ANTICOAGULATION FOLLOWED BY ELECTIVE CAROTID SURGERY IN PATIENTS WITHREPETITIVE TRANSIENT ISCHEMIC ATTACKS AND HIGH-GRADE CAROTID STENOSIS

Objective: To evaluate the results of preoperative heparin therapy fol lowed by carotid surgery for patients with repetitive transient ischem ic attacks (TIAs) and high-grade carotid stenoses. Design: A 4-year pr ospective study. Setting: Oregon Health Science University Hospital an d Portland (Ore) Veterans Affairs Hospital. Patients: Twenty-nine cons ecutive patients with repetitive TIAs referable to 30 high-grade (grea ter-than-or-equal-to 70%) ipsilateral carotid\ stenoses were treated w ith short-term heparin anticoagulation, followed by cerebral angiograp hy, routine preoperative evaluation, and subsequent carotid reconstruc tion. Interventions: Heparin sodium anticoagulation was maintained for a mean of 5 days. Surgical management consisted of 24 standard endart erectomies, five bypasses to the internal carotid artery, and one exte rnal carotid endarterectomy. Main Outcome Measures: Primary outcome va riables included perioperative hemorrhage, thrombocytopenia, stroke, a nd death. Secondary outcome variables included carotid occlusion and r ecurrent TIAs with heparin therapy. Results: One symptomatic common ca rotid occlusion and one asymptomatic internal carotid occlusion occurr ed during preoperative heparin therapy. Thirteen patients had addition al sporadic TIAs while receiving heparin. There were no preoperative c erebral infarcts, thrombocytopenia, or clinical bleeding associated wi th heparin therapy. There was one postoperative stroke and one death d ue to myocardial infarction. Conclusion: When necessary, heparin antic oagulation and delayed carotid reconstruction would appear to be an ac ceptable alternative to emergency carotid surgery in patients with hig h-grade carotid stenosis and acute repetitive TIAs.