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Zentralbl Chir 2001; 126(12): 969-974
DOI: 10.1055/s-2001-19646
Gefäßchirurgie

© Georg Thieme Verlag Stuttgart · New York

Wertigkeit der intraoperativen Duplexsonographie bei der Carotisendarterektomie

Assessment of Intraoperative Duplexsonography During Carotid EndarterectomyP. U. Reber, Nicola Ghisletta, H. Hakki, Irene Zwahlen, Iris Baumgartner, H. W. Kniemeyer
  • Abteilung für Gefäßchirurgie, Klinik für Herz- und Gefäßchirurgie, Inselspital, Universität Bern
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Publication History

Publication Date:
22 January 2002 (online)

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Summary

Introduction: Carotid endarterectomy (CEA) for prevention of strokes mandates a high amount of experience and a meticulous surgical technique. Intraoperative morphologic as well as hemodynamic monitoring of the endarterectomized arteries is rarely performed. The purpose of this study was to determine the value of intraoperative colour-coded-duplex-sonography to recognize eventual intraoperative technical problems that might result in serious cerebral damage.
Methods: Prospective analysis of the medical data of all patients who underwent CEA for treatment of high-grade carotid stenosis between 1996 and 1999. Adequacy of the repair was assessed intraoperatively by duplexsonography.
Results: Of 142 consecutive patients with a median age of 68 (43-84) years, 104 (73 %) were men and 38 (27 %) were women. 9 patients (6 %) had bilateral CEAs. Intraoperative duplexsonography revealed abnormalities during 11 (7 %) of 151 CEAs. 4 (3 %) were considered major and underwent immediate revision. There was one (0.7 %) temporary neurologic deficit (hyperperfusion syndrome) and 2 (1.3 %) cases of fatal intracerebral hemorrhage. 6 (4 %) postoperative surgical complications occurred, i. e. 3 cases of major wound hematoma (with revision) and 3 cases of temporary cranial nerve palsy. Median length of follow-up was 11 (3-35) months. No late neurologic event occurred during follow-up. 5 (3 %) patients developed asymptomatic restenosis.
Discussion: Routine intraoperative duplexsonography is a valuable and reliable diagnostic tool to detect correctable technical problems during CEA that subsequently may lead to neurological deficits, fatal stroke or a high incidence of restenosis.

Zusammenfassung

Einleitung: Die Carotisendarterektomie (CEA) bei hochgradigen oder symptomatischen Carotisstenosen ist gegenwärtig das Verfahren der Wahl zur Vermeidung eines cerebro-vaskulären Insultes (CVI). Zur Optimierung der Operationstechnik ist eine intraoperative Qualitätskontrolle unabdingbar. Ziel der Studie war die Untersuchung der Wertigkeit der intraoperativen Duplexsonographie in der Erkennung von technischen Fehlern und hämodynamischen Flussunregelmäßigkeiten, die unerkannt zu folgenschweren Komplikationen führen können.
Methodik: Prospektive Datenanalyse aller Patienten, die wegen Carotisstenosen zwischen 1996-1999 von 2 verantwortlichen Operateuren operiert worden sind. In allen Fällen wurde eine intraoperative Duplexsonographie als Qualitätskontrolle durchgeführt.
Ergebnisse: Unter 142 konsekutiven Patienten mit einem Durchschnittsalter von 68 (43-84) Jahren fanden sich 104 (73 %) Männer und 38 (27 %) Frauen. Bei 9 (6 %) Patienten wurde eine bilaterale CEA durchgeführt. Die intraoperative Duplexsonographie ergab insgesamt in 11 (7 %) Fällen einen pathologischen Befund, der in 4 (3 %) Fällen zur unverzüglichen Revision führte. Zwei (1,3 %) Patienten verstarben postoperativ als Folge eines hämorrhagischen CVI und ein Patient erlitt ein temporäres neurologisches Ereignis. Die Morbidiät betrug 4 %, entsprechend 3 Nachblutungen und 3 temporären Neuropraxien. Es waren keine neurologischen Spätkomplikationen während einer mittleren Nachkontrolldauer von 11 (3-35) Monaten zu verzeichnen. Fünf (3 %) Patienten entwickelten in der Folge eine asymptomatische Restenose.
Diskussion: Die routinemäßige intraoperative Duplexsonographie nach CEA ist ein zuverlässiges und sicheres diagnostisches Verfahren. Technische Fehler und hämodynamische Flussunregelmäßigkeiten, die unter Umständen Früh- oder Spätkomplikationen verursachen, können rechtzeitig erkannt und behoben werden.

Key words

Duplex sonography - Carotid artery - Endarterectomy - Results

Schlüsselwörter

Duplexsonographie - Carotis - Thrombendarterektomie - Resultate

Literatur

  • 1 Archie JP J r. A fifteen-year experience with carotid endarterectomy after formal operative protocol requiring highly frequent patch angioplasty.  J Vasc Surg. 2000;  31 724-735
    PubMedGoogle Scholar
  • 2 Avramovic J R, Fletcher J P. The incidence of recurrent carotid stenosis after carotid endarterectomy and its relationship to neurological events.  J Cardiovasc Surg. 1992;  33 54-58
    PubMedGoogle Scholar
  • 3 Baker W H, Koustas G, Hayes A C, Dorner D B, Stubbs D. Carotid endarterectomy without a shunt: a control series.  J Vasc Surg. 1984;  1 50-56
    PubMedGoogle Scholar
  • 4 Baker W H, Koustas G, Burke K, Littooy F N, Greisler H P. Intraoperative duplex scanning and late carotid artery stenosis.  J Vasc Surg. 1994;  19 829-833
    PubMedGoogle Scholar
  • 5 Barnett H JM, Taylor D W, Eliasziw M, Fox A J, Ferguson G G, Haynes R B. et al . Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.  N Engl J Med. 1998;  339 1415-1425
    CrossrefPubMedGoogle Scholar
  • 6 Blaisdell F W, Lim R, Hall A D. Technical results of carotid endarterectomy: arteriography assessment.  Am J Surg. 1967;  114 239-246
    PubMedGoogle Scholar
  • 7 Cao P, Giordano G, De Rango P, Carlini G, Verzini F, Parente B. et al . Computerised tomography findings as a risk factor in carotid endarterectomy: early and late results.  Eur J Vasc Endovasc Surg. 1996;  12 37-45
    PubMedGoogle Scholar
  • 8 Cina C S, Clase C M, Haynes R B. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev 2000; 2: CD 001 081
    Google Scholar
  • 9 Dorffner R, Metz V M, Trattnig S, Eibenberger K, Dock W, Hörmann M. et al . Intraoperative and early postoperative colour Doppler sonography after carotid reconstruction: follow-up of technical defects.  Neuroradiology. 1997;  39 117-121
    CrossrefPubMedGoogle Scholar
  • 10 ECST. European Carotid Surgery Trialists Collaborative Group . MCR European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99 %) or mild (0-29 %) carotid stenosis.  Lancet. 1991;  337 1235-1242
    CrossrefPubMedGoogle Scholar
  • 11 Endarterectomy for Asymptomatic Carotid Artery Stenosis - Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.  JAMA. 1995;  273 1421-1428
    CrossrefPubMedGoogle Scholar
  • 12 Fearn S J, Picton A J, Mortimer A J, Parry A D, McCollum C hN. The contribution of the external carotid artery to cerebral perfusion in carotid disease.  J Vasc Surg. 2000;  31 989-993
    CrossrefPubMedGoogle Scholar
  • 13 Hamdan A D, Pomposelli F Bjr, Gibbons G W, Campbell D R, Lo Gerfo F W. Perioperative stroke after 1 001 consecutive carotid endartrectomy procedures without an electroencephalogram: incidence, mechanism, and recovery.  Arch Surg. 1999;  134 412-415
    PubMedGoogle Scholar
  • 14 Hoff C, de Gier P, Buth J. Intraoperative duplex monitoring of the carotid bifurcation for the detection of technical defects.  Eur J Vasc Surg. 1994;  8 441-447
    PubMedGoogle Scholar
  • 15 Jacobowitz G R, Adelman M A, Riles T S, Lamparello P J, Imparato A M. Long-term follow-up of patients undergoing carotid endarterectomy in the presence of a contralateral occlusion.  Am J Surg. 1995;  170 165-167
    CrossrefPubMedGoogle Scholar
  • 16 Kinney E V, Seabrock G R, Kinney L Y, Bandyk D F, Towne J B. The importance of intraoperative detection of residual flow abnormalities after carotid endarterectomy.  J Vasc Surg. 1993;  17 912-923
    PubMedGoogle Scholar
  • 17 Kniemeyer H W, Aulich A, Schlachetzki F, Steinmetz H, Sandmann W. Pseudo- and segmental occlusion of the internal carotid artery: New classification, surgical treatment and results.  Eur J Vasc Endovasc Surg. 1996;  12 10-320
    PubMedGoogle Scholar
  • 18 Lattimer C R, Burnand K G. Recurrent carotid stenosis after carotid endarterectomy.  Br J Surg. 1997;  84 1206-1219
    CrossrefPubMedGoogle Scholar
  • 19 Mehigan J T, Olcott C. Video angioscopy as an alternative to intraoperative anteriography.  Am J Surg. 1986;  152 139-145
    CrossrefPubMedGoogle Scholar
  • 20 NASCET. North American Symptomatic Carotid Endarterecteomy Trial Collaborators . Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.  New Engl J Med. 1991;  325 445-453
    PubMedGoogle Scholar
  • 21 Naylor A R, Bell P RF, Ruckley C V. Monitoring and cerebral protection during carotid endarterectomy.  Br J Surg. 1992;  79 735-741
    PubMedGoogle Scholar
  • 22 Raithel D, Kasparzak P. Angioscopy after carotid endarterectomy.  Ann Chir Gynaecol. 1992;  81 192-195
    PubMedGoogle Scholar
  • 23 Riles T S, Imparato A M, Jacobowitz G R, Lamparello P J, Giangola G, Adelman M A. et al . The cause of perioperative stroke after carotid endarterectomy.  J Vasc Surg. 1994;  19 206-214
    CrossrefPubMedGoogle Scholar
  • 24 Sandmann W, Kniemeyer H W, Peronneau P. Carotid bifurcation doppler spectrum analysis at surgery. In: Greenhalgh RM (ed). Diagnostic techniques and assessment procedures in vascular surgery. Grune & Stratton, London 1985; 123-127
    Google Scholar
  • 25 Sandmann W, Willeke F, Kolvenbach R, Benecke R, Godehardt E. To shunt or not to shunt: The definite answer with a randomized study. In: Veith F (Hrsg). Current critical problems in vascular surgery. Quality Medical Publisher Inc, St. Louis 1993; 434-440
    Google Scholar
  • 26 Sawchuk A P, Flanigan D P, Machi J, Schuler J J, Sigel B. The fate of anrepaired minor technical defects detected by intraoperative ultrasonography during carotid endarterectomy.  J Vasc Surg. 1989;  9 671-675
    PubMedGoogle Scholar
  • 27 Stendel R, Brock M, Abo Al Hassan A, Hupp T. Mikrovaskuläre Dopplersonographie versus intraoperative Angiographie in der Carotischirurgie.  Gefaesschirurgie. 2000;  5 159-165
    PubMedGoogle Scholar
  • 28 Sundt T M, Houser O W, Whisnant J P, Fode N C. Correlation of postoperative and two-year follow-up angiography with neurological function in 99 carotid endarterectomies in 86 consecutive patients.  Ann Surg. 1986;  203 90-100
    PubMedGoogle Scholar
  • 29 Taylor D C, Strandness D E. Carotid artery duplex scanning.  J Clin Ultrasound. 1987;  15 635-644
    PubMedGoogle Scholar
  • 30 Washburn W K, Mackey W C, Belkin M, O'Donnell T F Jr. Late stroke after carotid endarterectomy: The role of recurrent stenosis.  J Vasc Surg. 1992;  15 1032-1037
    PubMedGoogle Scholar
  • 31 Zierler R E, Bandyk D F, Thiele B L. Intraoperative assessment of carotid endarterectomy.  J Vasc Surg. 1985;  1 73-83
    PubMedGoogle Scholar

Priv.-Doz. Dr. P. U. Reber

Abteilung für Angiologie und Gefäßchirurgie

Lindenhofspital

3003 Bern

Schweiz

Phone: +41/31-3 00 95 50

Fax: +41/31-3 00 95 59

Email: Peter.Reber@neuehorizonte.ch

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