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Bilateral One-stage Carotid Endarterectomy – is there an Indication?
Eur J Vasc Endovasc Surg 21, 575–576 (2001) doi:10.1053/ejvs.2001.1373, available online at http://www.idealibrary.com on
CASE REPORT
Bilateral One-stage Carotid Endarterectomy – is there an Indication? I. D. Kumar, S. Singh∗, G. Williams and J. Train Doncaster Royal Infirmary, U.K.
Introduction The indications for carotid endarterectomy (CEA) in symptomatic disease are established1,2 but may be refined in the future. Although CEA has been shown to confer benefit in asymptomatic patients with stenoses >70%, the results of the European Asymptomatic Carotid Surgery Trial (ACST) are awaited. Bilateral carotid endarterectomy (BCE) can be performed either as a one-stage procedure or in two stages.3,4 Although small series have reported satisfactory results with BCE performed as a one-stage procedure,4 these series invariably involved asymptomatic patients for whom CEA would not be currently advocated. We wish to report one-stage BCE performed for bilateral crescendo transient ischaemic attacks (TIAs).
(see Fig. 1). The patient was admitted urgently, commenced on intravenous heparin and underwent bilateral carotid endarterectomy as a single stage procedure under general anaesthesia. Shunts and dacron patches were used on both sides. The patient made an uneventful recovery and was discharged from hospital on the third postoperative day. Duplex assessment at 6 weeks showed both internal carotids to be widely patent and the patient remains symptom free one year after his operation.
Discussion Currently CEA is recommended for symptomatic disease where it has shown to be cost effective.5 Ac-
Case Report A 62-year-old male with a previous history of hypopituitarism, ischaemic heart disease and hypertension presented with recurrent bilateral TIAs. The TIAs consisted of amaurosis fugax, loss of sensation and weakness of the contralateral limb and face. These episodes affecting both sides of the body at least once or twice a day were occurring in spite of aspirin and dipyridamole. During duplex assessment of his carotid arteries, the patient suffered a TIA resulting in transient weakness of the contralateral arm. Duplex assessment revealed bilateral >90% stenoses at the origins of both internal carotid arteries with echolucent plaque. These findings were later confirmed by arch angiography
∗ Please address all correspondence to: S. Singh, Consultant Vascular Surgeon, Armthorpe Road, Doncaster DN2 5LT, UK. 1078–5884/01/060575+02 $35.00/0 2001 Harcourt Publishers Ltd.
Fig. 1. Arch angiogram.
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cordingly the indication for BCE would be bilateral symptomatic severe (>70% stenoses) carotid disease. In such patients staged BCE is favoured by many3 and has consistently produced satisfactory outcomes. However, the advocates of one-stage bilateral CEA argue that it requires one anaesthetic instead of two and obviates any delay or considerations with respect to timing. BCE as a single stage procedure would only be indicated if such a patient was experiencing bilateral symptoms simultaneously. In view of the fact that our patient’s bilateral symptoms were only controlled by intravenous heparin, we felt that he would be best served by BCE as a single stage procedure obviating the need for interim anticoagulation. We recommend this approach in patients with bilateral crescendo TIAs.
References 1 European Carotid Surgery Trialists’ Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial. Lancet 1998; 351: 1379–1387. 2 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998; 339: 1415–1425. 3 Dimakakos PB, Kotsis TE, Tsiligiris B, Antoniou A, Mourikis D. Comparative results of staged and simultaneous bilateral carotid endarterectomy; a clinical study and surgical treatment. Cardiovasc Surg 2000; 8: 10–17. 4 Maxwell JG, Covington DL, Churchill MP et al. Results of staged bilateral carotid endarterectomy. Arch Surg 1992; 127: 793–798. 5 Mead GE, O’Neill PA, Parry AD, McCollum CN. Carotid endarterectomy. Is cost effective. BMJ 1995; 310: 1135. Accepted 1 April 2001
Eur J Vasc Endovasc Surg Vol 21, June 2001
CASE REPORT
Bilateral One-stage Carotid Endarterectomy – is there an Indication? I. D. Kumar, S. Singh∗, G. Williams and J. Train Doncaster Royal Infirmary, U.K.
Introduction The indications for carotid endarterectomy (CEA) in symptomatic disease are established1,2 but may be refined in the future. Although CEA has been shown to confer benefit in asymptomatic patients with stenoses >70%, the results of the European Asymptomatic Carotid Surgery Trial (ACST) are awaited. Bilateral carotid endarterectomy (BCE) can be performed either as a one-stage procedure or in two stages.3,4 Although small series have reported satisfactory results with BCE performed as a one-stage procedure,4 these series invariably involved asymptomatic patients for whom CEA would not be currently advocated. We wish to report one-stage BCE performed for bilateral crescendo transient ischaemic attacks (TIAs).
(see Fig. 1). The patient was admitted urgently, commenced on intravenous heparin and underwent bilateral carotid endarterectomy as a single stage procedure under general anaesthesia. Shunts and dacron patches were used on both sides. The patient made an uneventful recovery and was discharged from hospital on the third postoperative day. Duplex assessment at 6 weeks showed both internal carotids to be widely patent and the patient remains symptom free one year after his operation.
Discussion Currently CEA is recommended for symptomatic disease where it has shown to be cost effective.5 Ac-
Case Report A 62-year-old male with a previous history of hypopituitarism, ischaemic heart disease and hypertension presented with recurrent bilateral TIAs. The TIAs consisted of amaurosis fugax, loss of sensation and weakness of the contralateral limb and face. These episodes affecting both sides of the body at least once or twice a day were occurring in spite of aspirin and dipyridamole. During duplex assessment of his carotid arteries, the patient suffered a TIA resulting in transient weakness of the contralateral arm. Duplex assessment revealed bilateral >90% stenoses at the origins of both internal carotid arteries with echolucent plaque. These findings were later confirmed by arch angiography
∗ Please address all correspondence to: S. Singh, Consultant Vascular Surgeon, Armthorpe Road, Doncaster DN2 5LT, UK. 1078–5884/01/060575+02 $35.00/0 2001 Harcourt Publishers Ltd.
Fig. 1. Arch angiogram.
576
I. D. Kumar et al.
cordingly the indication for BCE would be bilateral symptomatic severe (>70% stenoses) carotid disease. In such patients staged BCE is favoured by many3 and has consistently produced satisfactory outcomes. However, the advocates of one-stage bilateral CEA argue that it requires one anaesthetic instead of two and obviates any delay or considerations with respect to timing. BCE as a single stage procedure would only be indicated if such a patient was experiencing bilateral symptoms simultaneously. In view of the fact that our patient’s bilateral symptoms were only controlled by intravenous heparin, we felt that he would be best served by BCE as a single stage procedure obviating the need for interim anticoagulation. We recommend this approach in patients with bilateral crescendo TIAs.
References 1 European Carotid Surgery Trialists’ Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial. Lancet 1998; 351: 1379–1387. 2 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998; 339: 1415–1425. 3 Dimakakos PB, Kotsis TE, Tsiligiris B, Antoniou A, Mourikis D. Comparative results of staged and simultaneous bilateral carotid endarterectomy; a clinical study and surgical treatment. Cardiovasc Surg 2000; 8: 10–17. 4 Maxwell JG, Covington DL, Churchill MP et al. Results of staged bilateral carotid endarterectomy. Arch Surg 1992; 127: 793–798. 5 Mead GE, O’Neill PA, Parry AD, McCollum CN. Carotid endarterectomy. Is cost effective. BMJ 1995; 310: 1135. Accepted 1 April 2001
Eur J Vasc Endovasc Surg Vol 21, June 2001