By Christopher M. Loftus
Neurovascular tactics signify a massive point of a surgeon's perform. the new beneficial result of scientific trials on carotid endarterectomy for stroke prevention have ended in a growing to be call for for surgeons who practice this process. Surgeons should be ready to satisfy the call for via studying the fundamental rules, diagnositc standards and operative method for carotid endarterectomy. Dr Loftus stocks his perception and broad adventure during this clinically-oriented quantity. quite a few radiographic examples illustrate the subtleties of picking the diseased artery, in addition to anatomic adaptations that make prognosis and surgical procedure much more not easy. The process is illustrated with attractive line drawings followed through color pictures, and the textual content all through is an easy-reading, concise narrative. good points: * contains a distinctive part at the simple ideas underlying carotid endarterectomy * encompasses a part committed exclusively to diagnostic concerns with a variety of radiographic stories illustrating universal and anomalous anatomy * comprises hundreds and hundreds of images and drawings demonstrating all points of the process
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Additional resources for Carotid Endarterectomy: Principles and Technique
I2l,I]S Data concerning induced intraoperative hypertension are much more consistent. Significant increases in both local rCBF u4 and in stump pressurel]1 have been documented with pharmacologically induced hypertension in patients undergoing carotid cross-clamping. Many surgeons who choose to shunt on the basis ofintraoperative monitoring first attempt to reverse ischemic changes with a controlled elevation of arterial pressure. Current anesthetic management in carotid surgery aims at maintenance of normotensive levels with tolerance of systolic pressure up to 20% higher before antihypertensive measures are instituted.
Indeed, Gross et al. w 26 Only surgeons with excellent perioperative morbidity and mortality results can offer carotid patients an outcome superior to the best available medical management. In this section a technical scheme for carotid endarterectomy is presented that has yielded a combined morbidity and mortality rate of 2% (inclusive of patients in all risk grades, including recent st~oke) in my hands and allows me to confidently recommend carotid surgery to appropriate patients. I fully recognize that different techniques have proved successful for individual surgeons and eschew a dogmatic approach to carotid surgery.
Both surgeons stand on the operative side, the primary surgeon facing cephalad and the assistant facing the patient's feet. The operative nurse may stand either behind or across the table from the primary surgeon. The patient is positioned supine on the operating table with the head extended and turned away from the side of operation. Several folded pillowcases are placed between the shoulder blades to facilitate extension of the neck, and the degree of rotation of the head is determined by the relationship of the external and internal carotid arteries as demonstrated on preoperative angiography.