Is contralateral carotid artery occlusion a risk factor for carotid endarterectomy?

The Effect of Severe Contralateral Carotid Stenosis or Occlusion on Early Outcomes after Carotid Endarterectomy

BACKGROUND: Stenosis of the carotid arteries, as a consequence of atherosclerosis is the most common cause of cerebrovascular insult (CVI). Severe (>70%) contralateral stenosis or occlusion (SCSO) of the carotid artery may represent an additional pre-operative risk factor  for neurologic incidents.             AIM: The aim of this study was to confirm and compare early perioperative results (0-30 days) of carotid endarterectomy (CEA) in patients with and without SCSO.                 PATIENT AND METHODS: In our retrospective-prospective study, we analysed the results of 273 CEA, divided into two groups based on the presence of significant contralateral stenosis or occlusion (non-SCSO and SCSO groups)             RESULTS: 273 CEA’s were performed, divided into two groups: SCSO groups 40 (14.7%) and non-SCSO group 233 (85.3%). Between the two groups, a statistically significant difference between patients was found (54.1% compared to 87.5%; p<0.0005), CEA with patch angioplasty (25.3% compared to 52.5%; p=0.001),  and CEA with the use of a shunt (3.9% compared to 35%; p<0.0005) in favour of the SCSO group. There was no statistically significant difference (SCSO was not identified as a risk factor) for any type of stroke or mortality. Logistically regression confirmed SCSO to be an independent predictor of 30-day mortality (OR 21.58; 95% CI  1.27-36.3; p= 0.033) and any type of stroke or mortality (OR 9.27; 95% CI  1.61-53.22; p= 0.012). SCSO was not a predictor of any type of stroke within 30 days. Predictors of any type of stroke was dyslipidemia (OR 0.12, 95% CI  0.02-0.76; p= 0.024).             CONCLUSIONS: There was no statistically significant difference in the incidence of early (30 day) perioperative complications between the analysed groups. The percentage of perioperative complications remains within the accepted parameters, and thus, SCSO should not be qualified as a significant risk factor for CEA. We are of the opinion that CEA remains a safe and acceptable options for patients with SCSO, and SCSO should not be a reason for preferential use of carotid stenting.

Outcomes of Carotid Revascularization in Patients with Contralateral Carotid Artery Occlusion

BACKGROUND

Little is known about the best revascularization procedure for patients with contralateral carotid artery occlusion (CCO). We aim to compare the outcomes of transcarotid artery revascularization (TCAR), carotid endarterectomy (CEA), and transfemoral carotid artery stenting (TFCAS) in patients with CCO.

STUDY DESIGN

Patients in the Vascular Quality Initiative dataset who underwent CEA, TFCAS, or TCAR, and had CCO between September 2016 and April 2020, were included. Multivariable logistic analysis was used to evaluate in-hospital outcomes.

RESULTS

The final cohort included 1,144 TCARs, 1,182 TFCAS, and 2,527 CEA procedures performed in patients with CCO. Compared with TFCAS, TCAR was associated with a significant reduction in the odds of in-hospital stroke or death (odds ratio [OR] 0.26; 95% CI: 0.12-0.59; p < 0.01). However, no significant difference in stroke was noted (OR 0.71; 95% CI 0.34-1.51; p = 0.38). These results persisted after stratifying with respect to symptomatic status (p values of interaction = 0.92 and 0.74, respectively). There was no significant difference between TCAR and CEA in odds of in-hospital stroke or death on multivariable adjustment (OR 0.57; 95% CI: 0.29-1.10, p = 0.10). The interaction between procedure type and symptomatic status in predicting in-hospital stroke was statistically significant (p = 0.04). In asymptomatic patients, TCAR was associated with a 50% to 60% reduction in the odds of stroke (p = 0.04). Yet, no significant differences were observed in symptomatic patients.

CONCLUSIONS

TCAR has lower odds of in-hospital stroke or death compared to TFCAS, independent of symptomatic status. Compared to CEA, TCAR seems to be a better option in asymptomatic patients, with lower odds of in-hospital stroke. Yet, no significant difference is observed in symptomatic patients.

The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database

Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.

[Carotid endarterectomy in patients with symptomatic occlusions of the contralateral internal carotid artery]

The main aim of the study was to investigate the effect of carotid endarterectomy on the prognosis of chronic cerebral ischemia in patients with symptomatic occlusions of the contralateral internal carotid artery, assess risks of surgical complications, and substantiate the staged surgical approach for treatment of patients with this pathology. The article analyzes the experience in surgical treatment of 83 patients with symptomatic ICA occlusions who underwent surgery for contralateral carotid artery stenosis. In 40 patients, only carotid endarterectomy (CEA) was performed on the side of hemodynamically significant stenosis (group 1). In 43 (52%) cases, apart from CEA, extracranial-intracranial (EC-IC) bypass was performed at the second stage (23 cases, group 2) or the first stage (19 cases, group 3). A surgical treatment approach was chosen based on clinical symptoms, severity of contralateral carotid artery stenosis, and the magnitude of perfusion deficiency in the territory of carotid occlusion. The conducted analysis revealed that patients with symptomatic occlusions and contralateral carotid artery stenoses represented a heterogeneous group with a different efficacy of carotid endarterectomy and with risks of perioperative complications. As cerebrovascular insufficiency in the territory of carotid occlusion and a related neurological deficit worsen, the risks of complications of contralateral carotid endarterectomy increase, and its clinical efficacy decreases. In these cases, cerebral revascularization on the ICA occlusion side should be performed at the first stage.

The influence of contralateral occlusion on results of carotid interventions from the Society for Vascular Surgery Vascular Registry

OBJECTIVE

Data on the influence of contralateral carotid occlusion (CCO) on carotid endarterectomy (CEA) are conflicting and are absent for carotid artery stenting (CAS). This study evaluated the influence of CCO on CEA and CAS.

METHODS

We evaluated patients with and without CCO in the Society for Vascular Surgery Vascular Registry. Primary outcome was a composite of periprocedural death, stroke, or myocardial infarction (MI) (major adverse cardiovascular events [MACE]) and its individual components. Further analysis was done to identify the influence, if any, of symptom status on outcomes.

RESULTS

There were 1128 CAS and 666 CEA patients with CCO. CAS patients were more often symptomatic with a greater incidence of coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and New York Heart Association class >III. Absolute risk of periprocedural MACE (2.7% for CAS vs. 4.2% for CEA), death (1.1% for CAS vs. 0.7% for CEA), stroke (2.1% for CAS vs. 3.1% for CEA), and MI (0.3% for CAS vs. 0.6% for CEA) was statistically equivalent for both. This equivalence was maintained when patients with CCO were segregated according to symptom status and after adjusting for periprocedural risk. There were 16,646 patients without contralateral occlusion (5698 CAS; 10,948 CEA). Patients without contralateral occlusion with CEA have better outcomes in periprocedural MACE (1.8% for patients without contralateral occlusion vs 4.2% for patients with CCO), and stroke (1.1% for patients without contralateral occlusion vs. 3.1% for patients with CCO) (P < .0001 for both). In CAS patients, CCO did not significantly affect periprocedural MACE (3.2% for patients without contralateral occlusion vs. 2.7% for patients with CCO), death (0.8% for patients without contralateral occlusion vs. 1.0% for patients with CCO), stroke (2.3% for patients without contralateral occlusion vs. 2.1% for patients with CCO), or MI (0.6% for patients without contralateral occlusion vs. 0.3% for patients with CCO). In CEA patients, CCO increased MACE, primarily by increasing stroke rates in asymptomatic (0.7% vs. 2.0%; P = .0095) and symptomatic (1.7% vs. 4.9%; P = .0012) patients.

CONCLUSIONS

Although CEA is preferred in patients without contralateral occlusion, regardless of symptom status, based on lower rates of periprocedural MACE, death, and stroke, the benefit of CEA is lost in patients with CCO because of increased stroke rates in CCO patients after CEA but not after CAS regardless of symptom status. The results of CAS and CEA in patients with CCO are equivalent and within acceptable American Heart Association guidelines.

Stroke prevention-surgical and interventional approaches to carotid stenosis

Extracranial carotidartery stenosis is an important cause of stroke that often needs treatment with carotid revascularization. To prevent stroke recurrence, carotid endarterectomy has been well-established for many years in treating symptomatic high- and moderate-grade stenosis. Carotid stenting is an appealing, less invasive alternative to carotid endarterectomy, and several recent trials have compared the efficacy of the 2 procedures in patients with carotid stenosis. Carotid artery stenting has emerged as an important mode of therapy for high-risk patients with symtomatic high-grade stenosis. This review focuses on the current data available that will enable the clinician to decide optimal treatment strategies for patients with carotid stenosis.

Contralateral internal carotid artery occlusion impairs early but not 30-day stroke rate following carotid endarterectomy

Neurological complications and mortality within 30 days following carotid endarterectomy (CEA) alone or with concomitant cardiac surgery/cardiopulmonary bypass (CPB) were assessed in patients with or without contralateral occlusion of the internal carotid artery (CO-ICA).Of 335 patients undergoing CEA, 173 underwent concomitant cardiac surgery with CPB. Group A consisted of 260 patients without CO-ICA and group B of 75 patients with CO-ICA. The neurological complications (peripheral nerve damage, transient ischemic attack [TIA], prolonged reversible ischemic neurological deficit [PRIND], and stroke) and the Rankin index within 24 hours and 30 days postoperatively were compared. Strokes within 24 hours were significantly increased (P = .006) in group B (11%) compared with A (3.1%); TIA and PRIND did not differ (P = .33). The overall neurological complications and in particular for peripheral neurological damage, TIA/PRIND, and stroke did not differ within the 30-day-period postsurgery. A significantly higher stroke rate within 24 hours postsurgery occurred in patients with CO-ICA.

Delayed postconditioning protects against focal ischemic brain injury in rats

Background

We and others have reported that rapid ischemic postconditioning, interrupting early reperfusion after stroke, reduces infarction in rats. However, its extremely short therapeutic time windows, from a few seconds to minutes after reperfusion, may hinder its clinical translation. Thus, in this study we explored if delayed postconditioning, which is conducted a few hours after reperfusion, offers protection against stroke.

Methods and Results

Focal ischemia was generated by 30 min occlusion of bilateral common carotid artery (CCA) combined with permanent occlusion of middle cerebral artery (MCA); delayed postconditioning was performed by repetitive, brief occlusion and release of the bilateral CCAs, or of the ipsilateral CCA alone. As a result, delayed postconditioning performed at 3h and 6h after stroke robustly reduced infarct size, with the strongest protection achieved by delayed postconditioning with 6 cycles of 15 min occlusion/15 min release of the ipsilateral CCA executed from 6h. We found that this delayed postconditioning provided long-term protection for up to two months by reducing infarction and improving outcomes of the behavioral tests; it also attenuated reduction in 2-[¹⁸F]-fluoro-2-deoxy-D-glucose (FDG)-uptake therefore improving metabolism, and reduced edema and blood brain barrier leakage. Reperfusion in ischemic stroke patients is usually achieved by tissue plasminogen activator (tPA) application, however, t-PA's side effect may worsen ischemic injury. Thus, we tested whether delayed postconditioning counteracts the exacerbating effect of t-PA. The results showed that delayed postconditioning mitigated the worsening effect of t-PA on infarction.

Conclusion

Delayed postconditioning reduced ischemic injury after focal ischemia, which opens a new research avenue for stroke therapy and its underlying protective mechanisms.

Protective effects of ischemic postconditioning compared with gradual reperfusion or preconditioning

We examined the temporal factors of postconditioning, assessed whether gradual reperfusion reduces infarcts, and compared postconditioning's protection with that of both rapid and delayed preconditioning. Focal ischemia was generated by permanent occlusion of the left distal middle cerebral artery (dMCA) combined with 30 min of occlusion of both common carotid arteries (CCA) in rats. Postconditioning was performed by repetitive brief release and occlusion of CCA after 30 min of CCA occlusion. Gradual reperfusion was generated by controlled release of the bilateral CCA. We confirmed that postconditioning disrupted the early reperfusion but improved cerebral blood flow (CBF) thereafter. Postconditioning with three cycles, but not with 10 cycles, of 30 sec CCA release and 10 sec CCA occlusion (30s/10s) reduced infarction measured at 2 days after stroke. In addition, postconditioning with 10 cycles, but not with three cycles, of 10s/10s reduced infarction but it lost protection when initiated at 3 min after reperfusion. In addition, gradual reperfusion also reduced infarction. Moreover, both rapid and delayed preconditioning conducted 60 min and 3 days before stroke reduced infarct sizes. However, no additional protection was detected when postconditioning was combined with either rapid or delayed preconditioning. In conclusion, gradual reperfusion reduced infarction; postconditioning's protection depended on the number of cycles and duration of each cycle of reperfusion and occlusion and the onset time of postconditioning; postconditioning's protection was comparable to that of rapid preconditioning but not as robust as that of delayed preconditioning.

Surgery Insight: carotid endarterectomy--which patients to treat and when?

Over the past 15 years, we have witnessed a resurgence of surgery for prevention of ischemic stroke. Landmark trials including the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial have explored the role of carotid endarterectomy in this context, comparing the procedure with best medical treatment in patients with high-grade stenosis of the internal carotid artery and transient ischemic attack or minor nondisabling stroke in the same territory. Here, we discuss the lessons learnt from these trials, and review the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trial, which attempted to resolve the rather vexing issue of surgical treatment for patients with asymptomatic internal carotid artery stenosis. We also review the best medical treatment for patients undergoing carotid endarterectomy in the perioperative period, and examine the risk of ischemic stroke after CABG surgery, both when this procedure is performed alongside endarterectomy and when CABG surgery and endarterectomy are performed as a two-staged procedure.

Análise crítica das indicações e resultados do tratamento cirúrgico da doença carotídea

O tratamento da doença carotídea tem ganhado enfoque nos últimos anos, principalmente com o advento da técnica endovascular, que defende o emprego da angioplastia e stent de carótida (CAS), principalmente em pacientes considerados de "alto risco" para a endarterectomia carotídea (ECA). Através da revisão bibliográfica, analisamos os resultados do tratamento da lesão carotídea em ambas as técnicas, realizando comentários embasados na experiência pessoal e nos dados da literatura, sobretudo nos pacientes de alto risco. Até o presente momento, não há evidência e justificativa para o emprego da CAS em larga escala nos pacientes com doença carotídea, inclusive nas situações de alto risco, tais como nos octogenários. No entanto, acreditamos que a CAS possa ser um coadjuvante no tratamento de pequeno número de pacientes com lesão carotídea (até 4% dos casos), como na presença de pescoço hostil, radioterapia prévia e alguns casos de estenose carotídea alta. Quando realizada com os cuidados técnicos necessários, a ECA ainda continua a melhor opção terapêutica aos doentes com lesão carotídea.

Multidetector-row CT angiography in the study of atherosclerotic carotid arteries

Pathologies of the carotid arteries, and in particular atherosclerosis, are now an important medical problem. Stroke is the third leading cause of severe disability in the Western World leading to millions of deaths every year. Extracranial carotid atherosclerotic disease is the major risk factor for stroke. In years, with the advent of multidetector-row CT (MDCT) scanners and the use of specific angiographic protocols (MDCTA), CT imaging of the carotid arteries has become increasingly effective. In addition, the volume data obtained can be further rendered to generate high-quality two-dimensional and three-dimensional images. The purpose of this study was to review the atherosclerotic carotid arteries, their complications and how MDCTA depicts them, underlining the benefits and pitfalls of this diagnostic technique.

Carotid artery stenting with filter protection in high-risk patients showing severe electroencephalographic alterations during carotid endarterectomy

PURPOSE

To describe the results and efficacy of stent treatment in patients with carotid stenosis who had aborted carotid endarterectomy procedures due to the appearance of severe electroencephalographic (EEG) alterations.

METHODS

A retrospective study was conducted of 18 patients (11 men; mean age 72 years, range 62-84) with symptomatic high-grade carotid artery stenoses (> or = 70%) who experienced severe EEG alterations during carotid endarterectomy, causing the procedure to be aborted. Twelve patients had shown no hemodynamic alterations during preoperative transcranial Doppler evaluation after external compression of the common carotid artery; the remaining 6 could not be evaluated. The patients were referred for carotid artery stenting (CAS); 7 had contralateral internal carotid artery stenosis and 5 had contralateral occlusion. Endovascular intervention was carried out using standard techniques under filter protection. Follow-up was scheduled at 3, 6, and 12 months.

RESULTS

All patients were successfully treated without immediate complications. The EEG did not display any significant alterations during the endovascular procedure. Mean follow-up was 43 months. Magnetic resonance imaging at 6 months showed no signs of cerebral ischemia. Color Doppler ultrasound imaging documented normal stent patency in all patients.

CONCLUSION

Patients with symptomatic severe carotid stenosis (> or = 70%) who are considered at risk due to the appearance of severe EEG alterations during surgical treatment may benefit from CAS with respect to both major and minor complications. Larger studies are needed to confirm these findings.