title: Closing the loop: a 21-year audit of strategies for preventing stroke and death following carotid endarterectomy.
abstract: The objective of this review was to identify causes of stroke/death after carotid endarterectomy (CEA) and to develop transferable strategies for preventing stroke/death after CEA, via an overview of a 21-year series of themed research and audit projects. Three preventive strategies were identified: (i) intra-operative transcranial Doppler (TCD) ultrasound and completion angioscopy which virtually abolished intra-operative stroke, primarily through the removal of residual luminal thrombus prior to restoration of flow; (ii) dual antiplatelet therapy with a single 75-mg dose of clopidogrel the night before surgery in addition to regular 75 mg aspirin which virtually abolished post-operative thromboembolic stroke and may also have contributed towards a decline in stroke/death following major cardiac events; and (iii) the provision of written guidance for managing post-CEA hypertension which was associated with virtual abolition of intracranial haemorrhage and stroke as a result of hyperperfusion syndrome. The pathophysiology of peri-operative stroke is multifactorial and no single monitoring or therapeutic strategy will reduce its prevalence. Two of the preventive strategies developed during this 21-year project (peri-operative dual antiplatelet therapy, published guidance for managing post-CEA hypertension) are easily transferable to practices elsewhere.
authors.affiliation: The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, United Kingdom. ross.naylor@uhl-tr.nhs.uk
authors.forename: A R
authors.initials: AR
authors.lastname: Naylor
authors.forename: R D
authors.initials: RD
authors.lastname: Sayers
authors.forename: M J
authors.initials: MJ
authors.lastname: McCarthy
authors.forename: M J
authors.initials: MJ
authors.lastname: Bown
authors.forename: A
authors.initials: A
authors.lastname: Nasim
authors.forename: M J
authors.initials: MJ
authors.lastname: Dennis
authors.forename: N J M
authors.initials: NJ
authors.lastname: London
authors.forename: P R F
authors.initials: PR
authors.lastname: Bell
mesh_terms: D017546:Angioscopy; D001241:Aspirin / Q000008:administration & dosage; D002340:Carotid Artery Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002985:Clinical Protocols; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality / Q000592:standards; D006801:Humans; D006973:Hypertension / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D020766:Intracranial Embolism / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D020300:Intracranial Hemorrhages / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D007430:Intraoperative Care; D008485:Medical Audit; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011182:Postoperative Care; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D011787:Quality of Health Care; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives; D013997:Time Factors; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin
keywords: Carotid endarterectomy; Monitoring; Peri-operative stroke; Quality control