371
Eversion Endarteriectomy ofthe Internal Carotid Artery A. Bosse, P. A nsorg, B. May er, and 1. Mul ch
Summar)'
Eversion endarte riectomy has been proposed as a reliable and rapid method for ope rating on an ulce rated or stenosed internal
carotid artery. The surgical technique is presented in det ail. The perioperative course is appraised in a series of 60 operations. Irrespective of age and other diseases in the pat ients a nd th e preoperative state of the ipsila tera l and contralateral vessels. a perioperative morbidity of 1.6 % (a tem porary neur ological deficit) an d no lethal outcomes were found . Ind ication for ope ra tion on the ca rotid artery depends on the spontaneous prognosis based on the vascular morphology an d the rate of perioperative complica tions . The met hod of surgery descri bed esta blishes favorable cond itions for enda rteriec tomy even in the asy mpto ma tic stage as we ll as in exulcerauve lesion s of the ca roti d wall. Eversions endar te rektom ie de r A. ca r oti s inte r na Die Evers ionse nda rteriektomie (EEA) stellt cine efTe ktive Variante zur konventionellen Karoti s-Endarteriektomi e (TEA) dar. Sie errnoglicht eine vollsta ndtge Enda rte riektomie der stenoslerten un d ulzeri erten Caratis interna (ACI) unter Erha ltung des physiologisc he n Kalib ers . Eine na htbedingte Rest en asierun g wird bet dieser Technik sic he r vermle de n. gleichze itig wird eine begleiten de Elonga tio n oder Knickbildun g korrigiert. Die EEA wurde in der Zeit vorn 1. 1.-1 5. 9.1990 alternativ bei 60 Patien ten mit Karotis-St en ose nnd/oder Karot is-Ulze ra tio n vorge no mme n. Aufsono morphologisc he r Basis wu rd en 27 Operationen wege n ausgede hn ter Ulzera tio n. ulzerativer SoftPlaques ode r eine Ulkus-Stenose-Kcmblna tion mit Embo liege-
Introdu ction There is no absolute indication for carotid surgery. rather it is unde rta ken on the basis of the sponlaneous prognosis and the perioper ative risk. Depending on Ihe degree of differentiation of preoper ati ve diagnoslics on the basis of differing morp hological findings. the prognosis var ies: there is a sponlaneous risk ofcerebral stroke of up to 12.5% (Table 1). The per ioper ative risk is determi ned Jess by selection of the pat ient s (these a re always multi-morbid pat ients with a progressive arte rial occlusive disease) than by the technique of surge ry applied. A sta nda rdized techni que. surgical experience. monitorin g and quality control are prerequisites for the success of the ca rotid operation. Any peri operalive compli-
fahrdung und 33 Operationen wegen hochgradiger Stenosierung ausgefilhrt. Klinisch bestand in 55 .8 % ein asymptumatisches Stadium. in 44,1% waren TIA. PRIND ode r Amaurosis fugax ein- oder me hrfach vorausgegangen . Die Gegenseite war bei 30% in geringer Ausp ragung bet roffen . ein kontralat eraler ACI-YerschluB lag bel 9 Patienten vor04 .7 %). Techniseh bedeutsam ist die zirkula re Dissektion des a rterios klerotischen Zylinders nach vor heriger Abt ren nung der Carotis interna. Es schlieBt sich die Evers ion der Arterie an . bis sich na eh distal der lntimazylinder von der GefaBwa nd glatt ablosen HiBt. Die Ausk re mpelung der Carotis interna ka nn tibe r me hre re em erfolgen. Wichtig ist die so rgfalt ige Inspektion auf zurtickgebliebene Wandlefzen und de re n Entfern ung. Vor Beendigu ng der Reinsertion snah t sollte das EEA-Erge bn is unbe dingt angioskopisch kontrolliert wer den. Unse re mittler e Oper ationszeit betru g 47 min (30- 80 min), die mittie reAbklemmzei t 18 min (10-35 min ). Ein intralumi na rer Sh unt wurde niem als verwendet. Bei einern Pat ienten mit kontralater alem ACI·Yersc hluB wa r ein passageres neurologisches Deflzit a ufgetreten. Samit erga b sich eine per ia perative Morb lditat und Letalitat von 1,6 % und 0 %. Yer glichen mit den Erge bnisse n de r kanventianellen Ka ro tis-TEA bel 121 Patient en 0988-1989) mit einer Morbid ltat und Letalitat von 3.3 % und 1,6 % sind die besseren Erge bnisse der EEA aufe ine bes onde rs niedr ige Kompli kati on srate zurtlckzufi ihren. Grund legend si nd u. E. die urn 50 % red uzierte Operations dauer. die ku rze Abklem mzeit und der Yerz ich t a uf eine Sh un tei nlegung. Key words Carotis endart eriectomy by eversion
cation in carotid endarte riectomy (also the developme nt of per ivascular hemato ma with contingent revision) results in a deterio ralion in the chances of surviva l of thes e patients . The du ra tion of ope ration and the clamping lime are furthe r important factors. since the sta le of hea lth of most patients is unstable owing to their concomitant cardiac . respiratory, and renal diseases. The Nure mberg group of Kasp rzak and Raith el have published encouraging results of an eversion tech nique for endarterieclomy (3) and compatible with the limit of 4% per ioperalive morbidity and morta lity. This limit for any new surgical procedu re we have set as a result of our own and other authors ' experience of the customary ca rolid thromboendarterieclom y (TEA)(Tables I , 2).
This pap er was pr esented at the 20 th An n ual Meeting of the Germa n Society for Thoracic an d Cardiovascular Surg ery. Bonn, February 1991 Thorac. cardiovasc. Surgeon 39 (1991) 371-375 © Georg Thieme Ve rlag Stutt gart - New York
Received for Publi cation: Aug us t 1. 1991
Downloaded by: University of British Columbia. Copyrighted material.
Department of Va scular Su rgery, Municipal Hospital. DUsseldorf. Germany
A. Bosse, P. Ansorg, B. Mayer, and 1. Mulch
Th orae. eardiovase. Surge on 3 9 (1991) Table 1 Morbidity inspontaneouscourse and cou rse withintervention (compiled from theliterature) Annual morbidity inspontaneouscourse (T1A, PRI ND, Stroke) Authors Symptomatic Asympt. Morphology 3%-5%
3.0% 3.3% 20.6% 30.9% 0.4% 12.5%
calcifying echogenic soft type A type B +C
I
Rautenberg (6)
stenosis > 75% (sonographic) } ulcerative, non-stenotic (angiographic)
Intervention course: Perioperativemorb idity (mortality) Annual morbidity Symptomatic Asymptomatic 2.0% 2.4%(1.2%) 3.7% (1.1%) - (1.9%)
3.7%(0.0%) 1.2%(0.9%)
4.0% 1.5% 0.3%
Johnson (2) Moore (5)
Authors Rautenberg(6) Moore (5) Hamann (I) Becker (Munich. 1980) Uidtke-Handjery et al. (4)
- (0.0%)
Table 2 Perioperative morbidityand mortalityinthrombo-(TEA) and eversion (EEA) endarteriectomies of the carotid artery (N = 181, 1988-1990) Operation
Morbidity
Mortality
TEA (n ~ 121) EEA (n ~ 60)
33 % 1.6%
0.8% 0%
Table 3 Distribution of the indication for eversion endarteriectomy of the internalcarotid artery (1990) Indication Vessel condition
Ipsilateral (n = 60)
Contralateral (n = 34)
Scnornorphological ulcerative stenosed combined occluded disobliterated
14 33 13 0 0
4 10 4 9 7
Cl inicalstage I II III IV
33 27 0 0
28 2 0 4
This is a report on employing eversion endoarteriec-
lomy (EEA) in 60 cas es durin g 1990 . Patients a nd Methods We have carried out eversio n endarteriectomy 60 times in 55 patients from January 1990 to October 19 90 . There was no selec tion of the patients on the basis of the clinical stage or vascu lar morphology . In accordance with our attitude to the indication (see above), 27 operations were carried out beca use of exte nsive ulcera tions, ulcerative soft-plaque, or a combination of ulce r and stenosis with dange r of embo lism , and 33 operations were carried out beca use of high-degree stenos is as indicated by the sonomorphol ogy (Table 3). Clinically, there was an asymptomatic stage in 55 .8 %, and there were one or seve ral prior transitory ischemic attacks, prolonged reversi ble ischem ic neurologic deficienc y, or amauros is fugax in 44 .1 %. The contralateral side was involved to a small exte nt in 30%. There was an occlusion of the contralateral
internal carotid artery in nine patients (14.7%). The indicati on was esta blished on the bas is of a duplex so nographic diagnos is. Nevertheless, all patients we re checked preoperatively by ang io-
graphy(Fig. 1 and 2). Clamping was carried out as far cranially as possible (the hypoglossa l nerve was always ex posed ) under syste mic heparin protection after exposure of the carotid bifurcation and mobilization of the internal carotid artery. The latter was severed obliquely from the bifurcation. A circular detachment from the outer wa ll was attained by dissection of th e arteriosclerotic cylinder (mostly near to the adve ntitial tissue) with subse quent eversion of th e artery. The eve rsion of the artery can be carried out over several centimeters, and as a rule the sclerosis cylinder can be smoothly detached from the healthy intima (Fig. 3-6) . Meticulous screening for remaining pendulous flaps of the wall and removal of such flaps are important. Depend ing on the degree of stenos is, endarteriectomy of the carotid bifurcation including the origin of the external carotid artery was carried out in the usual way . The internal carotid artery was reinserted with stretchi ng, if necessary after proximal lengthening of the ACC arteriotomy, with 6/ 0 monofll sutures in continuous suture tec hnique. The result of EEA was checked angiosco pically before completion oft he anterior wall suture (Fig. 7).
Results Our average time of operation was 47 minutes (35- 80 minutes), and the average clamping time was 18 minutes (13- 35 minutes). An intraluminal shunt was never used . Only once did a floatin g intimal pendu lous flap . seen anglescopically, ha ve to be removed by longitudinal arteriotomy. In one patient, there was a planar subcutaneo us hematoma in consequence of the pr ior inhibition of aggregation with aspirin. Revision was not necessary in any patient. In one case , we saw a contralateral hemiparesi s directly after the operation. This regressed completely after a few hours. Clamping for 20 minutes was necessar y during the operation owing to an occlusion of the contralateral internal carotid artery in this patient. The intraoperative ischemia durin g clampin g was probably res ponsible for the temporary neuro logical deficit in this patient. None of the patient s died during the perioperati ve period of 30 days. The morbidity and mortality in this series of operations were thus 1.6 % and 0% respectively (Table 2). Of course. data on late results (e.g. resten osis) cannot be presented because the posloperative period is too short. All patients are being followed-up with duplex sonography six weeks after the operation and at interva ls of six month s. so that the prognosis can be reported on later. Discussion
The favorable perioperative results with regard to morb idity and mort ality are striking. even in the clinically asymptomalic stage. We did not find any ditTerences in the course of the operation and the periop erati ve results in relation to the pr eoperative vascular morphology (stenosis. ulceration. or contralateral internal carotid artery occlusion).
We believe that the better results of EEA as compared to those obtained with carotid TEA are attributable to the reduction in the durat ion of the opera tion by more than half. the short time of clamping. and the fact that a shunt was dispensed with. The analysis of the complications we observed after TEA linked them to an appreciably pr olonged durati on of operation. use of plaslic as patch material, and use of an intraluminal shunt.
Downloaded by: University of British Columbia. Copyrighted material.
372
Eversion Endarterie etomy ofthe Internal Carotid A rtery
Thorae. eardiol'ase. S urgeon 3 9 (1991)
373
Fig.2 PreoperativeDSAfindingsin high-degree stenosisof the internalcarotid artery
a
Fig.3 Intraoperative siteof thecarotid bifurcationwith additional kink stenosis of the internal carotid artery
b
Fig. 4 a/ b
Eversion endarteriectomy of the internal carotid artery
Downloaded by: University of British Columbia. Copyrighted material.
Fig. 1 Preoperativesonomorphological finding of anexulcerated doubleplaque, moderately stenotic
374
Thorae. eardiovase. S urgeon 3 9 (l991)
A. Bosse. P. Ansorg. B. Mayer. and 1. Mulch
c
Fig.4 c
Tensionstraightening of the internalcarotid arteryafter EEA
Fig.5
Carotid bifurcationafter reinsertion ofthe internal carotidartery
Fig.6
Preparationofthe sclerosiscylinderremoved with exukerated plaque
Particular difficulties do not arise in conseq uence ofthe length ofthe extracted sclerosis cylinder (Fig. 6), since problems ass ociated with a patch graft or direct suture ca nnot occur after cranial suture. Under smooth macroscopic conditions , the vessel wall left in position after eversion endarter iectomy only displays wall lesions which ar e angiosco pically visible (Fig. 7), whereas wall ulcerations which can be seen with the na ked eye often remain after conventiona l arteriectomy. The elimination of an elongation and kink ste nosis does not lead to an y prolongati on of the surgi cal opera tion. Other than with the patch or direct suture in the cra nial angle, a restenosis can be definitively avoided by the terminal reinsertion suture (Fig. 8). This experience of eve rsion endarteriectomy shows it to be a sa fe an d rap id method of operation in ulcerate d or ste nose d internal carotid artery . The physiological conditions in the region ofthe carotid bifurcation a re preserved . Periopera tive morbid ity and mortali ty a re more favora ble than with TEA.
Downloaded by: University of British Columbia. Copyrighted material.
Fig.7 Angioscopy oftheinternalcarotidarteryafter EEA (Olympus. PF 28J
Thome. eardiovase. Surgeon 39 (1991)
Eversion EndarterieclOmy a/the Interna l Carotid A rtery
375
Fig,8 Postoperative sonomorphology after eversion endarteriectomy of thecarotidartery
I
2
Hamann, H.: Carotid Enda rte riectomy: Prevention of Stroke in Asympto matic (Stage I) and Symptomatic (Stage II) patie nts? Thorae . ea rdiovase . Surgeon 36 (1988) 272 -2 75 Johnson, 1. M., M . M. Kennelly, W Decesare, S. Morqcns. and A. Sparrow : Natural History of Asymptomatic Carotid Plaque . Arch.
6
Rautenberg, w., V. Scheer, W. Moss. un d M. lIe nneridcy: Spontanverlaufund konservative Therapie extracra nieller Carotisp rozesse. In: Kriessman n. A. Hlrsg.f AktueJle Diagnostik und Therapie in der Angiologie. Stuttgart, New York, Thieme, 1988
Stirg. 120 (19851 1010-1012 3 4
5
Kasprzak . P. M., und D. Raithel: Eversionsen da rteriektornie der A. carotis inte rna (EEA). Angio. 12 (1990) 1 Liidtke -llandjery, A., und S. Tillmann : 1st Karotischi rurgie im Rahmen de r Allgeme inchir urgie vert retbar? Angio. 3 (1989) 11 Moore. W. 5., C. Boren. 1. M. Malone. A. J. Roon, R. Eisenberg, 1. Goldstone. and R. Rani: Natural History of Nonstenotic, Asympto matic Ulcerative Lesions of the Carotid Artery . Arch . Surg . 113
(1 978) 1352-1359
Dr. A. Bosse Gefalichiru rgische Klinik Stadtis che Klinik Dusseldorf-Gerresheim 0 -400 0 Dusseldor f 12 Germa ny
Downloaded by: University of British Columbia. Copyrighted material.
References
Eversion Endarteriectomy ofthe Internal Carotid Artery A. Bosse, P. A nsorg, B. May er, and 1. Mul ch
Summar)'
Eversion endarte riectomy has been proposed as a reliable and rapid method for ope rating on an ulce rated or stenosed internal
carotid artery. The surgical technique is presented in det ail. The perioperative course is appraised in a series of 60 operations. Irrespective of age and other diseases in the pat ients a nd th e preoperative state of the ipsila tera l and contralateral vessels. a perioperative morbidity of 1.6 % (a tem porary neur ological deficit) an d no lethal outcomes were found . Ind ication for ope ra tion on the ca rotid artery depends on the spontaneous prognosis based on the vascular morphology an d the rate of perioperative complica tions . The met hod of surgery descri bed esta blishes favorable cond itions for enda rteriec tomy even in the asy mpto ma tic stage as we ll as in exulcerauve lesion s of the ca roti d wall. Eversions endar te rektom ie de r A. ca r oti s inte r na Die Evers ionse nda rteriektomie (EEA) stellt cine efTe ktive Variante zur konventionellen Karoti s-Endarteriektomi e (TEA) dar. Sie errnoglicht eine vollsta ndtge Enda rte riektomie der stenoslerten un d ulzeri erten Caratis interna (ACI) unter Erha ltung des physiologisc he n Kalib ers . Eine na htbedingte Rest en asierun g wird bet dieser Technik sic he r vermle de n. gleichze itig wird eine begleiten de Elonga tio n oder Knickbildun g korrigiert. Die EEA wurde in der Zeit vorn 1. 1.-1 5. 9.1990 alternativ bei 60 Patien ten mit Karotis-St en ose nnd/oder Karot is-Ulze ra tio n vorge no mme n. Aufsono morphologisc he r Basis wu rd en 27 Operationen wege n ausgede hn ter Ulzera tio n. ulzerativer SoftPlaques ode r eine Ulkus-Stenose-Kcmblna tion mit Embo liege-
Introdu ction There is no absolute indication for carotid surgery. rather it is unde rta ken on the basis of the sponlaneous prognosis and the perioper ative risk. Depending on Ihe degree of differentiation of preoper ati ve diagnoslics on the basis of differing morp hological findings. the prognosis var ies: there is a sponlaneous risk ofcerebral stroke of up to 12.5% (Table 1). The per ioper ative risk is determi ned Jess by selection of the pat ient s (these a re always multi-morbid pat ients with a progressive arte rial occlusive disease) than by the technique of surge ry applied. A sta nda rdized techni que. surgical experience. monitorin g and quality control are prerequisites for the success of the ca rotid operation. Any peri operalive compli-
fahrdung und 33 Operationen wegen hochgradiger Stenosierung ausgefilhrt. Klinisch bestand in 55 .8 % ein asymptumatisches Stadium. in 44,1% waren TIA. PRIND ode r Amaurosis fugax ein- oder me hrfach vorausgegangen . Die Gegenseite war bei 30% in geringer Ausp ragung bet roffen . ein kontralat eraler ACI-YerschluB lag bel 9 Patienten vor04 .7 %). Techniseh bedeutsam ist die zirkula re Dissektion des a rterios klerotischen Zylinders nach vor heriger Abt ren nung der Carotis interna. Es schlieBt sich die Evers ion der Arterie an . bis sich na eh distal der lntimazylinder von der GefaBwa nd glatt ablosen HiBt. Die Ausk re mpelung der Carotis interna ka nn tibe r me hre re em erfolgen. Wichtig ist die so rgfalt ige Inspektion auf zurtickgebliebene Wandlefzen und de re n Entfern ung. Vor Beendigu ng der Reinsertion snah t sollte das EEA-Erge bn is unbe dingt angioskopisch kontrolliert wer den. Unse re mittler e Oper ationszeit betru g 47 min (30- 80 min), die mittie reAbklemmzei t 18 min (10-35 min ). Ein intralumi na rer Sh unt wurde niem als verwendet. Bei einern Pat ienten mit kontralater alem ACI·Yersc hluB wa r ein passageres neurologisches Deflzit a ufgetreten. Samit erga b sich eine per ia perative Morb lditat und Letalitat von 1,6 % und 0 %. Yer glichen mit den Erge bnisse n de r kanventianellen Ka ro tis-TEA bel 121 Patient en 0988-1989) mit einer Morbid ltat und Letalitat von 3.3 % und 1,6 % sind die besseren Erge bnisse der EEA aufe ine bes onde rs niedr ige Kompli kati on srate zurtlckzufi ihren. Grund legend si nd u. E. die urn 50 % red uzierte Operations dauer. die ku rze Abklem mzeit und der Yerz ich t a uf eine Sh un tei nlegung. Key words Carotis endart eriectomy by eversion
cation in carotid endarte riectomy (also the developme nt of per ivascular hemato ma with contingent revision) results in a deterio ralion in the chances of surviva l of thes e patients . The du ra tion of ope ration and the clamping lime are furthe r important factors. since the sta le of hea lth of most patients is unstable owing to their concomitant cardiac . respiratory, and renal diseases. The Nure mberg group of Kasp rzak and Raith el have published encouraging results of an eversion tech nique for endarterieclomy (3) and compatible with the limit of 4% per ioperalive morbidity and morta lity. This limit for any new surgical procedu re we have set as a result of our own and other authors ' experience of the customary ca rolid thromboendarterieclom y (TEA)(Tables I , 2).
This pap er was pr esented at the 20 th An n ual Meeting of the Germa n Society for Thoracic an d Cardiovascular Surg ery. Bonn, February 1991 Thorac. cardiovasc. Surgeon 39 (1991) 371-375 © Georg Thieme Ve rlag Stutt gart - New York
Received for Publi cation: Aug us t 1. 1991
Downloaded by: University of British Columbia. Copyrighted material.
Department of Va scular Su rgery, Municipal Hospital. DUsseldorf. Germany
A. Bosse, P. Ansorg, B. Mayer, and 1. Mulch
Th orae. eardiovase. Surge on 3 9 (1991) Table 1 Morbidity inspontaneouscourse and cou rse withintervention (compiled from theliterature) Annual morbidity inspontaneouscourse (T1A, PRI ND, Stroke) Authors Symptomatic Asympt. Morphology 3%-5%
3.0% 3.3% 20.6% 30.9% 0.4% 12.5%
calcifying echogenic soft type A type B +C
I
Rautenberg (6)
stenosis > 75% (sonographic) } ulcerative, non-stenotic (angiographic)
Intervention course: Perioperativemorb idity (mortality) Annual morbidity Symptomatic Asymptomatic 2.0% 2.4%(1.2%) 3.7% (1.1%) - (1.9%)
3.7%(0.0%) 1.2%(0.9%)
4.0% 1.5% 0.3%
Johnson (2) Moore (5)
Authors Rautenberg(6) Moore (5) Hamann (I) Becker (Munich. 1980) Uidtke-Handjery et al. (4)
- (0.0%)
Table 2 Perioperative morbidityand mortalityinthrombo-(TEA) and eversion (EEA) endarteriectomies of the carotid artery (N = 181, 1988-1990) Operation
Morbidity
Mortality
TEA (n ~ 121) EEA (n ~ 60)
33 % 1.6%
0.8% 0%
Table 3 Distribution of the indication for eversion endarteriectomy of the internalcarotid artery (1990) Indication Vessel condition
Ipsilateral (n = 60)
Contralateral (n = 34)
Scnornorphological ulcerative stenosed combined occluded disobliterated
14 33 13 0 0
4 10 4 9 7
Cl inicalstage I II III IV
33 27 0 0
28 2 0 4
This is a report on employing eversion endoarteriec-
lomy (EEA) in 60 cas es durin g 1990 . Patients a nd Methods We have carried out eversio n endarteriectomy 60 times in 55 patients from January 1990 to October 19 90 . There was no selec tion of the patients on the basis of the clinical stage or vascu lar morphology . In accordance with our attitude to the indication (see above), 27 operations were carried out beca use of exte nsive ulcera tions, ulcerative soft-plaque, or a combination of ulce r and stenosis with dange r of embo lism , and 33 operations were carried out beca use of high-degree stenos is as indicated by the sonomorphol ogy (Table 3). Clinically, there was an asymptomatic stage in 55 .8 %, and there were one or seve ral prior transitory ischemic attacks, prolonged reversi ble ischem ic neurologic deficienc y, or amauros is fugax in 44 .1 %. The contralateral side was involved to a small exte nt in 30%. There was an occlusion of the contralateral
internal carotid artery in nine patients (14.7%). The indicati on was esta blished on the bas is of a duplex so nographic diagnos is. Nevertheless, all patients we re checked preoperatively by ang io-
graphy(Fig. 1 and 2). Clamping was carried out as far cranially as possible (the hypoglossa l nerve was always ex posed ) under syste mic heparin protection after exposure of the carotid bifurcation and mobilization of the internal carotid artery. The latter was severed obliquely from the bifurcation. A circular detachment from the outer wa ll was attained by dissection of th e arteriosclerotic cylinder (mostly near to the adve ntitial tissue) with subse quent eversion of th e artery. The eve rsion of the artery can be carried out over several centimeters, and as a rule the sclerosis cylinder can be smoothly detached from the healthy intima (Fig. 3-6) . Meticulous screening for remaining pendulous flaps of the wall and removal of such flaps are important. Depend ing on the degree of stenos is, endarteriectomy of the carotid bifurcation including the origin of the external carotid artery was carried out in the usual way . The internal carotid artery was reinserted with stretchi ng, if necessary after proximal lengthening of the ACC arteriotomy, with 6/ 0 monofll sutures in continuous suture tec hnique. The result of EEA was checked angiosco pically before completion oft he anterior wall suture (Fig. 7).
Results Our average time of operation was 47 minutes (35- 80 minutes), and the average clamping time was 18 minutes (13- 35 minutes). An intraluminal shunt was never used . Only once did a floatin g intimal pendu lous flap . seen anglescopically, ha ve to be removed by longitudinal arteriotomy. In one patient, there was a planar subcutaneo us hematoma in consequence of the pr ior inhibition of aggregation with aspirin. Revision was not necessary in any patient. In one case , we saw a contralateral hemiparesi s directly after the operation. This regressed completely after a few hours. Clamping for 20 minutes was necessar y during the operation owing to an occlusion of the contralateral internal carotid artery in this patient. The intraoperative ischemia durin g clampin g was probably res ponsible for the temporary neuro logical deficit in this patient. None of the patient s died during the perioperati ve period of 30 days. The morbidity and mortality in this series of operations were thus 1.6 % and 0% respectively (Table 2). Of course. data on late results (e.g. resten osis) cannot be presented because the posloperative period is too short. All patients are being followed-up with duplex sonography six weeks after the operation and at interva ls of six month s. so that the prognosis can be reported on later. Discussion
The favorable perioperative results with regard to morb idity and mort ality are striking. even in the clinically asymptomalic stage. We did not find any ditTerences in the course of the operation and the periop erati ve results in relation to the pr eoperative vascular morphology (stenosis. ulceration. or contralateral internal carotid artery occlusion).
We believe that the better results of EEA as compared to those obtained with carotid TEA are attributable to the reduction in the durat ion of the opera tion by more than half. the short time of clamping. and the fact that a shunt was dispensed with. The analysis of the complications we observed after TEA linked them to an appreciably pr olonged durati on of operation. use of plaslic as patch material, and use of an intraluminal shunt.
Downloaded by: University of British Columbia. Copyrighted material.
372
Eversion Endarterie etomy ofthe Internal Carotid A rtery
Thorae. eardiol'ase. S urgeon 3 9 (1991)
373
Fig.2 PreoperativeDSAfindingsin high-degree stenosisof the internalcarotid artery
a
Fig.3 Intraoperative siteof thecarotid bifurcationwith additional kink stenosis of the internal carotid artery
b
Fig. 4 a/ b
Eversion endarteriectomy of the internal carotid artery
Downloaded by: University of British Columbia. Copyrighted material.
Fig. 1 Preoperativesonomorphological finding of anexulcerated doubleplaque, moderately stenotic
374
Thorae. eardiovase. S urgeon 3 9 (l991)
A. Bosse. P. Ansorg. B. Mayer. and 1. Mulch
c
Fig.4 c
Tensionstraightening of the internalcarotid arteryafter EEA
Fig.5
Carotid bifurcationafter reinsertion ofthe internal carotidartery
Fig.6
Preparationofthe sclerosiscylinderremoved with exukerated plaque
Particular difficulties do not arise in conseq uence ofthe length ofthe extracted sclerosis cylinder (Fig. 6), since problems ass ociated with a patch graft or direct suture ca nnot occur after cranial suture. Under smooth macroscopic conditions , the vessel wall left in position after eversion endarter iectomy only displays wall lesions which ar e angiosco pically visible (Fig. 7), whereas wall ulcerations which can be seen with the na ked eye often remain after conventiona l arteriectomy. The elimination of an elongation and kink ste nosis does not lead to an y prolongati on of the surgi cal opera tion. Other than with the patch or direct suture in the cra nial angle, a restenosis can be definitively avoided by the terminal reinsertion suture (Fig. 8). This experience of eve rsion endarteriectomy shows it to be a sa fe an d rap id method of operation in ulcerate d or ste nose d internal carotid artery . The physiological conditions in the region ofthe carotid bifurcation a re preserved . Periopera tive morbid ity and mortali ty a re more favora ble than with TEA.
Downloaded by: University of British Columbia. Copyrighted material.
Fig.7 Angioscopy oftheinternalcarotidarteryafter EEA (Olympus. PF 28J
Thome. eardiovase. Surgeon 39 (1991)
Eversion EndarterieclOmy a/the Interna l Carotid A rtery
375
Fig,8 Postoperative sonomorphology after eversion endarteriectomy of thecarotidartery
I
2
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(1 978) 1352-1359
Dr. A. Bosse Gefalichiru rgische Klinik Stadtis che Klinik Dusseldorf-Gerresheim 0 -400 0 Dusseldor f 12 Germa ny
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