Carotid exploration for acute postoperative thrombosis

To determine the incidence of carotid reoperation and to document operative findings and clinical results, the records of patients requiring early reoperation (after less than 24 hours) during a 10-year period were analyzed with respect to operative findings, clinical outcome, and arterial patency. Endarterectomy was performed in 920 patients, with 27 strokes (3%) and 10 deaths (1%). Early re-exploration was required for 27 patients (3%) for either expanding hematoma (6 patients) or suspected thrombosis associated with a new neurologic deficit (21 patients). Two patients bled from the arteriotomy and 4 bled from surrounding tissues. Exploration for new postoperative neurologic events confirmed thrombosis in 19 cases (91%). Two patients with patent arteries and normal operative arteriograms were felt to have distal embolization, and the arteriotomy was not opened. Causes of thrombosis were intimal flap in 6 patients and closure stenosis in 11; the cause was unknown in 2 cases. All arteries were repaired over a shunt with a patch. Follow-up studies were available for 16 arteries, all of which remained patent. Of patients explored for hemorrhage, there was one death (from myocardial infarction), no neurologic events, and no late infections. Of 21 patients who underwent a second operation for neurologic deficits, 2 died, 8 were unchanged, 2 had minor residual deficit, and 9 had completely resolved deficits. Severe contralateral disease was more common among patients with residual deficits (10 of 12) compared with patients without residual deficits (0 of 9; chi-square = 8.23, P < 0.005). Carotid re-exploration is most commonly undertaken for a new neurologic deficit, usually associated with thrombosis at the operative site. Thrombosis is more often due to arterial narrowing than to an intimal defect. Prompt repair will restore patency and result in improvement in 50% of cases. Neurologic recovery is related to the status of the contralateral artery.