Intraoperative high resolution duplex imaging during carotid endarterectomy: Which abnormalities require surgical correction?

Objectives:This study evaluates high resolution, duplex ultrasound imaging for quality control of carotid endarterectomy in order to determine which technical factors were linked to residual stenosis and to define duplex criteria for reexploration.Design, material and methods:A consecutive series of 100 patients undergoing carotid endarterectomy were evaluated. Duplex imaging was performed prior to wound closure and repeated at 6–8 weeks postoperatively. Stenoses were classified as non-significant, moderate or severe based on duplex criteria. Intimal flaps, shelves, kinks, clamp damage and fronds were identified by ultrasound imaging.Results:Five moderate stenoses were noted in the proximal endarterectomy site (PES), and at follow-up three had resolved. Adherent fronds were detected in 83% of vessels and resolved in all but three cases. At the distal endarterectomy site there were 10 severe and 12 moderate stenoses. Intimal flaps were associated with an increased incidence of residual stenosis (p = 0.010).Conclusions:We conclude that severe stenoses with an intimal flap should be corrected immediately. Further data is required to establish the significance of kinks. Residual intimal flaps in the PES appear to remodel. The role of completion duplex may lie in the modification of surgical technique to eradicate anatomical and haemodynamic imperfections

Transcranial measurement of blood velocities in the basal cerebral arteries using pulsed Doppler ultrasound: a method of assessing the circle of willis

Transcranial pulsed Doppler ultrasound and spectral analysis were used for detection of blood velocities in the basal cerebral arteries. The Doppler transducer was placed superior to the zygomatic arch and during insonation of the middle cerebral artery care was taken to obtain maximum Doppler-shift frequency signals since this allowed a small angle between the ultrasound beam and this artery. Doppler signals were obtained from the middle, anterior, and posterior cerebral arteries in 20 volunteers with the average depth of the Doppler gate at 4.9 (4.6-5.2 cm), 5.2 (4.9-5.4 cm), and 6.3 cm (6.0-6.9 cm), respectively. These measurements were in agreement with those obtained for 15 cadaver studies, in whom the distance from the proposed site of the Doppler transducer to each basal cerebral artery was measured as 4.7 ± 0.6, 5.3 ± 0.5, and 5.9 ± 0.9 cm, respectively. The reproducibility of middle cerebral artery blood velocity values was tested in seven subjects and showed a variation of not more than 8% in any individual. The method was used in combination with common carotid compression to assess four patients who had occlusive extracranial carotid disease; in three the disease was more severe on one side and reversal of blood flow in the proximal ipsilateral anterior cerebral artery was demonstrated, consistent with cross flow from the contralateral side via the anterior communicating artery of the Circle of Willis. In the fourth patient augmentation of posterior cerebral artery blood velocities during common carotid compression indicated the major collateral source was from the vertebrobasilar system.</p

Transcranial measurement of blood velocities in the basal cerebral arteries using pulsed Doppler ultrasound: velocity as an index of flow

Blood velocities have been measured transcranially, at small Doppler angles, in the middle cerebral artery of normal volunteers. Cerebral blood flow was changed by varying carbon dioxide tension. In four volunteers, the relationships between arterial pCO2 and percentage change in intensity weighted mean, median, and maximum Doppler-shifted frequencies in the internal carotid and middle cerebral arteries were linear with slopes of 2.5 and 2.8% per mm Hg change in pCO2. In 38 volunteers, the relationship between end-expiratory pCO2 and time-averaged maximum Doppler frequency was linear over the range of pCO2 20-60 mm Hg with slopes of 2.5 and 2.9 percentage change per mm Hg, for internal carotid and middle cerebral, respectively. These results are very similar to those reported using direct methods of measuring cerebral blood flow. As the transcranial Doppler method is reproducible, this indicates that changes in middle cerebral blood velocity may be used to monitor changes in flow.</p

Correlation of intra-operative duplex findings during carotid endarterectomy with neurological events and recurrent stenosis at one year

Objectives: carotid endarterectomy has been used to treat both asymptomatic and symptomatic disease and this has meant that recurrent stenosis and its effect on late stroke risk have become increasingly important. In this study we compared anatomical defects and residual stenosis identified intra-operatively with recurrent stenosis and new symptoms developing in the first year after surgery, Design, Materials & Methods: two hundred and forty-four consecutive patients undergoing carotid endarterectomy were studied prospectively, Residual anatomical defects were noted; residual stenosis was defined by intra-operative duplex ultrasound as >50%. New stenoses and clinical events during the one-year surveillance period were documented. Results: there was an increased incidence of recurrent stenosis at one year in vessels with residual stenoses (p < 0.001) and in vessels containing a residual anatomical defect (p = 0.037). There was no significant difference in recurrent stenosis rate with respect to closure (primary or patch) or seniority of surgeon but recurrent stenosis was increased in females (p = 0.026). The majority (70%) of restenotic lesions were localised to the origin of the internal carotid artery. The late stroke rate was 0.9% and was not related to recurrent stenosis or symptoms. Conclusions: residual stenosis and intra-luminal defects at completion increase the recurrent stenosis rate at one year, The aetiology of recurrent stenosis is multi-factorial and further studies are required to determine whether it is justified to modify the criteria for re-exploration with a view to reducing recurrent stenosis