Emergency carotid thromboendarterectomy: Safe and effective

Whether to perform emergency carotid thromboendarterectomy (CTEA) in the pr esence of crescendo transient ischemic attacks or stroke-in-evolution is co ntroversial, with the operative mortality in some reports exceeding 20% and improvement in neurologic deficit of less than 40% in others. Our anecdota l experience with emergency CTEA for acute, persistent, or crescendo neurol ogic deficit had been strikingly better than published reports. Accordingly , we carried out a restrospective comparison of 43 such patients undergoing emergency CTEA with 237 patients concurrently undergoing elective CTEA for conventional indications. A standard protocol followed in emergency CTEA p atients included carotid Doppler ultrasonography, computed cerebral tomogra phy (CT), four-vessel cerebral arteriography, and intravenous heparin. Excl usions from emergency CTEA included coma or cerebral CT scan evidence for e ither hemorrhagic or ischemic infarction with edema. Operative techniques i ncluded standard carotid endarterectomy with Dacron patch or direct suture, eversion endarterectomy, or shortening resection. No mortality or central neurologic complications resulted among the 43 emergency CTEA patients, in comparison to no deaths and one temporary hemiparesis (0.4% central neurolo gic morbidity) in the 237 elective CTEA patients. Our results suggest that in the absence of coma or cerebral CT scan evidence for an unstable blood-b rain barrier, emergency carotid reconstruction can be performed safely and with excellent outcome notwithstanding the magnitude and severity of the ac ute preoperative neurologic deficit.