Cardiology

Carotid Endarterectomy: Principles and Technique by Christopher M. Loftus

By Christopher M. Loftus

Neurovascular approaches symbolize a big point of a surgeon's perform. the hot beneficial result of scientific trials on carotid endarterectomy for stroke prevention have led to a starting to be call for for surgeons who practice this approach. Surgeons will be ready to fulfill the call for via studying the fundamental ideas, diagnositc standards and operative method for carotid endarterectomy. Dr Loftus stocks his perception and vast adventure during this clinically-oriented quantity. a number of radiographic examples illustrate the subtleties of selecting the diseased artery, in addition to anatomic adaptations that make prognosis and surgical procedure much more not easy. The approach is illustrated with attractive line drawings followed by way of color pictures, and the textual content all through is an easy-reading, concise narrative. good points: * incorporates a specific part at the simple rules underlying carotid endarterectomy * encompasses a part committed completely to diagnostic issues with a number of radiographic reviews illustrating universal and anomalous anatomy * includes countless numbers of photos and drawings demonstrating all features of the technique

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178 The ability of angiographic findings to predict intraoperative EEG changes has been IOW,183,184 and even patients with contralateral carotid occlusion, although appearing to require shunts more often than routine cases, have shown EEG changes in only 17% and 42%, respectively, in two series. 93 ,94 Despite the inclination of many surgeons, myself included, to use shunts on patients who have so-called moderate EEG changes as defined by Blume, Ferguson, and McNeill,185 it should be recognized that there are investigators who do not share this viewpoint.

These authors argue strongly that SSEP is a highly reliable predictor of the need for shunting, and they use it as their primary monitoring technique. In direct contradiction to this is a recent review by Kearse, Brown, and McPeck,198 who simultaneously monitored the EEG and SSEP in 53 carotid endarterectomies. Rather than using neurologic outcome as an end-point, their SSEP criteria were measured against the EEG "gold standard," and in their 23 patients with EEG evidence of ischemia after crossclamping, 10 had prolongation of the central conduction time but only one had an amplitude decrease of 50% or more.

H7 reported a similar statistically significant ability to predict decreased MCA velocities and shunt need in a somewhat smaller series of 23 patients. Sufficient experience with TCD monitoring now exists to allow the technique to be compared with other methods of intraoperative carotid endarterectomy monitoring. A number of articles have compared TCD monitoring with intraoperative stump pressure measurements, customarily using a stump pressure of less than 50 mm Hg as an indication for shunting.

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