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Eversion endarterectomy in surgery of the internal carotid artery
ELSEVIER SCIENCE5
Ever&on endarterectomy in surgery of the internal carotid artery L. Entz, Zs. JMnyi and A. Nemes Department of Cardiovascular Surge/y, Semmelwe& Medics/School. Budapest, Virosma&r u. 68., H- 1122, Hungary
A total of 361 eversionendarterectomies of the internal carotid artery havebeen carried out on 348 patients between January 1991 and December 1992. Of these patients, 126 were women and 222 were men: average age was 62.9 (range 42-84) years. Some 239 patients had hemispheric symptoms: 37 symptomless patients had a carotid endarterectomy before major vascular reconstruction, and 21 had the operation combined with heart surgery (19 aortocoronary bypasses,two valve replacements). In nine cases (Z.S%) a 6-mm interposition graft was used because of unsuccessful eversion endarterectomy. Postoperative bleeding occurred in six patients (1.7%) and postoperative stroke in seven(1.9%); of these patients, four died and two still have mild neurologicalsymptoms. Four reocclusionsoccurred during the first 6 months that the new method was used. Eversion endatterectomy of the internal carotid artery is a safe and useful technique and is comparable with standard endarterectomies. This technique may reduce the risk of restenosis. Keywords: carotid endarterectomy, eversion endarterectomy
Eversion endarterectomy is not a popular technique. It was first described by DeBakey and colleaguesl, who divided the common carotid artery below the bifurcation, everted the plaque from both the external and internal carotid artery and separated them. This type of endarterectomy is technically difficult because the side branches of the external carotid artery prevent correct removal of the plaque from the internal carotid artery, especially if there is a long stenosis. Indeed, DeBakey and co-workers had doubts about the method and finally abandoned it. Etheredge’ reported 72 cases in 1970, the operations being performed using the same technique as DeBakey. In 1989, Raithel and Kasprzak 3,4 first reported a series using a modified technique in which the plaque was everted in the internal carotid artery after it had been cut from the common carotid artery. They reported good results with more than 2700 carotid endarterectomies performed with this modification. Also in 1985, Kieny and colleagues’ in Strasbourg began to operate on the internal carotid artery using the eversion technique. Up to year-end 1990 they had
Correspondence to: Dr L. Entz
190
performed 212 operations with this technique, also with good results. The authors have performed carotid endarterectomy using the eversion technique and report results of a 2-year period finishing in December 1992. The eversion technique was attempted in all operations irrespective of the type of disease or the degree of stenosis present. If an eversion endarterectomy could not be carried out, an interposition graft was used to replace the resected internal carotid artery6.
Patients and methods A total of 529 carotid operations were carried out between 1 January 1991 and 31 December 1992 at the authors’ clinic. Of these, 361 were eversion endarterectomies; hence 68% of the total carotid operations were of the eversion type. Patient data are shown in Tables 1-4. Surgery was carried out under general anaesthesia, with controlled hypertension being used to increase brain perfusion if a shunt was not used. The operation was performed usin $ the technique described by Kasprzak and Raithel . In nine patients the operation was attempted using the eversion method. However, reimplantation proved impossible, and a polytetrafluoroethylene (PTFE) pros-
CARDIOVASCULAR SURGERY APRIL 1996 VOL 4 NO 2
EverSonendarterwomyandinternalcarotidartery.wgery L.Entzet al. Ti&le 1
Patient data for internal carotid artery surgery*
No. of patients Men Women Average age &ears) Men Women No. of patients with bilateral operation
306 193 60.3 58.3 30
*Total of 529 operations performed
Tabs% 2
Type of reconstruction of internal carotid artery
Reconstruction
No. of patients
Ever&n endarterectomy interposition Standard endarterectomy
361
Total
529
T&b 3 artery*
1z
Pat&r& data for ever&on endarterectomy of the internal carotid
No. ofpatients Men Women Av=w age Clean Men Women No. of patients with bilateral operation No. of patients with one-stage interposition No. of patients without shunt
222 126 62.7 63.4 13 9 82
*Total of 361 operations performed
thesis was inserted between the common carotid and internal carotid arteries (‘Table 3). An intraluminal shunt was usually inserted into the internal carotid artery after clamping. The need for a shunt was determined by monitoring cerebral circulation with transcranial Doppler. Shunts were not used in 82 cases, and no neurological complications developed in these patients. In 21 cases carotid and cardiac surgery was performed sequentially. One-stage operations were carried out after careful consideration of the patient’s condition. One of these patients died as a result of diffuse cerebral damage resulting from embolization thought to have been caused by the extracorporeal technique’. Operative technique
The operations were performed using endotracheal anaesthesia. The carotid bifurcation was dissected CARDIOVASCULAR SURGERY APRIL 1996 VOL 4 NO 2
Figure 1 a Schematic represenmon of the plaque eversion. lntraoperative procedure of plaque eversion
b
191
EverSonendarterectomy andinternalcarotidarterysurgery.:L.Entzet al. through an oblique skin incision parallel with the anterior border of sternocleidomastoid muscle. The common carotid artery was initially isolated followed by the external carotid artery and the distal part of the internal carotid artery. Intravenous heparin was then administered and the carotid bifurcation clamped. The bifurcation and proximal part of the internal carotid artery was then mobilized. Early clamping is performed to prevent embolization. The internal carotid artery was separated from its origin with a wide flap. The plaque is held with forceps while the adventitia is everted with another pair of forceps. The plaque came off easily in most cases and the remaining strands were removed with forceps (Figures 1 and 2). An endarterectomy was then carried out on the common and the external carotid arteries. The endarterectomy was extended proximally if there was extensive disease in the common carotid artery. The internal carotid artery was then reimplanted using a continuous 6/O prolene suture (Figure 3). Before completing this suture the internal carotid artery was mechanically dilated to 4.5 mm diameter. During the whole procedure the desobliterated surface was continuously irrigated with saline solution in order to remove any floating particles7.
Figure 3 Digital subtraction angiography control of an eversion endarterectomy of the internal carotid artery after 18 months
Results
Figure 2 Intraoperative procedure a&r elimination of the plaque. In this phase the small particles can be eliminated from the intima of the internal carotid artery under visual control
192
In total 352 operations are reported; nine operations were excluded as failures because they were performed with an interposition graft. These failures were usually the result of reaching extensive plaque a long way into the internal carotid artery. Nine patients developed neurological complications in the postoperative period: one remained unconscious at the end of the operation while six developed symptoms after surgery, four within 2 h, one after 24 h and one after 5 days. As postoperative stroke is the most severe complication of carotid surgery, these cases are discussed in detail. Thrombotic occlusion occurred in five cases. In two, the thrombosis developed as a consequence of problems with the distal intima, while in one the common carotid artery occluded and the exact cause could not be established. In the other two cases no technical mistakes were found. The thrombosis that occurred on day 5 after surgery was caused by extensive narrowing of the internal carotid artery which may develop if this vessel is cut from the common carotid with a flap that is not wide enough. The patient who
CARDIOVASCULAR SURGERY APRIL 1996 VOL 4 NO 2
Eve&on endarterrectomyandinternal carotid arterywqew Table 4
Stages of eve&on endarterectomy of the internal carotid artery
Stage
Symptom
No. of patients
I Ha
Symptomless Transient ischaemic attack - reversible intermittent neurological deficit Non-hemispheric symptoms Stroke
80 195
Ilb IV
42 44
remained in a coma with a hemiparesis at the end of the operation was re-explored. No thrombosis was found. A temporary neurological deficit developed in one patient 2 h after operation; immediate digital subtraction angiography showed a patent internal artery. No operation was performed and this patient had recovered completely at the time of discharge. One patient developed an embolism during the operation from a very extensive ulcerated plaque. This patient never regained consciousness after the operation and died after being in a coma for 5 days. Embolus was found in the middle cerebral artery at autopsy; the internal carotid artery remained patent. Three of the present patients in whom the artery occluded had the thrombosed carotid artery replaced with a PTFE interposition graft at reoperation, but all died subsequently. One patient died of an acute myocardial infarction which developed on day 3 after surgery. There was no neurological deficit. Six patients were reoperated on for postoperative bleeding, though none developed any haemorrhage from the anastomosis line.
Discussion All surgeons have been searching for the ideal surgical technique for endarterectomy which is safe and which will significantly improve long-term results. The rate of restenosis after carotid surgery can be very high. Civil and colleagues8 reported 20% restenosis rates in 40% of their patients during a 22-month follow-up period, though few of these patients required re-operation. Avramovic and Fletcher’ reported significant restenosis in only 9.1% of cases. Baker”, who collated data from the surgical results of 6000 operations reported by 12 authors found that the rate of carotid restenosis with complications was l-l 5%. There are few studies of long-term follow-up after eversion endarterectomy surgery. Kasprzak and Raitheli’ reported on 105 operations in 1990, their mean follow-up period being 28 (range 12-49) months. Only two patients (I .9%) had developed restenosis > 50%. Kieny et aL4 have reported on both a prospective and a retrospective study. A total of 176 patients operated on in 1987 were included in the first study, with follow-up examinations being carried out in 1988 and 1991. Some 156 of the 176 patients had a conventional endarterec-
CARDIDVASCMM
SURGERY APRiL 1996 VOL 4 NO 2
t. Entz et al.
tomy and 20 were operated on using the eversion technique. The follow-up examinations in 1988 showed an 11% restenosis rate, the patients all being from the group operated on using the conventional technique. In 1991 restenosis was found in 11.9% of patients, with occlusion in 1.5% of these. In 1991 all patients who underwent eversion endarterectomy were examined: 212 eversion carotid endarterectomies had been performed on 206 patients. Of these, 1.3 % had developed a > 50% restenosis and one patient had developed an occlusion’. If the late results of both studies are compared, the restenosis rates are 1.9% and 1.3%. Conventional operations have a lo-IS% restenosis rate, suggesting that eversion endarterectomy may reduce the risk of long-term problems. Late restensosis may develop because or progression of atherosclerosis but may also result from technical mistakes at the primary operation. ilt is therefore important that errors in the operative techmque are minimized. In two of the present cases occlusion and stroke were caused by the distal intimal flap In another case the internal carotid artery was cut with too small a diameter. If eversion endarterectomy i’z performed correctly and with great care the above mistakes can be avoided”. In the present study, the stroke rate was 2% (seven strokes in 352 operations). Five strokes occurred in the first 100 operations and two in the second hundred, but none has occurred in the last 150, suggesting that there is a clear learning period associated wir Bleeding from the suture line was not a problem. Wound healing disorders were not observed. The advantages of eversion endarterectom!, can be summarized as follows: (1) the incision line does not involve the internal carotid artery; (2) the incision line is of the made across the largest possible diameter bifurcation, so in the course of reimplantation narrowing of the anastomosis is avoided; (3) artificial material is not used for the reimplantation; (4) the correction of the co-existent tortuosity is simple. This may he important because uncorrected kinkmg may be a significant cause of restenosis if a patch plasty is used; (5) the original anatomical and physiological situation is restored after reconstruction of the carotid bifurcation; and (6) the eversion endarterectom! is quicker to perform than any other method. In addition, important technical considerations are: (1) not even the smallest intimal flap should remain at the distal end of the disobliteration; ‘2) m order to prevenr an early or late restenosis and occlusion the internal carotid artery should be cut off with a large flap from the bifurcation; (3) the rnternai carotid artery should be reimplanted using ~7 :iccuratc suture technique. The anastomosis line must he as smooth as possible; and (4) dilatation of the inrernal carotid artery to relieve the spasm of the artery is valuable. especially where a shunt is used.
193
Eversion endarterectomy and in ternal carotid artery surgery: L. Entz et al.
References 1.
2. 3. 4. 5.
DeBakey ME, Crawford ES, Cooley DA, Morris IC Jr. Surgical considerations of occlusive disease of innominate, carotid, subclavian and vertebral arteries. Ann Surg 1959; 149: 690-710. Etheredge SN. A simple technique of carotid endarterectomy. Am / Surg 1970; 120: 275-8. Raithel D, Kasprzak P. The eversion endarterectomy. A new technique. In: Greenhalgh RM, Hollier LH, eds. Surgery for Stroke. London: WB Saunders. 1993: 183-93. Kasprzak PM, Raithel D. Eversion carotid endarterectomy. Technique and early results. J Curdiouusc Surg (Torino) 1989; 30: 495. Kieny R, Hirsch D, Seiller Ch, Thiranos JC, Petit H. Les restenoses apres endarterectomie carotidienne par eversion et reimplantation. Annales de Cbirurgie Vasculaire 1993; 7: _^- _^
4u/-1.5.
194
6. 7.
8. 9. 10. 11.
Mogan I, Dzsinich Cs, Entz L, Papp S, Nemes A. Die Interna Interposition als Alternative einer TEA in der Karotis Chirurgie. Angie Arch 1988; 16: 161-2. Entz L, Mogan I, Jaranyi Zs et al. I$ miiteti technika az arteria carotis interna sebeszettben. Lege Artis Medicinae 1992; 2: 1032-6. Civil ID, O’Hara PJ, Hertzer NR et al. Late patency of the carotid artery after endarterectomy.] Vusc Surg 1988; 8: 79-85. Avramovic JR, Fletcher JP. The incidence of recurrent carotid stenosis after carotid endarterectomy and its relationship to neurological events. j Cardiouasc Surg (Torino) 1992; 33: 54-8. Baker JD. Restenosis, incidence, diagnosis, prognosis, therapies. In: Moore WS, ed. Surgery for CVS Disease. New York: Churchill Livingstone, 1987: 703-13. Kasprzak P, Raithel D., Eversionsendarterektomie der Arteria Carotis Interna (EEA). Angio 1990; 12: 1-8.
n raper accepted 4 January 1995
CARDIOVASCULAR SURGERY APRIL 1996 VOL 4 NO 2.
Ever&on endarterectomy in surgery of the internal carotid artery L. Entz, Zs. JMnyi and A. Nemes Department of Cardiovascular Surge/y, Semmelwe& Medics/School. Budapest, Virosma&r u. 68., H- 1122, Hungary
A total of 361 eversionendarterectomies of the internal carotid artery havebeen carried out on 348 patients between January 1991 and December 1992. Of these patients, 126 were women and 222 were men: average age was 62.9 (range 42-84) years. Some 239 patients had hemispheric symptoms: 37 symptomless patients had a carotid endarterectomy before major vascular reconstruction, and 21 had the operation combined with heart surgery (19 aortocoronary bypasses,two valve replacements). In nine cases (Z.S%) a 6-mm interposition graft was used because of unsuccessful eversion endarterectomy. Postoperative bleeding occurred in six patients (1.7%) and postoperative stroke in seven(1.9%); of these patients, four died and two still have mild neurologicalsymptoms. Four reocclusionsoccurred during the first 6 months that the new method was used. Eversion endatterectomy of the internal carotid artery is a safe and useful technique and is comparable with standard endarterectomies. This technique may reduce the risk of restenosis. Keywords: carotid endarterectomy, eversion endarterectomy
Eversion endarterectomy is not a popular technique. It was first described by DeBakey and colleaguesl, who divided the common carotid artery below the bifurcation, everted the plaque from both the external and internal carotid artery and separated them. This type of endarterectomy is technically difficult because the side branches of the external carotid artery prevent correct removal of the plaque from the internal carotid artery, especially if there is a long stenosis. Indeed, DeBakey and co-workers had doubts about the method and finally abandoned it. Etheredge’ reported 72 cases in 1970, the operations being performed using the same technique as DeBakey. In 1989, Raithel and Kasprzak 3,4 first reported a series using a modified technique in which the plaque was everted in the internal carotid artery after it had been cut from the common carotid artery. They reported good results with more than 2700 carotid endarterectomies performed with this modification. Also in 1985, Kieny and colleagues’ in Strasbourg began to operate on the internal carotid artery using the eversion technique. Up to year-end 1990 they had
Correspondence to: Dr L. Entz
190
performed 212 operations with this technique, also with good results. The authors have performed carotid endarterectomy using the eversion technique and report results of a 2-year period finishing in December 1992. The eversion technique was attempted in all operations irrespective of the type of disease or the degree of stenosis present. If an eversion endarterectomy could not be carried out, an interposition graft was used to replace the resected internal carotid artery6.
Patients and methods A total of 529 carotid operations were carried out between 1 January 1991 and 31 December 1992 at the authors’ clinic. Of these, 361 were eversion endarterectomies; hence 68% of the total carotid operations were of the eversion type. Patient data are shown in Tables 1-4. Surgery was carried out under general anaesthesia, with controlled hypertension being used to increase brain perfusion if a shunt was not used. The operation was performed usin $ the technique described by Kasprzak and Raithel . In nine patients the operation was attempted using the eversion method. However, reimplantation proved impossible, and a polytetrafluoroethylene (PTFE) pros-
CARDIOVASCULAR SURGERY APRIL 1996 VOL 4 NO 2
EverSonendarterwomyandinternalcarotidartery.wgery L.Entzet al. Ti&le 1
Patient data for internal carotid artery surgery*
No. of patients Men Women Average age &ears) Men Women No. of patients with bilateral operation
306 193 60.3 58.3 30
*Total of 529 operations performed
Tabs% 2
Type of reconstruction of internal carotid artery
Reconstruction
No. of patients
Ever&n endarterectomy interposition Standard endarterectomy
361
Total
529
T&b 3 artery*
1z
Pat&r& data for ever&on endarterectomy of the internal carotid
No. ofpatients Men Women Av=w age Clean Men Women No. of patients with bilateral operation No. of patients with one-stage interposition No. of patients without shunt
222 126 62.7 63.4 13 9 82
*Total of 361 operations performed
thesis was inserted between the common carotid and internal carotid arteries (‘Table 3). An intraluminal shunt was usually inserted into the internal carotid artery after clamping. The need for a shunt was determined by monitoring cerebral circulation with transcranial Doppler. Shunts were not used in 82 cases, and no neurological complications developed in these patients. In 21 cases carotid and cardiac surgery was performed sequentially. One-stage operations were carried out after careful consideration of the patient’s condition. One of these patients died as a result of diffuse cerebral damage resulting from embolization thought to have been caused by the extracorporeal technique’. Operative technique
The operations were performed using endotracheal anaesthesia. The carotid bifurcation was dissected CARDIOVASCULAR SURGERY APRIL 1996 VOL 4 NO 2
Figure 1 a Schematic represenmon of the plaque eversion. lntraoperative procedure of plaque eversion
b
191
EverSonendarterectomy andinternalcarotidarterysurgery.:L.Entzet al. through an oblique skin incision parallel with the anterior border of sternocleidomastoid muscle. The common carotid artery was initially isolated followed by the external carotid artery and the distal part of the internal carotid artery. Intravenous heparin was then administered and the carotid bifurcation clamped. The bifurcation and proximal part of the internal carotid artery was then mobilized. Early clamping is performed to prevent embolization. The internal carotid artery was separated from its origin with a wide flap. The plaque is held with forceps while the adventitia is everted with another pair of forceps. The plaque came off easily in most cases and the remaining strands were removed with forceps (Figures 1 and 2). An endarterectomy was then carried out on the common and the external carotid arteries. The endarterectomy was extended proximally if there was extensive disease in the common carotid artery. The internal carotid artery was then reimplanted using a continuous 6/O prolene suture (Figure 3). Before completing this suture the internal carotid artery was mechanically dilated to 4.5 mm diameter. During the whole procedure the desobliterated surface was continuously irrigated with saline solution in order to remove any floating particles7.
Figure 3 Digital subtraction angiography control of an eversion endarterectomy of the internal carotid artery after 18 months
Results
Figure 2 Intraoperative procedure a&r elimination of the plaque. In this phase the small particles can be eliminated from the intima of the internal carotid artery under visual control
192
In total 352 operations are reported; nine operations were excluded as failures because they were performed with an interposition graft. These failures were usually the result of reaching extensive plaque a long way into the internal carotid artery. Nine patients developed neurological complications in the postoperative period: one remained unconscious at the end of the operation while six developed symptoms after surgery, four within 2 h, one after 24 h and one after 5 days. As postoperative stroke is the most severe complication of carotid surgery, these cases are discussed in detail. Thrombotic occlusion occurred in five cases. In two, the thrombosis developed as a consequence of problems with the distal intima, while in one the common carotid artery occluded and the exact cause could not be established. In the other two cases no technical mistakes were found. The thrombosis that occurred on day 5 after surgery was caused by extensive narrowing of the internal carotid artery which may develop if this vessel is cut from the common carotid with a flap that is not wide enough. The patient who
CARDIOVASCULAR SURGERY APRIL 1996 VOL 4 NO 2
Eve&on endarterrectomyandinternal carotid arterywqew Table 4
Stages of eve&on endarterectomy of the internal carotid artery
Stage
Symptom
No. of patients
I Ha
Symptomless Transient ischaemic attack - reversible intermittent neurological deficit Non-hemispheric symptoms Stroke
80 195
Ilb IV
42 44
remained in a coma with a hemiparesis at the end of the operation was re-explored. No thrombosis was found. A temporary neurological deficit developed in one patient 2 h after operation; immediate digital subtraction angiography showed a patent internal artery. No operation was performed and this patient had recovered completely at the time of discharge. One patient developed an embolism during the operation from a very extensive ulcerated plaque. This patient never regained consciousness after the operation and died after being in a coma for 5 days. Embolus was found in the middle cerebral artery at autopsy; the internal carotid artery remained patent. Three of the present patients in whom the artery occluded had the thrombosed carotid artery replaced with a PTFE interposition graft at reoperation, but all died subsequently. One patient died of an acute myocardial infarction which developed on day 3 after surgery. There was no neurological deficit. Six patients were reoperated on for postoperative bleeding, though none developed any haemorrhage from the anastomosis line.
Discussion All surgeons have been searching for the ideal surgical technique for endarterectomy which is safe and which will significantly improve long-term results. The rate of restenosis after carotid surgery can be very high. Civil and colleagues8 reported 20% restenosis rates in 40% of their patients during a 22-month follow-up period, though few of these patients required re-operation. Avramovic and Fletcher’ reported significant restenosis in only 9.1% of cases. Baker”, who collated data from the surgical results of 6000 operations reported by 12 authors found that the rate of carotid restenosis with complications was l-l 5%. There are few studies of long-term follow-up after eversion endarterectomy surgery. Kasprzak and Raitheli’ reported on 105 operations in 1990, their mean follow-up period being 28 (range 12-49) months. Only two patients (I .9%) had developed restenosis > 50%. Kieny et aL4 have reported on both a prospective and a retrospective study. A total of 176 patients operated on in 1987 were included in the first study, with follow-up examinations being carried out in 1988 and 1991. Some 156 of the 176 patients had a conventional endarterec-
CARDIDVASCMM
SURGERY APRiL 1996 VOL 4 NO 2
t. Entz et al.
tomy and 20 were operated on using the eversion technique. The follow-up examinations in 1988 showed an 11% restenosis rate, the patients all being from the group operated on using the conventional technique. In 1991 restenosis was found in 11.9% of patients, with occlusion in 1.5% of these. In 1991 all patients who underwent eversion endarterectomy were examined: 212 eversion carotid endarterectomies had been performed on 206 patients. Of these, 1.3 % had developed a > 50% restenosis and one patient had developed an occlusion’. If the late results of both studies are compared, the restenosis rates are 1.9% and 1.3%. Conventional operations have a lo-IS% restenosis rate, suggesting that eversion endarterectomy may reduce the risk of long-term problems. Late restensosis may develop because or progression of atherosclerosis but may also result from technical mistakes at the primary operation. ilt is therefore important that errors in the operative techmque are minimized. In two of the present cases occlusion and stroke were caused by the distal intimal flap In another case the internal carotid artery was cut with too small a diameter. If eversion endarterectomy i’z performed correctly and with great care the above mistakes can be avoided”. In the present study, the stroke rate was 2% (seven strokes in 352 operations). Five strokes occurred in the first 100 operations and two in the second hundred, but none has occurred in the last 150, suggesting that there is a clear learning period associated wir Bleeding from the suture line was not a problem. Wound healing disorders were not observed. The advantages of eversion endarterectom!, can be summarized as follows: (1) the incision line does not involve the internal carotid artery; (2) the incision line is of the made across the largest possible diameter bifurcation, so in the course of reimplantation narrowing of the anastomosis is avoided; (3) artificial material is not used for the reimplantation; (4) the correction of the co-existent tortuosity is simple. This may he important because uncorrected kinkmg may be a significant cause of restenosis if a patch plasty is used; (5) the original anatomical and physiological situation is restored after reconstruction of the carotid bifurcation; and (6) the eversion endarterectom! is quicker to perform than any other method. In addition, important technical considerations are: (1) not even the smallest intimal flap should remain at the distal end of the disobliteration; ‘2) m order to prevenr an early or late restenosis and occlusion the internal carotid artery should be cut off with a large flap from the bifurcation; (3) the rnternai carotid artery should be reimplanted using ~7 :iccuratc suture technique. The anastomosis line must he as smooth as possible; and (4) dilatation of the inrernal carotid artery to relieve the spasm of the artery is valuable. especially where a shunt is used.
193
Eversion endarterectomy and in ternal carotid artery surgery: L. Entz et al.
References 1.
2. 3. 4. 5.
DeBakey ME, Crawford ES, Cooley DA, Morris IC Jr. Surgical considerations of occlusive disease of innominate, carotid, subclavian and vertebral arteries. Ann Surg 1959; 149: 690-710. Etheredge SN. A simple technique of carotid endarterectomy. Am / Surg 1970; 120: 275-8. Raithel D, Kasprzak P. The eversion endarterectomy. A new technique. In: Greenhalgh RM, Hollier LH, eds. Surgery for Stroke. London: WB Saunders. 1993: 183-93. Kasprzak PM, Raithel D. Eversion carotid endarterectomy. Technique and early results. J Curdiouusc Surg (Torino) 1989; 30: 495. Kieny R, Hirsch D, Seiller Ch, Thiranos JC, Petit H. Les restenoses apres endarterectomie carotidienne par eversion et reimplantation. Annales de Cbirurgie Vasculaire 1993; 7: _^- _^
4u/-1.5.
194
6. 7.
8. 9. 10. 11.
Mogan I, Dzsinich Cs, Entz L, Papp S, Nemes A. Die Interna Interposition als Alternative einer TEA in der Karotis Chirurgie. Angie Arch 1988; 16: 161-2. Entz L, Mogan I, Jaranyi Zs et al. I$ miiteti technika az arteria carotis interna sebeszettben. Lege Artis Medicinae 1992; 2: 1032-6. Civil ID, O’Hara PJ, Hertzer NR et al. Late patency of the carotid artery after endarterectomy.] Vusc Surg 1988; 8: 79-85. Avramovic JR, Fletcher JP. The incidence of recurrent carotid stenosis after carotid endarterectomy and its relationship to neurological events. j Cardiouasc Surg (Torino) 1992; 33: 54-8. Baker JD. Restenosis, incidence, diagnosis, prognosis, therapies. In: Moore WS, ed. Surgery for CVS Disease. New York: Churchill Livingstone, 1987: 703-13. Kasprzak P, Raithel D., Eversionsendarterektomie der Arteria Carotis Interna (EEA). Angio 1990; 12: 1-8.
n raper accepted 4 January 1995
CARDIOVASCULAR SURGERY APRIL 1996 VOL 4 NO 2.