Carotid endarterectomy in women: challenging the results from ACAS and NASCET.

OBJECTIVE: To evaluate and compare the short- and long-term outcomes in female and male patients after carotid endarterectomy (CEA). SUMMARY BACKGROUND DATA: Randomized carotid trials have clearly shown the benefits of CEA in specific symptomatic and asymptomatic patients. However, the short- and long-term benefits in women appear to be less clear, and the role of CEA among women with carotid disease remains uncertain. METHODS: During a 21-year period, 1,204 CEAs were performed, 464 (39%) in women and 739 (61%) in men. Complete follow-up was available in 70% of patients. RESULTS: Women were less likely to have evidence of coronary artery disease, were more likely to be hypertensive, and had a significantly greater incidence of diabetes. The mean age at CEA was 68.5 +/- 9.5 years for women and 68.0 +/- 8.5 years for men. There were no significant differences in the use of shunts, patching, tacking sutures, or severity of carotid stenoses between men and women. Surgical death rates were nearly identical for asymptomatic and symptomatic patients. Perioperative stroke rates were similar for asymptomatic and symptomatic patients. Life-table stroke-free rates at 1, 5, and 8 years were similar for asymptomatic women and men and symptomatic women and men. Long-term survival rates at 1, 5, and 8 years were higher for asymptomatic women compared with men and for symptomatic women compared with men. As a result, stroke-free survival rates at these follow-up intervals were greater for asymptomatic women compared with men, and for symptomatic women compared to men. CONCLUSIONS: The results from this study challenge the conclusions from the Asymptomatic Carotid Endarterectomy Study and the North American Symptomatic Carotid Endarterectomy Trial regarding the benefits of CEA in women. Female gender did not adversely affect early or late survival, stroke-free, or stroke-free death rates after CEA. The authors conclude that CEA can be performed safely in women with asymptomatic and symptomatic carotid artery disease, and physicians should expect comparable benefits and outcomes in women and men undergoing CEA.

A prospective study of discharge disposition after vascular surgery.

OBJECTIVE: The purpose of this study was to determine what factors are predictive of a decline in independent living after vascular surgery during recovery. METHODS: Demographics, risk factors, operations, complications, wound status, and discharge disposition for all patients admitted to a tertiary vascular surgery service for any surgical procedure were prospectively recorded at the time of discharge. The declining order of dispositions at discharge were home (no professional assistance), home (professional assistance), rehabilitation facility, and skilled nursing facility. RESULTS: Over a 15-month period, 380 patients underwent 442 primary operations. Primary operations included 74 (17%) carotid procedures, 38 (8%) aortic procedures, 186 (42%) extremity revascularizations, 29 (7%) major amputations, 45 (10%) minor amputations, and 70 (16%) other. There were 148 (33%) complications and 85 (20%) subsequent operations (same hospitalization); 159 (36%) open wounds occurred. Forty-six percent of the patients were discharged to home (no professional assistance), 28% to home (professional assistance), 3% to a rehabilitation facility, and 18% to a skilled nursing facility; 5% died. At discharge, 51% of patients required professional assistance, 39% had a decline in disposition, and 12% went from home (+/- professional assistance) to a facility. By multivariate regression analysis, a hospital stay more than 6 days, emergency operation, open operative wound, systemic complications, and minor amputation were significantly associated (P <.001) with a decline in disposition at discharge (odds ratios: 5.5, 3.7, 3.6, 3.6, and 2.8, respectively). CONCLUSIONS: Prospective study reveals that a large proportion of patients (39%) had a decline in disposition after vascular surgery. A hospital stay more than 6 days, emergency operation, open operative wound, systemic complications, and minor amputation were strong independent predictors of decline. This information suggests modifications in treatment strategies may improve independent living status after vascular surgery and decrease the intense use of extended care resources required for this patient population during recovery.

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral.

OBJECTIVE: Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report. METHODS: An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed). RESULTS: There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis. CONCLUSIONS: Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.

Special iliac artery considerations during aneurysm endografting.

BACKGROUND: The feasibility of endograft exclusion of abdominal aortic aneurysms (AAA) has been established. However, the technical challenges of graft delivery through tortuous or diseased iliac arteries and the treatment of associated iliac aneurysmal disease have received little attention. METHODS: Over 19 months, 74 patients underwent endoluminal repair of AAA and/or iliac artery aneurysms. Iliac anatomy that required special consideration during endografting was reviewed. RESULTS: Of the 74 patients, 35 (47%) had iliac anatomy that required special attention. Thirteen patients (18%) had aneurysmal involvement of a common iliac artery. Eleven of these patients required endograft extension into the external iliac artery (EIA) and hypogastric coil embolization due to the proximity of the aneurysm to the hypogastric origin. Eleven patients with ectatic, nonaneurysmal iliac arteries required aortic cuffs to achieve a distal seal in these oversized vessels. Iliac artery tortuosity or stenosis were complicating factors in 27 of the 74 patients (36%), requiring the use of brachial guidewire tension in 2 patients to facilitate tracking of the delivery device. Five patients with severely splayed aortic bifurcations required crossed placement of the iliac limbs to prevent kinking of the endograft. Occlusive atherosclerotic disease of the EIA mandated preprocedural dilatation and stenting in 3 patients and postprocedural surgical EIA reconstruction in another 5 patients. Three patients who underwent successful endograft placement required subsequent endovascular repair of traumatized EIAs. CONCLUSIONS: Iliac artery anatomy plays a significant role in the endoluminal treatment of infrarenal abdominal aortic aneurysms, complicating the procedure in up to 47% of patients with otherwise suitable anatomy. A variety of supplemental procedures, both surgical and endovascular, may be required to facilitate endograft placement. A special understanding of these constraints and proper planning is required for optimal therapy.

Algorithm for the diagnosis and treatment of endoleaks.

BACKGROUND: Endoluminal grafting of abdominal aortic aneurysms (AAA) has shown promising early results. However, endoleaks present a new and challenging obstacle to successful aneurysm exclusion. We report our experience with primary, persistent endoleaks and provide an algorithm for their diagnosis and management. METHODS: Over a 19-month period, 73 patients underwent endoluminal repair of their AAAs using a modular bifurcated endograft as part of a US FDA Investigational Device Exemption trial. Spiral computed tomography (CT) scanning was performed prior to discharge after repair to evaluate for complete aneurysm exclusion. If no endoleak was present on that initial CT scan, color-flow duplex scanning was performed at 1 month, with repeat CT scanning at 6 months and 1 year. If the initial CT scan revealed the presence of an endoleak, repeat CT scanning was performed at 2 weeks, 1 month, and 3 months, or until the endoleak resolved. Any patient with an endoleak that persisted beyond 3 months underwent angiographic evaluation to localize the source of the leak. RESULTS: At 1 month, 62 patients (85%) had successful aneurysm exclusion. The remaining 11 patients (15%) had primary endoleaks, 8 (11%) of which persisted beyond 3 months, prompting angiographic evaluation. In 2 patients the endoleak was related to a graft-graft or graft-arterial junction. One was from the endograft terminus in the common iliac artery and was successfully embolized, along with its outflow lumbar artery. The other required placement of an additional endograft component across a leaking graft-graft junction to successfully exclude the aneurysm. The remaining six endoleaks were due to collateral flow through the aneurysm sac. In 4 cases this was lumbar to lumbar flow fed by hypogastric artery collaterals to the inflow lumbar artery. In the remaining 2 patients the endoleak was found to be due to flow between a lumbar and inferior mesenteric artery. Resolution of the endoleak by coil embolization of the feeding hypogastric artery branch in 1 patient was unsuccessful due to rapid recruitment of another hypogastric branch. Two of the six collateral flow endoleaks have resolved spontaneously without treatment, while the remaining cases have been followed up without evidence of aneurysm expansion. CONCLUSION: Systematic postoperative surveillance facilitates proper diagnosis and treatment of endoleaks. This involves serial CT scans to detect the presence of endoleaks, followed by angiography to determine their etiology and guide treatment, if clinically indicated.

Feasibility of endovascular repair of abdominal aortic aneurysms with local anesthesia with intravenous sedation.

PURPOSE: Local anesthesia has been shown to reduce cardiopulmonary mortality and morbidity rates in patients who undergo selected peripheral vascular procedures. The efforts to treat abdominal aortic aneurysms (AAAs) with endovascular techniques have largely been driven by the desire to reduce the mortality and morbidity rates as compared with those associated with open aneurysm repair. Early results have indicated a modest degree of success in this goal. The purpose of this study was to investigate the feasibility of endovascular repair of AAAs with local anesthesia. METHODS: During a 14-month period, 47 patients underwent endovascular repair of infrarenal AAAs with local anesthesia that was supplemented with intravenous sedation. Anesthetic monitoring was selective on the basis of comorbidities. The patient ages ranged from 48 to 93 years (average age, 74.4 +/- 9.8 years). Of the 47 patients, 55% had significant coronary artery disease, 30% had significant chronic obstructive pulmonary disease, and 13% had diabetes. The average anesthesia grade was 3.1, with 30% of the patients having an average anesthesia grade of 4. The mean aortic aneurysm diameter was 5.77 cm (range, 4.5 to 12.0 cm). All the implanted grafts were bifurcated in design. RESULTS: Endovascular repair of the infrarenal AAA was successful for all 47 patients. One patient required the conversion to general anesthesia to facilitate the repair of an injured external iliac artery via a retroperitoneal approach. The operative mortality rate was 0. No patient had a myocardial infarction or had other cardiopulmonary complications develop in the perioperative period. The average operative time was 170 minutes, and the average blood loss was 623 mL (range, 100 to 2500 mL). The fluid requirements averaged 2491 mL. Of the 47 patients, 46 (98%) tolerated oral intake and were ambulatory within 24 hours of graft implantation. The patients were discharged from the hospital an average of 2.13 days after the procedure, with 87% of the patients discharged less than 48 hours after the graft implantation. Furthermore, at least 30% of the patients could have been discharged on the first postoperative day except for study protocol requirements for computed tomographic scanning at 48 hours. CONCLUSION: This is the first reported series that describes the use of local anesthesia for the endovascular repair of infrarenal AAAs. Our preliminary results indicate that the endovascular treatment of AAAs with local anesthesia is feasible and can be performed safely in a patient population with significant comorbidities. The significant potential advantages include decreased cardiopulmonary morbidity rates, shorter hospital stays, and lower hospital costs. A definitive evaluation of the benefits of local anesthesia will necessitate a direct comparison with other anesthetic techniques.

Local anesthesia for infrainguinal arterial reconstruction.

PURPOSE: Perioperative cardiac complications occur in 4% to 6% of patients undergoing infrainguinal revascularization under general, spinal, or epidural anesthesia. The risk may be even greater in patients whose cardiac disease cannot be fully evaluated or treated before urgent limb salvage operations. Prompted by these considerations, we investigated the feasibility and results of using local anesthesia in these high-risk patients. METHODS: From January 1, 1994, through August 30, 1996, 86 infrainguinal reconstructions were performed under local infiltration anesthesia (0.5% or 1.0% lidocaine). Supplementary intravenous sedation with propofol or other agents was given as needed for patients comfort. Most patients had arterial lines but Swan Ganz catheters were used infrequently. Postoperatively, continuous electrocardiographic monitoring was continued in the intermediate or intensive care units. Patients ranged in age from 37 to 86 years (mean 68 +/- 12); 47% were diabetic, 69% had severe coronary artery disease, and 14% had end-stage renal disease. RESULTS: Operations included 7 femoral-femoral, 21 femoral-popliteal, 16 femoral-tibial and 13 popliteal-tibial bypass grafts, 9 pseudoaneurysms, and 20 distal graft revisions (+/- thrombectomy). Autogenous vein was used in eight of the femoral-popliteal and all of the femoral-tibial and popliteal-tibial bypass grafts. There were two postoperative deaths. One patient died of a stroke (1.2%) on postoperative day (POD) 2 and one died on POD 27 of unknown cause. Two other (2%) patients had nonfatal subendocardial myocardial infarctions. Conversion to general anesthesia was required in four (5%) operations, three because patients became agitated and one because a long segment of vein had to be harvested from the opposite leg. Otherwise, patients tolerated the procedures well and postanesthetic recovery problems were minimized. CONCLUSIONS: Limb salvage operations can be done under local anesthesia with acceptable complication rates. In selected patients with high-risk coronary artery disease, local anesthesia has theoretic and practical advantages and should be considered an alternative to general or regional anesthesia.

Access to the vascular system for endovascular procedures: techniques and indications for percutaneous and open arteriotomy approaches.

The ability to reliably gain access to the vascular system is fundamental to the performance of all endovascular diagnostic and therapeutic procedures. Competence with a variety of different access sites and techniques is essential if one is to be able to address the full spectrum of vascular disease and diversity of clinical circumstances. Although open surgical access is sometimes indicated, most endovascular procedures can and should be performed percutaneously, because this is the least invasive technique. Understanding the advantages, risks, and potential pitfalls of the various approaches influences the site of access chosen and whether a percutaneous or open arteriotomy technique is used. Furthermore, this knowledge permits efforts to minimize attendant risks and facilitates recognition of problems when they do occur. The net result is a procedure unspoiled by failure to gain access or avoidable access site complications.

Prevalence and distribution of calf vein thrombosis in patients with symptomatic deep venous thrombosis: a color-flow duplex study.

PURPOSE: This retrospective study was performed to identify the patterns of calf vein thrombosis in patients in whom deep vein thrombosis (DVT) was suspected and to better define the role of color-flow duplex scanning (CDS) in the evaluation of this patient population. METHODS: Over a recent 9-month period, we reviewed the vascular laboratory charts of 540 symptomatic patients (696 limbs) who underwent CDS for clinically suspected acute DVT. Patients who had a previous episode of DVT were excluded. RESULTS: CDS satisfactorily visualized all three paired calf veins in 655 of the limbs (94%). Inadequate scans (n = 41) were attributed to edema in 29, excessive calf size in eight, and anatomic inaccessibility in four. Peroneal veins were the most difficult to visualize (n = 29), followed by posterior tibial (n = 10) and anterior tibial (n = 9) veins. CDS identified acute DVT in 159 of 655 limbs (24%) that had adequate scans. Calf vein thrombi were detected in 110 of the 655 limbs (17%) and in 69% of the 159 limbs with DVT. Clots were confined to the calf veins in 53 limbs with DVT (33%). Isolated calf vein thrombi were found in 45% of outpatient limbs and in 27% of inpatient limbs with DVT. The peroneal (81%) and posterior tibial veins (69%) were more frequently involved (p < 0.001) than the anterior tibial veins (21%). In limbs with calf DVT, the prevalence of thrombosis isolated to the peroneal and posterior tibial veins was similar (37% and 25%, respectively); no limb had an isolated anterior tibial DVT (p = 0.02). CONCLUSION: CDS is a reliable method for evaluating calf veins for DVT. Calf vein thrombosis is common in patients who have acute DVT and often occurs as an isolated finding. The peroneal and posterior tibial veins are involved in the majority of cases; thrombi occur much less frequently in the anterior tibial veins. We conclude that CDS should be the noninvasive method of choice for the initial evaluation of patients in whom DVT is suspected, and we recommend that calf veins should always be studied but that routine scanning of the anterior tibial veins may not be necessary.

Determinants of success of color-flow duplex-guided compression repair of femoral pseudoaneurysms.

BACKGROUND: Ultrasonography-guided compression repair is reported to be effective therapy for femoral pseudoaneurysms that develop after catheterization procedures. This study summarizes our experience with color-flow duplex-guided repair of these lesions. METHODS: A retrospective chart review of all patients who underwent this procedure was undertaken, with statistical analysis to identify factors associated with success. RESULTS: Compression repair of 69 pseudoaneurysms was attempted. Pseudoaneurysms developed after therapeutic catheterization in 48 patients and after diagnostic procedures in 21. Sites of arterial puncture were the common femoral artery in 59 patients and the superficial femoral or profunda femoris arteries in 10. Diameters of the pseudoaneurysms ranged from 3 to 60 mm (mean, 28 mm). Compression was attempted at a mean of 5 days (range, 1 to 21 days) after catheterization. Compression produced complete thrombosis of the pseudoaneurysm at the initial attempt in 43 (62%) of 69 patients. With repeated attempts the ultimate success was 47 (68%) of 69. Success was achieved in 44 (75%) of 59 common femoral pseudoaneurysms but in only 3 (30%) of 10 superficial femoral or profunda femoris lesions (p = 0.009). Anticoagulation, sheath size, pseudoaneurysm chamber size, and time between catheterization and compression were not significantly different between lesions that were successfully compressed and those that were not. No ischemic or embolic complications were observed. CONCLUSIONS: Color-flow duplex-guided compression repair can be safely attempted as the initial therapy for all uncomplicated pseudoaneurysms arising from the common femoral artery after catheterization, with the expectation of success in most.

Prospective evaluation of new duplex criteria to identify 70% internal carotid artery stenosis.

PURPOSE: Large multicenter trials (North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial) have documented the benefits of carotid endarterectomy for treating symptomatic patients with >or=70% stenosis of the internal carotid artery. Although color-flow duplex scanning has become the preferred method for noninvasive assessment of internal carotid artery disease, no criteria have been generally accepted to identify this subset of patients. We previously reported a retrospective series to establish such criteria. This study details our results when these criteria were applied prospectively. METHODS: Carotid color-flow duplex scans were compared with arteriograms in 457 patients who underwent both studies. Criteria for >or=70% internal carotid artery stenosis were peak systolic velocity >130 cm/sec and end-diastolic velocity >100 cm/sec. Internal carotid arteries with peak systolic velocity <40 cm/sec in which only a trickle of flow could be detected were classified as preocclusive lesions (95% to 99% stenosis). Arteriographic stenosis was determined by comparing the diameter of the internal carotid artery at the site of maximal stenosis to the diameter of the normal distal internal carotid artery. RESULTS: Internal carotid artery stenosis of >or=70% was detected with a sensitivity of 87%, specificity of 97% positive predictive value of 89%, negative predictive value of 96%, and overall accuracy of 95%. Eighty-seven percent of 70% to 99% stenoses were correctly identified. False-positive errors (n=10) were attributed to contralateral internal carotid artery occlusion or high-grade (>90%) stenosis (n=5) and to interpreter error (n=1); no explanation was apparent in the other four. Eleven of 12 false-negative examinations occurred in patients with 70% to 80% internal carotid artery stenosis. CONCLUSIONS: In our laboratories, prospective application of the above velocity criteria identified internal carotid artery stenosis of >or=70% with a reasonably high degree of accuracy. Errors occurred when stenoses were borderline and in patients with severe contralateral disease. With suitably modified velocity criteria, color-flow duplex scanning remains the most reliable noninvasive method for identifying symptomatic patients who are candidates for carotid endarterectomy.

Detection of total occlusion, string sign, and preocclusive stenosis of the internal carotid artery by color-flow duplex scanning.

BACKGROUND: Stroke prevention depends on the accurate differentiation of surgically treatable preocclusive lesions from total occlusions of the internal carotid artery. This prospective study was undertaken to review the accuracy of colorflow duplex scanning for identifying carotid string signs, focal preocclusive lesions (95% to 99% stenoses), and total occlusion of the internal carotid artery. MATERIALS AND METHODS: Over an 18-month period, 4,362 patients underwent color-flow duplex scanning of the carotid arteries. Angiograms of 596 internal carotid arteries were available for comparison with the duplex scan findings. Total occlusion was diagnosed by the absence of flow in internal carotid arteries visualized on B-mode scanning. Preocclusive lesions were identified by a trickle of flow in the vessel lumen. RESULTS: Of 65 color-flow duplex scans that predicted total occlusion, 64 (98%) were confirmed by angiography. The negative predictive value for total occlusion was 99%. Twenty-six (87%) of 30 string signs and focal 95% to 99% stenoses were correctly identified. Color-flow scanning prediction of preocclusive lesions was accurate in 84% of 31 cases. Low velocities in the internal carotid artery were usually associated with a string sign, and high velocities with a focal preocclusive lesion. CONCLUSIONS: Color-flow duplex scanning accurately differentiates between stenotic and totally occluded internal carotid arteries. Identification of preocclusive lesions is not as accurate but the results are promising. Arteriographic confirmation of duplex scan findings is necessary only when scans are equivocal.

Incorporation of endovascular training into a vascular fellowship program.

BACKGROUND: Despite expanding indications for endovascular therapy of peripheral vascular disease, vascular surgeons have largely remained bystanders in the use of this form of treatment for the disease, which is the focus of their profession. Lack of access to training in endovascular techniques is a major obstacle to increasing involvement by vascular surgeons. This paper reports our experience in the endovascular training of vascular surgical fellows without the involvement of radiologists. METHODS: The results of vascular surgery fellows receiving instruction in endovascular diagnostic and therapeutic procedures from vascular surgery faculty were reviewed. RESULTS: Endovascular training of vascular surgery fellows exceeded the case levels recommended by all involved societies. A diverse case mix of 355 endovascular diagnostic procedures were performed with a major complication rate of 0.3% and no procedure-related deaths. Two hundred six endovascular interventions were performed, with an initial technical success rate of 96.6%, a 30-day success rate of 93%, no major complications, and an overall intervention-related mortality rate of less than 1%. CONCLUSIONS: Vascular surgery fellows can receive endovascular training by vascular surgery faculty without the involvement of radiologists and can do so with acceptable success and complication rates. This experience is sufficient to qualify them to perform and teach endovascular therapy in their future practices.

Evolution of carotid endarterectomy in two community hospitals: Springfield revisited--seventeen years and 2243 operations later.

PURPOSE: The purpose of this study was to evaluate and update the results of carotid endarterectomy (CEA) in two community hospitals over a 17-year period and to determine whether there had been any reduction in the unacceptably high incidence of complications previously reported from these same two hospitals. METHODS: We retrospectively reviewed the records of 1981 patients who underwent 2243 CEAs from July 1976 to November 1993. RESULTS: There were 36 operative deaths (1.6%) and 120 operative strokes (5.3%), for a combined stroke-mortality rate of 6.3%. The mortality, stroke, and combined stroke-mortality rates all decreased significantly (p < 10(-5)) compared with the rates reported in the original study (6.6%, 14.5%, and 21.1%, respectively). Nonfatal stroke rates decreased significantly for patients diagnosed with asymptomatic carotid artery disease, 18.2% to 2.9% (p = 0.04); transient ischemic attacks, 17.8% to 3.9% (p < 10(-6)); and prior stroke, 15.2% to 8.0% (p = 0.04). Improvement in combined stroke-mortality rates occurred for all operative indications, but was significant only in the transient ischemic (p < 10(-8)) and prior stroke groups (p = 0.00002). Surgical experience varied, with 31 surgeons performing one to 236 CEAs. Although results were not significantly correlated with individual operative activity, 10 surgeons who performed more than 12 CEAs per year had a statistically lower incidence of operative stroke (4.1%) compared with 21 surgeons who performed fewer procedures (7.2%) (p = 0.009). The incidence of stroke (2.7%) and the combined stroke-mortality rate (3.7%) of surgeons with additional vascular training was superior to the stroke rate (6.8%) and combined stroke-mortality rate (7.9%) of surgeons who did not (p = 0.0014 and p = 0.0006); but several surgeons in the latter group had results that were comparable to those of the vascular group. CONCLUSIONS: Although overall operative complication rates in these two community hospitals have declined dramatically compared with previously reported results, they are still not optimal and probably will remain high as long as individual surgeons with high complication rates continue to perform CEAs.

The natural history of moderate (50% to 79%) internal carotid artery stenosis in symptomatic, nonhemispheric, and asymptomatic patients.

PURPOSE: This study was undertaken to determine the incidence of disease progression of moderate (50% to 79%) internal carotid artery stenosis in patients with symptoms, patients with nonhemispheric symptoms, and symptom-free patients and to define the risk of development of new neurologic events in each group. METHODS: Over a 6-year period, 272 patients with moderate internal carotid artery stenoses were monitored for a mean of 44 months with color-flow duplex scanning (CFS). At the time of the initial scan, 142 patients were symptom free, 87 had experienced transient ischemic attacks, amaurosis fugax, or mild strokes, and 43 had ill-defined nonhemispheric symptoms. The average number of follow-up scans was 2.4 per patient (range 1 to 11). RESULTS: During follow-up, 23 (26%) of the patients with symptoms, 17 (40%) of the patients with nonhemispheric symptoms, and 30 (21%) of the symptom-free patients had development of additional neurologic symptoms. Life-table comparison of ipsilateral ischemic events showed a significantly (p = 0.03) higher cumulative rate in the symptomatic group (20%) than in the asymptomatic group (7%) at 2 years. Mean annual stroke rates were 6% and 2% in patients in the symptomatic and asymptomatic groups, respectively. None of the patients in the nonhemispheric group had a stroke within 4 years of the initial study. Disease progression occurred in 16% of the patients. In the asymptomatic group, ipsilateral stroke occurred more frequently (p = 0.0001) in patients with disease progression (25%) than in patients with stable lesions (1%). CFS detected disease progression in 19 (79%) of 24 patients before the artery occluded or stroke occurred. In patients with symptoms, stroke was more frequent (p = 0.02) in patients with six or more risk factors (29%) than in those with five or fewer risk factors (7%). CONCLUSION: Although the risk of stroke is less in patients with moderate stenosis than it is in patients with severely stenotic lesions, symptom-free patients with advancing disease and patients with symptoms and multiple risk factors are at increased risk for development of neurologic events. These findings support the use of CFS to monitor patients with carotid artery disease and suggest that a more aggressive surgical approach may be indicated in selected patients with moderate carotid artery stenosis.

Carotid endarterectomy without angiography: is color-flow duplex scanning sufficient?

BACKGROUND: This study was designed to determine whether clinical evaluation and color-flow duplex scanning (CFS) alone provide enough information for patients to undergo carotid endarterectomy (CEA) safely without preoperative cerebral angiography and to assess the appropriate role of CFS in the evaluation of extracranial carotid artery disease. METHODS: During a 31-month period 167 patients (114 symptomatic and 53 asymptomatic) underwent CFS and angiography during evaluation for CEA. One hundred fifty-three patients were studied retrospectively, and 14 were studied prospectively. Data were reviewed to determine whether cerebral angiography added information not provided by duplex findings and, if so, did the results alter clinical management. RESULTS: Of the 167 patients studied, 149 underwent CEA and 18 were treated medically. Results of the two diagnostic modalities agreed perfectly in 82% of the patients, with 99% of the stenoses estimated by CFS being classified within one category of those measured with angiography. The sensitivity of CFS for detecting greater than 50% diameter-reducing stenoses of the internal carotid artery was 98%, and the positive predictive value was 99%. For detecting greater than 80% stenoses, CFS had a sensitivity of 84% and a positive predictive value of 95%. Clinical management was altered by angiographic findings in only seven patients (4%). False-positive results (n = 5) were due to poor scanning technique or interpreter error (n = 2), anatomic variations (n = 2), and unknown cause (n = 1). All false-negative results (n = 2) were due to poor scanning technique. CONCLUSIONS: Ninety-six percent of the patients in this study would have received appropriate clinical management based on neurologic history and the results of CFS alone. Our results indicate that CFS is sufficient for determining the need for surgery in patients being considered for CEA and can supplant cerebral angiography in nearly all clinical circumstances.