) without permanent neurological deficit. The attacks last from a few seconds up to several hours, but there was no residual neurological deficit after 24 hours. The attacks sometimes appeared as lateralizing signs with aphasia, dysphasia, amaurosis fugax, or hemiparesis and hemiplegia. They could also show nonlateralizing symptoms, including bilateral visual field defects, double vision, dizziness, staggering gait, headache, confusion, and personality changes. Sixty-two patients in this series had TIA. CHRONIC CEREBRAL ISCHEMIA. This category is more difficult to define. These patients sometimes experienced loss of memory, im-
124 The Annals of Thoracic Surgery
Vol 25 No 2
February 1978
Table 2 . lndications for Operation by Clinical Classification
Group Asymptomatic bruit Transient ischemic attacks Poststroke, stable Acute stroke, or emergency
No. of
No. of
(N = 100)
Patients
4 61 28 7
paired mentation, or gradual mental deterioration. Frequently they were described by their families as having undergone a personality change or as having become quite difficult to live with. Thompson found them difficult to classify and called them patients who cannot be placed in any other clinical category. They constituted only a small portion of his 1970 series (2.8% of nearly 600 patients [16]). These patients with chronic cerebral ischemia, however, occasionally experienced dramatic improvement in their symptoms postoperatively. FRANK STROKE. The category of frank stroke included all patients with some neurological deficit at the time of operation, whether the stroke was stable, improving, or worsening. Their condition ranged from mild deficit to complete hemiplegia and aphasia. This series included 35 patients who had had previous strokes.
Results One hundred patients underwent 122 carotid endarterectomies with an overall operative mortality of 3.27%. The 4 deaths occurred among patients in the stroke group-those who had had preexisting neurological deficits when operated on-whereas 82 operations were performed in 65 patients for TIA or asymptomatic bruit with no mortality. The 4 operative deaths included 2 from myocardial infarction and 2 from acute cerebral infarction. Among the 96 surviving patients there were 2 with mild, permanent neurological deficits. Three had transient deficits, all mild, which included arm weakness, facial fold flattening, and lip paralysis. N o patient in either the asymptomatic bruit group or the TIA group acquired a permanent deficit. This compares favorably with results reported in other series [9, 13, 191.
Operations (N = 122)
Percentage of Series
5 77 33 7
4 63 27 6
Five patients showed signs of hypoglossal nerve trauma; all regained normal function within three months. Nonfatal cardiac complications occurred in 9 patients, and hospital discharge was delayed by arrhythmia 7 times; 1 of these patients required a temporary cardiac pacemaker. Two patients had fatal coronary occlusions; 1 patient suffered a cardiac arrest and was successfully resuscitated without neurological impairment. One patient in the poststroke group developed iliovenous thrombosis, which was treated nonsurgically. No patient has developed an aneurysm at the site of the arteriotomy closure. There have been no wound infections, and no patient has required reoperation for bleeding. The 4 patients who had asymptomatic bruits were free of symptoms one month postoperatively. One of the 4 experienced a brief episode of mild arm weakness on the second postoperative day. No permanent neurological deficits or deaths occurred in this group. One reoperation was performed for recurrent stenosis in a woman of 84 years who was asymptomatic for three years following her original operation. Because of the recurrence of symptoms, arteriography was done and demonstrated a recurrent stenotic lesion. She was successfully operated on with relief of symptoms. This was the only reoperation in the entire series. The longest follow-up has been seven years. Among the 94 survivors followed longer than 30 days, 18 patients (19'/0) were followed for less than one year; the average length of follow-up was 32.3 months. Of the original 100 patients, 71 were known to be alive at the conclusion of the study. A total of 25 deaths were confirmed, 4 early and 21 late (Table 3). Among the late deaths, 4 of the 21 were from cerebral causes, bringing the total to 6 cerebral deaths for the
125
Cornell: Carotid Endarterectomy
Table 3 . Known Causes of Death in the Series Cause ~
Time of
Death
Operative Late
Total
No. of
Pa tien ts
Cerebral
Cardiac
Cancer
Renal Failure
4
2
0
4
2 12
0
19”
2
1
23
6
14
2
1
=Two additional deaths occurred 4 and 36 months postoperatively, cause unknown.
study, 19% of 102 patients developed frank stroke (usually without prior TIA) from two days to four years following detection of a bruit. I agree with Javid and associates [lo] that when there are no medical contraindications to operating, patients with an asymptomatic bruit should undergo diagnostic radiography and be treated surgically [19]. The neurological deficit and mortality rates in this group should approach zero. In this study, all 4 operated patients with asymptomatic bruits are alive. None has suffered a stroke or developed cerebral ischemic symptoms during the four to five years since carotid endarterectomy was carried out. Among the 61 patients in the TIA group there were no deaths and only 2 temporary neurological deficits, both of which were mild and cleared. Sixty (98%) of the TIA patients were normal or asymptomatic in the early follow-up period. One patient with bilateral carotid lesions developed hemiplegia between staged operations; the paralysis was related to the unoperated carotid artery, and the residual neurological deficit cleared after the second procedure, with full recovery. In the poststroke group, 40 operations were carried out in 35 patients and resulted in 4 Comment fatalities, 2 of cardiac and 2 of cerebral cause. There is still some disagreement as to both sig- Four operative survivors developed new neuronificance of the finding of a mid carotid bruit logical deficits, 2 transient and 2 permanent. In and operative indications among asymptomatic 27 of the 35 patients with preexisting deficits, patients [19]. Waiting for symptoms to appear the impairment had improved or entirely can be extremely hazardous. If a stenotic carotid cleared by 30 days postoperatively (Table 3). Several points evident from this study should artery undergoes acute total occlusion, the result can be a stroke with death. Various studies have be emphasized. Carotid endarterectomy is a safe shown that among patients with asymptomatic and effective procedure for preventing or relievbruit followed up to ten years, more than half ing severe neurological problems. The best rewill develop either TIA or frank stroke that may sults are obtained in patients with asymptomwell result in death [2, 17, 201. In one control atic bruit orTIA, but much benefit can be offered
entire series, both early and late. Five of these 6 deaths occurred in the stroke group; the sixth death related to a contralateral unoperated carotid artery. Twenty-three patients in the stroke group were alive at the conclusion of this study; 3 were judged neurologically worse, having deteriorated. The remaining 20 survivors (86.9%) were either functionally normal, stable, or improved following operation. In the combined TIA and asymptomatic bruit groups, 63 (95%) of the 65 patients were demonstrably helped by carotid endarterectomy. As for stroke incidence, Thompson has reported that 5% of 210 patients with asymptomatic bruit or TIA followed up to thirteen years after endarterectomy developed strokes [181. Here, among comparable patients followed up to eight years, 3 of 64 developed a neurological deficit related to the operated artery (4.6% frequency). In each instance the impairment was permanent; all deficits were mild. None of the patients with asymptomatic bruit have died or have developed strokes or symptoms of cerebral ischemia in the four to five years since their operation.
126 The Annals of Thoracic Surgery Vol 25 No 2 February 1978
t h e patient with a stable stroke. In addition to the relief of disabling symptoms, the goal of endarterectomy is stroke prevention. The operation must be accomplished so as not to produce new neurological deficits or worsen preexisting ones. I agree with numerous other authors that surgery is generally contraindicated in patients with acute profound o r progressive stroke [l, 2, 4, 5, 9, 111. A careful a n d accurate history was considered responsible for detecting numerous patients with ulcerative carotid lesions who had a variety of symptoms when first seen. Quite often, patients with mild symptoms of ischemia were found to have severe ulcerative lesions in one or both carotid arteries. Surgical technique was thought to be particularly important. I value the use of a standardized procedure featuring introduction of a n internal s h u n t a n d preventing hypertension while maintaining normotension. Arteriography was the most useful diagnostic tool i n evaluating this group of patients, and four-vessel selective arteriograms taken by t h e transfemoral route were utilized most often. Experience with older age groups has taught us to extend indications for arteriography to elderly people whose major presenting symptom is described clinically as ”senility.” Both angiographic findings a n d operative outcome have been encouraging. Evidence of improved mentation by IQ testing postoperatively has been documented i n the literature [6, 73. I have been impressed with the fact that often at operation an ulcerative lesion has proved to be much more severe than the arteriograms had indicated, an observation supported by others [ 8 ] . W e have considered it essential to include intracranial a n d cervical studies to rule o u t the presence of atherosclerosis or intracranial lesions, including neoplasm a n d aneurysm. It should be noted that arteriosclerotic lesions above the level of t h e carotid bifurcation were uncommon in this series, indicating that the majority of cerebrovascular symptoms originate in the cervical vessels, where they frequently lend themselves to surgical treatment.
2. Edwards WS: Present status of carotid surgery in stroke prevention. Am Surg 40:164, 1974 3. Engell HC: Studies in cerebral circulation. Bull Am Coll Surg 58:7, 1973 4. Fields WS: Selection of stroke patients for arterial reconstructive surgery. Am J Surg 125:527, 1973 5. Grindal AB, Toole JF: Surgical treatment of carotid and vertebral artery disease: an updating in 1974. Ann Intern Med 81:647, 1974 6. Haynes: in discussion of Ford JJ, Baker WH, Ehrenhaft JL: Carotid endarterectomy for nonhemispheric transient ischemia attacks. Arch Surg 110:1317, 1975 7. Home DJ, Royale JP: Cognitive changes after carotid endarterectomy. Med J Aust 1:316, 1974 8. Houser, OW, Sundt Th4, Holman CB, et al: Atherosclerotic disease of the carotid artery: a correlation of angiographic, clinical and surgical findings. J Neurosurg 41:321, 1974 9. Hughes RK: Carotid endarterectomy. Ann Thorac Surg 16:635, 1973 10. Javid H, Ostermiller WE, Hongesh JW, et al: Carotid endarterectomy for asymptomatic patients. Arch Surg 102:389, 1971 11. Najafi H, Javid H, Dye WS, et al: Emergency carotid endarterectomy: surgical results and indications. Arch Surg 103:610, 1971 12. Nunn DB: Carotid endarterectomy: an analysis of 234 operative cases. Ann Surg 182:733, 1975 13. Nunn DB: Carotid endarterectomy in the treatment of transient cerebral ischemia. J Florida Med Assoc 62:26, 1975 14. Rich NM, Hobson RW: Carotid endarterectomy under regional anesthesia. Am Surg 41:253, 1975 15. Thompson JE: Endarterectomy of the totally occluded carotid artery for stroke: results in 100 operations. Arch Surg 95:791, 1967 16. Thompson JE: Carotid endarterectomy for cerebrovascular insufficiency: long term results in 592 patients followed up to thirteen years. Ann Surg 172:663, 1970 17. Thompson JE: The development of carotid surgery. Arch Surg 107:643, 1973 18. Thompson JE, in discussion of DeWeese JA, Rob CG, Satron R, et al: Results of carotid endarterectomies for transient ischemia attacks five years later. Ann Surg 178:263, 1973 19. Thompson JE: Management of asymptomatic carotid bruits. Am Surg 42:77, 1976 20. Yashon D, Jane JA, Javid H: Long term results of carotid bifurcation endarterectomy. Surg Gynecol Obstet 122:517, 1966
Editor’s Note The author reports excellent results in a relatively References small series of patients cared for by him personally. 1. Clauss RH, Sanoudos GM, Ray JF 111, et al: Carotid While no new ideas or techniques are presented, the endarterectomy for cerebrovascular ischemia (col- well-documented series shows that good results can lective review). Surg Gynecol Obstet 136:993, be obtained in the community hospital by a careful surgeon. 1973
