1. Technical Adjuncts in High Risk Patients Undergoing Endarterectomy Joseph P. Archie Jr.

2. Risk Factors Systemic Co-morbidity (cardiac, pulmonary) Combined CEA-CAB Contralateral Internal Carotid Occlusion Hostile Neck - Prior Irradiation, Prior CEA High Internal Carotid Lesion

3. Cardio-Pulmonary Risk Technical Adjuncts Bradycardia - carotid sinus, vagal Block carotid sinus with xylocain Give atropine

4. Combined CEA - CAB Technical Adjuncts Combined risk = CEA risk + CAB risk Prep & drape for combined operations CEA done while vein harvested Saphenous vein patch Drain Added time about 45 minutes

5. Contralateral ICA Occlusion NASCET 6/43 (14 %) stroke or death, versus 86/737 (6 %), P = 0.84 ASAC 2/86 (2 %) stroke, versus 17/737 (2 %) Pooled stroke rate for 8 studies 1992-2001 26/592 (4.4%) versus 87/3,392 (2.3%) P = 0.013

6. Contralateral ICA Occlusion Technical Adjunct SHUNT - SHUNT - SHUNT Approximately 50 % of patients with contralateral occlusion meet selective shunt criteria

7. Prior Irradiated Neck Technical Adjuncts Cranial nerve protection - nerve stimulator Carotid exposure - friable internal carotid Autologous vein patch or bypass

8. Prior CEA Pooled outcomes from 10 studies 1995 to 2001 Stroke 24/847 (2.8 %) Death 6/847 (0.7%)

9. Prior CEA Technical Adjuncts Old operative note Expose common carotid proximal to and internal carotid distal to prior dissection (CW Doppler probe) Nerve stimulator Patch or bypass (outcomes similar) Material: vein and synthetics have similar outcomes for both patch and bypass