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A Journal on Vascular and Endovascular Surgery

Official Journal of the Italian Society of Vascular and Endovascular Surgery
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Giornale Italiano di Chirurgia Vascolare 1998 June;5(2):81-95

language: English, Italian

The advan­tag­es of peri­op­er­a­tive arter­i­og­ra­phy in carot­id sur­gery (POAC)

Jausseran J. M., Ferdani M., Houel F., Rudondy Ph., Del Guercio L., Reggi M., Mangiacotti B.

From the Service de Chirurgie Cardio-Vasculaire Hôpital Saint-Joseph, Marseille (France)


Background. Perioper­a­tive angio­gra­phy is an exam­ina­tion ­that is sim­ple to car­ry out and ­easy to inter­pret for the sur­geon and has ­thus ­become rou­tine prac­tice in vas­cu­lar sur­gery. The objec­tive is to ­decrease the inci­dence of ­postoper­a­tive neu­ro­log­i­cal ­events and pre­vent resten­o­sis.
Methods. 126 ­patients ­were oper­at­ed in 1996, 101 ­males and 25 ­females, ­mean age 71 ­years (­range 42-88 ­years). The ­risk fac­tors ­were arte­ri­al hyper­ten­sion in 56 ­patients (44%), ­heart dis­ease in 51 ­patients (40%), dia­betes in 18 ­patients (14%). Thirty-­eight ­patients (30%) had occlu­sive ­lesions and 56 ­were smok­ers (44%). On arter­i­o­grams, all ­patients had ste­nos­es super­i­or to 60%, 65 of ­which ­were locat­ed on the ­right ­side (50.4%) and 64 on the ­left ­side (49.6%). Three ­patients ­were oper­at­ed on ­both ­sides, ­this paten­cy was ­restored to 129 carot­id arter­ies. Before sur­gery 78 ­patients ­were clin­i­cal­ly asymp­to­mat­ic (­stage 0 - 62%), 42 had ­already had a TIA and 8 fleet­ing amau­ro­sis (stage I - 33%) and one ­patient pre­sent­ed ­with a devel­op­ing TIA (­stage II - 0.8%). Technically, endar­te­rec­to­my was per­formed by ever­sion on 81 carot­id arter­ies (64%), 35 had stan­dard endar­te­rec­to­my (27%) ­closed ­with a ­patch in 21 cas­es, 10 had a by­pass (8%) and 3 a re-implan­ta­tion (2.3%). One ­patient had an asso­ciat­ed subcla­vian ­artery re-implan­ta­tion and 2 ­patients had an asso­ciat­ed ver­te­bral ­artery re-implan­ta­tion. All of the cas­es ­were sub­mit­ted to a ­POCA ­check-ups.
­Results. In our ­series, 70 ­patients (54%) ­were clas­si­fied ­group I (nor­male ­POCA), 38 ­group II; includ­ing 12 ste­nos­es and irreg­u­lar­ities of the inter­nal carot­id ­artery, 22 ste­nos­es of the exter­nal carot­id ­artery due to inti­mal dis­place­ment and 8 ste­nos­es of the pri­mary carot­id due to a « stair­case ­effect » 15 ­patients in ­group III (12% pre­sent­ed ­with 3 ­tight ste­nos­es of the inter­nal carot­id ­artery and 12 throm­bo­sis of the exter­nal carot­id ­artery. Group IV includ­ed 6 ­spasms of the carot­id ­artery (4%), one of ­which ­required sur­gi­cal dila­tion. 14 cas­es had to be re-oper­at­ed (11%): 4 cas­es (3,1%) on the inter­nal carot­id (2 ­PTFE bypass­es, 1 Dacron ­patch, 1 dil­a­ta­tion ­with instru­men­ta­tion), 10 cas­es on the exter­nal carot­id ­artery (sep­ar­ate endar­te­rec­to­my). Two throm­boses of the exter­nal carot­id ­artery ­were not ­repaired. After revi­sion sur­gery, the ­POCA was nor­mal. The clin­i­cal ­results record­ed no ­death, no hem­i­ple­gia, 2 regres­sive neu­ro­log­i­cal ­events. The dis­cus­sion anal­y­ses the advan­tag­es of ­POCA in pre­vent­ing imme­di­ate ­postoper­a­tive ­events and lat­er resten­o­sis in carot­id sur­gery. It ­must be ­stressed ­that the meth­od is inof­fen­sive and ­POCA is com­pared ­with ultra­sound and angios­cop­ic pro­ce­dures.
Conclusions. ­POCA ­does con­trib­ute mod­est­ly to decreas­ing the inci­dence of ­postoper­a­tive neu­ro­log­i­cal com­pli­ca­tions and lat­er resten­o­sis ­because it ­helps to ­improve sur­gi­cal pro­ce­dure.

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