Twenty-three years of experience of carotid endarterectomy

Vascular Surgical Society of Great Britain and Ireland Twenty-three years of experience of carotid endarterectomy T. Hussain, J. W. B. Senaratine, F. R. Green, J. Collin, L. Hands and P. J. Morris John Radcliffe Hospital, Oxford, UK Background: Carotid endarterectomy CEA) has been an evidence-based treatment for symptomatic severe carotid stenosis since 1991. Surgical techniques and patient selection have changed over the years. The results of CEA in a single centre over a 23-year period were reviewed. Methods: Prospectively gathered preoperative, operative, post- operative and long-term follow-up data were analysed. Routine intraoperative shunting and patch closure has been used since 1988. Data were analysed using the v 2 test or by logistic regression, adjusting for age at operation and date of operation. Results: Five hundred and seventy-three CEAs 37 bilateral and three repeat procedures) were carried out on 533 patients. Trainees performed an increasing proportion of CEAs from 1996 to 1998 15, 50 and 56 per cent respectively). The perioperative death rate was 0á8 per cent and the rate of any perioperative neurological de®cit was 6á9 per cent. Other causes of morbidity included nerve injury 5á1 per cent) of which the commonest was to the hypoglossal nerve 2á7 per cent). During follow-up median 4 range 0±22) years) there were 81 neurological events 15á9 per cent) which included 35 ipsilateral 6á6 per cent) and 18 contralateral 3á4 per cent) strokes. There was no signi®cant difference in outcome for grade of surgeon, intraoperative shunting or patch closure. Major causes of death were cardiac death 74; 14á6 per cent) followed by stroke 23; 4á5 per cent) and cancer 20; 3á9 per cent). Conclusion: The introduction of routine intraoperative shunting and patch closure, as well as allowing surgical trainees to perform supervised CEAs, has not affected perioperative morbidity and mortality rates or long-term outcome. Audit of surgical technique during carotid endarterectomy by intraoperative duplex ultrasonography: trainees compared with consultant T. S. Padayachee, M. D. Brooks, G. Self, K. B. Moderesi and P. R. Taylor Guy's Hospital, London, UK Background: There has been increasing interest in audit of outcome following surgery. A previous study reported a signi®- cant difference in clinical outcome between consultant and trainees but there is no information on technical factors. Duplex ultrasonography before wound closure was used to compare clinical and technical outcome for consultant and trainees. Methods: Patients underwent endarterectomy 89 by consultant, 60 by six trainees). In the consultant group nine vessels were patched and 36 patients underwent shunting compared with seven and 31 respectively for trainees. Results: In the consultant group there were two deaths, one stroke, one transient ischaemic attack TIA) and two cranial nerve injuries. The neurological event rate was 2 per cent, and overall stroke and death rate 3 per cent. There were ten residual ¯aps 11 per cent) three re-explored) and eight kinks 9 per cent). The residual stenosis rate was 10 per cent nine of 89) and following re-exploration this reduced to 7 per cent. In the trainee group there was one death, two strokes, one TIA and one cranial nerve injury. The neurological event rate was 5 per cent, and the overall stroke and death rate 3 per cent. There were nine ¯aps 15 per cent) four re-explored) and 13 kinks 22 per cent). The residual stenosis rate was 22 per cent 13 of 60) which reduced to 15 per cent nine of 60) following re-exploration. There was no signi®cant difference in clinical outcome between consultant and trainees but there was an increased incidence of technical prob- lems among the trainees t 2á12, P <0á05). Conclusion: Intraoperative duplex ultrasonography is a valuable method for assessing surgical technique; it gives immediate feedback to the surgeon, enables corrective measures to be taken and may facilitate training. Carotid angiography is used more selectively in the Asymptomatic Carotid Surgery Trial P. Robless and A. Halliday on behalf of the Asymptomatic Carotid Surgery Trial collaborators Background: The ongoing Asymptomatic Carotid Surgery Trial ACST) has randomized more than 1900 patients to determine whether carotid endarterectomy prolongs stroke-free survival compared with best medical treatment alone. Previously the Asymptomatic Carotid Atherosclerosis Study demonstrated that preoperative angiography caused stroke or death in 1 per cent of patients, and many centres have now reduced or abandoned this practice. This study determined the changing practice of carotid angiography in the ACST. Methods: Collaborating surgeons completed questionnaires annually on their use and method of angiography. Information on patients in the ACST who had angiography at randomization was also obtained. Results: In 1993, 77 per cent of responding collaborators always performed preoperative angiography and 23 per cent used angiography selectively. This trend has reversed: by 1997, 26 per cent always used preoperative angiography, 70 per cent of respondents used preoperative angiography selectively and 4 per cent had abandoned angiography P <0á001, v 2 for trend). Information on carotid angiography at randomization has to date The following abstracts are from the papers presented to the 32nd Annual Conference of the Vascular Surgical Society of Great Britain and Ireland, held in Hull, UK, on 18±20 November 1998. President of the Society, Mr J. M. D. Galloway, was in the Chair. 690 British Journal of Surgery 1999, 86, 690±711 www.bjs.co.uk Ó 1999 Blackwell Science Ltd

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Twenty-three years of experience of carotid endarterectomy