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To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.

The hemodynamic significance of the kinked internal carotid artery and cerebrovascular insufficiency are demonstrated. Several procedures have been devised to correct a carotid kink, but these involve resection or excision of the internal, external or common carotid artery. We currently prefer a reimplantation technique whereby preservation of the external carotid is maintained, resection of the internal carotid artery is avoided and, when necessary, endarterectomy may be safely employed.

A fluid-filled oculoplethysmography (OPG) was used to assess carotid artery flow in 50 patients with symptoms of cerebral ischemia. Based on positioned OPG and angiographic studies, 20 patients had angioplastic procedures. At operation, positional electromagnetic flow measurements were obtained to confirm the preoperative noninvasive findings. Electromagnetic flow reductions were identified in 18 patients with positive preoperative positional OPGs. A high correlation between noninvasive testing data and intraoperative flow measurements suggests that positional OPG testing is helpful in identifying hemodynamically significant kinking of the internal carotid artery.

Although kinking of the internal carotid artery has been recognized for many years, the surgical significance of this lesion has remained controversial. The present study was designed to identify hemodynamic significance of kinking of the internal carotid artery using a positional testing technique with preoperative and postoperative noninvasive data that were correlated with intraoperative electromagnetic flow measurements to establish operative criteria. A fluid-filled oculoplethysmograph (OPG) was used to assess carotid artery flow in 26 patients with cerebral ischemic symptoms who had angiographic documentation of kinking of the internal carotid artery. OPG testing was done with the patient's head positioned first in the neutral, then in the right and left rotations, and then in extension-flexion positions. Sixteen patients underwent angioplasty. At operation electromagnetic flow measurements of the internal carotid artery were determined in these 16 patients with similar positional maneuvers. A reduction of flow from 30% to 80% was found on positional testing during operation in 14 of these 16, and all 14 of these patients also had abnormal preoperative OPG testing. After angioplasty, effects of position on internal carotid artery flow were eliminated, as proved by electromagnetic flowmeter measurements and by follow-up OPG studies in all 14 patients. The other two patients who had been subjected to surgical correction had no positional effects as documented by electromagnetic flowmeter testing. A high correlation between noninvasive data and operative flow measurements suggests that positional OPG testing is helpful in identifying hemodynamically significant kinking. Symptomatic patients with kinking of the internal carotid artery and abnormal OPG testing may be candidates for corrective surgery.

We reviewed 125 patients who had had stroke or reversible ischemic neurologic deficits (RIND) and who underwent carotid endarterectomy, with follow-up extending to six years. Phase I patients (n = 36) had endarterectomy and shunt placement at operation by surgeons' preference. The rate of postoperative neurologic deficit was 8%. Phase II patients (n = 36) had endarterectomy monitored by EEG and stump pressures. Postoperative deficits occurred in 9%. The EEGs and stump pressures in these patients were "normal"; therefore, no shunt was used. Phase III patients (n = 41) had endarterectomy again monitored by EEG and stump pressure. Despite normal EEGs or stump by EEG and stump pressure. Despite normal EEGs or stump pressure, all patients underwent endarterectomy with a temporary indwelling shunt. No complications occurred. In 368 patients operated on for transient ischemic attacks alone, the operative stroke rate was 1.6%. Stump pressure and EEG are unreliable indicators of cerebral perfusion during carotid endarterectomy in patients who have suffered stroke or RIND. Use of a temporary shunt is indicated in all of these patients.

Aspirin (ASA) and dipyridamole (DIP) have been shown to reduce the incidence of transient ischemic attacks (TIAs), but aspirin's ability to reduce the incidence of postoperative neurologic deficits in patients who require carotid endarterectomy (CE) is controversial. To evaluate the role of adjunctive ASA/DIP in conjunction with CE, 908 CE cases were reviewed. Four hundred sixty-seven patients took ASA (650 mg/day) and DIP (150 mg/day) preoperatively, while 381 received no ASA/DIP. There was no statistical difference in the distribution of postoperative neurologic deficits. Twenty-six transient deficits occurred: 14 (53%) patients were taking ASA/DIP, whereas 12 (47%) were not. Seventeen permanent deficits occurred: ten (58%) patients were taking ASA/DIP and seven (42%) were not. ASA/DIP are useful medications in combating ischemic cerebrovascular disease, but ASA/DIP cannot replace precise operative technique which affords unequaled protection against a postendarterectomy neurologic deficit.

The ideal management of the patient with an asymptomatic stenosis of the extracranial internal carotid artery remains controversial. The purpose of this article was to evaluate the effects of prophylactic carotid endarterectomy (CE) done to treat asymptomatic carotid stenosis (greater than 50% diameter reduction by angiography) 10 years later. In 1976, 42 prophylactic CEs were performed. There were no postoperative deaths or strokes. During 10-year follow-up two strokes occurred in the operated hemisphere; one stroke was fatal and was due to an intracranial hemorrhage, whereas the other stroke was thromboembolic in origin. Two other patients suffered strokes in the contralateral hemisphere and seven patients had transient ischemic attacks in the contralateral hemisphere, which necessitated CE. The survival rate at the end of the study period by life-table analysis was 57% (mean 8.7 years). Sixteen late deaths occurred, with coronary artery-related disease the most common cause of death. This review with actual 10-year follow-up demonstrated that prophylactic CE may be performed with minimal risk, that late stroke in the operated hemisphere was negligible, and that long-term survival was similar to that of a comparable age-matched population, possibly because late deaths attributed to stroke were reduced. On the basis of long-term follow-up, CE to treat asymptomatic high-grade carotid stenoses appears to be indicated in appropriate patients.

One hundred thirty-four patients referred for myocardial revascularization had oculoplethysmography/carotid phonoangiography (OPG/CPA) evaluations as a screening test for possible carotid arterial disease. On the basis of preoperative neurologic symptoms or hemodynamically positive OPG/CPA studies, 52 patients had carotid arteriography. Forty-six patients with coexistent carotid and coronary arterial occlusive disease were identified. Twenty-nine had a previous history of central nervous system (CNS) dysfunction, while ten patients (20%) were asymptomatic. Twenty-two patients had "staged" coronary artery bypass grafts (CABG) and carotid endarterectomy (CE) procedures, while 24 had simultaneous CABG/CE. Of the staged patients, one fatal myocardial infarction occurred after CE but prior to CABG; two patients experienced neurologic deficits after CABG yet prior to CE. Twenty-four patients had simultaneous CE/CABG, and no cardiac or neurologic complications occurred. All patients undergoing cardiovascular surgery should have preoperative noninvasive carotid screening studies performed. If OPG/CPA studies indicate a hemodynamically significant lesion, arteriography is indicated. When OPG/CPA studies are negative, yet a history consistent with previous CNS dysfunction is present, a digital intravenous arteriogram is performed. In the presence of coexistence severe coronary and extracranial carotid stenotic or ulcerative plaque disease, simultaneous CE/CABG is advocated.