Carotid endarterectomy (CEA) is now the single most commonly performed peripheral vascular procedure in the western world, and is one of the few surgical procedures to be evaluated in level 1 randomized trials. Yet, despite that it has a proven role in selected patients it still remains a source of continuing debate. At pres ent, there is little consensus on many of the individual aspects of the procedure, such as the role of patching, shunting, and general anesthesia. More recently, there has been an increasing interest in the role of periopera tive monitoring, largely because of increasing aware ness that most strokes follow inadvertent surgeon error. This article reviews the surgical aspects of CEA together with an overview of the evolution of a monitor ing program, which has contributed to a 60% reduction in operative risk.
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References
1.
Eastcott Hhg , Pickering GW, Robb CG: Reconstruction of the internal carotid artery in a patient with intermittent attacks of hemiplegia . Lancet2:994, 1954
2.
Warlow CP: Carotid endarterectomy: Does it work?Stroke15:1068-1076,1984
3.
Barnett Hjm, Plum F., Walton JN: Carotid endarterectomy: An expression of concern. Stroke15:941-943, 1984
4.
European Carotid Surgery Trialists' Collaborative Group: Randomised trial of endarterectomy for recently symptomatic carotid stenosis: Final results of the MRC European Carotid Surgery Trial (ECST). Lancet351:1379-1387, 1998
5.
Barnett Hjm, Taylor DW, Eliasziw M., et al: Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med339:1415-1425, 1989
6.
Hsai DC, Krushat WM, Moscoe LM: Epidemiology of carotid endarterectomy among Medicare beneficiaries . J Vasc Surg16:201-208, 1992
7.
Hsai DC, Krushat WM, Moscoe LM: Epidemiology of carotid endarterectomy among Medicare beneficiaries: 1985-1996 update. Stroke29:346-350, 1998
8.
Karp HR, Flanders D., Shipp CC, et al: Carotid endarterectomy among Medicare beneficiaries: A statewide evaluation of appropriateness and outcome. Stroke29:46-52, 1998
9.
Wennberg DE, Lucas FL, Birkmeyer JD, et al: Variation in carotid endarterectomy mortality in the Medicare population: Trial Hospitals, volume and patient characteristics. JAMA279:1278-1281, 1998
10.
CAVATAS Investigators: Results of the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) . Proceedings of the Annual Vascular Society Meeting of Great Britain and Ireland, Hull, UK, November 1998
11.
Counsell C. , Salinas R., Naylor AR, et al: A systematic review of the randomised trials of carotid patch angioplasty in carotid endarterectomy . Eur J Vasc Endovasc Surg13:345-354, 1997
12.
Counsell C. , Salinas R., Warlow CP, et al: The role of carotid artery shunting during carotid endarterectomy: A systematic review of the randomised trials of routine and selective shunting and the different methods of intra-operative monitoring, in Warlow CP, van Gijn J, Sandercock P (eds): Stroke Module of the Cochrane Database of Systematic Reviews, issue 2. London , UK, BMJ, 1996. Available at: http://hiru.mcmaster.ca/cochrane
13.
Tangkanakul C., Counsell C., Warlow CP: Local versus general anaesthesia in carotid endarterectomy: A systematic review of the evidence . Eur J Vasc Endovasc Surg13:491-499, 1997
14.
Naylor AR: Prevention of operation related stroke: Are we asking the right questions?Cardiovasc Surg7:155-157, 1999
15.
Whitney EG, Brophy CM, Kahn EM, et al: Inadequate cerebral perfusion is an unlikely cause of peri-operative stroke. Ann Vasc Surg11: 109-114, 1997
16.
Riles TS, Imparato AM, Jacobowitz GR, et al: The cause of peri-operative stroke after carotid endarterectomy . J Vasc Surg19:206-214, 1994
17.
Krul JM, van Gijn J., Ackerstaff RG, et al: Site and pathogenesis of infarcts associated with carotid endarterectomy . Stroke20:324-328, 1989
18.
Gaunt ME, Smith JL, Martin PJ, et al: A comparison of quality control methods applied to carotid endarterectomy. EurJ Vasc Endovasc Surg11:4-11, 1996
19.
Gaunt ME, Smith J., Martin PJ, et al: On-table diagnosis of incipient carotid artery thrombosis during carotid endarterectomy using transcranial Doppler sonography. J Vasc Surg20:104-107, 1994
20.
Gaunt ME, London Njm, Smith J., et al: Early diagnosis of post-operative carotid occlusion using transcranial Doppler ultrasound. J Vasc Surg20:1004-1005, 1994
21.
Lennard N., Smith JL, Gaunt ME, et al: A policy of quality control assessment reduces the risk of intra-operative stroke during carotid endarterectomy. Eur J Vasc Endovasc Surg17:234-240, 1999
22.
Levi CR, O'Malley HM, Fell G., et al: Transcranial Doppler detected cerebral embolism following carotid endarterectomy: High microembolic signal loads predict post-operative cerebral ischaemia. Brain120:621-629, 1997
23.
Spencer MP: Transcranial Doppler monitoring and causes of stroke from carotid endarterectomy . Stroke28:685-691, 1997
24.
Cantelmo NL , Babikian VL, Samaraweera RN, et al: Cerebral microembolism and ischaemia changes associated with carotid endarterectomy, J Vasc Surg27:1024-1030, 1998
25.
Lennard N., Smith JL, Abbott R., et al: Prevention of post-operative thrombotic stroke after carotid endarterectomy: The role of transcranial Doppler ultrasound. J Vasc Surg26:579-584, 1997
26.
Lennard N., Smith JL, Hayes P., et al: Transcranial Dopper directed Dextran therapy in the prevention of postoperative carotid artery thrombosis: 3 hrs monitoring is as effective as 6 hrs. EurJ Vasc Endovasc Surg17:301-305, 1999
27.
Halsey JH, McDowell HA, Gelman S., et al: Blood flow velocity in the middle cerebral artery and regional cerebral blood flow during carotid endarterectomy. Stroke20:53-58, 1989
28.
Naylor AR, Hayes PD, Allroggen H., et al: Reducing the risk of carotid surgery: A seven year audit of the role of monitoring and quality control assessment. J Vasc Surg (in press)
29.
Delamothe T. : Who killed cock robin?Br Med J316:1757, 1998
