Dale J. Austin

Carotid endarterectomy for cerebrovascular insufficiency: long-term results in 592 patients followed up to thirteen years.

Seven hundred forty-eight carotid endarterectomies were performed on 592 patients with cerebrovascular insufficiency during a 13-year period. Overall operative procedure mortality was 2.7%. In the last 6 years, using a shunt routinely and avoiding operation on acute strokes, mortality was 1.47%. In frank strokes it was 3.7%; in transient ischemia, 0.77%; and zero for chronic ischemia and asymptomatic bruits. Incidence of operation-related deficits among transient ischemia and asymptomatic bruit patients was 0.9% for transient weakness and 2% for permanent deficits. Of 172 long-term deaths, 23 were due to cerebral causes, or 3.9% of the entire series. Among frank stroke survivors, 30.2% are normal and 58.7% improved. In transient ischemia survivors 81% are normal and 15.7% improved. In 65 asymptomatic bruit patients operated upon electively, two had strokes during follow-up, one mild and one severe. Among 37 asymptomatic bruit control patients, 24 or 65% developed symptoms of transient ischemia or frank strokes. Of 118 totally occluded carotid arteries explored, flow was restored in 48 (40.7%) but could not be restored in 70 (59.3%). For cerebral protection during carotid endarterectomy the routine use of a temporary inlying bypass shunt with general anesthesia is advocated for all partial occlusions. Endarterectomy is most useful for transient ischemia and selected patients with mild frank strokes and asymptomatic bruits. Acute profound and rapidly progressing strokes should not be operated upon as an emergency, but allowed to stabilize for several weeks and then be considered for possible operation.

Carotid Endarterectomy for Cerebrovascular Insufficiency: Long-Term Results in 592 Patients Followed up to Thirteen Years

A series of 592 patients with cerebrovascular insufficiency treated by carotid endarterectomy is reported on. Indications, surgical techniques, and results are given. Endarterectomy is most useful for transient ischemia and selected patients with mild frank strokes and asymptomatic bruits.

Clinical Considerations in the Surgical Management of Strokes

Four hundred carotid endarterectomies were performed on 320 private patients with cerebrovascular insufficiency during an eight-year period. Patients are classified into four groups: frank stroke (135 patients), transient cerebral ischemia (151 patients), chronic cerebral ischemia (13 patients), and asymptomatic bruit (21 patients). Over-all operative procedure mortality was 3.5%. In frank strokes it was 7.4%; in transient ischemia, 1.02%; and in the other two groups was zero. As a safety factor during operation, the routine use of an inlying bypass shunt is advocated.Of 60 long-term deaths, six (10%) were due to strokes. Among frank stroke survivors, 42.8% are normal, and 48.4% are improved. One patient had a mild subsequent stroke. In transient ischemia survivors, 88.4% are normal, and 7% are improved. Three patients had strokes due to unoperated lesions. Surgery appears to have lowered the incidence of strokes in these groups. There were no strokes in the other two groups.Indications for and timing of operative procedures are suggested on the basis of the clinical results. Transient ischemia, chronic ischemia, and asymptomatic bruit patients may be operated upon electively unless an imminent total occlusion demands emergency operation. Acute and rapidly progressing strokes should not be operated upon as an emergency, but allowed to stabilize and be considered for surgery at a delayed time.The concept of total cerebral blood flow is discussed in relation to its therapeutic implications and the reversibility of neurological deficits. Carotid endarterectomy is a safe, definitive therapy in selected patients with cerebrovascular insufficiency.

Infected arteriosclerotic aneurysm of the abdominal aorta

Abstract A review of the literature reveals that tuberculous aortic aneurysm and an infected dissecting aortic aneurysm have been resected and replaced with grafts with success. However, no report of resection of an infected arteriosclerotic abdominal aortic aneurysm with survival of the patient was found. Such a case with nearly four years survival without complication of any kind is presented. The principles of (1) resection and removal of all dead and infected material, (2) replacement with minimal graft and suture material, and (3) massive and prolonged antibiotic therapy, both during and after operation, are thought to have contributed to the survival of the patient. Previous right iliac artery occlusion with establishment of adequate collateral for the viability of the right leg allowed for the use of minimal graft and suture material. The fact that the infecting organism was a hemolytic streptococcus which was highly sensitive to antibiotic agents further contributed to the happy outcome.