Carotid endarterectomy

Temporal profile of the healing process and effects of anticoagulation therapy

Restricted access

✓ The healing of the canine carotid endarterectomy was defined at intervals from 30 minutes to 3 months after surgery by means of angiography, light microscopy, and scanning electron microscopy. Immediately after flow was established, a fibrin-platelet carpet formed on the endarterectomized surface. A typical thrombus formed on this initial layer resulting in vessel occlusion in 52% of non-heparinized animals. By 48 hours after surgery, there was little evidence of active thrombus formation, and reendothelialization from existing endothelial cells was noted. One week later, most of the mural thrombus had disappeared and re-endothelialization was well underway; by 3 months after surgery, re-endothelialization was complete. Intraoperative heparinization resulted in a striking reduction in mural thrombus formation and 100% patency rate. Vessel closure with vein-patch grafts resulted in no improvement of vessel patency. However, the results of this aspect of the study cannot be totally extrapolated to human carotid endarterectomy for the reasons discussed. The survival of the vein-patch grafts was investigated.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Scanning electron micrograph of normal canine carotid artery endothelium. The surface projection of the nuclei (arrowhead) and the cell borders (arrow) are indicated. Scale = 10 µ.

  • View in gallery

    Low magnification photomicrographs of random transverse sections throughout the middle of the endarterectomized segment in a vessel closed with a patch graft and no heparin. The endarterectomy (a), vein-patch graft (v), thrombus (T), and a suture line (s) are shown. Scale = 1 mm, H & E. A: At 30 minutes a prominent mural thrombus consisting of fibrin, platelets, and red blood cells is adherent to the endarterectomized surface. × 20. B: At 24 hours a large thrombus is present over both the vein patch and the endarterectomy. × 20. C: At 7 days only a small amount of mural thrombus is present over the endarterectomy. × 16. D: At 1 month most thrombus is gone except for areas of typical thrombus organization and recanalization as shown here. × 16.

  • View in gallery

    Operative photographs show opened arterial segments 30 minutes after flow was established. The endarterectomized surface (a), adjacent endothelium (e), mural thrombus (t), and vein-patch graft (v) are shown. Scale = 2 mm. A: Prominent red and white thrombus are present over the endarterectomy in the non-heparinized vessel. B: Almost no thrombus is present on this vessel surface in which heparin was used.

  • View in gallery

    Scanning electron micrographs showing the acute mural thrombus that forms on the endarterectomized surface between 30 minutes and 4 hours after surgery. A: Stratification of the mural thrombus shows a deeper layer of fibrin and platelets (f) in which the platelets and fibrin strands form an amorphous sheet. The more superficial layer (t) shows identifiable fibrin and red blood cells (RBC's). Scale = 40 µ. B: A higher magnification of area (t) in A. Platelets (arrowhead) and RBC's (arrow) can be seen enmeshed with fibrin strands and fibrin sheets (s). Scale = 10 µ. C: Still higher magnification of area (t) in A, showing fibrin strands coalescing into fibrin sheets (s). Platelets (arrowhead) and RBC's (arrow) are enmeshed in the fibrin net. Scale = 2 µ. D: Higher magnification of area (f) in A, showing the fibrin-platelet layer. Scale = 2 µ.

  • View in gallery

    Scanning electron micrographs showing acute changes in the vein-patch graft endothelium during the first 4 hours. A: An area of minimal endothelial loss shows adherence of white blood cells (WBC's) (arrowheads) to the patches of denuded endothelium. In several areas, the WBC's have migrated beneath the endothelial layer (e). Scale = 10 µ. B: An unusual accumulation of WBC's (arrow-head) on the damaged endothelium (e). Scale = 10 µ. C: More severe endothelial cell loss with the adherence of platelets (arrow) and WBC's (arrowhead) to the subendothelial layers. Some endothelial cells (e) remain. Scale = 10 µ. D: Transition between preserved endothelium (e) and an area of endothelial loss with formation of a fibrin-platelet layer (f). Both WBC's (arrowhead) and platelets (arrow) are present. Scale = 10 µ.

  • View in gallery

    Scanning electron micrographs showing damaged endothelium adjacent to the endarterectomy within the first 4 hours after endarterectomy. A: Low magnification shows a spectrum of endothelial damage ranging from almost normal-appearing endothelium (1) to partial endothelial cell loss (2), to complete loss of endothelium and replacement with fibrin-platelet carpet (3). Scale = 40 µ. B: Higher magnification of area of complete endothelial cell loss with acute fibrin-platelet mural thrombus. Corresponds to area 3 in A. Scale = 10 µ. C: Area of incomplete endothelial cell loss showing normal endothelial cells (e) partially peeled up and replaced with a typical fibrin-platelet layer (f) over the exposed subendothelial layers. Corresponds to area 2 in A. Scale = 10 µ. D: An area of mild endothelial insult with only focal endothelial loss and adherence of white blood cells (arrow) and red blood cells (arrowhead). Corresponds to area 1 in A. Scale = 10 µ.

  • View in gallery

    Low magnification photomicrographs of random transverse sections through the middle of the endarterectomized segment in a vessel closed with a patch graft and heparin. The endarterectomy (a), vein-patch graft (v), and a suture line (s) are indicated. Scale = 1 mm, H & E. A: At 30 minutes there is no grossly visible thrombus on the endarterectomized segment. A shred of media (m) projects into the lumen. × 20. B: At 24 hours there is still no gross mural thrombus present, although medial hemorrhage exists (arrowheads). × 20. C: At 7 days there is little evidence of mural thrombus but areas of medial thickening are apparent in some specimens (between arrows). × 16. D: At 1 month no thrombus is present but generalized medial thickening is shown. × 16.

  • View in gallery

    Scanning electron micrographs of the endarterectomized vessel 2 days after endarterectomy show the regeneration of new endothelium over a thinned, inactive, fibrin-platelet layer. A: The remaining endothelium (e) with its typical folding (on the left) is giving rise to new endothelial cells (e1) that are growing onto the fibrin-platelet carpet (f). The leading edge of new endothelium is shown with arrowheads. The edge of the surgical endarterectomy is shown with arrows. Scale = 40 µ. B: Higher magnification showing new endothelial cells (e1) streaming from the remaining endothelium (e) onto the endarterectomy. Arrows show the edge of the surgical endarterectomy. Scale = 10 µ. C: High magnification of the leading edge of the regenerating endothelial cells (e1) growing onto the fibrin-platelet carpet (f). Direction of growth is left to right. Scale = 10 µ. D: Typical area of quiescent, thinned, fibrin-platelet layer over the endarterectomy before being covered by endothelium. Scale = 10 µ.

  • View in gallery

    Scanning electron micrographs showing quiescent mural thrombus on a damaged endothelial surface 2 days after surgery. A: Low magnification view of the fibrin-platelet layer covering a segment of vessel devoid of endothelium. A few normal platelets (arrowhead) are adherent to the fibrin-platelet layer (f). Scale = 10 µ. B: Higher magnification of area similar to A shows the amorphous fibrinplatelet layer and a few recognizable adherent platelets (arrowhead). Scale = 2 µ. C: The junction (arrows) between remaining endothelium (e) and fibrin-platelet layer (f). Scale = 10 µ. D: Higher magnification of the junction (arrow) between endothelium (e) and the fibrin-platelet layer (f). Scale = 2 µ.

  • View in gallery

    Scanning electron micrographs showing re-endothelialization of the damaged endothelium 7 days after surgery. A: There is a distinct border between the endothelium (e) and the endarterectomized surface (a). The absence of the internal elastic lamina over the endarterectomy accounts for the lack of longitudinal ridging. Scale = 40 µ. B: A higher magnification of the repaired endothelium showing normal endothelial cells (e) and the longer, thinner, more prominent and more disorganized nuclei of the regenerating endothelial cells (r). Scale = 10 µ.

  • View in gallery

    Scanning electron micrographs of the endarterectomized segment showing complete re-endothelialization 3 months after surgery. A: Regenerated endothelial cell arrangement shows prominent nuclei (arrow) and cell borders (arrowheads). Since the internal elastic lamina has not regenerated, there is no longitudinal folding of the endothelial surface. Scale = 10 µ. B: New endothelium covering a suture line (line) and sutures (s). Scale = 100 µ. C: A hole in the new endothelial layer over a suture showing changes in endothelial cell alignment caused by the turbulent flow over the defect. Arrow indicates the direction of flow through vessel. Scale = 50 µ. D: A collagen strand left hanging into the lumen which is completely covered with endothelium. Scale = 40 µ.

  • View in gallery

    Scanning electron micrographs of re-endothelialized vein-patch grafts at 3 months. A: A completely re-endothelialized vein patch (v) showing suture lines (lines), endothelialized sutures (s), and the adjacent endothelium (e). Scale = 400 µ. B, C, and D: Higher magnification of the regenerated venous endothelium showing nuclei (white arrowhead), microvilli (white arrow), cell borders (black arrow), and a rare white blood cell (black arrowhead). Scale = 10 µ.

  • View in gallery

    Angiographic appearance of the endarterectomized segment 30 minutes after flow was established. A vein patch was used. The endarterectomized segment is between the arrowheads. Scale = 10 mm. A: Without heparin. Note multiple filling defects from the mural thrombus. B: With heparin. There is a striking absence of mural thrombus.

References

  • 1.

    Baumgartner HR: Platelet interaction with vascular structures. Thromb Diath Haemorrh (Suppl 51):1611761972Baumgartner HR: Platelet interaction with vascular structures. Thromb Diath Haemorrh (Suppl 51):161–176 1972

  • 2.

    Baumgartner HRSpaet TH: Endothelial replacement in rabbit arteries. Fed Proc 29:7101970 (Abstract 2627)Baumgartner HR Spaet TH: Endothelial replacement in rabbit arteries. Fed Proc 29:710 1970 (Abstract 2627)

  • 3.

    Begent NBorn GVR: Growth rate in vivo of platelet thrombi, produced by iontophoresis of ADP, as a function of mean blood flow velocity. Nature 227:9269301970Begent N Born GVR: Growth rate in vivo of platelet thrombi produced by iontophoresis of ADP as a function of mean blood flow velocity. Nature 227:926–930 1970

  • 4.

    Blaisdell FWLim R JrHall AD: Technical result of carotid endarterectomy. Arteriographic assessment. Am J Surg 114:2392461967Blaisdell FW Lim R Jr Hall AD: Technical result of carotid endarterectomy. Arteriographic assessment. Am J Surg 114:239–246 1967

  • 5.

    Chatterjee KNWarren RGore I: Autogenous arterial patch graft for arteriotomy closure. Surgery 52:8908971962Chatterjee KN Warren R Gore I: Autogenous arterial patch graft for arteriotomy closure. Surgery 52:890–897 1962

  • 6.

    Dale WALewis MR: Lateral vascular patch grafts. Surgery 57:36471965Dale WA Lewis MR: Lateral vascular patch grafts. Surgery 57:36–47 1965

  • 7.

    Danese CAHaimov M: Inhibition of experimental arterial thrombosis in dogs with platelet-deaggregating agents. Surgery 70:9279341971Danese CA Haimov M: Inhibition of experimental arterial thrombosis in dogs with platelet-deaggregating agents. Surgery 70:927–934 1971

  • 8.

    Donaghy RMPYasargil MG (eds): Microvascular Surgery. Stuttgart: Georg Thieme Verlag1967 pp 7586Donaghy RMP Yasargil MG (eds): Microvascular Surgery. Stuttgart: Georg Thieme Verlag 1967 pp 75–86

  • 9.

    Edwards WSWilson TASBennett A: The long-term effectiveness of carotid endarterectomy in prevention of strokes. Ann Surg 168:7657701968Edwards WS Wilson TAS Bennett A: The long-term effectiveness of carotid endarterectomy in prevention of strokes. Ann Surg 168:765–770 1968

  • 10.

    Evans GMustard JF: Platelet-surface reaction and thrombosis. Surgery 64:2732801968Evans G Mustard JF: Platelet-surface reaction and thrombosis. Surgery 64:273–280 1968

  • 11.

    Fishman JARyan GBKarnovsky MJ: Endothelial regeneration in the rat carotid artery and the significance of endothelial denudation in the pathogenesis of myointimal thickening. Lab Invest 32:3393511975Fishman JA Ryan GB Karnovsky MJ: Endothelial regeneration in the rat carotid artery and the significance of endothelial denudation in the pathogenesis of myointimal thickening. Lab Invest 32:339–351 1975

  • 12.

    Flaherty JTPierce JEFerrans VJ et al: Endothelial nuclear patterns in the canine arterial tree with particular reference to hemodynamic events. Circ Res 30:23331972Flaherty JT Pierce JE Ferrans VJ et al: Endothelial nuclear patterns in the canine arterial tree with particular reference to hemodynamic events. Circ Res 30:23–33 1972

  • 13.

    French BNRewcastle NB: Sequential morphological changes at the site of carotid endarterectomy. J Neurosurg 41:7457541974French BN Rewcastle NB: Sequential morphological changes at the site of carotid endarterectomy. J Neurosurg 41:745–754 1974

  • 14.

    Friedman LILiem HGrabowski EFet al: Inconsequentiality of surface properties for initial platelet adhesion. Trans Am Soc Artif Intern Organs 16:63731970Friedman LI Liem H Grabowski EF et al: Inconsequentiality of surface properties for initial platelet adhesion. Trans Am Soc Artif Intern Organs 16:63–73 1970

  • 15.

    Ghani ARTibbs DJ: Role of blood-borne cells in organization of mural thrombi. Br Med J 1:124412471962Ghani AR Tibbs DJ: Role of blood-borne cells in organization of mural thrombi. Br Med J 1:1244–1247 1962

  • 16.

    Hoff HFGottlob R: A fine structure study of injury to the endothelial cells of the rabbit abdominal aorta by various stimuli. Angiology 18:4404511967Hoff HF Gottlob R: A fine structure study of injury to the endothelial cells of the rabbit abdominal aorta by various stimuli. Angiology 18:440–451 1967

  • 17.

    Hovig T: The effect of fibrin on platelet adherence to collagen and the subsequent aggregation reaction. Fed Proc 24:1551965 (Abstract)Hovig T: The effect of fibrin on platelet adherence to collagen and the subsequent aggregation reaction. Fed Proc 24:155 1965 (Abstract)

  • 18.

    Jørgensen L: Mechanisms of thrombosis. Pathobiol Annu 1:1392041971Jørgensen L: Mechanisms of thrombosis. Pathobiol Annu 1:139–204 1971

  • 19.

    Jørgensen LRowsell HCHovig Tet al: Resolution and organization of platelet-rich mural thrombi in carotid arteries of swine. Am J Pathol 51:6817191967Jørgensen L Rowsell HC Hovig T et al: Resolution and organization of platelet-rich mural thrombi in carotid arteries of swine. Am J Pathol 51:681–719 1967

  • 20.

    Kakkar VVTsapogas MJGleave EN: Experimental arterial patching using veins and other autologous tissues. Br J Surg 54:5335371967Kakkar VV Tsapogas MJ Gleave EN: Experimental arterial patching using veins and other autologous tissues. Br J Surg 54:533–537 1967

  • 21.

    Kawamura JGertz SDSunaga Tet al: Scanning electron microscopic observations on the luminal surface of the rabbit common carotid artery subjected to ischemia by arterial occlusion. Stroke 5:7657741974Kawamura J Gertz SD Sunaga T et al: Scanning electron microscopic observations on the luminal surface of the rabbit common carotid artery subjected to ischemia by arterial occlusion. Stroke 5:765–774 1974

  • 22.

    Khodadad G: Histological evaluation of long-term microvascular repair and replacement. Arch Surg 101:5035071970Khodadad G: Histological evaluation of long-term microvascular repair and replacement. Arch Surg 101:503–507 1970

  • 23.

    Kobayashi SHollenhorst RWSundt TM Jr: Retinal arterial pressure before and after surgery for carotid artery stenosis. Stroke 2:5695751971Kobayashi S Hollenhorst RW Sundt TM Jr: Retinal arterial pressure before and after surgery for carotid artery stenosis. Stroke 2:569–575 1971

  • 24.

    Leonard EF: The role of flow in thrombogenesis. Bull NY Acad Med 48:2732801972Leonard EF: The role of flow in thrombogenesis. Bull NY Acad Med 48:273–280 1972

  • 25.

    Moseley HSConnell RSKrippaehne WW: Healing of the canine aorta after endarterectomy: a scanning electron microscopy study. Ann Surg 180:3293351974Moseley HS Connell RS Krippaehne WW: Healing of the canine aorta after endarterectomy: a scanning electron microscopy study. Ann Surg 180:329–335 1974

  • 26.

    Murphey FMaccubbin DA: Carotid endarterectomy. A long-term follow-up study. J Neurosurg 23:1561681965Murphey F Maccubbin DA: Carotid endarterectomy. A long-term follow-up study. J Neurosurg 23:156–168 1965

  • 27.

    Mustard JF: Hemostasis and thrombosis. Semin Hematol 5:911061968Mustard JF: Hemostasis and thrombosis. Semin Hematol 5:91–106 1968

  • 28.

    Nelson ESunaga TShimamoto Tet al: Ischemic carotid endothelium. Scanning electron microscopical studies. Arch Pathol 99:1251311975Nelson E Sunaga T Shimamoto T et al: Ischemic carotid endothelium. Scanning electron microscopical studies. Arch Pathol 99:125–131 1975

  • 29.

    Norton LWSpencer FC: Long-term comparison of vein patch with direct suture. Technique of anastomosis of small arteries. Arch Surg 89:108310881964Norton LW Spencer FC: Long-term comparison of vein patch with direct suture. Technique of anastomosis of small arteries. Arch Surg 89:1083–1088 1964

  • 30.

    O'Neal RMJordon GL JrRabin ERet al: Cells grown on isolated Dacron hub or electron microscopic study. Exp Mol Pathol 3:4034121964O'Neal RM Jordon GL Jr Rabin ER et al: Cells grown on isolated Dacron hub or electron microscopic study. Exp Mol Pathol 3:403–412 1964

  • 31.

    Pena LIHusni EA: A comparative study of autogenous vein and Dacron patch grafts in the dog. Arch Surg 96:3693721968Pena LI Husni EA: A comparative study of autogenous vein and Dacron patch grafts in the dog. Arch Surg 96:369–372 1968

  • 32.

    Piepgras DGSundt TM JrDidisheim P: Effect of anticoagulants and inhibitors of platelet aggregation on thrombotic occlusion of endarterectomized cat carotid arteries. Stroke 7:2482541976Piepgras DG Sundt TM Jr Didisheim P: Effect of anticoagulants and inhibitors of platelet aggregation on thrombotic occlusion of endarterectomized cat carotid arteries. Stroke 7:248–254 1976

  • 33.

    Poole JCFSabiston DCFlorey HW Jret al: Growth of endothelium in arterial prosthetic grafts and following endarterectomy. Surg Forum 13:2252271962Poole JCF Sabiston DC Florey HW Jr et al: Growth of endothelium in arterial prosthetic grafts and following endarterectomy. Surg Forum 13:225–227 1962

  • 34.

    Poole JCFSanders AGFlorey HW: The regeneration of aortic endothelium. J Pathol Bacteriol 75:1331431958Poole JCF Sanders AG Florey HW: The regeneration of aortic endothelium. J Pathol Bacteriol 75:133–143 1958

  • 35.

    Reichle FAStewart GJEssa N: A transmission and scanning electron microscopic study of luminal surfaces in Dacron and autogenous vein bypasses in man and dog. Surgery 74:9459601973Reichle FA Stewart GJ Essa N: A transmission and scanning electron microscopic study of luminal surfaces in Dacron and autogenous vein bypasses in man and dog. Surgery 74:945–960 1973

  • 36.

    Rodbard SJohnson AC: Deposition of flow-borne materials on vessel walls. Circ Res 11:6646681962Rodbard S Johnson AC: Deposition of flow-borne materials on vessel walls. Circ Res 11:664–668 1962

  • 37.

    Rosenberg RD: Heparin action. Circulation 49:6036051974 (Editorial)Rosenberg RD: Heparin action. Circulation 49:603–605 1974 (Editorial)

  • 38.

    Rosental JJGaspar MRMovius HJ: Intraoperative arteriography in carotid thrombo-endarterectomy. Arch Surg 106:8068081973Rosental JJ Gaspar MR Movius HJ: Intraoperative arteriography in carotid thrombo-endarterectomy. Arch Surg 106:806–808 1973

  • 39.

    Rossi NPKoepke JASpencer FC: Histologic changes in long-term autologous arterial patch grafts in coronary arteries. Surgery 57:3353421965Rossi NP Koepke JA Spencer FC: Histologic changes in long-term autologous arterial patch grafts in coronary arteries. Surgery 57:335–342 1965

  • 40.

    Rowsell HCGlynn MFMustard JFet al: Effect of heparin on platelet economy in dogs. Am J Physiol 213:9159221967Rowsell HC Glynn MF Mustard JF et al: Effect of heparin on platelet economy in dogs. Am J Physiol 213:915–922 1967

  • 41.

    Salzman EW: The limitations of heparin therapy after arterial reconstruction. Surgery 57:1311381965Salzman EW: The limitations of heparin therapy after arterial reconstruction. Surgery 57:131–138 1965

  • 42.

    Schutz HFleming JFRAwerbuck B: Arteriographic assessment of carotid endarterectomy. Ann Surg 171:5095211970Schutz H Fleming JFR Awerbuck B: Arteriographic assessment of carotid endarterectomy. Ann Surg 171:509–521 1970

  • 43.

    Shimamoto T: Injury and repair in arterial tissue. Angiology 25:6827001974Shimamoto T: Injury and repair in arterial tissue. Angiology 25:682–700 1974

  • 44.

    Spaet THErichson RB: The vascular wall in the pathogenesis of thrombosis. Thromb Diath Haemorrh (Suppl 21):67861966Spaet TH Erichson RB: The vascular wall in the pathogenesis of thrombosis. Thromb Diath Haemorrh (Suppl 21):67–86 1966

  • 45.

    Spaet THStemerman MBLejneiks I: The role of smooth muscle cells in repopulation of rabbit aortic endothelium, following balloon injury. Fed Proc 32:2191973 (Abstract 41)Spaet TH Stemerman MB Lejneiks I: The role of smooth muscle cells in repopulation of rabbit aortic endothelium following balloon injury. Fed Proc 32:219 1973 (Abstract 41)

  • 46.

    Spaet THZucker MB: Mechanism of platelet plug formation and role of adenosine diphosphate. Am J Physiol 206:126712741964Spaet TH Zucker MB: Mechanism of platelet plug formation and role of adenosine diphosphate. Am J Physiol 206:1267–1274 1964

  • 47.

    Stahl WMKatsumura T: Reconstruction of small arteries. A study of methods. Arch Surg 88:3843881964Stahl WM Katsumura T: Reconstruction of small arteries. A study of methods. Arch Surg 88:384–388 1964

  • 48.

    Stehbens WE: Reaction of venous endothelium to injury. Lab Invest 14:4494591965Stehbens WE: Reaction of venous endothelium to injury. Lab Invest 14:449–459 1965

  • 49.

    Stewart GJRitchie WGMLynch PR: Venous endothelial damage produced by massive sticking and emigration of leukocytes. Am J Pathol 74:5075321974Stewart GJ Ritchie WGM Lynch PR: Venous endothelial damage produced by massive sticking and emigration of leukocytes. Am J Pathol 74:507–532 1974

  • 50.

    Stump MMJordan GL JrDe Bakey MEet al: Endothelium grown from circulating blood on isolated intravascular Dacron hub. Am J Pathol 43:3613681963Stump MM Jordan GL Jr De Bakey ME et al: Endothelium grown from circulating blood on isolated intravascular Dacron hub. Am J Pathol 43:361–368 1963

  • 51.

    Sundt TM JrSandok BAWhisnant JP: Carotid endarterectomy. Complications and preoperative assessment of risk. Mayo Clin Proc 50:3013061975Sundt TM Jr Sandok BA Whisnant JP: Carotid endarterectomy. Complications and preoperative assessment of risk. Mayo Clin Proc 50:301–306 1975

  • 52.

    Ts'ao C: Graded endothelial injury of the rabbit aorta with special reference to platelet deposition. Arch Pathol 90:2222291970Ts'ao C: Graded endothelial injury of the rabbit aorta with special reference to platelet deposition. Arch Pathol 90:222–229 1970

  • 53.

    Ts'ao C: Myointimal cells as a possible source of replacement for endothelial cells in the rabbit. Circ Res 23:6716821968Ts'ao C: Myointimal cells as a possible source of replacement for endothelial cells in the rabbit. Circ Res 23:671–682 1968

  • 54.

    von Kaulla KNMcDonald TS: The effect of heparin on components of the human fibrinolytic system. Blood 13:8118211958von Kaulla KN McDonald TS: The effect of heparin on components of the human fibrinolytic system. Blood 13:811–821 1958

  • 55.

    Wesolowski SAFries CCSawyer PN: The production and significance of turbulence in hemic systems. Trans Am Soc Artif Intern Organs 8:11181962Wesolowski SA Fries CC Sawyer PN: The production and significance of turbulence in hemic systems. Trans Am Soc Artif Intern Organs 8:11–18 1962

  • 56.

    Wessler SYin ET: Theory and practice of minidose heparin in surgical patients. A status report. Circulation 47:6716761973 (Editorial)Wessler S Yin ET: Theory and practice of minidose heparin in surgical patients. A status report. Circulation 47:671–676 1973 (Editorial)

  • 57.

    Wood EHCorrell JWBochenstein FKet al: Neuroradiologic evaluation of results of surgical treatment of extracranial atherosclerotic disease. Acta Radiol [Diagn] 9:5375481969Wood EH Correll JW Bochenstein FK et al: Neuroradiologic evaluation of results of surgical treatment of extracranial atherosclerotic disease. Acta Radiol [Diagn] 9:537–548 1969

  • 58.

    Wylie EJEhrenfeld WK: Extracranial Occlusive Cerebrovascular Disease: Diagnosis and Management. Philadelphia: WB Saunders1970 pp 214225Wylie EJ Ehrenfeld WK: Extracranial Occlusive Cerebrovascular Disease: Diagnosis and Management. Philadelphia: WB Saunders 1970 pp 214–225

  • 59.

    Yin ETGiudice LCWessler S: Inhibition of activated factor X-induced platelet aggregation: the role of heparin and the plasma inhibitor to activated factor X. J Lab Clin Med 82:3903981973Yin ET Giudice LC Wessler S: Inhibition of activated factor X-induced platelet aggregation: the role of heparin and the plasma inhibitor to activated factor X. J Lab Clin Med 82:390–398 1973

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 41 41 8
Full Text Views 432 432 0
PDF Downloads 74 74 0
EPUB Downloads 0 0 0

PubMed

Google Scholar