Carotid endarterectomy: indications and surgical technique

Carotid endarterectomy is a therapeutic option for patients with symptoms of focal cerebral ischaemia, when it can be performed with a combined morbidity and mortality below the yearly risk of stroke (5%). The experience with 815 carotid endarterectomies performed from 1979 to 1992 is presented. There were 530 (65%) men and 285 (35%) women of ages from 34 to 82 (median 65); risk factors included diabetes mellitus 196 (24%), hypertension 554 (68%), and smoking 570 (70%). Clinical presentation consisted of transient ischaemic attacks 464 (57%), cerebral infarction with minimal neurological residual 228 (28%), stroke in evolution 2 (0.2%), and asymptomatic stenosis 121 (15%). According to Sundt's classification of medical risk groups, the patients fit the following grades: Grade I: 106 (13%), Grade II: 350 (43%), Grade III: 357 (44%), Grade IV: 2 (0.2%). All patients received endotracheal anaesthesia with trans-operative monitoring of intra-arterial pressure, central venous pressure and arterial blood gases. Thiopental (3-5 mg/kg) and lidocaine (1 mg/kg) were given for induction and at 15 minutes intervals during carotid cross-clamping. Intraluminal shunts were used in 14 (2%). A conventional (open) endarterectomy was performed in 379 (46%) and a limited endarterectomy (closed) in 436 (54%). Complications included 8 (1%) deaths, 24 (3%) developed a major neurological deficit that persisted, 24 (3%) had perioperative TIAs which resolved completely. Of the patients with preoperative neurological deficits, 32 (4%) recovered. Therefore, at one month after surgery, 782 (96%) were either as well or better than preoperatively. Of 483 (59%) postoperative angiograms, 40 (5%) showed an internal carotid artery occlusion. Six of these patients developed an immediate postoperative cerebral infarction and one died. Non-neurologic complications were: cardiac 40 (5%), peripheral nerve 24 (3%), and local wound problems 16 (2%). A carotid endarterectomy can be performed safely when it is done with meticulous attention to detail and consistent surgical technique.