Carotid endarterectomy

RESUMO

Carotid endarterectomy should be considered for patients with symptoms of focal cerebral ischemia, when it can be performed with a combined morbidity and mortality below the annual risk of stroke (5 per cent). The experience with 815 carotid endarterectomies performed from 1979 to 1992 is presented. There were 530 (65 per cent) men and 285 (35 per cent) women of ages from 34 to 82 (median 65); risk factors included diabetes mellitus 196 (24 per cent), hypertension 554 (68 per cent), and smoking 570 (70 per cent). Clinical presentation consisted of transient ischemic attacks 464 (57 per cent), cerebral infarction with minimal neurological residual 228 (28 per cent), stroke in evolution 2 (0.2 per cent), and asymptomatic stenosis 121 (15 per cent). By Sundt's classification of medical risk the groups were: grade I, 106 (13 per cent); grade II, 350 (43 per cent); grade III, 357 (44 per cent); grade IV, 2 (0.2 per cent). All patients received endotracheal anesthesia. Thiopental (3-5 mg/kg) and lidocaine (1 mg/kg) were given for induction and at 15 minutes intervals during carotid cross-clamping. Intraluminal shunts were used in 14 (2 per cent). A conventional (open) endarterectomy was performed in 379 (46 per cent) and a limited endarterectomy (closed) in 436 (54 per cent). Complications included 8 (1 per cent) deaths, 24 (3 per cent) developed a major neurological deficit that persisted, 24 (3 per cent) had perioperative TIA's which resolved completely. Of the patients with preoperative neurological deficits, 32 (4 per cent) recovered. Therefore, at one month after surgery, 782 (96 per cent) were either as well or better than preoperatively.Of 483 (59 per cent) postoperative angiograms, 40 (5 per cent) showed an internal carotid artery occlusion. Six of these patients developed and immediate postoperative cerebral infarction and one died. Non-neurologic complications were: cardiac 40 (5 per cent), peripheral nerve 24 (3 per cent), and local wound problems 16 (2 per cent). A carotid endarterectomy can be performed safely when it is done with meticulous attention to detail and consistent surgical technique.