By Christopher M. Loftus
Neurovascular approaches signify a big element of a surgeon's perform. the new beneficial result of medical trials on carotid endarterectomy for stroke prevention have led to a growing to be call for for surgeons who practice this process. Surgeons might be ready to fulfill the call for via studying the fundamental rules, diagnositc standards and operative strategy for carotid endarterectomy. Dr Loftus stocks his perception and large event during this clinically-oriented quantity. quite a few radiographic examples illustrate the subtleties of determining the diseased artery, in addition to anatomic diversifications that make prognosis and surgical procedure much more hard. The method is illustrated with attractive line drawings observed by means of color photos, and the textual content all through is an easy-reading, concise narrative. gains: * features a exact part at the uncomplicated rules underlying carotid endarterectomy * includes a part dedicated completely to diagnostic concerns with various radiographic reviews illustrating universal and anomalous anatomy * comprises thousands of pictures and drawings demonstrating all elements of the approach
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Extra info for Carotid Endarterectomy: Principles and Technique
1 19211 and with few exceptions 2l1 there has been no effective direct means available to continuously monitor shunt flow before the development of TeD monitoring. The possibility of distal intimal damage leading to embolization or carotid dissection is also present. 212 Because of these risks, numerous nonshunting series have been accumulated and the results published. Gross et al. 2IJ successfully substituted barbiturate-induced burst suppression for shunt placement in cases in which EEG changes did not respond to hypertensive therapy, but this method has not been widely accepted.
We will examine each of these monitoring considerations in turn. TCD monitoring may have the ability to preoperatively predict the need for shunting. Benichou et al. l -l6 divided 91 patients into two groups: group A patients had TCD identification of a functional anterior communicating artery and either one or two posterior communicating arteries preoperatively; group B patients had no such communicating arteries identified. Group B patients had a significantly higher (1) incidence of stump pressures less than 50 mm Hg at surgery and (2) clinical need for shunting.
109 Piepgras et a1. llo have quoted somewhat lower figures with their use of patch graft repair (1 % symptomatic, 4% to 5% total at 2-year follow-up). III,112 Reoperation for carotid stenosis is a technically difficult procedure. It is associated with significantly higher risks than primary endarterectomy, and Piepgras et a1. 5o/o-four times their customary figure. At our institution the possibility ofreoperation for carotid stenosis is considered for patients who present with angiographically proved disease and classic neurologic symptoms referable to the appropriate artery.