Reducing the risk of carotid surgery: A 7-year audit of the role of monitoring and quality control assessment

被引:83
作者
Naylor, AR [1 ]
Hayes, PD
Allroggen, H
Lennard, N
Gaunt, ME
Thompson, MM
London, NJM
Bell, PRF
机构
[1] Leicester Royal Infirm, Dept Surg, Leicester LE2 7LX, Leics, England
[2] Leicester Royal Infirm, Dept Neurol, Leicester LE2 7LX, Leics, England
关键词
D O I
10.1067/mva.2000.108007
中图分类号
R61 [外科手术学];
学科分类号
摘要
Background and Purpose: The current risk of stroke after carotid endarterectomy may be worse than reported in the international trials. Because studies have suggested that most operative strokes follow surgeon error, the aim of the current study was to audit the impact of introducing a strategy of perioperative monitoring and quality control assessment on outcome. Methods: A total of 500 patients underwent carotid endarterectomy with intraoperative transcranial Doppler scan monitoring, completion angioscopy, and 3 hours of postoperative transcranial Doppler scan monitoring. The last of these guided selective dextran therapy in patients with high rates of postoperative embolization, which in previous series has been shown to be highly predictive of progression to thromboembolic stroke. Results: Intimal flaps were repaired in 3% of patients and luminal thrombus removed in 4% of patients. The rate of intraoperative stroke was 0.2%. A total of 313 patients had more than one embolus detected postoperatively (96% within 2 hours of now restoration), but only 22 patients had sustained embolization requiring dextran. Embolization ceased in all but one patient receiving dextran, although the dose had to be increased in seven patients (36%). One patient was unable to receive adequate dextran therapy because of severe cardiac failure. Overall, the 30-day death/stroke rate was 2.2%, no patient had a perioperative stroke because of carotid thrombosis, and the rate of ipsilateral embolic stroke was 0.8%. Most complications resulted from cardiac pathology or intracranial hemorrhage. Conclusions: A program of monitoring and quality control assessment has been associated with a 60% decrease in the operative risk in comparison with that observed before implementation of the protocol.
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页码:750 / 759
页数:10
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