Carotid Artery Bypass in Acute Postendarterectomy Thrombosis Philip S.K. Paty, MD, R. Clement Darling, III, MD, Juan A. Cordero, Jr., MD, Dhiraj M. Shah, MD, Benjamin B. Chang, MD, Robert P. Leather, MD, Albany, New York BACKGROUND: Carotid endarterectomy has dem- onstrated excellent results over the past 2 dec- ades with combined stroke mortality of ~4% in most active centers. However, the optimal tech- nique for surgical reconstruction for patients with acute postoperative deficits is more controver- sial. PATIENTSAND METHODS: In the last 10 years (1985 to 1995), we performed 1,267 carotid endat-terec- tomies, with 17 strokes (1.3%) and 16 deaths (1.2%). Twenty-four patients developed acute (within 72 hours) postoperative neurologic defi- cits. In 10 patients, the carotid artery was con- firmed patent by duplex scan or angiography, and the neurologic deficit resolved without further therapy. Early reexploration was performed in 14 cases for suspected thrombosis associated with a new neurologic deficit. In each case, resection of the endarterectomy site and an interposition bypass was performed with greater saphenous vein (1 l), jugular vein (2), or polytetrafluoroethyl- ene (2) grafts. (One patient required a new bypass for acute occlusion of the initial vein bypass.) Postoperatively, 8 patients had complete resolu- tion of their deficit, 3 had minimal residual defi- cits, and 3 suffered permanent stroke. However, 2 of these patients died. RESULTS: Carotid artery bypass with exclusion of the endarterectomy site resulted in improvement in symptoms in 79% (11 of 14) of the patients and complete resolution in 57% (8 of 14). In long-term follow up (1 to 41 months), there have been no occlusions and one restenosis requiring revision at 11 months. CONCLUSIONS: Carotid artery bypass can be per- formed safely with acceptable results. The use of autogenous venous conduits allows reconstruc- tion with an endothelial lined conduit that may improve results in patients with acute postopera- tive neurologic deficit secondary to thrombosis of the endatterectomized carotid artery. Am J Surg. 1996;172:181-183. Requests for reprints should be addressed to R. Clement Darling Ill, MD, Vascular Surgery, A-61, Albany Medical College, 47 New Scotland Avenue, Albany, NY 12208. Presented at the 24th Annual Meeting of The Society for Clinical Vascular Surgery, Ranch0 Mirage, California, March 20-24, 1996. From the Vascular Surgery Section, Albany Medical College, Al- From the Vascular Surgery Section, Albany Medical College, Al- bany, New York. bany, New York. Requests for reprints should be addressed to R. Clement Darling Ill, MD, Vascular Surgery, A-61, Albany Medical College, 47 New Scotland Avenue, Albany, NY 12208. Presented at the 24th Annual Meeting of The Society for Clinical Vascular Surgery, Ranch0 Mirage, California, March 20-24, 1996. T he occurrence of postoperative stroke following ca- rotid endarterectomy is currently less than 2% to 3% when performed hy an experienced surgeon.’ The etiology of postoperative stroke may he related to intra- operative embolization, cerebral ischemia during clamp time, intracerehral edema, or hemorrhage, as well as to thrombosis of the endarterectomy site. Postoperative thrombosis of the carotid artery after endarterectomy occurs with a reported incidence of 2% to 18% when evaluated by hemodynamic or imaging studies, although symptomatic occlusion associated with neurologic defects may occur less commonly.‘~‘” In the past, conventional wisdom advised against operation in the acute setting for profound neuro- logic deficits owing to a high operative mortality and poor salvage of neurologic function.““.’ More recently, the con- sensus of opinion is that these patients should he reexplored emergently; however, the optimal method for surgical treat- ment of this condition and the need for preoperative testing are yet to be determined conclusively. In the present study, we reviewed our experience in patients with acutely throm- bosed carotid arteries following endartetectomy treated by exclusion of the endarterectomized carotid artery and in- terposition bypass. PATIENTS AND METHODS The records of all patients undergomg carotid endarterec- tomy over the past 10 years were reviewed. Procedures per- formed concomitantly with cardiac procedures were ex- cluded from this analysis. Procedures were preferentially performed under regional cervical block anesthesia. Carotid endarterectomy was performed either hy standard bifurca- tion endarterectomy or eversion methods.” All patients presenting with transient ischemic attacks postoperatively were evaluated with angiography or duplex scan. Patients with an identifiable abnormality in these studies or post- operative stroke were returned to the operating room for reexploration. Carotid reexploration procedures were preferentially per- formed under general anesthesia. The patients were given an intravenous heparin holus (‘10 u/kg body weight) and 100 mg of solumedrol. The incision was reopened and the carotid artery inspected visually and insonated with an ex- ternal Doppler probe to determine patency. The arteriot- omy was reopened and the thromhus removed. If this ma- neuver was not successful in reinstituting internal carotid artery back flow, a 2-French Fogarty cmholectomy catheter was gently passed distally into the internal carotid artery to retrieve any thromboemholic debris. A shunt was then placed. The endarterectomized surface of the artery was then resected, and arterial continuity was reestablished preferentially with an interposition vein bypass. Postoper- #G 1996 by Excerpta Medica, Inc. All rights reserved. 0002-961 O/96/$1 5.00 181 PII SOOO2-9610(96)00147-X