Carotid endarterectomy. Long term follow-up with specific reference to recurrent stenosis, contralateral progression, mortality and recurrent neurological episodes.

This study follows up 292 carotid endarterectomy operations in 256 patients using the colour coded carotid Doppler Imager and oculoplethysmography and reports the rate of ipsilateral restenosis, contralateral progression, late (after 30 days postoperatively) neurological symptoms and mortality in life table form. The restenosis rate was 15% at 5 years. No case of restenosis presented with symptoms and none required reoperation. The contralateral progression rate from less than 50% internal carotid artery stenosis to greater than 50% was 20% over 5 years. Significantly more symptoms were associated with cases of contralateral progression (p = 0.05). The late neurological symptom rate was 14% at 5 years and was associated with widespread intra/extracranial vascular disease rather than restenosis. The late death rate was 12% at 5 years of which 40% were due to myocardial infarction. The overall postoperative death rate over 5 years was the same as an age and sex matched population. A more aggressive approach to coronary artery disease does not appear justified. The value of noninvasive tests in the post-endarterectomy situation is stressed with particular reference to documentation of contralateral progression.

Quantitative common carotid artery blood flow: prediction of internal carotid artery stenosis.

Common carotid artery (CCA) blood flow was measured noninvasively with a pulsed Doppler duplex scanner modeled after the Octoson (Ultrasonics, Inc., No. Yonkers, N.Y.). The aim of the study was to determine normal values and to assess the accuracy of CCA flow as a predictor of internal carotid artery (ICA) stenosis. One hundred one people who did not have disease were studied; the overall mean flow rate was 395 +/- 79 ml/min (mean +/- S.D.). There was no significant correlation with age, height, or body surface area but there was with body weight (p less than 0.05). A statistically significant difference was evident between men (424 +/- 88 ml/min) and women (371 +/- 62 ml/min) (p less than 0.001). The intrasessional variation (S.D./mean) was 13% and the intersessional variation, 16%. No significant difference was seen between the sides. Ninety-two patients who had carotid angiography were studied and the flow rates compared with the degree of ICA stenosis on each side. The flow rate for mild ICA stenosis (1% to 39%) was 404 +/- 109 ml/min, for moderate stenoses (40% to 69%), 390 +/- 91 ml/min, and for severe stenoses (70% to 99%), 351 +/- 109 ml/min. There was a significant difference in flows only between mild and severe grades of stenosis of the ICA (p less than 0.01). With unilateral stenosis, comparison of flow values in the normal and affected sides showed the greatest discriminatory power when the absolute difference of flow values was taken (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Duplex scanning of the portal vein and portasystemic shunts.

This article describes the preliminary findings of a Duplex ultrasound technique that enables the patency of the portal circulation and portosystemic shunt patency to be determined. In addition, the equipment allows the noninvasive measurement of quantitative rates of blood flow in these vessels. Portal vein flow was 952 +/- 273 ml/min in 10 normal subjects after an overnight fast and increased by 50% at 30 minutes in response to a standard 660-calorie liquid meal. Thirteen portosystemic shunts were scanned, and hemodynamic information was obtained from 10. Three of the four patients who had a Warren shunt performed 3 to 4 years earlier had portal vein occlusion. There is evidence of an increase in flow through the Warren shunt on feeding, suggesting a hemodynamic connection to the mesenteric side of the circulation. The apparatus, technique of examination, and the characteristics and difficulties with particular types of shunts are described.

Intraoperative ultrasound during carotid artery surgery.

Intraoperative B-mode ultrasound (OPUS) has been used to scan 155 carotid bifurcations during endarterectomy. Intimal flaps, residual plaque and suture line stenosis were detected by this method. Most defects were found in the external carotid artery (11%) and the importance of adequately clearing this vessel is stressed. The internal carotid artery had defects in 8% of cases, most of which were of a minor nature (less than 30% encroachment on luminal diameter). The presence of minor technical defects at operation was not significantly associated with the development of postoperative bruits or restenosis. Major defects were corrected at the time of surgery. OPUS is a useful adjunct in ensuring a technically satisfactory endarterectomy.

Fluid filled oculoplethysmography and carotid artery disease: imperfect but useful.

Fluid filled oculoplethysmography (OPG) is a widely used method of assessing carotid stenosis but it has limitations in the detection of bilateral internal carotid artery lesions and of external carotid artery stenoses. In this study, 157 consecutive patients having carotid angiography and fluid filled OPG were assessed to determine the accuracy of the technique and define the sources of error. Haemodynamically significant stenosis (HDS) was defined as at least 50% stenosis of the internal carotid artery (ICA). Only the most severely stenosed side of the 35 bilateral HDS lesions was detected owing to the poor reliability of ear pulse delays. Eye/eye delays alone detected the most severely stenosed side in 82 of 98 patients with an HDS stenosis of one or both ICAs for a sensitivity of 84% a specificity of 71% (41/59) and accuracy of 79% (81/157). The measurement of ear/ear pulse delays for external carotid artery (ECA) stenosis had a sensitivity of only 15% (5/34). Ear/eye pulse delays detected none of the 35 patients with bilateral HDS ICA stenosis. Bilateral equal HDS ICA stenoses were a significant source of error. Stenotic disease was present in the aortic arch and branches (five patients) or the carotid siphon (eight patients) and in seven cases it resulted in an incorrect localization on OPG. There was no diagnostic relationship between the severity of delay and the presence of total occlusion. Chronic local eye pathology was present in 13 patients and did not affect the results of the OPG. We have ceased to use ear pulse measurements for routine assessment but continue to use the eye/eye delays in conjunction with a carotid doppler imaging system.

Colour-coded carotid Doppler imaging: an angiographic comparison of 324 bifurcations.

The accuracy of a colour-coded Doppler ultrasound imaging system in the assessment of the extracranial carotid tree is presented. A series of 162 consecutive patients (324 bifurcations) were assessed with angiographic control. Doppler frequency shifts of between 3600 and 5000 Hz, corresponding to yellow on the colour code, detected carotid arteries that were stenosed greater than or equal to 50% with a sensitivity of 95%, a specificity of 72% and an overall accuracy of 81%. At frequency shifts of over 5000 Hz corresponding to the blue code, the sensitivity was 83%, specificity 90% and accuracy 87%. With highly stenosed lesions (90-99%), 24% were incorrectly diagnosed as occlusion by the imager. In those cases with a haemodynamically significant lesion on one side there is no evidence of a compensatory increase in velocity on the other side. The technique is readily learnt but an awareness of its pitfalls is essential for accurate scanning and these are discussed. Carotid Doppler imaging has superseded phono-angiography and peri-orbital Doppler examination in our laboratory and is used with the oculoplethysmograph in the routine assessment of patients with suspected carotid bifurcation disease.

Sipple syndrome: marked variability of the disease within a family and implications for management.

Familial medullary carcinoma of the thyroid gland is often associated with phaeochromocytoma; this condition is known as Sipple syndrome. The rate of progression of the disease and the degree of malignancy of the medullary carcinoma may vary from family to family. Thus the nature and behaviour of this disease in any particular family influences the management of the thyroid carcinoma component. The authors measured plasma calcitonin and plasma catecholamines in 21 members of a family with Sipple syndrome. In one branch of this family 5 out of 7 members have so far been affected, 4 with metastases or recurrence of the carcinoma and 2 with development of phaeochromocytomas. In contrast, of the 14 members in the other 4 family branches, only 4 have had pathologically elevated plasma calcitonin concentrations following alcohol provocation, probably representing C-cell hyperplasia or very early neoplasia and apparently not progressing. None has evidence of phaeochromocytoma. This family demonstrates a striking variability in the natural history of Sipple syndrome which, despite increasing discovery of more families with medullary thyroid carcinoma, has not been previously reported. In the light of this finding, a reappraisal of the management of the thyroidal component of this disease is necessary. It appears that radical neck surgery may be needed to prevent recurrence of the disease.

Abdominal tuberculosis.

In Britain abdominal tuberculosis is an uncommon condition and most cases come to laparotomy for diagnosis. A high index of suspicion is required in areas with a large immigrant population and in areas which are overcrowded and nutritionally deprived. Nine of 28 patients presented acutely and a wide variety of preoperative diagnoses were entertained. Most of the remainder had a long history of vague constitutional symptoms and laparotomy was required for diagnosis in all but 5. Histology proved the surest way of establishing the diagnosis.