Carotid endarterectomy in a community hospital: a change in physicians' practice patterns

Article Abstract:

Strokes, in which the blood supply to part of the brain is interrupted, are the third leading cause of death in the United States, and a major cause of disability. Disease of the external carotid arteries (the arteries that provide the main blood supply to the brain) is associated with strokes. Carotid endarterectomy is a surgical procedure widely used to remove the cholesterol-plaque-thickened inner lining of the carotid artery, thereby allowing better blood flow. The possibility of preventing strokes has led to an increase in the number of carotid endarterectomies being performed. A retrospective study was undertaken of carotid endarterectomy; these results prompted the development of guidelines, including indications for performing the surgery. Two hundred forty-three carotid endarterectomies performed over a 22-month period were reviewed retrospectively. Fifty-six percent of these patients (137) underwent surgery without symptoms of external carotid disease; of these, 37 percent had up to 80 percent narrowing of the artery. Six patients (3 percent) died, and 12 patients (5 percent) had strokes. Guidelines specifying criteria for use of surgery were developed. Following the adoption of these guidelines, a prospective study was undertaken of 148 operations performed in a 21-month period. The number of operations performed was reduced by 36 percent from the pre-guideline period. Use of surgery for asymptomatic disease was reduced to 31 percent of the total number of operations. There were no deaths and six strokes (4 percent); this decrease was not statistically significant. The reduction in the number of carotid endarterectomies performed seems to be due to a decrease in the number of inappropriate procedures being done. By making the surgeons and primary care physicians aware of the data, practice patterns were changed within the institution without the application of pressure from external agencies. (Consumer Summary produced by Reliance Medical Information, Inc.)

Prevention, Statistics, Stroke (Disease), Stroke, Surgeons

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Combined carotid endarterectomy and myocardial revascularization

Article Abstract:

There is no consensus regarding the best surgical treatment for patients with atherosclerosis (cholesterol plaque formation on the inner layer of the artery wall) affecting both the coronary and carotid arteries. The coronary arteries supply the myocardium, the muscle of the heart; the carotid arteries provide the main blood supply for the brain. Coronary artery disease may be treated with myocardial revascularization or coronary bypass surgery. Carotid artery disease may be treated with carotid endarterectomy, a procedure which removes the cholesterol plaque-thickened inner lining of the carotid artery. When both diseases are present surgical treatment options include delayed, staged or simultaneous procedures. A review is presented of 95 patients who underwent simultaneous myocardial revascularization and carotid endarterectomy. The procedures were performed between February 1971 through 1987. The average patient age was 65, and 58 percent of the patients were men. The main reason for heart surgery was intractable angina pectoris (chest pain); 37 patients had history of transient ischemic attack and/or stroke, and 58 patients were without symptoms but had clinical evidence of stenosis (narrowing) of the arteries. The rate of postoperative stroke was 2 percent, and mortality was 4 percent for the entire study period. Patients who underwent surgery during the 1980s (89 percent of the patients) had mortality rate of 1 percent, and a postoperative stroke rate of 2 percent. Follow-up revealed restenosis of more than half the diameter of the vessel occurred in 25 percent of patients. This was documented by duplex scan, a noninvasive ultrasound and Doppler study that provides detail of the vessel wall structure; only 2 patients had symptoms of restenosis. It is concluded that a combined approach to coronary and carotid artery disease can be performed safely. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Coronary heart disease

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Comparison of regional and general anesthesia for carotid endarterectomy

Article Abstract:

The author studied 221 patients who had been operated on for the removal of a blockage (stenosis) of the carotid artery, the main artery of the head and neck, and removal of the blocking material (i.e., the blocking material of atherosclerosis or hardening of the arteries). This operation, carotid endarterectomy, was studied for death rate in two groups of patients: (1) 37 patients anesthetized with general anesthetic and (2) 184 patients who underwent the procedure with local anesthetic. The author found no difference between the two groups and suggests that the choice of anesthetic should be left to the surgeon and the operative team.

Patient outcomes, Mortality, Anesthesia

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