Summary
For patients with symptomatic carotid artery disease, carotid endarterectomy can only be considered a therapeutic option when performed with a combined morbidity and mortality that is below the yearly risk (5%) of stroke. The experience with 790 carotid endarterectomies performed between January, 1979 and December, 1991 is presented. There were 514 (65%) men and 276 (35%) women of ages 34–82 years (median 65 years); risk factors included diabetes mellitus [190 (24%)], hypertension [537 (68%)], and smoking [553 (70%)]. Clinical presentation consisted of transient ischemic attacks [450 (57%)], cerebral infarction with minimal neurological residual [221 (28%)], stroke in evolution [two (0.2%)], and asymptomatic stenosis [117, (15%)]. According to Sundt's classification of medical risk groups, the patients fit the following grades: Grade I [102 (13%)], Grade II [339 (43%)], Grade III [347 (44%)]. and Grade IV [two (0.2%)]. All patients received endotracheal anesthesia with transoperative monitoring of intraarterial pressure, central venous pressure, and arterial blood gases. Thiopental (3–5 mg/kg) and lidocaine (1 mg/kg) were given for induction and at 15 min intervals during carotid cross-clamping. Intraluminal shunts were used in 14 (2%) patients. A conventional (open) endarterectomy was performed in 379 (48%) patients and a limited endarterectomy (closed) in 411 (52%) patients. Complications included eight (1%) deaths, 24 (3%) persistent major neurological deficit, and 24 (3%) perioperative TIAs that resolved completely. Of the patients with preoperative neurological deficits, 32 (4v) recovered. Therefore, at 1 month after surgery, 758 (96%) patients were either as well or better than preoperatively. Of 458 (58%) postoperative angiograms, 40 (5%) patients showed an internal carotid artery occlusion; six of these developed an immediate postoperative cerebral infarction, and one patient died. Nonneurologic complications were cardiac [40 (5%)], peripheral nerve [24 (3%)], and local wound problems [16 (2%)]. A carotid endarterectomy can be performed safely when it is done with meticulous attention to detail and consistent surgical technique founded on frequent exposure to the procedure.
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