Carotid endarterectomy-Part II: surgical risks, techniques, complications and acute stroke management

We report surgical risks and complications in patients undergoing carotid endarterectomy (CEA) for carotid occlusive diseases by analyzing the results of a nationwide questionnaire. In 1014 patients who underwent CEA in Japan for 2 years from 2000 to 2001, the rate of disabling stroke and death was 1.9%, and in 394 patients who underwent endovascular surgery including stent placement for carotid artery stenosis during the same period, the rate of disabling stroke and death was 4.5%. From our experience of 336 patients who underwent CEA in our institute between 1975 and 2002, ischemic heart disease was a major cause of death during the CEA perioperative and follow-up periods. Combined angiography and careful management of coronary artery stenosis can be expected to decrease the mortality and morbidity in patients treated with CEA. Intraoperative multiple monitoring system using deviation ration topography of EEG, somatosensory evoked potentials, near-infrared spectrophotometry for measurement of cerebral regional SO2 and transcranial Doppler ultrasonography (TCD) is useful to prevent ischemic complications. Postoperative hyperperfusion syndrome can be checked serially and non-invasively by using TCD. The management of acute stroke patients with thrombosed occlusion or sever stenosis of the internal carotid artery is still controversial. Acute stage CEA was taken into consideration to treat the patients only in 5 (9%) of the 54 Japanese institutes which answered the questionnaire.