EEG monitoring, selective shunting and patch graft angioplasty in carotid endarterectomy. Early and longterm results

From March 1980 to July 1986 at the Department of Vascular Surgery of the University of Padua, 182 patients underwent 210 carotid revascularizations for atherosclerotic stenosis involving the carotid bifurcation (28 operations were bilateral). Carotid endarterectomies (CE) and patch graft angioplasty totalled 192 (166 patients); an enlarging patch graft angioplasty of the internal carotid artery (ICA) without CE was performed in 14 cases (13 patients); in the remaining four surgical procedures (3 patients), for technical reasons prohibiting CE, the operation consisted of a great saphenous vein bypass between a donor vessel and the ICA distal to the lesion. The preoperative symptoms in 182 patients were as follows: TIAs (98 cases, 54%), non-hemispheric symptoms (21 cases (12%) and fixed stroke or TIAIR (10 cases, 5%). Fifty-three patients (29%) were asymptomatic. In all cases, continuous EEG monitoring was employed. The operation was performed without a temporary intraluminal shunt in the patients showing tolerance to carotid clamping. The protection of the shunt was required only in patients with EEG changes (47 cases). The arteriotomy was routinely closed with a PTFE patch graft angioplasty. Early results of the operation were excellent: none of the patients presented permanent or transient neurological deficits in the immediate postoperative period and none of them died. All patients were reassessed with C.W. Doppler sonography and Duplex scanning in the postoperative period. In all cases, the success of the operation was demonstrated. Longterm follow-up (6-72 months, mean follow-up: 35 months) was done in 121 patients (142 operations): 107 patients were completely asymptomatic, 5 remained stable or slightly improved the preoperative status. Five patients had a new or recurrent TIAs, 3 suffered a stroke, one showed a recurrence of non-hemispheric symptoms. With the exception of two patients suffering a stroke, all had a second arteriography but none of these patients showed extracranial lesions. Two patients presented an asymptomatic restenosis of the ICA. Eight patients (8.8%) revealed a significant evolution of the disease of the contralateral unoperated ICA.(ABSTRACT TRUNCATED AT 400 WORDS)