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Arteriography After Carotid Endarterectomy

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Arteriography After Carotid Endarterectomy 325 Arteriography after Carotid Endarterectomy John Holder 1 Of 55 patients undergoing carotid endarterectomy, 16 had abnormal postoperative Eugene F. Binet2 angiograms by accepted literature criteria. Five of the 16 were symptomatic. The other Stevenson Flanigan3 11 were neurologically stable or improved from their preoperative condition. None of the 16 patients underwent reoperation. Of those 11 who had abnormal postoperative Ernest J. Ferris 1 angiograms but a good clinical result, four had a second postoperative angiogram some months later that demonstrated marked improvement in the appearance of the endarterectomy site. Patients undergoing carotid endarterectomy should not be sub­ jected to routine postoperative angiography without clinical indications nor should they undergo reoperation on the basis of angiographic findings alone without consideration of their clinical status. Cerebral angiography remains th e most precise method to evaluate the path­ ologic changes that occur in extracrani al cerebrovascular disease involving th e internal carotid artery in th e neck. Several authors have strongly endorsed its use in the immediate postoperative period to evalu ate the patency of th e end­ arterectomy site. In some institutions reoperation is performed if the angiographic findings appear unsatisfactory without consideration of the patient's neurologic status. This report will examine the preoperative and postoperative angiograms of patients who were not subjected to reoperation despite having abnormal appearing postoperative carotid angiograms. Materials and Methods Postoperative arteriography has been routinely perform ed on all pati ents subiected to carotid endarterectomy by the Neurosurgery Service at the Little Rock Veterans Adminis­ tration Medical Center. The angiographic studies of 55 such patients operated on during a Received August 28, 1980; accepted after re­ 6 year period were evaluated. These male patients were 42- 81 years old (average, 60 '12 vision March 4 , 1981 years). Seventy percent of the patients were seen with transient ischemi c epi sodes and Presented at the annual meeting of the Ameri­ 30 % were evaluated for completed stroke. In addition to th eir extracran ial cerebrovascular can Roentgen Ray Society , Las Vegas, NV, April disease, two patients had diabetes mellitus, two had hyperlipidemi a, and 1 2 showed 1980. intracranial cerebrovascular disease at angiograph y. , Department of Radiology, University of Arkan­ The preoperative angiographic evaluation in these cases consisted of selecti ve cathe­ sas for Medical Sciences, 4301 W. Markham, terizati on of both common carotid arteries with anteroposteri or and lateral angiography of Little Rock, AR 72205. Address reprint requests both the head and neck vessels performed in all patients. In certain cases selecti ve to J. Holder. vertebral angiograms were also obtained . Oblique projecti ons of th e carotid bifurcati on 2 Department of Radiology, Veterans Ad minis­ were also included when necessary. Aortic arch examinati on preceded the selecti ve studies tration Medical Center, Little Rock , AR 72206. in 75% of the cases. Th e postoperative angiographic evalu at ion consisted of selective 3 Department of Neurosurgery, University of catheterization of the " operated artery " with an teroposteri or and lateral angiograms of th e Arkansas for Medical Sciences, Little Rock , AR 72205. head and neck plus selective study of the opposite carotid artery if significant disease was noted involving that vessel on th e preoperative study. This article appears in July / August 198 1 AJNR and September 198 1 AJR. All patients were operated under general anesthesia, most with electroencephalographic mon itoring. Intraarterial shunts were not used unless electroencephalog raphic changes AJNR 2:325-329, July / AU9ust 1981 0 195-6108/ 8 1/ 0204 - 0325 $00.00 occurred or disease on th e contralateral side was present. © Am eri can Roentg en Ray Society Th e hospital charts on 48 (87%) of the 55 pati en ts were avail able for review. These 48 326 HOLDER ET AL. AJNR:2, July/ August 198 1 pati ents were foll owed an average of 15'/2 months; th e longest carotid artery on postoperative arteriography, three with foll ow-up was 5 years, 3 months and th e shortest was 6 weeks. significant stenosis in the distal limb of their endarterectomy, Two patients died in th e immediate postoperati ve peri od. and three with stenosis of th e proximal limb. Also included were three patients with large persistent filling defects or webs on the postoperative angiographic study. Four of the Results 11 patients in this group had a second follow-up angiogram Of th e 48 patients avail able for c linical follow-up, 77% at 19, 19.5, 20, and 33 months, respectively. Their case were stated to have had a good c linical result. That is, their presentations foll ow. transient ischemi c episodes ceased or their cerebrovascular disease did not progress in the postoperative period. On the o th er hand , 23% of th e pati ents available for foll ow-up had a poor result; th at is, they suffered a stroke in the postop­ Case Reports erative period or th eir transient ischemi c episodes contin­ ued. Case 1 Of the 55 immediate postoperative angiograms obtained A 55-year-old man had acute onset of ri ght-sided weakness and in this seri es, 9% were given an excellent rating. An excel­ expressive aphasia. His preoperative angiogram demonstrated 95% lent postoperative angiogram was interpreted as entirely stenosis of the left intern al carotid artery (fig. 1 A) . A follow-up normal or showing very minimal postoperative changes. angiog ram 9 days aft er a successful endarterectomy showed a Another 57.5% of the angiograms were given a good rating. thick cuff of ti ssue at th e proximal margin of th e endarterectomy They showed only irregularity of th e vessel wall , occlu sion site with 50% stenosis of the common carotid artery and 99% stenosis of the external carotid artery (fig . 1 B). The paiient was of the external carotid artery, or a stenosis of the internal clinicall y stabl e and was not returned to th e operating room . Foll ow­ caroti d artery th at did not exceed 30% . The other 33.5% of up angiogram 19 months later showed very minimal postoperative angiograms were given a poor appearance rating as they changes. Th e cuff had disappeared and the extern al carotid artery showed stenosis of the internal carotid artery greater than had returned to normal (figs. 1 C and 1 D) . Th e pati ent remained 30% . Almost two-thirds of th e patients had th eir follow-up well. angiogram within 30 days of th eir surgical procedure, most of th em while still in the hospital. In an attempt to compare th e results of th e surgical procedure and th e radiographic Case 2 appearance of the carotid artery on the postoperative an­ A 60-year-old man was seen after several attacks of aphasia. A giogram, the patient population was divided into four groups. 95% stenosis of th e carotid artery was seen on preoperati ve angio­ Group 1. Thi s group compri sed the 26 patients having a gram (fig. 2A). Repeat angiogram 5 days after su rg ery showed a good c linical result and a good or excell ent appearance of large intimal flap within the lumen of the common caroti d artery (fig. the carotid artery on their postoperative angiogram. The 2B). The patient was asymptomati c so surgery was deferred. Fol­ average c linical follow-up for this group was 12.7 months low-up angiogram at 95 days again identified th e intimal flap (figs. with the longest pati ent being foll owed 3 '12 years and th e 2C and 2D) . Th e patient remained asymptomatic. A subsequent shortest, 2 months. angiogram at 19.5 months after endarterectomy revealed th e fl ap Group 2. These six patients had a poor c linical result but to still be present but less prominent (figs. 2E and 2F). The patient's a good or excell ent appearance on th eir postoperati ve an­ c linical statu s remained stable during thi s period . giogram. Their average follow-up time was 3'12 months. In cluded in thi s group were several pati ents whose transient Case 3 ischemic episodes either persisted into or returned in the early postoperative period despite a satisfactory appearing A 59-year-old known hypertensive white man had sudden onset internal carotid artery on postoperative arteriography. of left hemiparesis and left facial numbness. Hi s preoperati ve ca­ Group 3 . These fi ve patients had a poor c linical result and rotid angiogram demonstrated a 40% stenosis of the internal carotid a poor radiographic appearance on their postoperative an­ artery with ulcerati on (fig . 3A) . A foll ow-up study 6 days aft er giograms. They had an average clinical follow-up of 21 surgery showed a thick cuff of ti ssue at the proximal margin of the months with th e longest being 5 years, 3 months and the endarterectomy causing a 50% stenosis of th e common carotid artery (fig. 3 B). The patient was asymptomati c so no surgery was shortest being 1 day. In this group were several patients performed. A second angiogram at 20 months after surgery showed who complained of persistent transient ischemic attacks or only very minimal postoperative c hanges (figs. 3C and 3D) . The vertebrobasilar insuffic iency. One patient died of a massive patient has been well since surgery. cerebral infarc t. Several postoperati ve angiograms in this group showed internal carotid artery occlusion or intralu­ minal c lots or webs. Case 4 Group 4. These 11 patients were said to have a good A 60-year-old man had transient diplopia.
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