title: Early control of the distal internal carotid artery during endarterectomy: achievability and results.
abstract: OBJECTIVE
  The purpose of this study was the report of the results of a consecutive series of carotid endarterectomy (CEA), performed by one surgeon and independently assessed by a neurologist, in which the achievability of selective early control of the distal internal carotid artery (ICA) was prospectively recorded.
  
  
  METHODS
  All patients who underwent CEA by the surgical author between November 17, 1999, and November 15, 2001, were entered into a prospective study during which early selective exposure and clamping of the distal ICA were attempted (with initial avoidance of carotid bifurcation exposure and retraction), which allowed the remainder of the procedure (in patients without shunting) to be performed with ICA clamp protection and anticoagulation therapy. All the procedures were performed with local cervical block anesthesia, all the patients underwent a vein patch procedure, and, with one exception, cerebral angiography was not used. Major morbidity (stroke and myocardial infarction), mortality, and consecutiveness were independently verified by a neurologist.
  
  
  RESULTS
  148 consecutive CEAs were performed. In 142 cases (96%), the soft distal ICA could be initially isolated and controlled without dissection of the plaque-bearing bulb bifurcation area (group A), and in the remaining six cases, the carotid bifurcation had to be exposed and retracted to allow ICA clamping (group B). A shunt was needed in 15 cases (14 in group A, one in group B), which left 128 cases (86%) in which the procedure could be performed with the ICA clamped and the brain theoretically protected from particulate plaque embolism. There were no strokes or deaths, one patient had temporary vertebrobasilar ischemia, one patient had a myocardial infarct, one patient had a temporary accessory nerve palsy, one patient returned to the operating room for release of a cervical hematoma, and 94% spent one postoperative night in the hospital.
  
  
  CONCLUSIONS
  Early selective distal ICA control is highly achievable during CEA without apparently compromising clinical results. Its use is relevant when selective methods of shunting that do not need initial control of the common and external carotid arteries (eg, local cervical block anesthesia, electroencephalography/other monitoring) are used. Further evaluation with transcranial Doppler scan monitoring is suggested to substantiate the theoretic potential of this method in the reduction or elimination of particulate plaque embolism.
authors.affiliation: Department of Vascular Surgery, Central Coast Area Health Service, Gosford, New South Wales, Australia. Dr.Bourke@GVS.COM.AU
authors.forename: Bernard M
authors.initials: BM
authors.lastname: Bourke
authors.forename: Denis S
authors.initials: DS
authors.lastname: Crimmins
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002343:Carotid Artery, Internal / Q000601:surgery*; D016893:Carotid Stenosis / Q000150:complications / Q000601:surgery; D002533:Cerebral Angiography; D001026:Coronary Artery Bypass; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D012720:Severity of Illness Index; D016896:Treatment Outcome