[Current aspects of cerebral protection in carotid surgery: update]. / Aspects actuels de la protection cérébrale en chirurgie carotidienne: mise au point.

The goal of cerebral protection in carotid surgery is to reduce postoperative central neurological complications and thus reduce morbidity-mortality of carotid endarterectomy. With improving understanding of the mechanism leading to neurological complications, means of achieving cerebral protection have been developed. Preoperative evaluation of the ischemic risk is based on the neurological examination and on computed tomography and magnetic resonance imaging findings. The possibilities of arterial supply during carotid cross-clamping can be recognized with the help of arteriography, transcranial Doppler or angio-MRI. Selective or systematic use of an intraluminal shunt and preoperative heparin therapy are the main methods used for cerebral protection. The risk of early postoperative stroke can also be reduced by careful preoperative anatomic control to detect any technical failure. Discussion on the usefulness of monitoring cerebral function during the procedure is closely related to the experience of the surgical team. The only method currently accepted by all surgeons is the use of stents during carotid angioplasty to achieve cerebral protection.

[Carotid endarterectomy using eversion. One year radiologic results]. / Endartériectomie carotidienne par éversion. Résultats radiologiques à un an.

A prospective study was done in 100 patients operated on for a stenosis of the carotid artery by the eversion endarterectomy method of Van Maele (section-eversion-anastomosis) between January 1994 and August 1995. Ten patients were operated on bilaterally (thus, 110 procedures). The distribution of the patients was as follows 81 males and 19 females, mean age 71 years. Clinically, 50 patients were asymptomatic, 44 stage I, 2 stage II and 4 stage III. Arteriography of these patients showed 42 stenoses greater than or equal to 90%, 56 stenoses between 70 and 90% and 12 ulcerated plaques (according to the ESCT measurement standards). Concerning the supra-aortic vessels, 24 lesions of the vertebral-subclavian branches and 21 lesions of the intra-cerebral vessels were observed. Five endarterectomies out of the 110 (5.4%) could not be performed by this eversion method because of the immediate poor technical result before angiography. At the end of the procedure digital angiography was performed for all the patients who underwent an eversion endarterectomy (105 cases). Six images of the internal carotid artery presenting stenoses less than 30% were observed at the level of the implantation site. Two narrow stenoses of the distal part of the endarterectomy made the interposition of a PTFE graft necessary in 20% of the cases, a secondary procedure was necessary after the peri-operative angiography 2 implantations of PTFE in the internal carotid artery, 8 additional endarterectomies of the external carotid artery, 11 infiltrations with Papaverine. The immediate post-operative results were 1 death after hemiplegia, 1 hemiplegia with sequelae (mortality/morbidity approximately 2%, i.e. 2/103 eversions), 3 regressive hemipareses. Angiographic follow-ups after 1 year were performed on 100 out of 110 operated carotid arteries. With regard to the internal carotid artery, 4 patients showed a stenosis less than 30%, 1 patient a 50% stenosis, 1 patient a pre-occlusive stenosis making an operation with the interposition of a PTFE graft necessary (restenosis rate after one year 2%). All the patients followed after one year remained asymptomatic. Eversion endarterectomy is possible for the majority of the atheromatous stenoses of the carotid artery (5.4% were not possible for technical reasons). We find this method not appropriate when a shunt must be placed. Immediate results are comparable to those of classical surgical endarterectomy with or without patching. The restenosis rate at 1 year in our series is 2%. This technique provides an excellent anatomic result by peri-operative angiography and can especially be adapted to stenoses with excess of length of the carotid artery.

Aneurysms of anomalous splenomesenteric trunk: clinical features and surgical management in two cases.

Aneurysms of the splenic artery that anomalously arise from a splenomesenteric trunk are a rarity. Aneurysmal disease of visceral arteries is found in only 0.2% of the general population. The celiac trunk and superior mesenteric artery (SMA) are involved in less than 10% of all visceral aneurysms. Although rupture seems to occur in 20% to 22% of patients, the related mortality rate can rise as high as 100%. Anomalies of the celiac trunk and SMA, more common than previously claimed, include the splenic artery arising from the SMA, which occurs in only 1% of patients. We present two cases of young patients who had 4-cm aneurysms behind the pancreas that involved an anomalous splenic artery. The first patient required dissection of the entire splenopancreatic bloc through a transverse abdominal incision to excise the aneurysm and repair the SMA. The second patient was treated by the classic approach, through a median incision and by entering the mesenteric root. There do not seem to be reports of similar cases, except for two cases of aneurysms involving the celiomesenteric trunk. The cause of these aneurysms can be attributed to mesenchymal alterations during the embryonic formation of aortic collateral branches. A correct surgical approach to splanchnic aneurysms calls for awareness of potential vascular variations of the arteries and their collateral pathways.

Long-term results with the Palmaz stent in the superficial femoral artery.

PURPOSE: Femoral stenting has demonstrated inconsistent and often disappointing long-term results. To compare out experience, we retrospectively analyzed a series of patients who had Palmaz balloon-expandable stents placed exclusively for superficial femoral artery (SFA) lesions. METHODS: From January 1990 to November 1993, 39 patients were evaluated for claudication (79%) or critical ischemia in 42 limbs. The culprit lesions were confined to the SFA: 24 (57%) occlusions and 18 (43%) stenoses, including 3 restenotic lesions. Stenting was elective in 12 (29%) cases: the 3 restenoses and 9 chronic, calcified occlusions. The remaining stents were applied for postangioplasty residual stenosis or angioscopic findings of thrombogenic luminal irregularities. A total of 55 prostheses were successfully implanted. All patients were maintained on ticlopidine and followed by routine duplex scanning. Follow-up angiography was performed in 28 (72%) patients between 4 and 45 months. RESULTS: In the postprocedural period, two acute thromboses (4.8%) occurred within 48 hours in patients who had long occlusions and poor runoff; no other major complications were encountered, for a clinical success rate of 95%. Follow-up evaluation ranged from 4 months to 4 years with a mean of 25 months. The restenosis rate was 19% (34% in occlusions; 10% in stenotic lesions, p = NS). At 24 months, cumulative primary patency was 77% and secondary patency 89%. CONCLUSIONS: Palmaz stents performed will in the SFA, demonstrating a low acute thrombosis rate and good long-term patency. The incidence of restenosis is likely to be greater in occlusions than in stenoses.

In vitro testing of six inferior vena cava filters: filtering efficiency and pressure measurements.

UNLABELLED: The purpose of this study is to compare in standarddised ex vivo conditions the performances of six percutaneous vena cava filters available on the European Market. METHODS: We use a mock circulation with polyethylene beads simulating clots to objectively determine the filtering efficiency of the different devices. We measured pressure at contact points with the wall of the tube simulating vena cava, and also gradient of pressure induced by the empty and full filter. Statistical analysis of the data obtained (at least 100 measurements for each filter) showed great consistency in the response of a given filter to the different conditions of mock circulation. RESULTS: The Greenfield Filter, which served as the reference, was compared to the other models. Its filtering efficiency was acceptable as was that of the L.G. Filter. The Cardial Filter and Vascor Filter were the most efficient. The Antheor Filter and the Filcard Filter performed poorly. CONCLUSION: The mock circulation give reliable and reproducible data on the filtering efficiency for a device but ease of placement and clinical studies must be taken into account for the choice of the filter.

[Video-assisted thoracic surgery with mini-thoracotomy: limits and indications]. / Chirurgie thoracique vidéo-assistée avec mini-thoracotomie: limites et indications.

Video-assisted thoracic surgery (VATS) combines a 5 cm mini-thoracotomy and videoscopic control using a camera. This technique is designed to reduce surgical invasiveness. From January 1993 to March 1994, we operated on 60 patients by 61 VATS. The conversion rate to classical thoracotomy was 8%. The cases treated included 18 lung cancers, 20 cases of pulmonary emphysema, 6 cases of non-malignant pulmonary nodules, 2 cases of bronchectasies and 10 operations on the pleura, pericardium or thoracic sympathetic nerves. We performed 12 lobectomies, 24 atypical segmentectomies and 10 other operations. The hospital mortality rate was 2/60 (3.5%), the mean thoracic drainage duration was 3.2 days, and the mean hospital stay was 9.2 days. VATS provides certain analgesic and esthetic benefits but the functional benefit must be studied in more detail. VATS can be applied to segmentectomies and lobectomies for T1 or T2 lung cancers; but the benefits relating to malignancy must be precisely identified by long-term studies.

Interruption of the inferior vena cava using the Vascor filter: preliminary series of 51 cases.

Between February 1991 and October 1991, vena cava filters made of Vascor (Toulon, France) were inserted into 51 patients. The male:female ratio was 29:22 and mean age 74 (range 45-94) years. Diagnosis of thrombophlebitis was established by venography in 48 patients (94%) and ultrasonography in three (6%). Thrombosis was unilateral in 49 patients and bilateral in two, involved the pelvic veins in 38 (75%) and the leg veins in 13 (25%). Of the 51 patients, 17 (33%) presented pulmonary emboli and 12 (24%) had waving supracrural clots. The Vascor umbrella filter is a two-stage stainless-steel device with attachment tabs for anchoring and centering. It can be placed either percutaneously using a 7-gauge French introducer via the jugular, subclavian or brachial vein or surgically. In the present series, placement was achieved percutaneously via the jugular vein, in 49 cases (96%) and surgically in two (4%). Postoperative and follow-up examinations included coagulation tests, Doppler ultrasonography and abdominal radiography. In the immediate postoperative period, one patient developed a pneumothorax which was treated by pleural drainage and five died from cancer within the first month after placement. There were no postoperative accidents and no patient had recurrent embolism. In three patients, the filter tilted 30 degrees and in one caval thrombosis was identified. Follow-up examinations were performed in 46 patients, with a mean duration of 12 months. Ten patients have died. Caval thrombosis occurred in two patients (4%) but proximal migration of the filter and recurrence of pulmonary embolism have not been observed.

Transluminal angioplasty for recurrent stenosis after carotid endarterectomy. Prognostic factors and indications.

Over a 15-month period ending in July 1992, 9 patients (7 male, 2 female; mean age 67 years) with recurrent stenosis of the internal carotid artery underwent transluminal angioplasty (TLA). The mean interval between endarterectomy and treatment of recurrent stenosis was 45 months (range: 9 to 84 months). All patients were symptomatic except one with extensive bilateral carotid dysplasia. Three patients had recurrence proximal to the endarterectomized segment (Group I); in one of these patients the narrowing was extensive. The other 6 patients (Group II) demonstrated stenoses distally. In one of these latter patients, the narrowing developed in a vein bypass. Balloon dilation was performed by the surgical route in 3 patients and percutaneously in the other 6. Perioperative transcranial Doppler (TCD) monitoring was employed in all procedures. Postoperative treatment consisted of oral Ticlopicine. In Group I (proximal recurrence), immediate complications included one case of reversible spasm and two dissections that led to acute thrombosis treated by emergency bypass and to sylvian artery embolism complicated by transient hemiplegia. In Group II (distal disease), dissection was not encountered, and only one case of transient neurologic manifestations due to cerebral edema following reperfusion was observed. Mean follow-up has been 18 months (range: 9 to 24 months). All patients are presently asymptomatic. In Group II, 2 patients presented with secondary recurrence at 6 months and were treated again by angioplasty. In one of these cases, a Palmaz stent was placed to prevent restenosis by elastic recoil.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary surgical resection of tumors of the anterior mediastinum]. / Exérèse chirurgicale première des tumeurs du médiastin antérieur.

Seventy-two anterior mediastinal tumors were operated upon between 1981 and 1991. This accounted for 2% of the 3579 thoracotomies performed during the same period (excluding cardiac surgery). With the exception of Hodgkin's disease, lymphomas and metastases diagnosed either by anterior mediastinoscopy or at thoracotomy, other tumors were treated by the widest possible excision followed by adjuvant treatment in case of incomplete excision. These tumors included 16 metastatic carcinomas and 55 affecting the thymus-including 27 malignant thymomas and 15 benign tumors of the thymus including 2 carcinoids, 6 cases of Hodgkin's disease involving the thymus, 5 non-seminomatous germinal tumors, one differentiated neuro-endocrine carcinoma, 1 thymus lymphoma and 1 seminoma. The approach was via sternotomy in 32 cases and thoracotomy in the other 40. Excision was deemed complete in 45 cases, incomplete in 25 cases and impossible in 2 cases. Extension of surgical excision involved various adjacent organs: the lung in 10 cases and the pericardium in 5. Involvement of the phrenic nerves was found in 25 cases, the aorta in 1, the pulmonary artery in 1 and the vena cava or its afferent vessels in 33 cases. Seven PTFE venous bypasses were performed. Operative mortality was nil. One patient died on the 8th day of undefined causes. Mean tumour survival in metastatic thymomas was nevertheless 19 months. Survival in malignant thymomas was related to the stage of progression of the tumour. When complete excision was possible, survival was 89% with a mean follow-up of 57 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Place of the right gastro-epiploic artery in coronary revascularization by exclusive arterial grafts]. / Place de l'artère gastro-épiplooïque droite dans les revascularisations coronaires par greffons artériels exclusifs.

From March 1990 to July 1991, 35 patients underwent coronary artery bypass grafts using the right gastro-epiploic artery (GEA). Twenty-nine patients had exclusively arterial grafts using a combination of GEA and internal mammary artery (IMA) in situ. The selection criteria for this group of 29 patients included a life expectancy exceeding ten years to avoid the need for reoperation due to deterioration of the grafts. This group consisted of 27 men and two women under the age of 70 years (mean age: 58 years, range: 36 to 70), 11 patients (38%) were under the age of 50 years and 15 (52%) were under the age of 60 years. Cardiac status was relatively well preserved. The mean ejection fraction was 58% (range: 25-70%). Fourteen patients (48%) had had a preoperative myocardial infarction. Fifty-five p. cent were smokers, 41% suffered from HT and 31% had a dyslipidaemia. Six patients (20%) had respiratory failure, 6 others (20%) were severely overweight and 2 patients were diabetic. According to the NYHA classification, 14 patients (48%) were stage IV, 9 patients (31%) were stage III and 6 patients (20%) were stage II. The mean number of bypass grafts per patient was 2.8 and 8 sequential bypass grafts (27%) were performed. The GEA was used in 29 cases, the left IMA was used in 28 cases, the right IMA was used in 13 cases and the epigastric artery was used as a free graft in 3 cases. Associated lesions included a resected left ventricular aneurysm. No associated valve procedures were performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke prevention during carotid surgery in high risk patients (value of transcranial Doppler and local anesthesia).

In a series of 114 cases, carotid surgery was performed under local anesthesia by cervical block in order to assess cerebral status. Preoperative transcranial Doppler was used to select high risk patients for shunting. Intraoperatively brain function was checked by carotid arterial blood pressure monitoring and transcranial Doppler. No stroke occurred during the procedure. Postoperatively two deaths (1.8%) occurred, one due to intracerebral hemorrhage and one to a late myocardial infarct. The predictive value of both transcranial Doppler and stump pressure monitoring for shunting was 97% respectively. In combination, the two methods provided 100% protection. During the same period, 1406 patients underwent carotid surgery under general anesthesia. Carotid surgery stroke can be prevented either by using transcranial Doppler together with carotid stump pressure monitoring when the procedure is performed under general anesthesia or by operating under local anesthesia.

Long-term peripheral stent evaluation using angioscopy.

To evaluate incorporation of peripheral artery stents into the arterial wall, we performed angioscopy on 13 patients fitted with Palmaz endoluminal stents. Of the 15 stents inspected, 5 were in the iliac artery, 9 in the femoral artery and 1 in the popliteal artery. The indications for placement were occlusion in 4 cases and high-grade stenosis in 11 cases including 3 restenosis after balloon dilatation and 1 restenosis after surgery. In 9 cases prosthesis insertion was preceded by laser treatment (Trimedyne Nd:YAG Cardiolase 4000). The decision to use a stent was based on radiologic findings in 3 cases (residual stenoses, dissections) and on angioscopic visualization in 7 cases (2 dissections, 5 flaps). In the remaining cases stent placement was performed electively. The only postoperative treatment was antiplatelet therapy (Ticlopidin). At the time of examination, the mean duration of placement was 6 months (extremes: 2 and 12 months). Inspection was made using Sopro-Meadox angioscope with a 0.75 mm probe mounted on an occlusive balloon for stents in the iliac artery and with a 2.2 mm probe with a working channel and sometimes a deflecting device for stents in the femoral or popliteal artery. Angioscopy was successful in all cases. Angiography was always performed at the same time as endoscopy. Endothelialization was observed in all cases. It appeared as a uniform and smooth whitish layer with a thickness proportional to the duration of placement. Endothelialization was most rapid in femoropopliteal arteries, total coverage being achieved within 4 months. Endothelialization took the longest on medial side of the iliac artery which may remain partially exposed after 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Descending thoracic aorta as an inflow source for late occlusive failures following aortoiliac reconstruction.

From November 1984 to March 1990, 10 descending thoracic aorta-to-femoral artery bypass procedures were performed after failure of one or several aortoiliofemoral reconstructions. All patients were men, mean age 60 years. Indications included noninfected false aneurysm of an infrarenal end-to-side aortoprosthetic anastomosis in one case; one occlusion of an axillofemoral bypass; degradation of an aortobifemoral prosthetic graft; two occlusions of aortofemoral bypass; and five occlusions of aortobiliac or aortobifemoral bypasses. Eight bifurcated grafts, one aortoprosthetic tube graft, and one aortopopliteal tube graft were inserted. One patient died 23 days postoperatively of multiple organ failure. Three patients underwent a successful seconary lower limb reconstruction procedure (prosthetic limb thrombectomy, embolectomy, femoral bifurcation angioplasty in one case each). Mean survival time was 14 months (range 3-48 months). Two patients were lost to follow-up, and one died of myocardial infarction six months postoperatively with a patent bypass. Graft thrombosis occurred in two patients. One was treated by thrombectomy at five months, the other was treated by in-situ thrombolysis at 15 months. Both of these patients had patent grafts at 12 and 21 months, respectively. The four other patients had patent grafts at 48 months. Primary patency was 55.5% (5/9 survivors) and secondary patency was 100% (9/9). This is a relatively simple method for constructing an extraanatomic aortofemoral or aortobifemoral bypass in late failures of aortoiliofemoral reconstructive surgery without having to re-enter the abdomen.

Secondary aortoduodenal fistulas: value of initial axillofemoral bypass.

Between January 1970 and April 1989, 20 patients underwent operation for secondary aortoduodenal fistulas. When the preoperative diagnosis was certain and emergency control of bleeding not required, initial axillofemoral bypass was performed before ablation of the infected aortic prosthetic graft during the same operation. When diagnosis was uncertain or severity of bleeding required emergency laparotomy, the therapeutic plan varied over time. Until 1980, we performed either a direct repair (three cases) or the ablation of the aortic graft followed by secondary axillofemoral bypass (four cases). After 1980, the order of procedures was 1) control of bleeding whenever necessary, 2) axillofemoral bypass, and 3) ablation of the aortic graft. Postoperative mortality was two of 13 in patients undergoing initial axillofemoral bypass, compared with six of seven patients undergoing direct surgery or initial ablation of the aortic graft. Of the 12 patients surviving the postoperative period, three died of aortic stump hemorrhage, four, 12, and 14 months after operation. Two patients had a new aortic graft inserted. Repeat replacement of the abdominal aorta graft was performed in one case and ascending thoracic aortobifemoral bypass in the other because of secondary thrombosis of the axillofemoral bypass. We conclude that initial axillofemoral bypass before dealing with the aortic graft improves the immediate prognosis in operations for secondary aortoduodenal fistulas. This procedure does not, however, preclude the possibility of aortic stump infection which can lead to recurrent aortoduodenal fistula. The risk of infection or secondary occlusion of axillofemoral bypass is minimal. Secondary prosthetic replacement is not systematically necessary.

[Revascularization of the distal portion of the deep femoral artery. Indications and results]. / Revascularisation de l'artère fémorale profonde distale. Indications et résultats.

Most of the times, the distal part of the deep femoral artery is not affected by atheromatous disease. It constitutes an acceptable alternative, whenever the femoral bifurcation is not usable for bypass. This artery is readily approached directly, at a point removed from Scarpa's fascia. We used this technique on 60 patients. Indications included: multiple reoperations (45 cases, 75%), infection of Scarpa's fascia (2 cases, 3%), calcified or thrombosed femoral bifurcation (13 cases, 22%). Lim salvage for decubital pain, grade-IV or acute ischemic disease involved 49 cases (82%). After a mean 28.5 month follow-up period, arterial permeability was 74% and 53% after one year and 5 years, respectively. These results are compared with literature data. Long-term permeability is related to two factors: proximal bypass implantation site and the state of the popliteal reentry and arterial network of the leg. Utilization of the distal segment of the deep femoral artery via an elective approach is interesting of the deep femoral artery via an elective approach is interesting and sensible, whenever the femoral bifurcation is unusable owing to progressive atheromatous disease, repeated surgery or infection.

The albumin-coated knitted Dacron aortic prosthesis: a clinical study.

Between June 1987 and January 1989, a total of 123 albumin-coated, knitted Dacron aortic prosthetic grafts were used in 120 patients. The aim of this study was to determine the degree of graft impermeability to blood as well as short- and medium-term patency of the graft material. Patients were grouped as follows: group I (64 patients), operation for chronic aortoiliac obliteration; group II (45 patients), operation for abdominal aortic aneurysm; group III (14 patients), operation on the thoracic aorta. Ninety-one bifurcated and 32 albumin-coated grafts were inserted. Abnormal bleeding was seen in five cases but did not lead to any adverse clinical consequences and stopped spontaneously. In group I there were two instances of early thromboses thought to be due to hemodynamic compromise, which were successfully treated surgically. In group III, two patients had early thrombosis due to coagulation disorders. These were treated by thrombectomy and medical therapy. One hundred and fourteen patients (95%) were followed for a mean of 8.2 months (range 1-18 months). Three late complications related to the prosthesis were observed: one patient had a false aneurysm occurring at month 14 and was corrected surgically. Two other patients experienced thrombosis of their graft treated by extraanatomical bypasses. Primary patency at the end of the follow-up period was 93% while secondary patency was 98%. There were no early or late infectious complications. We conclude that albumin-coated Dacron prosthesis is a reliable material for aortic replacement. Intraoperative loss of blood is reduced and short- and medium-term patency is comparable to those of uncoated aortic prosthetic material.

[Isolated dissection of the celiac trunk and its branches. X-ray computed tomography and angiography findings. A case report]. / Dissection isolée du tronc coeliaque et de ses branches. Aspects tomodensitométriques et artériographiques. A propos d'un cas.

A case of primary dissection of the celiac trunk in a young hypertensive patient is presented. The diagnosis, suspected by ultrasonography, was confirmed by angiography and CT which also allowed a study of the visceral complications. Appropriate surgical treatment was successfully carried out.

[Justifications and benefits of exploratory thoracotomy in stage IIIb bronchopulmonary cancer]. / Justification et bénéfices des thoracotomies exploratrices dans le cancer broncho-pulmonaire au stade IIIb.

From January 1980 to December 1984, 270 patients underwent exploratory surgery for Non Small Cell Lung Cancer with or without peritumoral lymph node involvement. In group 1: for 167 patients (62%) unresectable cancer was found. In group 2: for 103 patients (38%) an extensive resection was feasible. This study allows comparison of these two groups and confirms the value of exploratory thoracotomy. The resection was extended to the superior vena cava in 12% of cases, the trachea and carina in 28.15% and the left atrium in 49.50%. Survival in group 1 was similar to that of non operated patients (i.e. less than 10% at one year) and the mortality was 1.2% with no operative mortality. Survival of group 2 was considerably better: 58% at 1 year, 26% at 3 years, 23% at 5 years. The mortality was 3.9% with no operative mortality. Three year survival of patients with T4 N0 was clearly higher than that of T4 N2 (38% versus 17%). Although the results were poor for patients with N3 disease and those who underwent incomplete resections, they were nonetheless better than in those patients with unresectable tumors (16% versus 9% at 18 months). We conclude that: exploratory thoracotomy is safe, a significant number of patients (38% in our series) may benefit from this approach, and that it is sometimes hazardous to contra-indicate surgery for patients suffering from lung cancer only on the basis of X-Ray findings.

Carotid surgery under cervical block anesthesia. A simple method of heart and brain protection in high risk patients.

Between January 1, 1985, and December 15, 1987, 60 patients underwent surgery for carotid lesions under local cervical block anesthesia. Sixty-seven reconstruction procedures were performed including 64 endarterectomies and 3 vein bypasses. During the same 3 year period, 938 other reconstruction procedures were carried out under general anesthesia for a total of 1005 procedures. These 60 patients, who accounted for 6.7% of our indications, were selected for surgery under local anesthesia because they were at high risk for cardiac and neurologic complications. As far as staging is concerned, this subgroup of patients included: 14 asymptomatic cases (stage 0), i.e., 21%; 44 transient ischemic attacks (stage I), i.e., 66%; 2 progressive stroke (stage II), i.e., 3%; 7 patients with neurologic sequels (stage III), i.e., 10%. In all 79% of the patients were symptomatic. The asymptomatic patients all presented bilateral tight stenosis sometimes with thrombosis of the contralateral carotid. The technique of local anesthesia and endarterectomy were classic: closing with a bougie to calibrate the lumen, systematic intraoperative arteriography and immediate correction of technical failures (2 times); no death occurred among the patients in stages 0, 1 and II; 1 early asymptomatic occlusion that was not corrected was noted; in one case, a ligation of the carotid was necessary after technical failure, without consequences; one death occurred in stage III after intracerebral hemorrhage. On the basis of our experience local cervical block anesthesia appears to be a simple and reliable method of ensuring intraoperative diagnosis of cerebral ischemia. It eliminates all intraoperative cerebral complications secondary to ischemia and allows a better understanding of the physiopathologic mechanisms underlying perioperative neurologic complications. The absence of neurologic and cardiac complications in this series of very high risk patients enables us to extend eligibility for surgery to include patients with unstable cardiac and cerebral disease.