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Neukirchen M, Schaefer MS, Legler A, Hinterberg JZ, Kienbaum P. The Effect of Xenon-Based Anesthesia on Somatosensory-Evoked Potentials in Patients Undergoing Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2019; 34:128-133. [PMID: 31451368 DOI: 10.1053/j.jvca.2019.07.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the influence of xenon-based anesthesia on somatosensory-evoked potentials. DESIGN Observational cohort study. SETTING University hospital. PARTICIPANTS Twenty subsequent adult patients undergoing elective carotid endarterectomy. INTERVENTIONS Xenon-based anesthesia. MEASUREMENTS AND MAIN RESULTS Cortical-evoked responses to median nerve stimulation were quantified by measurement of the amplitude and latency of the N20 wave, which are typically assessed during carotid surgery to detect intraoperative cerebral hypoperfusion and ischemia. Primary (N20 amplitude and latency) and secondary (mean arterial pressure, norepinephrine requirements and depth of anesthesia) were assessed during (1) propofol/remifentanil and (2) subsequent xenon/remifentanil anesthesia. Xenon at an inspiratory fraction of 62.5 ± 7% decreased norepinephrine requirement (0.067 ± 0.04 v 0.028 ± 0.02 µg/kg/min, p < 0.001), and mean arterial pressure was unchanged (90.6 ± 15.0 v 93.1 ± 9.6 mmHg, p = 0.40). Somatosensory-evoked potentials were available in all patients during xenon/remifentanil. Despite similar depth of anesthesia (Narcotrend index 38.4 ± 6.2 v 38.5 ± 5.8) during propofol and xenon, N20 amplitude was reduced after xenon wash-in from 3.7 ± 1.7 to 1.4 ± 2.8 µV, p < 0.001 on the surgical and 3.6 ± 1.6 to 1.4 ± 0.6 µV, p < 0.001 on the contralateral side. N20 latency remained unchanged during xenon (22.9 ± 2.1 v 22.5 ± 2.8 ms, p = 0.34 and 22.9 ± 2.0 v 22.9 ± 3.0, p = 0.97). CONCLUSIONS Xenon influences somatosensory-evoked potentials measurement by reducing N20 wave amplitude but not latency. When xenon is considered as an anesthetic for carotid endarterectomy, wash-in needs to be completed before carotid surgery is commenced to provide stable baseline somatosensory-evoked potential measurement.
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Affiliation(s)
- Martin Neukirchen
- Department of Anaesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Maximilian S Schaefer
- Department of Anaesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany; Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
| | - Annette Legler
- Department of Anaesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Jonas Z Hinterberg
- Department of Anaesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
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Reddy RP, Brahme IS, Karnati T, Balzer JR, Crammond DJ, Anetakis KM, Thirumala PD. Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy for 30-day perioperative stroke. Clin Neurophysiol 2018; 129:1819-1831. [DOI: 10.1016/j.clinph.2018.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/25/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
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Aburahma AF, Mousa AY, Stone PA. Shunting during carotid endarterectomy. J Vasc Surg 2011; 54:1502-10. [PMID: 21906905 DOI: 10.1016/j.jvs.2011.06.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/02/2011] [Accepted: 06/08/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of shunting during carotid endarterectomy (CEA) is controversial. While some surgeons advocate routine shunting, others prefer selective shunting or no shunting. Several large series have documented excellent results of CEA with routine shunting or without shunts. Others reported similar results with selective shunting using transcranial Doppler (TCD), electroencephalogram (EEG) monitoring, carotid stump pressure (SP), cervical block anesthesia (CBA), and somatosensory evoked potential (SSEP). In this study, we review the available evidence supporting shunting, nonshunting, and selective shunting during CEA. METHODS An electronic PubMed/MEDLINE search was conducted to identify all published CEA studies between January 1990 and December 2010, that analyzed the perioperative outcome of routine shunting, routine nonshunting, routine versus selective shunting, selecting shunting versus avoiding a shunt, and selective shunting based on EEG, TCD, SP, CBA, and SSEP. RESULTS The mean reported perioperative stroke rate for CEAs with routine shunting was 1.4% and for routine nonshunt was 2%. Meanwhile, the mean perioperative stroke rates for selecting shunting were 1.6% using EEG, 4.8% using TCD, 1.6% using SP, 1.8% using SSEP, and 1.1% for CBA. Similar results were noted for perioperative stroke and death rates. CONCLUSIONS The use of routine shunting and selective shunting was associated with a low stroke rate. Both methods are acceptable, and the individual surgeon should select the method with which they are more comfortable.
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Affiliation(s)
- Ali F Aburahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV 25304, USA.
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Ibáñez J, Vilalta A, Mena MP, Vilalta J, Topczewski T, Noguer M, Sahuquillo J, Rubio E. [Intraoperative detection of ischemic brain hypoxia using oxygen tissue pressure microprobes]. Neurocirugia (Astur) 2004; 14:483-9; discussion 490. [PMID: 14710303 DOI: 10.1016/s1130-1473(03)70505-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE AND IMPORTANCE Detection of intraoperative ischemic events could lead to the resolution of their cause and to the prevention of the definitive establishment of a postoperative infarct. We want to illustrate the possibilities that intraoperative monitoring of oxygen tissue pressure (PtiO2) in critical areas during a neurosurgical vascular procedure offers, enhancing its reliability and immediacy in obtaining information about tissue oxygenation status as a marker of ischemia in the vascular territory at risk. CLINICAL PRESENTATION We report the case of a 32 year-old male with a deep arteriovenous malformation (AVM) localised in the insular region. The patient had been previously treated with radiosurgery without achieving a satisfactory result. INTERVENTION AVM removal was performed through a transylvian transinsular approach. PtiO2 was monitorised at the temporal pole (reference area) and at the posterior temporal region (risk area). Both probes maintained close tissue oxygenation levels until the last stage of the AVM resection when, during the coagulation of a supposed afferent vessel, a brisk fall of the oxygen tissue pressure in the posterior temporal region was detected. An ischemic infarct in this area was observed postoperatively. CONCLUSIONS PtiO2 monitoring has a high reliability in the detection of intraoperative tissue hypoxia. Data obtained could lead to early identification of these events and, whatever possible, to resolve this situation preventing the definitive establishment of an ischemic infarct.
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Affiliation(s)
- J Ibáñez
- Unidad de Neurotraumatología, Institut de Reccerca Vall d'Hebron. Universidad Autónoma. Barcelona. Spain
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Abstract
Although not universally adopted, the growing body of literature provides strong evidence of the clinical utility of IOM in a variety of cerebrovascular surgical and endovascular procedures. The Therapeutics and Technology Subcommittee of the American Academy of Neurology and Fisher et al concluded that the following are useful and noninvestigational: 1. EEG, compressed spectral array, and SSEP in CEA and brain surgeries that potentially compromise cerebral blood flow, 2. BAEP and cranial nerve monitoring in surgeries performed in the region of the brainstem or inner ear, 3. SSEP monitoring performed for surgical procedures potentially involving ischemia or mechanical trauma of the spinal cord. They also came to the conclusion that although promising, motor EPs and visual EPs are still investigational. Further investigation, especially in the area of outcomes research and cost-effectiveness, is required before IOM can become standard practice.
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Affiliation(s)
- Jaime R López
- Department of Neurology and Neurological Sciences, Intraoperative Neurophysiologic Monitoring Program, Stanford University School of Medicine, 300 Pasteur Drive, Room A-343, Stanford, CA 94305, USA.
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Sbarigia E, Schioppa A, Misuraca M, Panico MA, Battocchio C, Maraglino C, Speziale F, Fiorani P. Somatosensory Evoked Potentials versus Locoregional Anaesthesia in the Monitoring of Cerebral Function During Carotid Artery Surgery: Preliminary Results of a Prospective Study. Eur J Vasc Endovasc Surg 2001; 21:413-6. [PMID: 11352515 DOI: 10.1053/ejvs.2001.1342] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE to relate changes in somatosensory-evoked potentials (SEPs) with onset of neurological deficits in patients having carotid endarterectomy (CEA) under locoregional anaesthesia. METHODS a prospective study of 50 consecutive patients. RESULTS SEPs yielded an accuracy of 98%, specificity 100%, and sensitivity 89%. In all concordant cases the onset of a neurological deficit in awake patients corresponded to a 30--40% reduction in amplitude of N20-P25 waveforms. After shunting, the N20-P25 took 2--3 min to return to normal. CONCLUSIONS SEPs are associated with a 2% false negative rate. Their threshold for detecting cerebral ischaemia is lower than the currently reported value for patients under general anaesthesia. The time needed for evoked potentials (2--3 min) to return to normal after shunting limits their usefulness in verifying effective shunting.
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Affiliation(s)
- E Sbarigia
- I Cattedra di Chirurgia Vascolare, University of Rome La Sapienza, Rome, Italy
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Yamane K, Shima T, Okada Y, Nishida M. Hemodynamic evaluation by using near infrared spectroscopy during carotid endarterectomy. J Stroke Cerebrovasc Dis 1999; 8:211-6. [PMID: 17895167 DOI: 10.1016/s1052-3057(99)80069-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/1997] [Accepted: 11/23/1998] [Indexed: 10/24/2022] Open
Abstract
To evaluate the hemodynamic changes during carotid endarterectomy, we compared changes in oxyhemoglobin levels with changes in the internal carotid artery flow and the somatosensory evoked potential (SEP). In 40 of 42 patients, the oxyhemoglobin level, measured in the frontal area on the operated side using near infrared spectroscopy (NIRS), decreased immediately after cross-clamping the internal carotid artery and returned to the preclamping level after the clamp was removed. There was no linear relationship between the internal carotid flow and the decrement in the oxyhemoglobin level after carotid clamping. Nineteen patients (45%) had a large internal carotid flow (> or =90 mL/min), but a small decrease in the oxyhemoglobin level (<0.04 in index); presumably these patients had adequate collateral circulation. Eight patients (19%) had a large internal carotid flow and a marked decrease in the oxyhemoglobin level (> or =0.04); presumably these patients had insufficient collateral circulation. The changes in oxyhemoglobin and SEP after carotid clamping agreed in 77.5% of the patients; however, in the other 22.5%, the disparity between the two factors indicated different causes of cerebral ischemia following carotid clamping. A marked decrease in oxyhemoglobin without a significant change in SEP suggests ischemia predominantly in the frontal area, whereas a small decrease in oxyhemoglobin and a significant change in SEP suggest ischemia predominantly in the somatosensory pathway or cortex. In conclusion, the relationship between the internal carotid flow and the change in HbO(2) provides information about the collateral circulation. Simultaneous monitoring of NIRS and SEP is useful for assessing of the pattern of cerebral ischemia during carotid clamping.
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Affiliation(s)
- K Yamane
- Department of Neurosurgery, Chugoku Rousai Hospital, Kure, Japan
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Wöber C, Zeitlhofer J, Asenbaum S, Claeys L, Czerny M, Wölfl G, Grubhofer G, Polterauer P, Deecke L. Monitoring of median nerve somatosensory evoked potentials in carotid surgery. J Clin Neurophysiol 1998; 15:429-38. [PMID: 9821070 DOI: 10.1097/00004691-199809000-00007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study was to compare median somatosensory evoked potentials (SEP) in patients undergoing carotid endarterectomy (CEA) with routine shunting and nonshunting (excluding the option of selective shunting) and to evaluate the significance of a decrease in the amplitude of the cortically generated waveforms of the SEP and/or an increase in the central conduction time (CCT) on the one hand, and that of a loss of the cortical SEP, on the other. Somatosensory evoked potentials were recorded in 32 patients before, during, and after CEA with routine shunting or nonshunting. The N13 and N20 latency, the CCT, and the N20/P25 amplitude were evaluated. In addition, a meta-analysis of 15 previous studies was performed comprising a total of 3,136 patients. The intraoperative cortical SEP showed no differences between shunted and nonshunted patients, apart from the preclamping value of the N20/P25 amplitude which was lower in the nonshunted subjects. The number of patients with decreased and/or delayed cortical SEP (findings frequently used as criterion for selective shunting) was similar in the two study groups. A loss of the cortical SEP occurred in one patient operated on without an indwelling shunt. None of these patients had a new neurologic deficit after surgery. In the meta-analysis, the positive predictive value of decreased and/or delayed cortical SEP was extremely poor, that of absent cortical SEP was poor to moderate and the prevalence of new neurologic deficits was similar in patients undergoing CEA with routine shunting-nonshunting and those with selective shunting-nonshunting. Our study suggests that decreased and/or delayed cortical SEP are unreliable predictors of the neurological outcome of CEA patients and consequently an unsuitable criterion for selective shunting. The meta-analysis confirms this finding and shows that the neurologic outcome is not improved by using an indwelling shunt selectively based on SEP monitoring.
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Affiliation(s)
- C Wöber
- Department of Neurology, University of Vienna, Vienna, Austria
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Ackerstaff RG, van de Vlasakker CJ. Monitoring of brain function during carotid endarterectomy: an analysis of contemporary methods. J Cardiothorac Vasc Anesth 1998; 12:341-7. [PMID: 9636921 DOI: 10.1016/s1053-0770(98)90019-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- R G Ackerstaff
- Department of Clinical Neurophysiology, St. Antonius Hospital, Utrecht, The Netherlands
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Guérit JM. Neuromonitoring in the operating room: why, when, and how to monitor? ELECTROENCEPHALOGRAPHY AND CLINICAL NEUROPHYSIOLOGY 1998; 106:1-21. [PMID: 9680160 DOI: 10.1016/s0013-4694(97)00077-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This review considers the main principles and indications of EEG and evoked potential (EP) neuromonitoring in the operating room. Neuromonitoring has a threefold purpose: to warn the surgeon that he has to adjust his strategy, to confirm his decision, and to help him improve subsequent procedures. The pathophysiology of intraoperative events liable to alter the EEG or the EPs is first considered. The usefulness of neuromonitoring in preventing neurological complication relies on its ability to detect neurological dysfunction at a reversible stage. This applies especially to ischemia and compressive damage. The anesthetic influences on EEG and EPs are then considered. Knowledge of them is essential to disentangle these neurophysiological alterations due to intraoperative events from those merely due to anesthesia and to use neurophysiological parameters to evaluate the depth of anesthesia. Third, the main indications and limitations of neuromonitoring are considered: prevention of ischemic brain or spinal cord damage, prevention of mechanical injuries of the brain, spinal cord or peripheral nerve, and localization of the motor cortex in cortical neurosurgery or of cranial nerves in posterior fossa surgery. Finally, the 3 levels of neuromonitoring (neurophysiological feature extraction, neurophysiological pattern recognition, clinical integration of the neurophysiological patterns) are discussed together with the rules that should guide the dialogue between the surgeon, the anesthesiologist, and the neurophysiologist.
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Affiliation(s)
- J M Guérit
- Clinical Neurophysiology Unit, Cliniques Saint-Luc, University of Louvain Medical School, Brussels, Belgium.
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Guérit JM, Witdoeckt C, de Tourtchaninoff M, Ghariani S, Matta A, Dion R, Verhelst R. Somatosensory evoked potential monitoring in carotid surgery. I. Relationships between qualitative SEP alterations and intraoperative events. ELECTROENCEPHALOGRAPHY AND CLINICAL NEUROPHYSIOLOGY 1997; 104:459-69. [PMID: 9402888 DOI: 10.1016/s0168-5597(97)00022-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This paper presents the results of intraoperative median nerve SEP monitoring in 205 successive patients undergoing isolated carotid endarterectomy (CE) (N = 172) or CE followed by coronary bypass (CBP) and/or vascular replacement (VR) (N = 33). The left and right median nerves were alternately stimulated and recordings performed on 4 channels: cervical, ipsi- and contralateral parietal, and frontal. SEPs were qualitatively rated in terms of mild, moderate, or severe ipsilateral, contralateral, or bilateral abnormalities. The SEP abnormalities were subdivided into 5 categories as a function of their relationships with intraoperative events: no alterations (67.3%), early or late SEP alterations after carotid cross-clamping (15.6%), SEP alterations after a drop in blood pressure (occurring outside of or within the cross-clamping period) (15.1%), SEP alterations of a most likely embolic origin (2.4%), SEP changes after head positioning (1%), and SEP changes after a modification of the anesthetic regimen (1.5%). Only moderate to severe SEP alterations occurring soon after carotid cross-clamping justified shunt installation in 16% of the cases. SEP alterations after a drop in blood pressure were reversed merely by restoring blood pressure. The neurological outcome was uneventful in 94.2% of cases. Of the 12 patients who developed neurological sequellae, only one case presented transient sequellae after isolated CE without SEP changes while most cases either had undergone combined CE and CBP and/or VR (6 cases) or had presented SEP alterations of embolic origin (3 cases). We conclude that our system of qualitative rating of SEPs proved very sensitive to intraoperative hemodynamic disturbances or macroembolisms.
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Affiliation(s)
- J M Guérit
- Clinical Neurophysiology Unit, Cliniques Universitaires Saint-Luc, University of Louvain Medical School, Brussels, Belgium
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Witdoeckt C, Ghariani S, Guérit JM. Somatosensory evoked potential monitoring in carotid surgery. II. Comparison between qualitative and quantitative scoring systems. ELECTROENCEPHALOGRAPHY AND CLINICAL NEUROPHYSIOLOGY 1997; 104:328-32. [PMID: 9246070 DOI: 10.1016/s0168-5597(97)00021-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This paper compares the respective yields of our SEP scoring system ('qualitative' criteria), based on the subdivision of SEP abnormalities into mild, moderate, and severe abnormalities, and a quantitative one ('classical' criteria), based on a more than 1 ms CCT increase or 50% decrease of N20 amplitude, for the detection of brain ischemia justifying shunt placement during carotid endarterectomy (CE). For that purpose, we examine the sensitivities of several neurophysiological parameters (the ipsilateral and contralateral CCT, the amplitudes of the ipsilateral and contralateral frontal and parietal SEPs) to carotid cross-clamping or to a drop of blood pressure. Our data first confirm that shunted patients developed a CCT increase and a decrease of N20 amplitude on the ipsilateral hemisphere. They further demonstrate that 50% of the patients who were immediately shunted on the basis of qualitative criteria would not have been shunted or would have been shunted with a longer delay on the basis of quantitative criteria. Simultaneously, the overall percentage of shunted patients was not significantly higher than in studies using the 'classical' criteria. Thus, it was hard to decide between the 'qualitative' and the 'classical' criteria on the basis of patient data. However, our 'qualitative' system appears advantageous in that it smooths out the influence of factors liable to interfere with the quantitative parameters.
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Affiliation(s)
- C Witdoeckt
- Clinical Neurophysiology Unit, Cliniques Saint-Luc, University of Louvain Medical School, Brussels, Belgium
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Wilke HJ, Ellis JE, McKinsey JF. Carotid endarterectomy: perioperative and anesthetic considerations. J Cardiothorac Vasc Anesth 1996; 10:928-49. [PMID: 8969405 DOI: 10.1016/s1053-0770(96)80060-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- H J Wilke
- Department of Anesthesia and Critical Care, University of Chicago, IL 60637, USA
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Abstract
In reviews in the 1980s, we discussed both indications for and surgical techniques in carotid endarterectomy. Significant changes in the practice of extracranial cerebrovascular reconstruction have occurred over the past few years. The newest indications and cooperative study data have recently been discussed by Camarata and Heros in this topic review series. In this article, we aim to review the advances in operative monitoring and surgical techniques of the last decade. We would be remiss, however, not to note that the latest Asymptomatic Carotid Atherosclerosis Study data, released in September 1994, indicate that carotid endarterectomy is significantly superior to medical therapy for asymptomatic stenosis of > 60%. These data, along with the North American Symptomatic Carotid Endarterectomy Trial results, will revitalize and lend scientific validity to carotid artery reconstruction.
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Affiliation(s)
- C M Loftus
- Division of Neurological Surgery, University of Iowa College of Medicine, Iowa City, USA
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Pistolese GR, Ippoliti A, Crispo E, Ronchey S, Marchetti AA. Is the use of shunts in carotid endarterectomy still a problem? EUROPEAN JOURNAL OF VASCULAR SURGERY 1993; 7:604-9. [PMID: 8270060 DOI: 10.1016/s0950-821x(05)80703-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- G R Pistolese
- Department of Vascular Surgery, University of Rome, Tor Vergata S. Eugenio Hospital, Italy
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