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Giornale Italiano di Chirurgia Vascolare 1998 June;5(2):81-95

Copyright © 2000 EDIZIONI MINERVA MEDICA

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)


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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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