3. Surgical management of internal carotid artery stenosis: preventing complications.

Although the North American Symptomatic Carotid Endarterectomy Trial and the European Collaborative Trial demonstrated the efficacy of carotid surgery for the prevention of stroke in patients with symptomatic high grade stenosis, it is important to remember that within the surgical arms of these studies the perioperative stroke rate was 5.5% and 7.5% respectively. Few studies have addressed the factors responsible for perioperative stroke. In a recent report from our institution, 66 of 3062 carotid endarterectomies were complicated by perioperative stroke. Of these, 65% were due to a failure in surgical technique. The mechanisms of failure included ischemia during carotid clamping (10), postoperative thrombosis and embolism (25) and other factors (8). Strokes not related to technical failures were due to reperfusion injuries and intracranial hemorrhage (12) and other events in the postoperative period (30 days). Specific problems and possible solutions are discussed. Further improvements in the technique of carotid endarterectomy may lead to lower complication rates and a wider acceptance of surgery for the prevention of stroke.