Eversion Carotid Endarterectomy Periprocedural Care
- Author: Jovan N Markovic, MD; Chief Editor: Vincent Lopez Rowe, MD more...
Both local/regional anesthesia and general anesthesia have been used for eversion carotid endarterectomy (eCEA); which approach is preferable in this setting remains a matter of debate. Data from several randomized trials comparing regional and general anesthesia, including an international multicenter randomized trial of 3526 patients from 24 countries, have shown that the choice of anesthesia does not independently predict the outcome of the operative procedure.[73, 74, 75, 76]
Subsequent analysis of data from the same database showed that in patients for whom either anesthetic approach was clinically indicated, cost-effectiveness analysis favored local anesthesia. Ultimately, the surgeon, in consultation with the anesthesiologist and the patient, must make the final decision regarding the best anesthetic management in each case.
If local/regional anesthesia is selected, mild sedation may be administered, but the patient must be alert enough to be evaluable for neurologic changes. Usually, two or three simple questions are agreed on with the patient in advance and then repeated during carotid cross-clamping. Drapes may be suspended above the patient’s head on a Mayo stand to create more space for the patient.
Generally, regional anesthesia is optimal in calm patients with slender and mobile necks; it may be less successful in patients who are claustrophobic or anxious, have high lesions or immobile necks, or have previously undergone carotid endarterectomy (CEA).
The patient is placed in the supine position with the neck hyperextended (see the image below). Once the neck is hyperextended, the head is rotated 15-20o away from the side of the lesion to face the opposite side. This maneuver moves the mandible superiorly, exposes the mediolateral aspect of the neck, and opens up the angle of access to the anterior neck triangles on the side of the lesion. Folded sheets may be placed under the shoulders, or a tape may be placed across the patient’s forehead and secured at the edges of the table.
Proper positioning is important because excessive hyperextension of the neck can tighten the sternocleidomastoid muscle and restrict the mobility of the common carotid artery (CCA) and the carotid bifurcation, thereby making exposure of the lesion more difficult. Another reason for avoiding extensive hyperextension of the neck is to ensure that the internal jugular vein remains lateral, rather than anterior, to the carotid artery.
Because cervical arthritis is prevalent in the age group for which eCEA is most commonly indicated, the neck must be carefully manipulated and slowly hyperextended at the craniocervical joint. Introducing some degree (10-20°) of reverse Trendelenburg is useful for maximizing exposure, reducing venous pressure and congestion, and minimizing bleeding.
After proper positioning, a topical antiseptic agent is carefully applied to the neck with minimal pressure (to avoid dislodging emboli from the carotid plaque). The operating area is cordoned off with four sterile drapes (see the image below). Incorporating the ear lobe and mastoid process (superiorly) and the neck midline (medially) and the sternoclavicular joint (inferiorly) into the surgical field is essential. A single weight-based dose of an intravenous antibiotic (cefazolin) is administered within 1 hour of making the incision.
Monitoring and Follow-up
If the patient is afebrile, neurologically intact, and hemodynamically stable, he or she may safely be discharged on postoperative day 1. Before discharge, the neck is examined and the Blake drain removed. The patient is instructed to return if any problems develop and given detailed discharge instructions. A routine follow-up visit is scheduled 4 weeks after the operation; this visit should include carotid duplex evaluation.
Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006 May 27. 367(9524):1747-57. [Medline].
Thom T, Haase N, Rosamond W, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006 Feb 14. 113 (6):e85-151. [Medline].
Matsumoto N, Whisnant JP, Kurland LT, Okazaki H. Natural history of stroke in Rochester, Minnesota, 1955 through 1969: an extension of a previous study, 1945 through 1954. Stroke. 1973 Jan-Feb. 4(1):20-9. [Medline].
Sacco RL, Wolf PA, Kannel WB, McNamara PM. Survival and recurrence following stroke. The Framingham study. Stroke. 1982 May-Jun. 13 (3):290-5. [Medline].
Kleindorfer D, Panagos P, Pancioli A, Khoury J, Kissela B, Woo D, et al. Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke. 2005 Apr. 36 (4):720-3. [Medline].
Bonita R, Stewart A, Beaglehole R. International trends in stroke mortality: 1970-1985. Stroke. 1990 Jul. 21(7):989-92. [Medline].
Gasparis AP, Ricotta L, Cuadra SA, Char DJ, Purtill WA, Van Bemmelen PS. High-risk carotid endarterectomy: fact or fiction. J Vasc Surg. 2003 Jan. 37(1):40-6. [Medline].
Hobson RW 2nd, Mackey WC, Ascher E, Murad MH, Calligaro KD, Comerota AJ. Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2008 Aug. 48(2):480-6. [Medline].
Moore WS, Barnett HJ, Beebe HG, Bernstein EF, Brener BJ, Brott T. Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation. 1995 Jan 15. 91(2):566-79. [Medline].
de Bray JM, Baud JM, Delanoy P, et al. Reproducibility in ultrasonic characterization of carotid plaques. Cerebrovasc Dis. 1998 Sep-Oct. 8(5):273-7. [Medline].
Arnold JA, Modaresi KB, Thomas N, Taylor PR, Padayachee TS. Carotid plaque characterization by duplex scanning: observer error may undermine current clinical trials. Stroke. 1999 Jan. 30(1):61-5. [Medline].
Montauban van Swijndregt AD, Elbers HR, Moll FL, de Letter J, Ackerstaff RG. Ultrasonographic characterization of carotid plaques. Ultrasound Med Biol. 1998 May. 24(4):489-93. [Medline].
Salonen JT, Salonen R. Ultrasound B-mode imaging in observational studies of atherosclerotic progression. Circulation. 1993 Mar. 87(3 Suppl):II56-65. [Medline].
AbuRahma AF, Richmond BK, Robinson PA, Khan S, Pollack JA, Alberts S. Effect of contralateral severe stenosis or carotid occlusion on duplex criteria of ipsilateral stenoses: comparative study of various duplex parameters. J Vasc Surg. 1995 Dec. 22(6):751-61; discussion 761-2. [Medline].
Fujitani RM, Mills JL, Wang LM, Taylor SM. The effect of unilateral internal carotid arterial occlusion upon contralateral duplex study: criteria for accurate interpretation. J Vasc Surg. 1992 Sep. 16(3):459-67; discussion 467-8. [Medline].
Busuttil SJ, Franklin DP, Youkey JR, Elmore JR. Carotid duplex overestimation of stenosis due to severe contralateral disease. Am J Surg. 1996 Aug. 172(2):144-7; discussion 147-8. [Medline].
Legemate DA. Overestimation of a stenosis in the internal carotid artery by duplex sonography caused by an increase in volume flow. J Vasc Surg. 1999 Apr. 29(4):756. [Medline].
van Everdingen KJ, van der Grond J, Kappelle LJ. Overestimation of a stenosis in the internal carotid artery by duplex sonography caused by an increase in volume flow. J Vasc Surg. 1998 Mar. 27(3):479-85. [Medline].
Maldonado TS. What are current preprocedure imaging requirements for carotid artery stenting and carotid endarterectomy: have magnetic resonance angiography and computed tomographic angiography made a difference?. Semin Vasc Surg. 2007 Dec. 20(4):205-15. [Medline].
Wintermark M, Jawadi SS, Rapp JH, Tihan T, Tong E, Glidden DV. High-resolution CT imaging of carotid artery atherosclerotic plaques. AJNR Am J Neuroradiol. 2008 May. 29(5):875-82. [Medline].
Yuan C, Mitsumori LM, Ferguson MS, Polissar NL, Echelard D, Ortiz G. In vivo accuracy of multispectral magnetic resonance imaging for identifying lipid-rich necrotic cores and intraplaque hemorrhage in advanced human carotid plaques. Circulation. 2001 Oct 23. 104(17):2051-6. [Medline].
Fabiano S, Mancino S, Stefanini M, Chiocchi M, Mauriello A, Spagnoli LG. High-resolution multicontrast-weighted MR imaging from human carotid endarterectomy specimens to assess carotid plaque components. Eur Radiol. 2008 Dec. 18(12):2912-21. [Medline].
Mathiesen EB, Bonaa KH, Joakimsen O. Echolucent plaques are associated with high risk of ischemic cerebrovascular events in carotid stenosis: the tromsø study. Circulation. 2001 May 1. 103(17):2171-5. [Medline].
Pedro LM, Pedro MM, Gonçalves I, et al. Computer-assisted carotid plaque analysis: characteristics of plaques associated with cerebrovascular symptoms and cerebral infarction. Eur J Vasc Endovasc Surg. 2000 Feb. 19(2):118-23. [Medline].
Das M, Braunschweig T, Muhlenbruch G, Mahnken AH, Krings T, Langer S. Carotid plaque analysis: comparison of dual-source computed tomography (CT) findings and histopathological correlation. Eur J Vasc Endovasc Surg. 2009 Jul. 38(1):14-9. [Medline].
O'Leary DH, Polak JF, Kronmal RA, Manolio TA, Burke GL, Wolfson SK Jr. Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. Cardiovascular Health Study Collaborative Research Group. N Engl J Med. 1999 Jan 7. 340 (1):14-22. [Medline].
Chambless LE, Folsom AR, Clegg LX, Sharrett AR, Shahar E, Nieto FJ. Carotid wall thickness is predictive of incident clinical stroke: the Atherosclerosis Risk in Communities (ARIC) study. Am J Epidemiol. 2000 Mar 1. 151(5):478-87. [Medline].
Lorenz MW, von Kegler S, Steinmetz H, Markus HS, Sitzer M. Carotid intima-media thickening indicates a higher vascular risk across a wide age range: prospective data from the Carotid Atherosclerosis Progression Study (CAPS). Stroke. 2006 Jan. 37(1):87-92. [Medline].
Norris EJ. Anesthesia for vascular surgery. Miller RD, ed. Miller’s Anesthesia. Philadelphia: Churchill Livingstone Elsevier; 2010. 1985-2044.
Bogousslavsky J, Van Melle G, Regli F. The Lausanne Stroke Registry: analysis of 1,000 consecutive patients with first stroke. Stroke. 1988 Sep. 19(9):1083-92. [Medline].
Fryer JA, Myers PC, Appleberg M. Carotid intraplaque hemorrhage: the significance of neovascularity. J Vasc Surg. 1987 Oct. 6(4):341-9. [Medline].
Arroyo LH, Lee RT. Mechanisms of plaque rupture: mechanical and biologic interactions. Cardiovasc Res. 1999 Feb. 41(2):369-75. [Medline].
McCarthy MJ, Loftus IM, Thompson MM, Jones L, London NJ, Bell PR. Angiogenesis and the atherosclerotic carotid plaque: an association between symptomatology and plaque morphology. J Vasc Surg. 1999 Aug. 30(2):261-8. [Medline].
Montauban van Swijndregt AD, Elbers HR, Moll FL, de Letter J, Ackerstaff RG. Cerebral ischemic disease and morphometric analyses of carotid plaques. Ann Vasc Surg. 1999 Sep. 13(5):468-74. [Medline].
Carr S, Farb A, Pearce WH, Virmani R, Yao JS. Atherosclerotic plaque rupture in symptomatic carotid artery stenosis. J Vasc Surg. 1996 May. 23(5):755-65; discussion 765-6. [Medline].
Inzitari D, Eliasziw M, Gates P, Sharpe BL, Chan RK, Meldrum HE. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 2000 Jun 8. 342(23):1693-700. [Medline].
Timsit SG, Sacco RL, Mohr JP, Foulkes MA, Tatemichi TK, Wolf PA. Early clinical differentiation of cerebral infarction from severe atherosclerotic stenosis and cardioembolism. Stroke. 1992 Apr. 23(4):486-91. [Medline].
Risk of stroke in the distribution of an asymptomatic carotid artery. The European Carotid Surgery Trialists Collaborative Group. Lancet. 1995 Jan 28. 345(8944):209-12. [Medline].
Chu B, Kampschulte A, Ferguson MS, Kerwin WS, Yarnykh VL, O'Brien KD. Hemorrhage in the atherosclerotic carotid plaque: a high-resolution MRI study. Stroke. 2004 May. 35(5):1079-84. [Medline].
Lusby RJ, Ferrell LD, Ehrenfeld WK, Stoney RJ, Wylie EJ. Carotid plaque hemorrhage. Its role in production of cerebral ischemia. Arch Surg. 1982 Nov. 117(11):1479-88. [Medline].
Mofidi R, Crotty TB, McCarthy P, Sheehan SJ, Mehigan D, Keaveny TV. Association between plaque instability, angiogenesis and symptomatic carotid occlusive disease. Br J Surg. 2001 Jul. 88(7):945-50. [Medline].
Pessin MS, Duncan GW, Mohr JP, Poskanzer DC. Clinical and angiographic features of carotid transient ischemic attacks. N Engl J Med. 1977 Feb 17. 296(7):358-62. [Medline].
Mohr JP. Transient ischemic attacks and the prevention of strokes. N Engl J Med. 1978 Jul 13. 299(2):93-5. [Medline].
Eastcott HH, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954 Nov 13. 267(6846):994-6. [Medline].
Jones CE, Jescovitch AJ Jr, Kahn A, Walters GK, Johnson CJ. Technical results from the eversion technique of carotid endarterectomy. Am Surg. 1996 May. 62(5):361-5. [Medline].
Shah DM, Darling RC 3rd, Chang BB, Paty PS, Kreienberg PB, Lloyd WE. Carotid endarterectomy by eversion technique: its safety and durability. Ann Surg. 1998 Oct. 228(4):471-8. [Medline].
Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011 Sep. 54(3):e1-31. [Medline].
Cao P, Giordano G, De Rango P, Zannetti S, Chiesa R, Coppi G, et al. A randomized study on eversion versus standard carotid endarterectomy: study design and preliminary results: the Everest Trial. J Vasc Surg. 1998 Apr. 27 (4):595-605. [Medline].
Vanmaele R, Van Schil P, De Maeseneer M. Closure of the internal carotid artery after endarterectomy: the advantages of patch angioplasty without its disadvantages. Ann Vasc Surg. 1990 Jan. 4(1):81-4. [Medline].
Raithel D, Kasprzak PM. The eversion endarterectomy-a new technique. Greenhalgh RM, Hollier LJ, eds. Surgery for Stroke. London: WB Saunders; 1993. 183-91.
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991 Aug 15. 325(7):445-53. [Medline].
Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998 May 9. 351(9113):1379-87. [Medline].
Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995 May 10. 273(18):1421-8. [Medline].
Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN. Carotid endarterectomy--an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2005 Sep 27. 65(6):794-801. [Medline].
Stoner MC, Abbott WM, Wong DR, Hua HT, Lamuraglia GM, Kwolek CJ. Defining the high-risk patient for carotid endarterectomy: an analysis of the prospective National Surgical Quality Improvement Program database. J Vasc Surg. 2006 Feb. 43(2):285-295; discussion 295-6. [Medline].
Matsen SL, Chang DC, Perler BA, Roseborough GS, Williams GM. Trends in the in-hospital stroke rate following carotid endarterectomy in California and Maryland. J Vasc Surg. 2006 Sep. 44(3):488-95. [Medline].
LaMuraglia GM, Brewster DC, Moncure AC, Dorer DJ, Stoner MC, Trehan SK. Carotid endarterectomy at the millennium: what interventional therapy must match. Ann Surg. 2004 Sep. 240(3):535-44; discussion 544-6. [Medline].
Ballotta E, Da Giau G, Piccoli A, Baracchini C. Durability of carotid endarterectomy for treatment of symptomatic and asymptomatic stenoses. J Vasc Surg. 2004 Aug. 40(2):270-8. [Medline].
Moore WS, Kempczinski RF, Nelson JJ, Toole JF. Recurrent carotid stenosis : results of the asymptomatic carotid atherosclerosis study. Stroke. 1998 Oct. 29(10):2018-25. [Medline].
Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004 May 8. 363(9420):1491-502. [Medline].
Berguer R. Eversion endarterectomy of the carotid bifurcation. Veith FJ, ed. Current Critical Problems in Vascular Surgery. St Louis: Quality Medical Publishing; 1993. vol 5: 441-7.
Bosse A, Ansorg P, Mayer B, Mulch J. Eversion endarteriectomy of the internal carotid artery. Thorac Cardiovasc Surg. 1991 Dec. 39(6):371-5. [Medline].
Reigner B, Reveilleau P, Gayral M, Papon X, Enon B, Chevalier JM. Eversion endarterectomy of the internal carotid artery: midterm results of a new technique. Ann Vasc Surg. 1995 May. 9 (3):241-6. [Medline].
Darling RC 3rd, Paty PS, Shah DM, Chang BB, Leather RP. Eversion endarterectomy of the internal carotid artery: technique and results in 449 procedures. Surgery. 1996 Oct. 120(4):635-9; discussion 639-40. [Medline].
Koskas F, Kieffer E, Bahnini A, Ruotolo C, Rancurel G. Carotid eversion endarterectomy: short- and long-term results. Ann Vasc Surg. 1995 Jan. 9(1):9-15. [Medline].
Kasprzak PM, Raithel D. Eversion carotid endarterectomy. Technique and early results. J Cardiovasc Surg. 1989. 30:495.
Cao P, Giordano G, De Rango P, Zannetti S, Chiesa R, Coppi G. Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg. 2000 Jan. 31(1 Pt 1):19-30. [Medline].
Cao P, De Rango P, Zannetti S. Eversion vs conventional carotid endarterectomy: a systematic review. Eur J Vasc Endovasc Surg. 2002 Mar. 23(3):195-201. [Medline].
Ballotta E, Toniato A, Da Giau G, Lorenzetti R, Da Roit A, Baracchini C. Durability of eversion carotid endarterectomy. J Vasc Surg. 2014 Jan 11. [Medline].
Schneider JR, Helenowski IB, Jackson CR, Verta MJ, Zamor KC, Patel NH, et al. A comparison of results with eversion versus conventional carotid endarterectomy from the Vascular Quality Initiative and the Mid-America Vascular Study Group. J Vasc Surg. 2015 May. 61 (5):1216-22. [Medline].
Ben Ahmed S, Daniel G, Benezit M, Ribal JP, Rosset E. Eversion carotid endarterectomy without shunt: concerning 1,385 consecutive cases. J Cardiovasc Surg (Torino). 2015 Feb 12. [Medline].
AbuRahma AF. Processes of care for carotid endarterectomy: surgical and anesthesia considerations. J Vasc Surg. 2009 Oct. 50(4):921-33. [Medline].
GALA Trial Collaborative Group, Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008 Dec 20. 372 (9656):2132-42. [Medline].
McCleary AJ, Dearden NM, Dickson DH, Watson A, Gough MJ. The differing effects of regional and general anaesthesia on cerebral metabolism during carotid endarterectomy. Eur J Vasc Endovasc Surg. 1996 Aug. 12(2):173-81. [Medline].
Gough MJ, Bodenham A, Horrocks M, Colam B, Lewis SC, Rothwell PM. GALA: an international multicentre randomised trial comparing general anaesthesia versus local anaesthesia for carotid surgery. Trials. 2008. 9:28. [Medline].
Gomes M, Soares MO, Dumville JC, Lewis SC, Torgerson DJ, Bodenham AR. Cost-effectiveness analysis of general anaesthesia versus local anaesthesia for carotid surgery (GALA Trial). Br J Surg. 2010 Aug. 97(8):1218-25. [Medline].
Bond R, Rerkasem K, AbuRahma AF, Naylor AR, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev. 2004. CD000160. [Medline].
Mannheim D, Weller B, Vahadim E, Karmeli R. Carotid endarterectomy with a polyurethane patch versus primary closure: a prospective randomized study. J Vasc Surg. 2005 Mar. 41(3):403-7; discussion 407-8. [Medline].
Counsell C, Salinas R, Warlow C, Naylor R. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev. 2000. (2):CD000160. [Medline].
Bond R, Rerkasem K, Naylor AR, Aburahma AF, Rothwell PM. Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. J Vasc Surg. 2004 Dec. 40(6):1126-35. [Medline].
De Bakey Me, Crawford ES, Cooley DA, Morris GC Jr. Surgical considerations of occlusive disease of innominate, carotid, subclavian, and vertebral arteries. Ann Surg. 1959 May. 149(5):690-710. [Medline].
Etheredge SN. A simple technic for carotid endarterectomy. Am J Surg. 1970 Aug. 120 (2):275-8. [Medline].
Kieny R, Hirsch D, Seiller C, Thiranos JC, Petit H. Does carotid eversion endarterectomy and reimplantation reduce the risk of restenosis?. Ann Vasc Surg. 1993 Sep. 7(5):407-13. [Medline].
Darling RC 3rd, Mehta M, Roddy SP, Paty PS, Kreienberg PB, Ozsvath KJ. Eversion carotid endarterectomy: a technical alternative that may obviate patch closure in women. Cardiovasc Surg. 2003 Oct. 11(5):347-52. [Medline].
Entz L, Jaranyi S, Nemes A. Eversion endarterectomy in surgery of the internal carotid artery. Cardiovasc Surg. 1996 Apr. 4(2):190-4. [Medline].
Shah DM, Darling RC 3rd, Chang BB, Paty PS, Kreienberg PB, Lloyd WE, et al. Carotid endarterectomy by eversion technique: its safety and durability. Ann Surg. 1998 Oct. 228 (4):471-8. [Medline].
LYONS C, CLARK LC Jr, MCDOWELL H, MCARTHUR K. CEREBRAL VENOUS OXYGEN CONTENT DURING CAROTID THROMBINTIMECTOMY. Ann Surg. 1964 Oct. 160:561-7. [Medline].
Larson CP, Ehrenfeld WK, Wade JG, et al. Jugular venous oxygen saturation as an index of adequacy of cerebral oxygenation. Surgery. 1967. 62:31.
Harris EJ, Brown WH, Pavy RN, Anderson WW, Stone DW. Continuous electroencephalographic monitoring during carotid artery endarterectomy. Surgery. 1967 Sep. 62(3):441-7. [Medline].
Baker JD, Gluecklich B, Watson CW, Marcus E, Kamat V, Callow AD. An evaluation of electroencephalographic monitoring for carotid study. Surgery. 1975 Dec. 78(6):787-94. [Medline].
Trojaborg W, Boysen G. Relation between EEG, regional cerebral blood flow and internal carotid artery pressure during carotid endarterectomy. Electroencephalogr Clin Neurophysiol. 1973 Jan. 34(1):61-9. [Medline].
Friedman JA, Anderson RE, Meyer FB. Techniques of intraoperative cerebral blood flow measurement. Neurosurg Focus. 2000. 9(5):e4. [Medline].
Lam AM, Manninen PH, Ferguson GG, Nantau W. Monitoring electrophysiologic function during carotid endarterectomy: a comparison of somatosensory evoked potentials and conventional electroencephalogram. Anesthesiology. 1991 Jul. 75(1):15-21. [Medline].
Wellman BJ, Loftus CM, Kresowik TF, Todd M, Granner MA. The differences in electroencephalographic changes in patients undergoing carotid endarterectomies while under local versus general anesthesia. Neurosurgery. 1998 Oct. 43(4):769-73; discussion 773-5. [Medline].
Cho I, Smullens SN, Streletz LJ, Fariello RG. The value of intraoperative EEG monitoring during carotid endarterectomy. Ann Neurol. 1986 Oct. 20(4):508-12. [Medline].
Manninen PH, Tan TK, Sarjeant RM. Somatosensory evoked potential monitoring during carotid endarterectomy in patients with a stroke. Anesth Analg. 2001 Jul. 93(1):39-44. [Medline].
Salvian AJ, Taylor DC, Hsiang YN, Hildebrand HD, Litherland HK, Humer MF. Selective shunting with EEG monitoring is safer than routine shunting for carotid endarterectomy. Cardiovasc Surg. 1997 Oct. 5(5):481-5. [Medline].
van der Schaaf IC, Horn J, Moll FL, Ackerstaff RG,. Transcranial Doppler monitoring after carotid endarterectomy. Ann Vasc Surg. 2005 Jan. 19(1):19-24. [Medline].
Gaunt ME, Martin PJ, Smith JL, Rimmer T, Cherryman G, Ratliff DA. Clinical relevance of intraoperative embolization detected by transcranial Doppler ultrasonography during carotid endarterectomy: a prospective study of 100 patients. Br J Surg. 1994 Oct. 81(10):1435-9. [Medline].
Ackerstaff RG, Jansen C, Moll FL, Vermeulen FE, Hamerlijnck RP, Mauser HW. The significance of microemboli detection by means of transcranial Doppler ultrasonography monitoring in carotid endarterectomy. J Vasc Surg. 1995 Jun. 21(6):963-9. [Medline].
Spencer MP. Transcranial Doppler monitoring and causes of stroke from carotid endarterectomy. Stroke. 1997 Apr. 28(4):685-91. [Medline].
Moore WS, Hall AD. Carotid artery back pressure: a test of cerebral tolerance to temporary carotid occlusion. Arch Surg. 1969 Dec. 99(6):702-10. [Medline].
Krul JM, van Gijn J, Ackerstaff RG, Eikelboom BC, Theodorides T, Vermeulen FE. Site and pathogenesis of infarcts associated with carotid endarterectomy. Stroke. 1989 Mar. 20(3):324-8. [Medline].
Bond R, Rerkasem K, Counsell C, et al. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev. 2002. CD000190. [Medline].