Simultaneous Bilateral Carotid Endarterectomies Roy
H. Clauss, MD; Prafull V. Bole, MD; Mario Paredes, MD; William Doscher, MD; Adebayo Adeyemo, MD; Martin W. Kreminitzer, MD
\s=b\ Twelve patients with bilateral symptomatic lesions of internal carotid arteries have had bilateral carotid endarterectomy at single operations without complications. These were patients up to age 80 who had prior myocardial infarction, stroke with recovery, and hemispheric and nonhemispheric episodes. Neurologist's clearance and three- or four-vessel intracranial\x=req-\ extracranial angiography preceded all operations, which were performed with the patient under general anesthesia. Stump pressure measurements were the principal guideline of adequacy of collateral flow and predictor of safe outcome. The safety of this concept of bilateral operations during one anesthesia can eliminate uncertainties of sequence and timing, obviate delay and indecision, and avoid the hazards of a second
anesthetic-operative experience. (Arch Surg 111:1304-1306, 1976) of carotid endarterectomy are rare, and and mortality are low, yet two serious are possible—new neurologic deficit and myocardial infarction. Simultaneous bilateral carotid endarterectomy need not increase the incidence of stroke, and it can decrease the frequency of myocardial infarctions. One operative expe¬ rience is advocated for three reasons: The physiology of the brain accommodates sequential unilateral interruption and restoration of flow. Necessary operations on the second side, now finished, cannot be delayed or precluded by possible complications. There is no second challenge of a second operation. Third, the indications for endarterec¬ tomy may be equally compelling for each side, or, converse¬ ly, in patients with nonhemispheric attacks, the angio¬ graphie definition of structural abnormalities may seem too inconclusive to warrant further surgery.
Compl ications morbidity complications
Accepted publication July 9, 1976. From the Departments of Surgery (Drs Clauss, Bole, Paredes, Doscher, and Adeyemo) and Neurology (Dr Kreminitzer), New York Medical College, Flower and Fifth Ave Hospital and Metropolitan Hospital Center, New York. Read before the 24th scientific meeting of the International Cardiovascular Society, Albuquerque, NM, June 19, 1976. Reprint requests to Department of Surgery, New York Medical College, 1249 Fifth Ave, New York, NY 10029 (Dr Clauss). for
PATIENTS AND METHODS Twelve patients, aged 46 to 80 years old, constitute the basis of this report. Seven were women, five men, all with consciousness and motor power intact. All patients had experienced transient ischemie attacks, convincing to neurologists who ordered fourvessel angiography. In all patients' angiograms there was concur¬ rence of opinions of neuroradiologist, neurologist, and surgeon that stenotic, ulcerating, or irregular lesions existed in internal carotid arteries bilaterally. General anesthesia was induced with intravenous agents and maintained with 30% oxygen, 70% nitrous oxide, and eucarbic ventilation. An extension of the endotracheal tube fastened at the forehead permitted skin preparation and draping, rotation of the head, and easy access to both sides of the neck. Incision was made along one sternocleidomastoid muscle and the vessels were isolated. When a similar procedure was started on the second side, 98% oxygen was inhaled along with halothane anesthesia. Hypercarbia exceeding Pco., of 60 mm Hg was induced by reduced minute ventilation and absence of CO,, absorber. Central venous pressure was elevated to above initial levels by rapid infusion of dextran 40 (Rheomacrodex) at room temperature. Lateral sinus blood gases were measured, reported, recorded, and responded to before, during, and at intervals after carotid clamping. Heparin sodium was given intravenously. One external carotid artery was clamped, followed by clamping the internal carotid artery and recording of stump pressure. (Stump pressure greater than 50 mm Hg and lateral sinus oxygen saturation (Svo2) greater than 70% are sought.) An internal shunt was used when the stump pressure was less than 30 mm Hg, when the Svo... did not exceed 70%, and invariably in the presence of a residual neurologic deficit. Systolic blood pressure was never allowed to fall below 80% of control and was maintained with phenylephrine (Neo-Synephrine) hydrochlo¬ ride or dopamine hydrochloride solution infusions as necessary.
RESULTS No neurologic complications of myocardial infarctions occurred. However, observations in eight patients merit mention. Prior to operation, two patients developed unilateral carotid artery occlusion without clinical hemispheric defi¬ cit. Both patients, one aged 56 and the other 80 years, have remained well for more than a year after one reconstructed artery has remained patent. In two patients the mean
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initial stump pressures were less than 50 mm Hg, but to fluid challenge in one and to fluids and vasopressor agents in the second patient. In two other patients the Svo2 of lateral sinus exceeded 70% despite test stump pressures below 25 mm Hg. Obviously, internal shunts were indicated. Finally, manifestations of myocardial disease did occur in two patients. Four days after operation, a 71-year-old woman developed low electrolyte concentrations secondary to diuretic therapy, and atrial tachyarrhythmia, hypoten¬ sion, and confusion. This cleared rapidly and the woman is self-sufficient 35 months afterward. The eighth patient, a 57-year-old woman, was discharged on the eighth day after bilateral carotid operation. Myocardial infarction occurred on the 33rd day after surgery. There were no neurologic abnormalities preceding sudden death on the 35th day. Autopsy showed fresh soft thrombus in the left anterior
responded
descending coronary artery.
COMMENT
Hemodynamically disturbing and nonobstructing irreg¬ ular lesions of carotid arteries may cause cerebrovascular insufficiency.' Removal of either type of offending process is likely to relieve as well as to prevent recurrent symp¬ toms.- The key concept may be removal of abnormalities of two internal carotid arteries at one operation.s It is part of our obligation to identify subgroups of patients in whom surgical treatment provides better prog¬ nosis than nonsurgical treatment. The clinical significance of the lesion in the second internal carotid artery must not be overlooked. In 1970, the Joint Study "progress report of prognosis following surgery or non-surgical treatment for transient ischemie attack (TIA) and cervical carotid lesions" showed that TIA recurred in 38% of surgically treated patients, mainly in territory not affected by operation.4 Thus, the second-side lesion, unappreciated and unoperated on, portends trouble! The hazards of a second operation on the contralateral carotid artery have been stressed. The Joint Study's reported incidence of strokes after a second-side operation was five times that of unilateral operation, 26% vs 4.8%, respectively. Simultaneous bilateral carotid endarterec¬ tomy was reported in 1969,'' but the results were not unlike those of operations staged seven to ten days apart. The authors' interpretations-"errors in surgical technique accounted for the poor results"-put the blame where it belongs, on technique, not concept. In 1971, Sensenig, observing hemispheric stroke one day after unilateral endarterectomy in a patient with bilateral carotid artery stenoses, decided henceforth to perform bilateral endarter¬ ectomy, which he did through 1973 and reported in 1974. ' Many surgeons perform staged bilateral operations on internal carotid artery lesions, and some combine revascu¬ larization of arteries of two sensitive end-organs. Favaloro,'1 in 1973, recommended operations on carotid and coronary arteries at the same time, and in 1976 Urschel and colleagues7 described good results with concomitant oper¬ ations for carotid and coronary artery disease. Neither reported bilateral carotid operations concurrently.
The commonest cause of late mortality in cerebrovascular insufficiency patients is cardiac disease. This can be a problem at operation also. Sundt et als reported a 10% incidence of myocardial infarction after carotid endarter¬ ectomy in patients with angina pectoris. Such occurrences delay or complicate anesthesia and operation, especially if surgery is required within months of myocardial infarc¬ tion. Men over 50 years old constitute a special risk group. Men over 50 with prior myocardial infarction face ten times the risk compared with peers without infarction. Statistics exonerate anesthetic agents and location, type, and duration of operation." The patient with bilateral carotid artery lesions treated at a single operation is subjected to just one period of anxiety and physiologic perturbation. The operation on the second side is a simpler repetition of the procedure just practiced. "Always" doing operation on the second side may be no less justified than "always" doing our prefer¬ ence, eg, operation rather than anticoagulation therapy. Radioactive studies of cerebral blood flow (CBF) before, during, and after unilateral· occlusion of a carotid artery disclose predictable correlations with stump pressure in the internal carotid artery and with the electroencephalo¬ gram.'" During carotid artery occlusions, physiologic accommodation of vascular resistance partially com¬ pensates," and adjunctive measures help to increase CBF. On restoration of flow, the duration of hyperemic response is only two to seven minutes, just enough time to assure hemostasis, reposition the head, and prepare for measure¬ ment of back pressure in the second side artery. There is no oxygen debt precluding concurrent contralateral carotid artery occlusion.'-' It is desirable that critical levels of ischemia be brief and metabolic conditions normal if tissue oxygénation is expected to parallel regional blood flow. Names and Trademarks of Drugs
Nonproprietary
Dextran 40—Gentran 40, LMD, Rheomacrodex, Rheotran.
Dopamine hydrochloride-Zrairopm. References 1. Gomensoro JB, Maslenikov V, Azambaja N, et al: Joint study of extracranial arterial occlusion: VIII. Clinical-radiographic correlation of carotid bifurcation lesions in 177 patients with transient cerebral ischemic attacks. JAMA 224:985-991, 1973. 2. Bauer RB, Meyer JS, Fields WS, et al: Joint study of extracranial arterial occlusion: III. Progress report of long-term survival in patients with and without operation. JAMA 208:509-518, 1969. 3. Sensenig DM: Bilateral carotid artery endarterectomy at one operation. J Maine Med Assoc 65:304-305, 1974. 4. Fields WS, Maslenikov V, Meyer JS et al: Joint study of extracranial occlusion: V. Progress report of prognosis following surgery or nonsurgical treatment for transient cerebral ischemic attacks and cervical carotid artery lesions. JAMA 211:1993-2003, 1970. 5. Young JR, Humphries AW, Beven EG, et al: Carotid endarterectomy without a shunt: Experiences using hyperbaric general anesthesia. Arch Surg 99:293-297, 1969. 6. Favaloro RG: Achievements of surgical intervention in angina pectoris, in Russek HI (ed): New Horizons in Cardiovascular Practice. Baltimore,
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/02/2015
University
Park Press, 1975, pp 171-177. 7. Urschel HC, Razzuk MA, Paulson DL: Management of concomitant carotid and coronary artery occlusive disease. J Thorac Cardiovasc Surg, to be published. 8. Sundt TM Jr, Sandok BA, Whisnant JP: Carotid endarterectomy: Complications and pre-operative assessment of risk. Mayo Clinic Proc 50:301-306, 1975. 9. Topkins MJ, Artusio JF Jr: Myocardial infarction and surgery: A five year study. Anesth Analg 43:716-720, 1964.
10. Sundt TM Jr, Sharbrough FW, Trautmann JC, et al: Monitoring techniques for carotid endarterectomy, in Williams RH (ed): Clinical Neurosurgery. Baltimore, Williams & Wilkins Co, 1975, p 199. 11. Levy LL, Wallace JD, Stolwijk JA, et al: Cerebral blood flow regulation: Vascular resistance adjustments in the circle of Willis. Stroke
7:147-150, 1976.
12. Scheinberg P, Meyer JS, Reivich M, et al: Report of the joint committee for stroke facilities: XIII. Cerebral circulation and metabolism in stroke. Stroke 7:212-234, 1976.
Discussion David Sensenig, MD, Bangor, Me: In 1974 I reported a few cases to our state journal and to the Maine Vascular Society supporting the concept of correcting bilateral carotid abnormalities at one operation, and in the discussion that followed I gathered that some of my colleagues had relegated me to the lunatic fringe. The first patient was a 64-year-old left-handed man with dizzy spells and severe bilateral carotid artery stenosis. Operation on the left carotid artery was performed in May 1971. The following morning the patient developed a stroke-like picture involving the left arm and leg. The symptoms cleared in an hour, but recurred six hours later and persisted. An emergency endarterectomy on the right side with clot removal resulted in clearing of the left
hemiparesis.
The second patient was a 78-year-old woman with episodes of blurred vision and ataxia. She too had severe stenosis bilaterally and a bilateral operation with a good result. A third patient was a 58-year-old man with bilateral stenosis who had a minor degree of weakness of the left arm and leg, but after angiography showed more than 90% occlusion of the left carotid artery with similar marked narrowing on the right side, he developed bilateral hemiplegia and some loss of consciousness. An emergency bilat¬ eral carotid endarterectomy was done; postoperatively, he was neurologically intact, talking and moving all extremities. I have no more cases because I usually favor staging in bilateral disease in order to minimize neck swelling and cerebral edema and to avoid the possibility of bilateral injury to the hypoglossal or recurrent nerves. The cases described show that at times bilateral procedures at one operation can be rewarding. In case 1, failure to do both sides at one operation resulted in a stroke. When bilateral severe internal carotid artery stenosis exists, serious consideration should be given to bilateral procedures at one operation to avoid a stroke in the immediate postoperative period from the thrombosis on the side not operated on. Dr Clauss, in a larger series, has demonstrated the safety of simultaneous bilateral surgery. Alton Ochsner, Jr, MD, Métairie, La: Dr Clauss and his associates are certainly to be congratulated for the success they are having, but I rise to express caution about the adoption of this procedure, for fear it may produce problems we do not need. I am not so much concerned about the possibility of getting postopera¬ tive internal carotid thrombosis bilaterally-which, of course, would be a terrible catastrophe and probably lethal—but I am concerned about producing respiratory problems. A fair number of patients undergoing carotid endarterectomy have pharyngeal muscle weakness and cord paresis that is seldom recognized but is manifested by difficulty in handling secretions and hoarseness. Fortunately, this condition improves with time.
However, it is my fear that simultaneous bilateral operations may result in a more severe type of respiratory difficulty that could lead to more cardiac anoxia and perhaps even the need for
tracheostomy. Hugh Beebe, MD, Seattle:
We have had no experience at the Mason Clinic with simultaneous bilateral operations, but we recently had a problem with a staged bilateral operation. About one in 20 carotid endarterectomy patients will have a hypoglossal nerve palsy. It usually clears very quickly after operation. Even when we are very far from the nerve, it will occur in some
patients. We recently went ahead and operated on the contralateral side of a patient who had a persisting hypoglossal palsy from the first side, and ended up with a bilateral nerve palsy and a very severe airway problem immediately after the operation. We encountered a serious problem in the recovery room because of failure to recognize this. I would like to ask the authors if they ever had a problem with bilateral 12th nerve palsy. Anthony M. Imparato, MD, New York: I rise to gently chide my good friend, Roy Clauss-who I am sure will forgive me—to the effect that in dealing with neurologically intact patients, where one is permitted a mortality of 1% or less and a neurologic complication rate of 1%, 2%, or 3% or less, 12 cases really don't tell very much. We have limited our simultaneous bilateral oper¬ ations to patients who have had bilateral simultaneously occurring cerebral hemispheric symptoms, an incidence of less than 1%. We reported two cases of bilateral hypoglossal palsy some years ago and offered some suggestions as to how it might be pre¬ vented. Dr Clauss: In the same spirit in which Dr Imparato offered his comments, I would recall a sign in the operating room of Dr Robert Gross: "If the operation is not going well, you're not doing it us
properly."
I suppose everyone has had cases of hypoglossal nerve palsy, and I suppose one needs to make a critical mistake only once, as Dr Spencer suggested previously, to put into one's computer bank how to avoid it. I would be happy to run the series up to statistical significance as the cases are reported. I ask two questions: Do we recommend it? Can we recommend it? I think you must make the choice
yourselves. We have had no respiratory problems. It is always a good idea to leave the endotracheal tube in place until the patient makes that enormously dangerous trip from the operating room to the intensive care unit, where the surgeon can evaluate the condi¬ tion.
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H. Clauss, MD; Prafull V. Bole, MD; Mario Paredes, MD; William Doscher, MD; Adebayo Adeyemo, MD; Martin W. Kreminitzer, MD
\s=b\ Twelve patients with bilateral symptomatic lesions of internal carotid arteries have had bilateral carotid endarterectomy at single operations without complications. These were patients up to age 80 who had prior myocardial infarction, stroke with recovery, and hemispheric and nonhemispheric episodes. Neurologist's clearance and three- or four-vessel intracranial\x=req-\ extracranial angiography preceded all operations, which were performed with the patient under general anesthesia. Stump pressure measurements were the principal guideline of adequacy of collateral flow and predictor of safe outcome. The safety of this concept of bilateral operations during one anesthesia can eliminate uncertainties of sequence and timing, obviate delay and indecision, and avoid the hazards of a second
anesthetic-operative experience. (Arch Surg 111:1304-1306, 1976) of carotid endarterectomy are rare, and and mortality are low, yet two serious are possible—new neurologic deficit and myocardial infarction. Simultaneous bilateral carotid endarterectomy need not increase the incidence of stroke, and it can decrease the frequency of myocardial infarctions. One operative expe¬ rience is advocated for three reasons: The physiology of the brain accommodates sequential unilateral interruption and restoration of flow. Necessary operations on the second side, now finished, cannot be delayed or precluded by possible complications. There is no second challenge of a second operation. Third, the indications for endarterec¬ tomy may be equally compelling for each side, or, converse¬ ly, in patients with nonhemispheric attacks, the angio¬ graphie definition of structural abnormalities may seem too inconclusive to warrant further surgery.
Compl ications morbidity complications
Accepted publication July 9, 1976. From the Departments of Surgery (Drs Clauss, Bole, Paredes, Doscher, and Adeyemo) and Neurology (Dr Kreminitzer), New York Medical College, Flower and Fifth Ave Hospital and Metropolitan Hospital Center, New York. Read before the 24th scientific meeting of the International Cardiovascular Society, Albuquerque, NM, June 19, 1976. Reprint requests to Department of Surgery, New York Medical College, 1249 Fifth Ave, New York, NY 10029 (Dr Clauss). for
PATIENTS AND METHODS Twelve patients, aged 46 to 80 years old, constitute the basis of this report. Seven were women, five men, all with consciousness and motor power intact. All patients had experienced transient ischemie attacks, convincing to neurologists who ordered fourvessel angiography. In all patients' angiograms there was concur¬ rence of opinions of neuroradiologist, neurologist, and surgeon that stenotic, ulcerating, or irregular lesions existed in internal carotid arteries bilaterally. General anesthesia was induced with intravenous agents and maintained with 30% oxygen, 70% nitrous oxide, and eucarbic ventilation. An extension of the endotracheal tube fastened at the forehead permitted skin preparation and draping, rotation of the head, and easy access to both sides of the neck. Incision was made along one sternocleidomastoid muscle and the vessels were isolated. When a similar procedure was started on the second side, 98% oxygen was inhaled along with halothane anesthesia. Hypercarbia exceeding Pco., of 60 mm Hg was induced by reduced minute ventilation and absence of CO,, absorber. Central venous pressure was elevated to above initial levels by rapid infusion of dextran 40 (Rheomacrodex) at room temperature. Lateral sinus blood gases were measured, reported, recorded, and responded to before, during, and at intervals after carotid clamping. Heparin sodium was given intravenously. One external carotid artery was clamped, followed by clamping the internal carotid artery and recording of stump pressure. (Stump pressure greater than 50 mm Hg and lateral sinus oxygen saturation (Svo2) greater than 70% are sought.) An internal shunt was used when the stump pressure was less than 30 mm Hg, when the Svo... did not exceed 70%, and invariably in the presence of a residual neurologic deficit. Systolic blood pressure was never allowed to fall below 80% of control and was maintained with phenylephrine (Neo-Synephrine) hydrochlo¬ ride or dopamine hydrochloride solution infusions as necessary.
RESULTS No neurologic complications of myocardial infarctions occurred. However, observations in eight patients merit mention. Prior to operation, two patients developed unilateral carotid artery occlusion without clinical hemispheric defi¬ cit. Both patients, one aged 56 and the other 80 years, have remained well for more than a year after one reconstructed artery has remained patent. In two patients the mean
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/02/2015
initial stump pressures were less than 50 mm Hg, but to fluid challenge in one and to fluids and vasopressor agents in the second patient. In two other patients the Svo2 of lateral sinus exceeded 70% despite test stump pressures below 25 mm Hg. Obviously, internal shunts were indicated. Finally, manifestations of myocardial disease did occur in two patients. Four days after operation, a 71-year-old woman developed low electrolyte concentrations secondary to diuretic therapy, and atrial tachyarrhythmia, hypoten¬ sion, and confusion. This cleared rapidly and the woman is self-sufficient 35 months afterward. The eighth patient, a 57-year-old woman, was discharged on the eighth day after bilateral carotid operation. Myocardial infarction occurred on the 33rd day after surgery. There were no neurologic abnormalities preceding sudden death on the 35th day. Autopsy showed fresh soft thrombus in the left anterior
responded
descending coronary artery.
COMMENT
Hemodynamically disturbing and nonobstructing irreg¬ ular lesions of carotid arteries may cause cerebrovascular insufficiency.' Removal of either type of offending process is likely to relieve as well as to prevent recurrent symp¬ toms.- The key concept may be removal of abnormalities of two internal carotid arteries at one operation.s It is part of our obligation to identify subgroups of patients in whom surgical treatment provides better prog¬ nosis than nonsurgical treatment. The clinical significance of the lesion in the second internal carotid artery must not be overlooked. In 1970, the Joint Study "progress report of prognosis following surgery or non-surgical treatment for transient ischemie attack (TIA) and cervical carotid lesions" showed that TIA recurred in 38% of surgically treated patients, mainly in territory not affected by operation.4 Thus, the second-side lesion, unappreciated and unoperated on, portends trouble! The hazards of a second operation on the contralateral carotid artery have been stressed. The Joint Study's reported incidence of strokes after a second-side operation was five times that of unilateral operation, 26% vs 4.8%, respectively. Simultaneous bilateral carotid endarterec¬ tomy was reported in 1969,'' but the results were not unlike those of operations staged seven to ten days apart. The authors' interpretations-"errors in surgical technique accounted for the poor results"-put the blame where it belongs, on technique, not concept. In 1971, Sensenig, observing hemispheric stroke one day after unilateral endarterectomy in a patient with bilateral carotid artery stenoses, decided henceforth to perform bilateral endarter¬ ectomy, which he did through 1973 and reported in 1974. ' Many surgeons perform staged bilateral operations on internal carotid artery lesions, and some combine revascu¬ larization of arteries of two sensitive end-organs. Favaloro,'1 in 1973, recommended operations on carotid and coronary arteries at the same time, and in 1976 Urschel and colleagues7 described good results with concomitant oper¬ ations for carotid and coronary artery disease. Neither reported bilateral carotid operations concurrently.
The commonest cause of late mortality in cerebrovascular insufficiency patients is cardiac disease. This can be a problem at operation also. Sundt et als reported a 10% incidence of myocardial infarction after carotid endarter¬ ectomy in patients with angina pectoris. Such occurrences delay or complicate anesthesia and operation, especially if surgery is required within months of myocardial infarc¬ tion. Men over 50 years old constitute a special risk group. Men over 50 with prior myocardial infarction face ten times the risk compared with peers without infarction. Statistics exonerate anesthetic agents and location, type, and duration of operation." The patient with bilateral carotid artery lesions treated at a single operation is subjected to just one period of anxiety and physiologic perturbation. The operation on the second side is a simpler repetition of the procedure just practiced. "Always" doing operation on the second side may be no less justified than "always" doing our prefer¬ ence, eg, operation rather than anticoagulation therapy. Radioactive studies of cerebral blood flow (CBF) before, during, and after unilateral· occlusion of a carotid artery disclose predictable correlations with stump pressure in the internal carotid artery and with the electroencephalo¬ gram.'" During carotid artery occlusions, physiologic accommodation of vascular resistance partially com¬ pensates," and adjunctive measures help to increase CBF. On restoration of flow, the duration of hyperemic response is only two to seven minutes, just enough time to assure hemostasis, reposition the head, and prepare for measure¬ ment of back pressure in the second side artery. There is no oxygen debt precluding concurrent contralateral carotid artery occlusion.'-' It is desirable that critical levels of ischemia be brief and metabolic conditions normal if tissue oxygénation is expected to parallel regional blood flow. Names and Trademarks of Drugs
Nonproprietary
Dextran 40—Gentran 40, LMD, Rheomacrodex, Rheotran.
Dopamine hydrochloride-Zrairopm. References 1. Gomensoro JB, Maslenikov V, Azambaja N, et al: Joint study of extracranial arterial occlusion: VIII. Clinical-radiographic correlation of carotid bifurcation lesions in 177 patients with transient cerebral ischemic attacks. JAMA 224:985-991, 1973. 2. Bauer RB, Meyer JS, Fields WS, et al: Joint study of extracranial arterial occlusion: III. Progress report of long-term survival in patients with and without operation. JAMA 208:509-518, 1969. 3. Sensenig DM: Bilateral carotid artery endarterectomy at one operation. J Maine Med Assoc 65:304-305, 1974. 4. Fields WS, Maslenikov V, Meyer JS et al: Joint study of extracranial occlusion: V. Progress report of prognosis following surgery or nonsurgical treatment for transient cerebral ischemic attacks and cervical carotid artery lesions. JAMA 211:1993-2003, 1970. 5. Young JR, Humphries AW, Beven EG, et al: Carotid endarterectomy without a shunt: Experiences using hyperbaric general anesthesia. Arch Surg 99:293-297, 1969. 6. Favaloro RG: Achievements of surgical intervention in angina pectoris, in Russek HI (ed): New Horizons in Cardiovascular Practice. Baltimore,
Downloaded From: http://archsurg.jamanetwork.com/ by a Oakland University User on 06/02/2015
University
Park Press, 1975, pp 171-177. 7. Urschel HC, Razzuk MA, Paulson DL: Management of concomitant carotid and coronary artery occlusive disease. J Thorac Cardiovasc Surg, to be published. 8. Sundt TM Jr, Sandok BA, Whisnant JP: Carotid endarterectomy: Complications and pre-operative assessment of risk. Mayo Clinic Proc 50:301-306, 1975. 9. Topkins MJ, Artusio JF Jr: Myocardial infarction and surgery: A five year study. Anesth Analg 43:716-720, 1964.
10. Sundt TM Jr, Sharbrough FW, Trautmann JC, et al: Monitoring techniques for carotid endarterectomy, in Williams RH (ed): Clinical Neurosurgery. Baltimore, Williams & Wilkins Co, 1975, p 199. 11. Levy LL, Wallace JD, Stolwijk JA, et al: Cerebral blood flow regulation: Vascular resistance adjustments in the circle of Willis. Stroke
7:147-150, 1976.
12. Scheinberg P, Meyer JS, Reivich M, et al: Report of the joint committee for stroke facilities: XIII. Cerebral circulation and metabolism in stroke. Stroke 7:212-234, 1976.
Discussion David Sensenig, MD, Bangor, Me: In 1974 I reported a few cases to our state journal and to the Maine Vascular Society supporting the concept of correcting bilateral carotid abnormalities at one operation, and in the discussion that followed I gathered that some of my colleagues had relegated me to the lunatic fringe. The first patient was a 64-year-old left-handed man with dizzy spells and severe bilateral carotid artery stenosis. Operation on the left carotid artery was performed in May 1971. The following morning the patient developed a stroke-like picture involving the left arm and leg. The symptoms cleared in an hour, but recurred six hours later and persisted. An emergency endarterectomy on the right side with clot removal resulted in clearing of the left
hemiparesis.
The second patient was a 78-year-old woman with episodes of blurred vision and ataxia. She too had severe stenosis bilaterally and a bilateral operation with a good result. A third patient was a 58-year-old man with bilateral stenosis who had a minor degree of weakness of the left arm and leg, but after angiography showed more than 90% occlusion of the left carotid artery with similar marked narrowing on the right side, he developed bilateral hemiplegia and some loss of consciousness. An emergency bilat¬ eral carotid endarterectomy was done; postoperatively, he was neurologically intact, talking and moving all extremities. I have no more cases because I usually favor staging in bilateral disease in order to minimize neck swelling and cerebral edema and to avoid the possibility of bilateral injury to the hypoglossal or recurrent nerves. The cases described show that at times bilateral procedures at one operation can be rewarding. In case 1, failure to do both sides at one operation resulted in a stroke. When bilateral severe internal carotid artery stenosis exists, serious consideration should be given to bilateral procedures at one operation to avoid a stroke in the immediate postoperative period from the thrombosis on the side not operated on. Dr Clauss, in a larger series, has demonstrated the safety of simultaneous bilateral surgery. Alton Ochsner, Jr, MD, Métairie, La: Dr Clauss and his associates are certainly to be congratulated for the success they are having, but I rise to express caution about the adoption of this procedure, for fear it may produce problems we do not need. I am not so much concerned about the possibility of getting postopera¬ tive internal carotid thrombosis bilaterally-which, of course, would be a terrible catastrophe and probably lethal—but I am concerned about producing respiratory problems. A fair number of patients undergoing carotid endarterectomy have pharyngeal muscle weakness and cord paresis that is seldom recognized but is manifested by difficulty in handling secretions and hoarseness. Fortunately, this condition improves with time.
However, it is my fear that simultaneous bilateral operations may result in a more severe type of respiratory difficulty that could lead to more cardiac anoxia and perhaps even the need for
tracheostomy. Hugh Beebe, MD, Seattle:
We have had no experience at the Mason Clinic with simultaneous bilateral operations, but we recently had a problem with a staged bilateral operation. About one in 20 carotid endarterectomy patients will have a hypoglossal nerve palsy. It usually clears very quickly after operation. Even when we are very far from the nerve, it will occur in some
patients. We recently went ahead and operated on the contralateral side of a patient who had a persisting hypoglossal palsy from the first side, and ended up with a bilateral nerve palsy and a very severe airway problem immediately after the operation. We encountered a serious problem in the recovery room because of failure to recognize this. I would like to ask the authors if they ever had a problem with bilateral 12th nerve palsy. Anthony M. Imparato, MD, New York: I rise to gently chide my good friend, Roy Clauss-who I am sure will forgive me—to the effect that in dealing with neurologically intact patients, where one is permitted a mortality of 1% or less and a neurologic complication rate of 1%, 2%, or 3% or less, 12 cases really don't tell very much. We have limited our simultaneous bilateral oper¬ ations to patients who have had bilateral simultaneously occurring cerebral hemispheric symptoms, an incidence of less than 1%. We reported two cases of bilateral hypoglossal palsy some years ago and offered some suggestions as to how it might be pre¬ vented. Dr Clauss: In the same spirit in which Dr Imparato offered his comments, I would recall a sign in the operating room of Dr Robert Gross: "If the operation is not going well, you're not doing it us
properly."
I suppose everyone has had cases of hypoglossal nerve palsy, and I suppose one needs to make a critical mistake only once, as Dr Spencer suggested previously, to put into one's computer bank how to avoid it. I would be happy to run the series up to statistical significance as the cases are reported. I ask two questions: Do we recommend it? Can we recommend it? I think you must make the choice
yourselves. We have had no respiratory problems. It is always a good idea to leave the endotracheal tube in place until the patient makes that enormously dangerous trip from the operating room to the intensive care unit, where the surgeon can evaluate the condi¬ tion.
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