Local versus general anaesthesia for carotid endarterectomy

Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine

BACKGROUND

This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association.

METHODS

GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations.

RESULTS

The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]).

CONCLUSIONS

This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

Anesthetic management of carotid endarterectomy: an update from Italian guidelines

BACKGROUND AND AIMS

In order to systematically review the latest evidence on anesthesia, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure management for carotid endarterectomy. The present review is based on a single chapter of the Italian Health Institute Guidelines for diagnosis and treatment of extracranial carotid stenosis and stroke prevention.

METHODS AND RESULTS

A systematic article review focused on the previously cited topics published between January 2016 and October 2020 has been performed; we looked for both primary and secondary studies in the extensive archive of Medline/PubMed and Cochrane library databases. We selected 14 systematic reviews and meta-analyses, 13 randomized controlled trials, 8 observational studies, and 1 narrative review. Based on this analysis, syntheses of the available evidence were shared and recommendations were indicated complying with the GRADE-SIGN version methodology.

CONCLUSIONS

From this up-to-date analysis, it has emerged that any type of anesthesia and neurological monitoring method is related to a better outcome after carotid endarterectomy. In addition, insufficient evidence was found to justify reversal or no-reversal of heparin at the end of surgery. Furthermore, despite a low evidence level, a suggestion for blood pressure monitoring in the postoperative period was formulated.

Incidence of postoperative, major, adverse cardiac events in patients undergoing carotid endarterectomy: A single-center, retrospective study

OBJECTIVE

This study aimed to determine the incidence of postoperative major adverse cardiac events for patients undergoing carotid endarterectomy.

METHODS

This single-center, retrospective study recruited 171 carotid endarterectomy patients between January 1999 and June 2018. Patients who received a carotid endarterectomy in conjunction with other surgery were excluded. The primary outcomes were the incidences of major adverse cardiac events (comprising myocardial infarction, significant arrhythmias, congestive heart failure, and cardiac death) within 7 days, 7-30 days, and > 30 days-1 year, postoperatively. The secondary outcomes were the factors related to major adverse cardiac events and the incidence of postoperative stroke. The patients' charts were reviewed, and direct contact was made with them to obtain information on their status post discharge.

RESULTS

The incidences of major adverse cardiac events within 7 days, 7-30 days, and >30 days-1 year of the carotid endarterectomy were 3.5% of patients (95% confidence interval: 0.008-0.063), 1.2% (95% confidence interval: 0.004-0.028), and 1.8% (95% confidence interval: 0.002-0.037), respectively. The major adverse cardiac events occurring within 7 days were arrhythmia (2.3% of patients), cardiac arrest (1.8%), myocardial infarction (1.2%), and congestive heart failure (1.2%), while the corresponding postoperative stroke rate was 4.7%.

CONCLUSION

The 7-day incidence of major adverse cardiac events after the carotid endarterectomy was 3.5%. The most common major adverse cardiac event during that period was cardiac arrhythmia.

Local versus general anaesthesia for carotid endarterectomy

BACKGROUND

Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be minimised by performing the operation under local rather than general anaesthetics. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004, 2008, and 2013.

OBJECTIVES

To determine whether carotid endarterectomy under local anaesthetic: 1) reduces the risk of perioperative stroke and death compared with general anaesthetic; 2) reduces the complication rate (other than stroke) following carotid endarterectomy; and 3) is acceptable to individuals and surgeons.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trials registers (to February 2021). We also reviewed reference lists of articles identified.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the use of local anaesthetics to general anaesthetics for people having carotid endarterectomy were eligible.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data, assessed risk of bias, and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, ipsilateral stroke, stroke or death, myocardial infarction, local haemorrhage, and arteries shunted.

MAIN RESULTS

We included 16 RCTs involving 4839 participants, of which 3526 were obtained from the single largest trial (GALA). The main findings from our meta-analysis showed that, within 30 days of operation, neither incidence of stroke nor death were significantly different between local and general anaesthesia. Of these, the incidence of stroke in the local and general anaesthesia groups was 3.2% and 3.5%, respectively (Peto odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.26; P = 0.58; 13 studies, 4663 participants; low-quality evidence). The rate of ipsilateral stroke under both types of anaesthesia was 3.1% (Peto OR 1.03, 95% CI 0.71 to 1.48; P = 0.89; 2 studies, 3733 participants; low-quality evidence). The incidence of stroke or death in the local anaesthesia group was 3.5%, while stroke or death incidence was 4.1% in the general anaesthesia group (Peto OR 0.85, 95% CI 0.62 to 1.16; P = 0.31; 11 studies, 4391 participants; low-quality evidence). A lower rate of death was observed in the local anaesthetic group but evidence was of low quality (Peto OR 0.61, 95% CI 0.35 to 1.06; P = 0.08; 12 studies, 4421 participants).

AUTHORS' CONCLUSIONS

The incidence of stroke and death were not convincingly different between local and general anaesthesia for people undergoing carotid endarterectomy. The current evidence supports the choice of either approach. Further high-quality studies are still needed as the evidence is of limited reliability.

Safe carotid endarterectomy: "one fits all strategy"

Introduction

Carotid artery stenosis of 50% or more in the extracranial internal carotid artery is responsible for 10–15% of all strokes. Interventional treatment options include carotid endarterectomy and carotid artery stenting, where endarterectomy is proven to be superior.

Aim

In this study, we report the carotid endarterectomy results of patients we operated on using the strategy we termed the “one fits all strategy”.

Material and methods

Seventy-six patients undergoing carotid endarterectomy between July 2016 and April 2020 were retrospectively studied. Conventional endarterectomy under general anesthesia with primary closure of the arteriotomy was performed in all patients. We used a near infrared spectroscopy oximeter to measure regional cerebral oxygenation continuously throughout the surgery.

Results

The mean age of the patients was 70.96 8.15 years. There were 52 male and 24 female patients. The mean follow-up time was 20.6 ±13.6 months. Coronary artery disease was detected in 52 (73.6%) patients. Coronary artery bypass operation was indicated in 19 patients in whom a staged approach was performed in 13 and a reverse staged approach in 1. There were two perioperative strokes one of which recovered fully spontaneously and the other partially with physiotherapy. Eight cases were revised due to hematoma formation.

Conclusions

Carotid endarterectomy continues to prove its safety in carotid artery stenosis patients. Continuous cerebral oxygenation monitoring is indispensable for carotid surgery. Despite discrepancies in surgical techniques, we believe that “one fits all strategy: general anesthesia, conventional endarterectomy without patch plasty, never shunter and always NIRS monitorization” may be used safely in patients undergoing carotid endarterectomy.

The Role of Carotid Stump Pressure in Carotid Endarterectomy: A Systematic Review and Meta-Analysis

This review evaluates the carotid stump pressure (CSP)’s role as a single parameter at any given pressure as an indicator for selective shunting, or vice versa, in carotid endarterectomy (CEA). A systematic review of literature in MEDLINE and the Cochrane Library from 1969 to 2019 was conducted. The primary end point was set at 0 to 30-day mortality, ischemic stroke (IS), transient ischemic attack (TIA), and a secondary point at recognition of an optimal CSP pressure. The data was subjected to meta-analytics. The odds ratio (OR) was reported at 95% confidence interval (CI). This study has been registered with PROSPERO: CRD42019119851. The pooled analysis on the primary endpoint of IS demonstrated higher incidence of stroke in shunted CEAs solely based on CSP measurement alone (OR, 0.14, 95%CI: 0.08–0.24, I²=48%, p<0.001). Sub group analysis demonstrated similar patterns at 25 mmHg (OR, 0.06, 95%CI: 0.01–0.5, p<0.01), 30 mmHg (OR, 0.07, 95%CI: 0.01–0.63, p=0.02) and 40 mmHg (OR, 0.23, 95%CI: 0.09–0.57, p<0.01). This effect on end points of mortality and TIA demonstrated no benefit in either direction. CSP, as a single criterion, is not a reliable parameter in reduction of TIA, mortality, and IS at any given pressure range.

High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis

OBJECTIVE

To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization.

BACKGROUND

Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated.

METHODS

We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model.

RESULTS

We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts).

CONCLUSIONS

We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications.

REGISTRATION

This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.

Anaesthetic management in endovascular total aortic arch repair via needle-based in situ fenestration: a case series of 14 patients

Objective

Endovascular total aortic arch repair (ETAAR) via needle-based in situ fenestration (ISF) is a major challenge for anaesthesiologists because of haemodynamic instability and the risk of cerebral hypoxia. We herein summarise our experience with anaesthetic management of patients who underwent this procedure.

Methods

Fourteen patients who underwent ETAAR via ISF for arch pathologies involving the major supra-arch branches were included. Regional cerebral oxygen saturation was measured to monitor cerebral perfusion. Partial extracorporeal circulation (EC) support from the right common femoral vein to the right axillary artery was introduced to provide cerebral perfusion.

Results

During ISF, vessel rupture occurred in three patients and ventricular fibrillation occurred in one patient. The regional cerebral oxygen saturation significantly decreased during the potential risk period for cerebral ischaemia. Establishment of EC effectively prevented cerebral ischaemia.

Conclusions

During ETAAR, the risks of haemodynamic instability caused by the procedure and vessel rupture during ISF need to be overcome. Partial EC ensured good cerebral protection in our study, and regional cerebral oxygen saturation monitoring may help to reduce the rate of desaturation.

Qualitative study of clinician and patient perspectives on the mode of anaesthesia for emergency surgery

Background

Although delivering a chosen mode of anaesthesia for certain emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate. This qualitative study explored clinician and patient perspectives about mode of anaesthesia for emergency surgery.

Methods

Snowball sampling was used to recruit participants from eight National Health Service Trusts that cover the following three emergency surgery settings: ruptured abdominal aortic aneurysms, hip fractures and inguinal hernias. A qualitative researcher conducted interviews with clinicians and patients. Thematic analysis was applied to the interview transcripts.

Results

Interviews were conducted with 21 anaesthetists, 21 surgeons, 14 operating theatre staff and 23 patients. There were two main themes. The first, impact of mode of anaesthesia in emergency surgery, had four subthemes assessing clinician and patient ideas about: context and the ‘best’ mode of anaesthesia; balance in choosing it over others; change and developments in anaesthesia; and the importance of mode of anaesthesia in emergency surgery. The second, tensions in decision‐making about mode of anaesthesia, comprised four subthemes: clinical autonomy and guidelines in anaesthesia; conforming to norms in mode of anaesthesia; the relationship between expertise, preference and patient involvement; and team dynamics in emergency surgery. The results highlight several interlinking factors affecting decision‐making, including expertise, preference, habit, practicalities, norms and policies.

Conclusion

There is variation in practice in choosing the mode of anaesthesia for surgery, alongside debate as to whether anaesthetic autonomy is necessary or results in a lack of willingness to change.

Carotid endarterectomy with primary closure versus patch angioplasty in patients with symptomatic and significant stenosis: protocol for a systematic review with meta-analyses and trial sequential analysis of randomised clinical trials

INTRODUCTION

Use of patch angioplasty in carotid endarterectomy (CEA) is suggested to reduce the risk of restenosis and recurrent ipsilateral stroke. The objective is to conduct a systematic review with meta-analysis and trial sequential analysis as well as Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessments comparing the benefits and harms of CEA with primary closure of the arterial wall versus CEA with patch angioplasty in patients with a symptomatic and significant carotid stenosis.

METHODS AND ANALYSIS

The review shall be conducted according to this published protocol following the recommendations of the 'Cochrane' and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Randomised clinical trials comparing CEA with primary closure of the arterial wall versus CEA with patch angioplasty (regardless of used patch materials) in human adults with a symptomatic and significant carotid stenosis will be included. Primary outcomes are all-cause mortality at maximal follow-up, health-related quality of life and serious adverse events. Secondary outcomes are symptomatic or asymptomatic arterial occlusion or restenosis, and non-serious adverse events. We will primarily base our conclusions on meta-analyses of trials with overall low risk of bias. However, if pooled point estimates of all trials are similar to pooled point estimates of trials with overall low risk of bias and there is lack of a statistical significant interaction between estimates from trials with overall high risk of bias and trials with overall low risk of bias we will consider the precision achieved in all trials as the result of our meta-analyses.

ETHICS AND DISSEMINATION

The proposed systematic review will collect and analyse secondary data from published studies therefor ethical approval is not required. The results of the systematic review will be disseminated by publication in a peer-review journal and submitted for presentation at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42014013416.

Randomised, masked study of local anaesthesia administered prior to external dacryocystorhinostomy under general anaesthesia

OBJECTIVES

To determine whether administration of local anaesthetic at the site of skin incision during open lacrimal drainage surgery under general anaesthesia alters the total dosage of anaesthetic drugs required during total intravenous anaesthesia (TIVA), and whether it alters postoperative pain and recovery.

STUDY DESIGN

Masked comparison of a randomized, two-group interventional study.

PATIENTS AND METHODS

Patients undergoing unilateral external dacryocystorhinostomy under total intravenous general anaesthesia were recruited from the lacrimal service at Moorfields Eye Hospital between September 2012 and February 2014. The patients were randomised to receive, after induction and stabilisation of general anaesthesia, infiltration of the ipsilateral paranasal tissues with 2.5 ml of 0.5% bupivacaine with 1:100000 epinephrine ("treatment" group), or a sham injection ("control" group); the infiltration was performed about 7 min prior to the skin incision. The infusion rates for propofol and remifentanil were adjusted to maintain a steady intra-operative mean blood pressure of 55-70 mmHg and BIS score of 40-60%. The time taken for extubation of the patient after cessation of TIVA was recorded, and postoperative pain scores (on a Likert scale from 0-10) were taken at regular intervals after extubation. The average intra-operative mean blood pressures, total drug usage, extubation time and pain scores for each of the two groups were compared using two-tail Student's t-testing and Wilcoxon rank sum testing.

RESULTS

There were 12 patients (7 female; 58%) in the treatment group and 11 (7 female; 64%) in the control group, with similar average age at surgery (59 years treatment, 53 years control; p = 0.38) The average operative time was 45 min in the treatment group (median 42, range 30-55) and 47 min (median 45; range 37-61) in the control group (p = 0.52). The mean dosage of propofol required to maintain satisfactory GA was significantly less in the "treatment" group (89.8 mcg/kg/min) as compared to the "control" group (mean 126 mcg/kg/min) (p = 0.0007). Likewise, remifentanil dosage was significantly less in the "treatment" group (100 ng/kg/min) as compared to controls (259 ng/kg/min) (p = 0.00007). The mean non-invasive blood pressure was consistently lower during surgery in the "treated" group, and showed less intra-operative variation. After surgery, the patients receiving LA had a significantly shorter extubation time (mean time 6.0 min in "treated" group, 12.1 min in "controls"; P < 0.0002) and also significantly lower pain scores at 10, 30, 60, 120 and 180 min after extubation (p < 0.01, p < 0.01, p < 0.01, p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

Ipsilateral infiltration of local anaesthesia containing epinephrine in the paranasal tissues just prior to open dacryocystorhinostomy under total intravenous anaesthesia is associated with a 28% reduction in mean propofol usage, and a 61% reduction in remifentanil usage. LA usage during GA also produces improved and less variable intra-operative mean blood pressures, a significantly shorter extubation time and significantly lower postoperative pain scores.

Carotid Access for Aortic Interventions: Genius or Madness?

The endovascular-first approach remains is omnipresent ubiquitous amongst in the vascular community today. However, several key issues have ensued remain, one of which involves the choice of vessel site. Although the transfemoral route is the first-line approach has been established as first-line approach in endovascular interventions of the aorta (endovascular aortic repair [EVAR], thoracic endovascular aortic repair [TEVAR], and transcatheter aortic valve implantation [TAVI]), there remains a select some group of patients who are contraindicated for the aforementioned this as well as for alternatives vessel routes such as the transapical approach. The carotid artery, first used in aortic aneurysm repair, is potential alternative for these patients. Emerging evidence appears to support this relatively unpopular approach in EVAR, TEVAR and TAVI. Sporadic case reports and series have reported the transcarotid approach for EVAR and TEVAR, and collectively show relatively low rates of mortality and neurological complications. For TAVI, the carotid artery appears to be a safe and effective route of access compared to the transapical and even the transfemoral approach. However, technical aspects have not been ironed out; there are procedural variations, for example, in type of anaesthesia used, intraoperative neurological monitoring and choice of common carotid artery. The overall quality of evidence is poor, since the majority of it consists of case reports, and retrospective and prospective cohort studies. Although a randomised controlled trial (RCT) is needed to compare the transcarotid against the transfemoral approach, this is unlikely to take place because of ethical considerations. Therefore, the authors recommend future research to consider cohort studies with adequately powered sample sizes to establish any firm conclusions. However, as transcarotid procedures are performed infrequently, most institutions will have relatively small sample sizes. Therefore, it is recommended that collaborative efforts are undertaken to increase the overall sample size in the cohort analysis.

Ultrasound-guided superficial cervical plexus block under dexmedetomidine sedation versus general anesthesia for carotid endarterectomy: a retrospective pilot study

Background

Carotid endarterectomy (CEA) has been performed under regional and general anesthesia (GA). The general anesthesia versus local anesthesia for carotid surgery study compared the two techniques and concluded that there was no difference in perioperative outcomes. However, since this trial, new sedative agents have been introduced and devices that improve the delivery of regional anesthesia (RA) have been developed. The primary purpose of this pilot study was to compare intraoperative hemodynamic stability and postoperative outcomes between GA and ultrasound-guided superficial cervical plexus block (UGSCPB) under dexmedetomidine sedation for CEA.

Methods

Medical records from 43 adult patients who underwent CEA were retrospectively reviewed, including 16 in the GA group and 27 in the RA group. GA was induced with propofol and maintained with sevoflurane. The UGSCPB was performed with ropivacaine under dexmedetomidine sedation. We compared the intraoperative requirement for vasoactive drugs, postoperative complications, pain scores using the numerical rating scale, and the duration of hospital stay.

Results

There was no difference between groups in the use of intraoperative antihypertensive drugs. However, intraoperative inotropic and vasopressor agents were more frequently required in the GA group (p<0.0001). In the GA group, pain scores were significantly higher during the first 24 h after surgery (p<0.0001 between 0-6 h, p<0.004 between 6-12 h, and p<0.001 between 12-24 h). The duration of hospital stay was significantly more in the GA group (13.3±4.6 days in the GA group vs. 8.5±2.4 days in the RA group, p<0.001).

Conclusion

In this pilot study, intraoperative hemodynamic stability and postoperative outcomes were better in the RA compared to the GA group.

[Regional anesthesia for carotid surgery : An overview of anatomy, techniques and their clinical relevance]

BACKGROUND

Perioperative care for patients undergoing carotid endarterectomy (CEA) often presents a challenge to the anesthesia provider, as this patient group commonly suffers from a wide range of comorbidities. Although clinical trials could not demonstrate a significant benefit associated with regional anesthesia for outcomes such as insult, cardiac infarction or mortality, many authors concur that regional anesthetic techniques might be preferential in specific patient populations for this type of surgery.

OBJECTIVES

This article aims to present an overview of the currently used techniques for regional anesthesia in CEA, as well as discussing their influence on the perioperative outcome.

MATERIALS AND METHODS

After performing an extensive search of medical databases (Pubmed/Medline) the authors present a narrative analysis and interpretation of recent literature.

RESULTS

Currently there is a clear trend towards ultrasound guided regional anesthesia and away from classic landmark based techniques. The literature seems to support the notion that superior and intermediate cervical blocks are safer and less invasive than deep blocks.

CONCLUSIONS

With regional anesthetic techniques evolving to be more and more complex, the use of ultrasound is becoming increasingly indispensable in the operating theatre. For anesthesiologists with sufficient training and a profound knowledge of the respective anatomy, regional anesthesia seems to be a veritable alternative to general anesthesia for CEA.

Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

OBJECTIVE

Carotid endarterectomy (CEA) is usually performed under general anesthesia (GA), although some advocate regional anesthesia (RA) to reduce hemodynamic instability and allow neurologic monitoring and selective shunting. RA does not reduce risk of periprocedural stroke or death, although some series show a reduction in myocardial infarction (MI). We investigated the association of anesthesia type and periprocedural MI among patients receiving GA or RA for CEA and patients undergoing carotid artery stenting (CAS) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).

METHODS

Between 2000 and 2008, 1151 patients underwent CEA (anesthetic type available for 1149 patients), and 1123 patients underwent CAS ≤30 days of randomization in CREST. CEA patients were categorized by anesthetic type (GA vs RA). CREST defined protocol MI as chest pain or electrocardiogram change plus biomarker evidence of MI, and total MI was defined as protocol MI plus biomarker-positive (+)-only MI. The incidence of protocol MI and total MI in patients undergoing CEA under GA and RA were compared with those undergoing CAS. Other study end points were similarly compared. Differences in baseline characteristics and periprocedural events were evaluated among the three groups. Logistic regression, adjusting for age and symptomatic status, was used to assess group differences.

RESULTS

The three groups had similar demographic risk factors, except for prevalence of symptomatic carotid stenosis, which was lowest in the CEA-RA group (P = .03). Of the 111 patients in the CEA-RA group, no protocol MIs occurred and only two biomarker+-only MIs, for an overall incidence of 1.8%, similar to the 1.7% overall incidence in patients undergoing CAS. In contrast, the combined incidence of protocol and biomarker+-only MIs in the 1038 patients in the CEA-GA group was significantly higher at 3.4% (P = .04), twice the risk of protocol MI and biomarker+-only MI compared with those undergoing CAS (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.14-3.54). Direct comparison of the MI incidence between CEA-RA and CEA-GA showed no statistical difference. Patients undergoing CEA-GA had lower odds of a periprocedural stroke (OR, 0.48; 95% CI, 0.28-0.79) and stroke or death (OR, 0.46; 95% CI, 0.27-0.76) compared with those undergoing CAS but were not significantly different from those undergoing CEA-RA.

CONCLUSIONS

Patients in CREST undergoing CEA-RA had a similar risk of periprocedural MI as those undergoing CAS, whereas the risk for CEA-GA was twice that compared with patients undergoing CAS. Nevertheless, because periprocedural MI is one of the few variables favoring CAS over CEA and has been associated with decreased long-term survival, RA should be seriously considered for patients undergoing CEA.

Selective Carotid Shunting Based on Intraoperative Transcranial Doppler Imaging during Carotid Endarterectomy: A Retrospective Single-Center Review

Background

Carotid endarterectomy (CEA) with selective shunting is the surgical method currently used to treat patients with carotid artery disease. We evaluated the incidence of major postoperative complications in patients who underwent CEA with selective shunting under transcranial Doppler (TCD) at our institution.

Methods

The records of 45 patients who underwent CEA with TCD-based selective shunting under general anesthesia from November 2009 to June 2015 were reviewed. The risk factors for postoperative complications were analyzed using univariate and multivariate analysis.

Results

Preoperative atrial fibrillation was observed in three patients. Plaque ulceration was detected in 10 patients (22.2%) by preoperative computed tomography imaging. High-level stenosis was observed in 16 patients (35.5%), and 18 patients had contralateral stenosis. Twenty patients (44.4%) required shunt placement due to reduced TCD flow or a poor temporal window. The 30-day mortality rate was 2.2%. No cases of major stroke were observed in the 30 days after surgery, but four cases of minor stroke were noted. Univariate analysis showed that preoperative atrial fibrillation (odds ratio [OR], 40; p=0.018) and ex-smoker status (OR, 17.5; p=0.021) were statistically significant risk factors for a minor stroke in the 30-day postoperative period. Analogously, multivariate analysis also found that atrial fibrillation (p<0.001) and ex-smoker status (p=0.002) were significant risk factors for a minor stroke in the 30-day postoperative period. No variables were identified as risk factors for 30-day major stroke or death. No wound complications were found, although one (2.2%) of the patients suffered from a hypoglossal nerve injury.

Conclusion

TCD-based CEA is a safe and reliable method to treat patients with carotid artery disease. Preoperative atrial fibrillation and ex-smoker status were found to increase the postoperative risk of a small embolism leading to a minor neurologic deficit.

Randomized controlled trials: still the backbone of vascular surgery?

Prior to the introduction of evidence-based medicine, decision-making was largely based upon ‘intuitive reasoning’, whereby senior clinicians dictated practice based upon personal dogma, personal experience and (often) biased observational studies. This era began to end (in vascular surgery) following completion of the landmark randomized trials in carotid disease, which recruited patients throughout the 1980s. Despite scepticism amongst some surgeons of the time these particular randomized trials have stood the test of time and remain the cornerstone of virtually every guideline of practice to this day. The carotid randomized trials became a beacon for using ‘evidence’ rather than ‘intuitive reasoning’ and randomized trials have now been used to determine optimal practice in a plethora of carotid surgery and stenting trials, lower limb revascularization and numerous aortic aneurysm based studies.

The literature abounds with situations where practice (previously based on observational study data) was changed overnight following publication of a well-designed randomized trial. However, while observational studies are prone to selection bias, randomized trials bring their own unique limitations including problems with external validity, they take too long to complete, they are very expensive, they are notorious for problems with recruitment and they can frequently become obsolete. This has led to a (not unreasonable) call for more observational studies to be used in the development of practice guidelines. Unfortunately, the principle guideline bodies around the world, e.g. National Institute for Health and Care Excellence (NICE) and the American Heart Association (AHA), prioritize randomized trial evidence above all else. Until that changes, guideline makers will find it very difficult to deviate from using historical randomized trial evidence, even when high quality observational data suggest that ‘real world’ practice bears little comparison to that reported in the randomized trials. Nowhere is that more evident than in developing contemporary guidelines for the management of asymptomatic carotid disease.

Carotid Endarterectomy: Current Concepts and Practice Patterns

Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.

Systematic Review and Meta-Analysis of Carotid Artery Stenting Versus Endarterectomy for Carotid Stenosis: A Chronological and Worldwide Study

There are disparities among the results of meta-analyses under different circumstances of carotid artery stenting (CAS) versus endarterectomy (CEA) for carotid stenosis. This study aimed to assess the efficacies of CAS and CEA for carotid stenosis at 5-year intervals and worldwide.Comparative studies simultaneously reporting CAS and CEA for carotid stenosis with at least 10 patients in each group were identified by searching PubMed and Embase in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines, and by reviewing the reference lists of retrieved articles.The studies were stratified into different subgroups according to the publication year, location in which the study was mainly performed, and randomized and nonrandomized study designs.Thirty-five comparative studies encompassing 27,525 patients were identified. The risk ratios (RRs) of stroke/death when CAS was compared with CEA within 30 d of treatment were 1.51 (95% CI 1.32-1.74, P < 0.001) for overall, 1.50 (95% CI 1.14-1.98, P = 0.004) from 2011 to 2015, 1.61 (95% CI 1.35-1.91, P < 0.001) from 2006 to 2010, 1.59 (95% CI 1.27-1.99, P < 0.001) in North America, 1.50 (95% CI 1.24-1.81, P < 0.001) in Europe, 1.63 (95% CI 1.31-2.02, P < 0.001) for randomized, and 1.44 (95% CI 1.20-1.73, P < 0.001) for nonrandomized comparative studies. CEA decreased the risks of transient ischemic attack at 30 d (RR: 2.07, 95% CI 1.50-2.85, P < 0.001) and restenosis at 1-year (RR: 1.97, 95% CI 1.28-3.05, P = 0.002). Data from follow-up showed that the RRs of stroke/death were 0.74 (95% CI 0.55-0.99, P = 0.04) at 1 year, 1.24 (95% CI 1.04-1.46, P = 0.01) at 4 year, and 2.27 (95% CI 1.39-3.71, P = 0.001) at 10 year. This systematic review, compared with those of other meta-analyses, included all available comparative studies and analyzed them at 5-year intervals, in different continents, and under different study designs. Current evidence suggests that the efficacy of CEA is superior to CAS for freedom from stroke/death within 30 d, especially from 2006 to 2015, in North America and Europe. Meanwhile, the superiority was also observed for restenosis at 1-year, transient ischemic attack within 30 d, and stroke/death at 4- and 10-year follow-ups.

Local anaesthetic infiltration at the end of carotid endarterectomy improves post-operative analgesia

BACKGROUND

Wound infiltration at the end of carotid endarterectomy under general anaesthesia is a simple technique that can be delegated to the surgeon. It was hypothesised that this technique could improve early post-operative analgesia by reducing the need for post-operative opioids.

METHODS

Forty patients underwent carotid endarterectomy under general anaesthesia with desflurane and remifentanil supplemented with morphine for post-operative analgesia. In a prospective double-blinded randomised study, patients were allocated pre-operatively to receive either subcutaneous infiltration of both wound edges with 20 ml of 0.75% ropivacaine or infiltration with isotonic saline. The primary outcome was morphine consumption while in the post-anaesthesia care unit (PACU). Pain scores at rest and movement, sedation, and patient satisfaction were the other main outcomes used to assess post-operative analgesia.

RESULTS

The median dose of morphine administered in the PACU was 2 mg [0-3] in the ropivacaine vs. 4 mg [3-6] in the placebo group (P = 0.0004, Mann-Whitney's test). Pain at rest and at movement was lower in the ropivacaine group throughout observation in the PACU. No difference was found for both pain and opioid consumption after discharge from the PACU or for patient satisfaction. Sedative events in the early post-operative period were less frequent in the ropivacaine group.

CONCLUSIONS

Local anaesthetic wound infiltration performed before closure reduces the need for additional opioids, lowers the immediate post-operative pain and improves alertness. These results argue for the use of local infiltration anaesthesia for carotid endarterectomy.

Intraoperative management of carotid endarterectomy

First reports on surgical treatment of cerebrovascular atherosclerosis date to the early 1950s. With advancements in surgical technique, carotid endarterectomy (CEA) has become the treatment of choice for patients with both symptomatic and asymptomatic severe carotid stenosis. Given the benefits that surgery offers beyond medical management, the number of CEA procedures continues to increase. The intraoperative management of patients undergoing CEA is challenging because of the combination of patient and surgical factors. This article explores and reviews the literature on anesthetic management and considerations of patients undergoing CEA.

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

BACKGROUND

Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. This may improve outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2009.

OBJECTIVES

To assess the effect of routine versus selective or no shunting during carotid endarterectomy, and to assess the best method for selecting people for shunting.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 8), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013) and Index to Scientific and Technical Proceedings (1980 to August 2013). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed the searches and applied the inclusion criteria. For this update, we identified two new relevant randomised controlled trials.

MAIN RESULTS

We included six trials involving 1270 participants in the review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. In general, reporting of methodology in the included studies was poor. For most studies, the blinding of outcome assessors and the report of prespecified outcomes were unclear. For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. No significant difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring, However, this analysis was inadequately powered to reliably detect the effect. There was no significant difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited.

AUTHORS' CONCLUSIONS

This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. Large scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.