Intraoperative duplex ultrasound during carotid endarterectomy.

The purpose of this study was to examine the technical aspects of intraoperative duplex ultrasound (DUS) following carotid endarterectomy (CEA), suggest criteria to differentiate significant lesions requiring immediate surgical revision from normal or benign defects, and evaluate how frequently intraoperative DUS provides useful or unsuspected information. A retrospective study was performed on all patients who had both CEA and intraoperative carotid DUS between January 1, 1990, and January 1, 1995. A total of 155 DUS examinations were performed in 149 patients. Findings were grouped into three categories: normal; minor/insignificant lesions; and hemodynamically significant lesions based on the presence or absence of elevated peak systolic velocities, visible stenosis/thrombus, or intimal flap/dissection. Postoperative status was correlated with intraoperative DUS findings. Ninety-one (59%) examinations performed on 87 patients produced normal findings. Forty-seven (30%) examinations performed on 45 patients showed minor abnormalities consisting of insignificant residual plaque, residual external carotid artery stenoses, small intimal flaps, elevated velocities with no associated anatomic lesion, or an arterial kink. Fourteen patients (9%) had significant findings requiring immediate surgical revision. These consisted of large intimal flaps or dissection in six patients, marked residual plaque and significant stenosis in five patients, thrombus in two patients, and a kink in one patient. Three additional patients (2%) had significant findings but were not revised for various reasons. No significant difference was identified in morbidity or mortality rates between those patients with normal findings, those patients with minor technical defects, and those patients with significant abnormalities undergoing immediate surgical revision. However, two of three patients who had significant abnormalities within the common carotid artery that were not revised suffered perioperative ipsilateral strokes. Intraoperative DUS is a safe and accurate method to assess the technical adequacy of CEA. Intraoperative DUS showed significant lesions in 11% of patients. Identification and immediate repair of significant technical defects may decrease perioperative complication rate and long-term restenosis rate.

Gastric carcinoid tumors associated with chronic hypergastrinemia in a patient with Zollinger-Ellison syndrome.

A patient with long-standing Zollinger-Ellison syndrome, treated for 14 years with antisecretory agents, underwent computed tomography and upper gastrointestinal examination because of upper gastrointestinal bleeding. Radiologic and pathologic examinations showed multiple nodular masses arising from the wall of the stomach that were determined to be mucosal carcinoid tumors. A gastrin-producing islet cell tumor of the pancreatic head was also present. Gastric carcinoid tumors occurred as a consequence of chronic hypergastrinemia.

Intraoperative color-flow duplex ultrasonography following carotid endarterectomy.

Intraoperative color-flow duplex ultrasonography represents the state-of-the-art imaging following carotid endarterectomy. At a reasonable cost and at no risk to the patient, it provides a high-resolution image of the operative site and reproducible hemodynamic velocity measurements. Although significant technical abnormalities have been noted in approximately 10% of patients, important lesions are found in only 5% of common or internal carotid arteries. In our opinion, these common and internal carotid artery defects represent the lesions that should be re-explored and corrected prior to leaving the operating room. The most cost-effective way to utilize intraoperative color-flow duplex ultrasonography is to arrange a 15- to 20-minute visit to the operating room by a technologist bringing a duplex scanner from the vascular laboratory or department of radiology. If the surgeon is not experienced in performing duplex ultrasonography, the test should be performed in conjunction with another physician, surgeon, or radiologist who specializes in ultrasound. In our experience, color-flow duplex ultrasonography enhances endarterectomy technique and consequently minimizes postoperative strokes and restenosis.