Intraoperative iodine 125 implants. Their use in large tumors in the neck attached to the carotid artery

Modern head and neck brachytherapy: from radium towards intensity modulated interventional brachytherapy

Intensity modulated brachytherapy (IMBT) is a modern development of classical interventional radiation therapy (brachytherapy), which allows the application of a high radiation dose sparing severe adverse events, thereby further improving the treatment outcome. Classical indications in head and neck (H&N) cancers are the face, the oral cavity, the naso- and oropharynx, the paranasal sinuses including base of skull, incomplete resections on important structures, and palliation. The application type can be curative, adjuvant or perioperative, as a boost to external beam radiation as well as without external beam radiation and with palliative intention. Due to the frequently used perioperative application method (intraoperative implantation of inactive applicators and postoperative performance of radiation), close interdisciplinary cooperation between surgical specialists (ENT-, dento-maxillary-facial-, neuro- and orbital surgeons), as well interventional radiotherapy (brachytherapy) experts are obligatory. Published results encourage the integration of IMBT into H&N therapy, thereby improving the prognosis and quality of life of patients.

An investigation of 125I seed permanent implantation for recurrent carcinoma in the head and neck after surgery and external beam radiotherapy

BACKGROUND

A preliminary assessment was conducted of the feasibility, efficacy, and morbidity of 125I seed implantation for recurrent head and neck carcinoma after surgery and external beam radiotherapy.

METHODS

Nineteen patients with recurrent head and neck carcinomas underwent 125I seed implantation under ultrasound or computed tomography guidance. The actuarial D90 of 125I seed implantation ranged from 90 to 160 Gy (median, 131 Gy). The follow-up period ranged from 3 to 44 months (median, 11 months).

RESULTS

The median local control was 24 months (95% confidence interval, 10.2 to 37.8). The one- year, two-year and three-year local controls were 73.3%, 27.5% and 27.5%, respectively, whereas the one-year, two-year and three-year survival rates were 53.0%, 18.2% and 18.2%, respectively, and the median survival was 13 months (95% confidence interval, 6.6 to 19.4). A total of 26.3% of patients (5/19) died of local recurrence and 21.1% of patients (4/19) died of metastases. One suffered from a grade 1 skin reaction.

CONCLUSIONS

125I seed implantation is feasible and safe as a salvage treatment for patients with recurrent head and neck cancers. The high local control results and low morbidity merits further investigation.

CT-guided iodine-125 seed permanent implantation for recurrent head and neck cancers

BACKGROUND

To investigate the feasibility, and safety of 125I seed permanent implantation for recurrent head and neck carcinoma under CT-guidance.

RESULTS

A retrospective study on 14 patients with recurrent head and neck cancers undergone 125I seed implantation with different seed activities. The post-plan showed that the actuarial D90 of 125I seeds ranged from 90 to 218 Gy (median, 157.5 Gy). The follow-up was 3 to 60 months (median, 13 months). The median local control was 18 months (95% CI, 6.1-29.9 months), and the 1-, 2-, 3-, and 5- year local controls were 52%, 39%, 39%, and 39%, respectively. The 1-, 2-, 3-, and 5- survival rates were 65%, 39%, 39% and 39%, respectively, with a median survival time of 20 months (95% CI, 8.7-31.3 months). Of all patients, 28.6% (4/14) died of local recurrence, 7.1% (1/14) died of metastases, one patient died of hepatocirrhosis, and 8 patients are still alive to the date of data analysis.

CONCLUSION

CT-guided 125I seed implantation is feasible and safe as a salvage or palliative treatment for patients with recurrent head and neck cancers.

Advanced cervical metastasis involving the carotid artery

PURPOSE OF REVIEW

This paper will review recent reports of the surgical management of the carotid artery when cancer is adherent to it and will highlight the author's experience at Clarian Health Partners in Indianapolis.

RECENT FINDINGS

Recent trends in treating metastatic neck cancer with chemoradiation initially and reserving surgery for the treatment of residual or recurrent disease has tasked the head and neck surgeon with extirpating cancer in significantly altered tissue with loss of tissue planes and scarring that conceals the extent of cancer spread. Cancer that is adherent to the carotid presents a treatment dilemma to the surgeon, given that historically the local control and survival has been dismal and the complications of surgery are high.

SUMMARY

The heavy burden of deciding to resect the carotid artery involved with recurrent or residual cancer should be balanced against the natural history of the disease process if not it is treated. It requires detailed understanding by the patient and family as well as coordination among the interventional radiologist, anesthesiologist, radiation oncologist, intensivist, and head and neck surgeon.

Microsurgical Free Flap Reconstruction Outcomes in Head and Neck Cancer Patients after Surgical Extirpation and Intraoperative Brachytherapy

OBJECTIVES

The management of recurrent or persistent head and neck cancer poses a challenging problem. Salvage surgery for these individuals consists of ablative surgery, interstitial brachytherapy, and microsurgical free flap reconstruction. This study reviews complications after such reconstruction.

METHODS

We reviewed 139 consecutive head and neck cancer patients undergoing free flap reconstruction from January 1994 to May 2002. These included 66 patients with recurrent head and neck cancer undergoing intraoperative brachytherapy (IOBT) and free flap reconstruction and 73 undergoing free flap reconstructions only. A total of 142 reconstructions were performed, with three patients in IOBT group receiving two free flap reconstructions per patient, giving us a total of 69 reconstructions in the IOBT group versus 73 in the non-IOBT group. Nine patients were excluded from the IOBT group because of nonsynchronous use of brachytherapy and reconstruction, and 10 patients were excluded from the other group because they had prior radiotherapy or surgical treatment, leaving us with a total of 123 reconstructions, 60 in the IOBT group and 63 in the non-IOBT group. The IOBT group patients received iodine Vicryl seed implants, palladium seed implants, or both, to deliver an average dose of 79.3 +/- 31.8 Gy (mean +/- 1SD) to the surgical bed.

RESULTS

All patients were followed for evidence of local wound complications. The IOBT group showed multiple complications in 23 (38.33%) of 60 reconstructions, the most common being wound dehiscence in 11. This, when compared with the non-IOBT group complications (15.87%), was found to be statistically significant (chi test, P <.01).

CONCLUSION

IOBT increases the rate of complications in patients undergoing microvascular free tissue transfer. This, however, should not deter or alter the aggressiveness of cancer therapy used for managing recurrent head and neck cancer.

Early wound complications in advanced head and neck cancer treated with surgery and Ir 192 brachytherapy

OBJECTIVES

Brachytherapy, either as primary or adjuvant therapy, is increasingly used to treat head and neck cancer. Reports of complications from the use of brachytherapy as adjuvant therapy to surgical excision have been limited and primarily follow Iodine 125 (I125) therapy. Early complications include wound breakdown, infection, flap failure, and sepsis, and late complications may include osteoradionecrosis, bone marrow suppression, or carotid injuries. The authors sought to identify the early wound complications that follow adjuvant interstitial brachytherapy with iridium 192 (IrS92).

STUDY DESIGN

A retrospective chart review of all patients receiving adjuvant brachytherapy at a tertiary medical center over a 4-year period.

METHODS

Nine patients receiving Ir192 brachytherapy via afterloading catheters placed during surgical resection for close or microscopically positive margin control were evaluated. It was used during primary therapy in six patients and at salvage surgery in three. Early complications were defined as those occurring within 6 weeks of surgical therapy.

RESULTS

The overall complication rate was 55% (5/9), and included significant wound breakdown in two patients, minor wound dehiscence in three, and wound infection, bacteremia, and local tissue erosion in one patient each. All complications occurred in patients receiving flap reconstruction and one patient required further surgery to manage the complication. Complication rates were not associated with patient age, site, prior radiotherapy, timing of therapy, number of catheters, or dosimetry.

CONCLUSIONS

The relatively high complication rate is acceptable, given the minor nature of most and the potential benefit of radiotherapy. Further study should be undertaken to identify those patients who will achieve maximum therapeutic benefit without prohibitive local complications.

Carotid artery resection and vein grafting for malignancy

Neck recurrence following multi-modality therapy generally indicates a poor prognosis. Many of these recurrences are considered inoperable due to invasion of the Internal Carotid artery. Resec-tion of the carotid artery in these circumstances is associated with a high risk of neurological morbidity. However, in certain selected patients, resection of the carotid artery and replacement with a sephenous vein graft has been shown to be both safe and to provide a reasonable chance of disease control.This paper presents a case report of a 50 years old male with carcinoma of the larynx, who following radiotherapy and salage laryngectomy, developed a neck recurrence invading the carotid artery. A neck dissection along with carotid artery resection and vascular continuity using a saphenous vein graft was performed successfully. The surgical technique is presented alone with the review of relevant literature.

Intraoperative brachytherapy, laryngopharyngoesophagectomy, and gastric transposition for patients with recurrent hypopharyngeal and cervical esophageal carcinoma

OBJECTIVE

To evaluate the role of laryngopharyngoesophagectomy (LPE), intraoperative 125I brachytherapy (IOBT), and gastric transposition (GT) in patients with recurrent carcinoma involving the hypopharynx, or cervical esophagus.

METHODS

Between 1988 and 1994 a total of 21 patients were managed with LPE/IOBT/GT. All patients had documentation of recurrent disease at the hypopharynx or cervical esophagus and had previously been treated with external-beam radiation (EBRT) to a total median dose of 60 Gy. Median age was 67 years, with 17 male patients and four female. IOBT was performed in all cases with permanent 125I implantation. Medical records were retrospectively reviewed. Overall survival, local control, and complications were evaluated. Median follow-up was 6 months.

RESULTS

The median activity of 125I was 36 mCi, with a median dose of 80 Gy to the region at risk. Fifteen patients had lymph node dissections performed in conjunction with LPE, and 10 patients had nodal involvement on pathologic examination. Margins were microscopically positive in nine patients, and lymphvascular space invasion noted in 13. Actuarial survival at 1 and 3 years was 32% and 14%, respectively, with patients alive and with local control at 6, 24, 36, and 48 months (negative margins). Actuarial local control at 1 and 3 years was 63%. Complications included fistula in five patients, facial edema in four, protracted facial pain in two, cervical abscess in one, and mucosal hemorrhage in one.

CONCLUSION

Patients with recurrent carcinoma of the hypopharynx or cervical esophagus after EBRT have an extremely poor prognosis. LPE, IOBT, and GT may provide very good local control for all candidates and prolonged survival for a small percentage of patients with an acceptable risk profile.

Effects of postoperative external beam irradiation after carotid artery stripping of nodal metastasis

PURPOSE

The objective of this study was to determine the effects of postoperative external beam irradiation (PEBI) on patients after stripping the carotid vessel of nodal metastasis.

PATIENTS AND METHODS

Of 245 patients who underwent radical neck dissection for cancer of the upper aerodigestive tract between 1981 and 1995, 13 patients with nodal metastasis adherent to the carotid artery (NMCA) received a full course of PEBI after the tumor was peeled off the carotid vessel. Patterns of treatment failure, survival, and serious morbidity were evaluated.

RESULTS

At the time of last follow-up (range, 3 to 125 months), fewer than half of the patients (46%) were free of disease, and two patients (15%) had developed distant metastases. The estimated 2-year survival rate was 23%. There were no intraoperative, postoperative, or post-radiation therapy complications.

CONCLUSION

PEBI after carotid artery stripping of tumor can achieve locoregional disease control in select patients without an increased risk of vessel rupture. However, if the prognosis for patients with NMCA is to improve, other effective management strategies need to be investigated.

Interstitial iodine 125 in advanced recurrent squamous cell carcinoma of the head and neck with follow-up evaluation of carotid artery by ultrasound

We retrospectively reviewed our experience with 24 patients in the treatment of advanced recurrent squamous cell carcinoma of the head and neck, using salvage surgery and intraoperative iodine 125 (125I) implantation. Surgical complications and survival results were compiled and compared with those of other studies. The long-term effect of 125I on the carotid artery was evaluated by ultrasound. We had a major complication rate of 21% and an overall complication rate of 50%. Our 2-year overall and determinate survivals were 29% and 50%, respectively. Within the survival group, carotid ultrasounds were obtained to evaluate the long-term effect of 125I. All ultrasounds obtained at least 1 year from the time of treatment showed minimal or no change from the contralateral side. We conclude that intraoperative 125I and salvage surgery are an acceptable treatment for recurrent squamous cell carcinoma with minimal complication and effect on the carotid artery.

Resection of the internal carotid artery and replacement with greater saphenous vein: a safe procedure for en bloc cancer resections with carotid involvement

PURPOSE

Many patients who have advanced cancer of the neck will have involvement of the internal carotid artery. The management of this condition remains controversial, and a wide range of therapeutic options have been suggested including ligation, "shaving" the tumor off the carotid, or en bloc resection and replacement of the internal carotid artery by polytetrafluoroethylene, vein, or superficial femoral artery. We reviewed our experience with en bloc resections of the internal carotid artery in a consecutive series of patients who had malignancies involving the internal carotid artery at a single institution from 1989 to 1995.

METHODS

We used a retrospective chart review based on a list of 20 patients generated by the Hospital Cancer Registry and our Vascular Surgery clinical database.

RESULTS

All patients had their internal carotid artery removed and replaced with a greater saphenous vein while they were under general anesthesia. A resection of their cervical malignancy was also performed. Concomitant myocutaneous flaps were rotated over the carotid bypass in six (30%) patients. Eight (40%) of the bypass grafts were nonreversed, and 12(60%) were reversed, with a clear trend towards using nonreversed veins more recently. Shunts were used in 18(90%). Eighteen of the 20 patients had some form of intraoperative contamination including tracheostomies, pharyngostomies, or fistulas. Half of the patients had intraoperative radiation therapy, and 16(80%) patients underwent operation for recurrent cancer. During the follow-up period two (10%) patients had strokes (one minor and one major), and one patient had a graft blowout, which was treated by ligation without stroke. One patient had an asymptomatic occlusion of his graft.

CONCLUSIONS

From these results we conclude that the use of the greater saphenous vein to replace the internal carotid artery after en bloc resection is not attended by a high rate of infectious complications or graft blowout even in the presence of intraoperative tracheopharyngeal contamination and that the greater saphenous vein is the conduit of choice for replacing an internal carotid artery after cancer resections.

Management of carotid artery rupture by monitored endovascular therapeutic occlusion (1988-1994)

The reported mortality (40%) and neurologic morbidity (25%) rates for carotid rupture remain unacceptably high. This study was conducted to assess the impact of endovascular detachable balloon occlusion and the changing characteristics of carotid rupture in head and neck surgery. Between January 1, 1988, and June 30, 1994, 18 carotid ruptures were identified in 15 patients. Etiologic factors included radical surgery, radiation therapy, wound complications, and recurrent or persistent carcinoma. In 15 of 18 instances of carotid rupture, patients survived without major neurologic sequelae. After the introduction of endovascular techniques in 1991, the 12 patients whose hemorrhage was definitively managed through permanent balloon occlusion survived without significant neurologic sequelae. Endovascular occlusion techniques in the monitored patient may significantly improve the outcome after carotid rupture.

Outcome of carotid artery resection for neoplastic disease: a meta-analysis

PURPOSE

To determine the neurologic morbidity and oncologic effectiveness of carotid resection in patients with advanced squamous cell carcinoma of the head and neck.

METHODS

A retrospective review of all published cases of squamous cell carcinoma of the head and neck treated by carotid resection was performed.

RESULTS

A major neurologic complication occurred in 17% of patients. Neurologic morbidity was not associated with the method of carotid artery reconstruction. Two-year disease-free survival was 22%. The majority of recurrences were local or regional. Comparison of survival of this group to a similarly staged control group demonstrated no significant difference in survival.

CONCLUSION

This review of the literature suggests that elective carotid resection achieves significant local/regional control of disease and that carotid artery involvement is not a poor prognostic factor in patients with advanced head and neck cancer.

Recurrent hemangiopericytoma and brachytherapy

A 42-year-old woman had two recurrences following excision of a hemangiopericytoma of the left orbit. A third local excision was followed by postoperative brachytherapy (55 Gy in 100 hours). One year later there is no sign of recurrence and the side-effects are minimal.

Iodine-125 seed implantation as an adjunct to surgery in advanced recurrent squamous cell cancer of the head and neck

Survival for extensive recurrent squamous cell carcinomas of the head and neck remains poor, with the major cause of death being local recurrence. Surgical implantation of iodine-125 interstitial seeds allows tumoricidal doses of radiation to be delivered to residual tumor while minimizing radiation doses to the surrounding tissues. From 1978 to 1988, 39 implantations were performed on 35 patients for extensive recurrent squamous cell carcinoma of the head and neck. The decision for implantation was based on positive margins or close to resection margins from frozen sections after salvage resection. The determinate 5-year disease-free survival was 41%, with both the overall and no evidence of disease 5-year survivals being 29%. Significant complications occurred in 36% of all cases. This figure increased to 56% when flap reconstruction was required. Possible reasons for this seemingly high complication rate are discussed. Considering the advanced nature of these recurrent carcinomas, surgical resection with iodine-125 seed implantation appears to be an effective method of managing disease that might otherwise be judged unresectable and treated for palliation only.

Interstitial 192Ir flexible catheter radiofrequency hyperthermia treatments of head and neck and recurrent pelvic carcinomas

Since September 1983, five patients with head and neck cancers and five patients with pelvic or perineal recurrences of colorectal neoplasms received 192Ir interstitial implants through flexible afterloading catheters that were modified to allow RF hyperthermia treatments of the tumor within 1 hr pre- and post-brachytherapy. Local control in the implant volume was obtained in three of the patients with head and neck cancers (base tongue--2/4; floor of mouth--1/1) with follow-up of 9 to 42 months. Two patients had local recurrences after disease-free periods of 8 and 24 months. Two of the five patients treated for pelvic recurrences had complete responses lasting less than 3 months; prolonged stabilization (12 months) of a presacral mass in a third patient also occurred, but the neoplasm eventually regrew. Average temperatures of 39.2 degrees C to 43.7 degrees C were obtained in the implant volumes of these patients during the 45 minute heating periods which took place prior to loading, and just after removal, of the 192Ir seeds in each patient. No instances of intra or post-operative hemorrhage or necrosis of bone or soft tissues occurred in these patients. However, one individual required a permanent tracheostomy for persistent epiglottic edema after implantation as part of a base-tongue brachytherapy procedure. Interstitial RF hyperthermia in conjunction with brachytherapy appears to be a relatively safe and effective modality, but must be tested prospectively to compare its efficacy to interstitial irradiation alone.

Radical radiation alone versus radical radiation plus microwave hyperthermia for N3 (TNM-UICC) neck nodes: a prospective randomized clinical trial

Between September 1985 and December 1986, 44 N3 (TNM-UICC) metastatic squamous cell cervical lymph-nodes were randomized to receive conventionally fractionated radical irradiation (RT) to a total dose of 64-70 Gy, or conventionally fractionated radical irradiation plus twice a week local microwave hyperthermia (Ht). The two major end points of this study were (a) local control rates evaluated at 3 months after the end of combined therapy and (b) incidence of acute local toxicity. Thirty-six nodes (82%) were evaluable as of December 1986, at which time there was a premature closure of this study due to ethical reasons. An interim analysis had revealed a statistically significant difference in complete response rates in favor of the combined arm (p = 0.0152). The complete response rates were 82.3% (14/17) for the combined treatment arm versus 36.8% (7/19) for the control irradiation arm, leading to an iso-dose thermal enhancement ratio (TER) value of 2.23. Both arms are comparable in average total RT dose delivered (RT: 67.05 Gy; RT + Ht: 67.85 Gy) and in average maximum node diameter (RT arm: 4.81 cm; RT + Ht: 4.88 cm). Acute local toxicities were similar in irradiated and heated plus irradiated neck regions; only one skin burn was observed. As possible treatment related death, one patient in the RT + Ht arm died 2 months after completion of therapy with a carotid rupture associated with extensive tumor necrosis. These results confirm previous non-randomized reports suggesting that hyperthermia in combination with full dose conventionally fractionated irradiation significantly enhances the chance of early local control of fixed N3 neck nodes without exhibiting an increase of acute local toxicity.

Treatment of 'inoperable' neck nodes using surgical clearance and postoperative interstitial irradiation

The inability to remove all disease at the time of a radical neck dissection, or inoperable recurrent disease after a neck dissection, are both familiar problems for the head and neck surgeon. All too frequently the conventional treatment options have already been used, the patient having received external beam radiotherapy and possibly cytotoxic chemotherapy. In such circumstances, and provided that the primary tumour remains under control, a positive approach to the further management of the neck metastases should be adopted, given that the patient is in otherwise reasonable health and does not have gross distant metastatic disease. We describe our experience with postoperative interstitial irradiation (brachytherapy) using after-loaded iridium-192 (192Ir) wires positioned at the site of the tumour after its surgical exposure and debulking or clearance. All the treated patients had previously received external beam irradiation to the neck and in the first three cases local skin necrosis occurred as a sequel to interstitial implantation. Therefore, in the other five patients, cutaneous or myocutaneous flaps were used to resurface the area at the time of implant placement. This combination of techniques, which has not been described previously, provided local tumour control in four out of the five cases without irradiation necrosis occurring in any of them.

Salvage surgery for recurrent neck carcinoma after multimodality therapy

Recurrent carcinoma of the neck after treatment by radical neck dissection and radiotherapy leads to a progressive downhill course if no further therapy is instituted. Nine such patients having fixed, recurrent neck tumors with carotid artery involvement underwent 10 salvage procedures with carotid artery resection and replacement. One patient developed a transient hemiparesis that resolved in 3 days, and in another, a permanent hemiparesis occurred. Three patients have survived longer than 12 months. One patient is free of disease at 42 months following two salvage operations. We attribute the low operative morbidity to the frequent use of the subclavian artery for proximal anastomosis and myocutaneous flaps to resurface cutaneous and mucosal defects. We conclude that salvage surgery with carotid artery replacement can be performed on selected patients who have failed combined therapy as a palliative and possibly curative measure.

Intraoperative adjuvant radiotherapy for advanced cancers of the head and neck. Preliminary report

We have reported the early local control and survival results of treatment of recurrent or metastatic head and neck tumors with intraoperative brachytherapy. All six patients were locally free of disease after curative surgery and intraoperative brachytherapy for 4 months to 1 year, whereas two of eight patients were alive at last follow-up at 7 and 8 months with some complications after palliative surgery and intraoperative brachytherapy. We advocate such a technique not only in hopelessly advanced tumors but also in less advanced tumors, as well as a definitively integrated plan of management. Doses of iodine-125 of up to 15,000 rads are safe and well tolerated, even in the presence of a past history of radiotherapy.

Intraoperative radiotherapy in patients with recurrent head and neck cancer

Patients with head and neck cancer who have a relapse of the disease above the clavicles can sometimes be salvaged by additional surgery. However, if all gross tumor cannot be removed during surgery or if the resection margins are unsatisfactory, the likelihood of salvage is remote, especially when postoperative radiotherapy is not feasible due to previous radiotherapy. Between 1979 and 1983, we employed intraoperative brachytherapy for 21 such patients. Sixteen patients had a recurrence after previous surgery and radiotherapy, and 5 after radical radiotherapy. All gross tumor could not be removed in 15 patients, whereas satisfactory margins could not be obtained in 6. In 11 patients, we delivered radiotherapy by a temporary implant of iridium-192 (median dose 4,800 rads in 6 days). In 10 patients, radiotherapy was delivered by a permanent implant of iodine-125 (median activity 13 mCi). Three patients (14 percent) had a relapse within the surgical field, whereas six others (28 percent) had a relapse elsewhere or had development of metastases. Complications developed in four patients (19 percent) and were fatal in one patient. The actuarial disease-free survival rate at 2 years was 55 percent, whereas the rate of local disease control was 81 percent. Our experience suggests that intraoperative brachytherapy can salvage certain high-risk patients with head and neck cancer.

Use of intraoperative 125iodine implants for large tumors attached to the carotid artery

Twenty-nine patients with large masses attached to the carotid artery underwent surgical resection with preservation of the artery, and intraoperative 125Iodine implantation via an absorbable suture. Eighteen were treated for recurrent neoplasms, having failed prior surgery and/or irradiation therapy. Eleven were treated primarily. With the minimum follow-up of one year, 76% were disease free in the implant volume and 62% were disease free in the entire neck. Distant metastasis occurred in 45%. Mean survival was 15 months in the primary group (range, 2-50 months) and 12 months in the recurrent group (range, 4-26 months). This technique shows promise in providing local control without necessity for sacrifice of the carotid artery.

Elective carotid resection for squamous cell carcinoma of the head and neck

Patients with squamous cell carcinoma adherent to the carotid artery have a very poor prognosis, but some can be salvaged by aggressive surgical resection. Preoperative four vessel arteriography with intracranial views is mandatory to detect coexisting arteriosclerotic disease which may limit collateral perfusion of the ipsilateral cerebral hemisphere. Matas-type occlusive tests performed preoperatively are potentially dangerous and do not provide quantitative information that can be obtained intraoperatively by measuring internal carotid artery stump pressures. If the stump pressure is 50 mm Hg or greater, carotid reconstruction is unnecessary. A stump pressure of less than 50 mm Hg is an indication for reconstruction if the pharynx has not been entered during resection. If mucosal entry will be necessary and the stump pressure is less than 50 mm Hg, resection should not be carried out because of the increased risk of graft complications. Somatosensory evoked potentials predict cerebral tolerance to temporary interruption of flow but do not necessarily predict tolerance to permanent interruption of flow. Autogenous vein is the graft material of choice for reconstruction. In those patients not reconstructed, low-dose heparinization started before operation and continued for 10 days may lessen the likelihood of delayed stroke from embolization of a propagated thrombus in the carotid stump.