Suggested standards for reports dealing with cerebrovascular disease

Cranial nerve injuries post carotid endarterectomy: a 15-year prospective study with routine otolaryngologist and neurological evaluation

OBJECTIVE

The aim of this prospective monocentric cohort study was to analyze the risk of otolaryngologist-assessed cranial nerve injuries (CNIs) following carotid endarterectomy (CEA) in our academic center during a 15-year period, and to identify possible risk factors for CNI development.

METHODS

From January 2007 to December 2022, 3749 consecutive CEAs were performed and their data prospectively recorded in a dedicated database. CNIs were assessed and defined according to a standardized protocol. Instrumental ear, nose, and throat (ENT) evaluations were conducted within 30 days before intervention and before discharge. Preoperative neurological assessments were carried out in all patients with symptomatic carotid stenosis, whereas postoperative neurological evaluations were performed in all patients. Patients with newly onset CNIs underwent follow-up assessments at 30 days and, if necessary, at 6, 12, and 24 months. Perioperative results, including mortality, major central neurological events, and postoperative CNIs, were analyzed. Regression or persistence of lesions during follow-up visits was assessed, and multivariate analysis (binary logistic regression) was conducted to evaluate clinical, anatomical, and surgical technique factors influencing the occurrence of CNIs.

RESULTS

CEAs were performed more frequently in male patients (2453 interventions; 65.5%) than in females (1296 interventions; 34.5%). The interventions were performed in asymptomatic patients in 3078 cases (82%). In 66 cases, the interventions followed a previous ipsilateral CEA. At preoperative ENT evaluation, no cases of ipsilateral pre-existent CNI were recorded. The 30-day stroke and death rate was 1%. In 113 patients (3%), a postoperative neck bleeding requiring surgical revision and drainage was noted. Pre-discharge ENT evaluations identified 259 motor CNIs, accounting for 6.9% of the entire study group. Eighteen patients had lesions in more than one cranial nerve. ENT and neurological evaluations at 30 days showed the complete resolution of 161 lesions, whereas in 98 cases (2.6%), the CNI persisted. At 1 year, the rate of persistent CNI was 0.4% (10 patients), whereas at 2 years, it was 0.25% (6 cases), in all but one asymptomatic. At multivariate analysis, urgent intervention in unstable patients, secondary intervention, a clamping time >40 minutes, a hematoma requiring revision, and a postoperative stroke were independent predictors of CNIs.

CONCLUSIONS

Data from this prospective monocentric cohort study showed that the occurrence of CNI following CEA was low, even when an independent multi-specialist evaluation was performed. The percentage of persistent lesions at 2 years was negligible and, in most cases, asymptomatic.

Natural History of Symptomatic and Asymptomatic Carotid Artery Occlusion Contralateral to Carotid Endarterectomy: A Prospective Study

The natural history of carotid occlusion (CO) has generally been analyzed in the presence of a contralateral patent but diseased internal carotid artery (ICA). Few previous studies have focused on the fate of CO contralateral to the side of a prior carotid endarterectomy (CEA). The aim of this study was to analyze the mortality rate and the incidence of cerebrovascular events in the hemisphere ipsilateral to CO (HICO) in patients who had undergone contralateral CEA. The 30-day and long-term outcomes of 153 consecutive patients who had CEA for severe symptomatic and asymptomatic ICA lesions contralateral to a symptomatic or asymptomatic CO over a 15-year period were considered. The endpoints of the study were mortality and neurological events in the HICO. Overall, the 30-day mortality and stroke rates were 0.6% (1/153) and 1.9% (3/153), respectively; the only death was stroke-related and the stroke was ipsilateral to the operated side. The other 2 strokes were ipsilateral to a symptomatic CO. The follow-up was completed for all patients (mean, 7.7 years; range, 1-172 months). Overall, there were 4 late strokes (2.6%), one of them lacunar in a patient with a symptomatic CO, whereas the other 3 were atheroembolic and ipsilateral to the operated ICA. The risk of late stroke in the HICO at 5 and 12 years was 2%. Overall, there were 19 late deaths, none of them stroke-related. CO, with or without symptoms, contralateral to CEA could be considered a locally benign condition in the long term.

Three-year outcomes after carotid artery revascularization: Gender-related differences

Objectives

Carotid artery stenosis is thought to cause up to 10% of ischemic strokes. Historically, carotid artery endarterectomy has shown a higher risk of perioperative adverse events for women. More recent trials reported conflicting results regarding the benefit of carotid artery endarterectomy and carotid artery stenting for men and women. The aim of the present retrospective study was to investigate the influence of gender on the short- (30 days) and long-term (3 years) outcomes of carotid artery endarterectomy and carotid artery stenting in a single centre.

Methods

From 2010 to 2017, 912 consecutive symptomatic and asymptomatic patients who underwent carotid artery endarterectomy (389, 42.7%) or carotid artery stenting (523, 57.3%) in a single institution had been evaluated to determine the influence of sex (540 men, 59.2%, vs. 372 women, 40.8%) on the outcomes after both revascularization procedures during three years of follow-up. The primary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the short-term follow-up. The secondary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the long-term follow-up.

Results

Mean clinical follow-up was 21.1 (16.1) months. Women had internal and common carotid artery diameters significantly smaller with respect to men. For peri-procedural outcomes, women undergoing carotid artery stenting had a higher risk of moderate (50–70%) restenosis (6 women, 2.9%, vs. 3 men, 1.0%). For long-term outcomes, women undergoing carotid artery endarterectomy had a higher rate of moderate restenosis (16 women, 16.3%, vs. 11 men, 7.6%). No significant differences in long-term outcomes were observed between men and women undergoing carotid artery stenting, even after stratification for baseline risk factors.

Conclusions

Contrary to previous reports, from this single-centre study, long-term risk of events seems to be higher in women who underwent carotid artery endarterectomy than in those who underwent carotid artery stenting, while fewer differences were observed in men.

Does metabolic syndrome influence short and long term durability of carotid endarterectomy and stenting?

AIMS

The metabolic syndrome (MetS) is composed of a cluster of related cardiovascular risk factors. The aim of the present study was to determine how MetS contributes to short- (30-day) and long-term complications and restenosis after carotid endarterectomy (CEA) or stenting (CAS).

METHODS

A consecutive cohort of 752 patients undergoing CEA (n = 314) and CAS (n = 438) in a single institution was examined, of which 296 (39.4%) were identified as having MetS. All patients were followed-up with carotid duplex ultrasound scan of the supraaortic vessels and a neurological assessment of symptoms status at 30-day postprocedure and at 3, 6, and 12 months, with annual follow-up thereafter for 3 years.

RESULTS

Patients with MetS had a significant increased risk in their 30-day death, major adverse events (MAE), and restenosis rates, both after CEA and after CAS (death: 0.7% vs 0.0%; MAE: 5.3% vs 2.7%; and restenosis: 1.7% vs 0.2%; p < 0.05). The MAE and restenosis rates remained statistically different at 36 months, with both procedures (29.2% vs 24.2% and 9.5% vs 3.3%, p < 0.05, for patients with and without MetS, respectively). Among the components of MetS, high fasting serum glucose, low high-density lipoprotein cholesterol, and elevated body mass index were associated with increased risk of complications at 30 days and within 36 months.

CONCLUSIONS

The current study suggested that the presence of MetS is an important risk factor for morbidity and restenosis after CEA and CAS.

Characterization and Natural History of Patients with Internal Carotid Occlusion: A Comparative Study

BACKGROUND

To characterize patients with internal carotid occlusion (ICO) with respect to demographic data, associated diseases, medical management, and risk factors and to compare these patients with those with nonsignificant stenosis (NSS; less than 50% stenosis). Secondary end points were new neurologic events, progression of contralateral degree of stenosis, cardiovascular symptoms, and death during follow-up.

METHODS

Retrospective analysis was performed using data collected from clinical records and added to a prospective database. Missing data were obtained during phone interviews or requested medical appointments.

RESULTS

From 2005 to 2013, 213 patients with ICO and 172 with NSS were studied (medium follow-up 37.81 months). Among the patients with ICO, a greater proportion were men, had a history of smoking, and presented with peripheral arterial disease and a lower creatinine clearance compared with those with NSS (P < 0.05). At the time of diagnosis, 76.1% of the patients with ICO were symptomatic compared with 35.5% of those with NSS (P = 0.000001). The patients in the ICO group exhibited significant progression of contralateral stenosis compared with those in the control group with progression on any side (15.0% vs. 2.3%, P = 0.00011). In addition, 18 patients in the ICO group (8.5%) exhibited new neurological symptoms compared with 13 (7.6%) in the NSS group (P = 0.41). When the ICO and NSS groups were combined, 10.8% of the initially symptomatic patients presented with new symptoms compared with 4.3% of those who were initially asymptomatic (P = 0.0218). The number of deaths was significantly higher among the patients in the ICO group (14.1% vs. 6.4%, P = 0.0150).

CONCLUSIONS

Patients presenting with ICO have more risk factors and higher mortality by any cause. Initially, symptomatic patients will likely present with more neurological symptoms during follow-up, independent of carotid morphology, ICO, or NSS. Efforts must be made to identify those at risk before occlusion and to prevent secondary events and death.

Is diabetes a marker of higher risk after carotid revascularization? Experience from a single centre

PURPOSE

This single centre study investigates the influence of diabetes mellitus on outcomes following carotid artery endarterectomy or stenting.

METHODS

In total, 752 carotid revascularizations (58.2% carotid artery stenting and 41.8% carotid endarterectomy) were performed in 221 (29.4%) patients with diabetes and 532 (70.6%) patients without diabetes. The study outcomes were death, disabling and non-disabling stroke, transient ischaemic attack and restenosis within 36 months after the procedure.

RESULTS

Patients with diabetes had higher periprocedural risk of any stroke or death (3.6% diabetes vs 0.6% no diabetes; p < 0.05), transient ischaemic attack (1.8% diabetes vs 0.2% no diabetes; p > 0.05) and restenosis (2.7% diabetes vs 0.6% no diabetes; p < 0.05). During long-term follow-up, there were no significant differences in Kaplan-Meier estimates of freedom from death, any stroke and transient ischaemic attack, between people with and without diabetes for each carotid artery stenting and carotid endarterectomy subgroup. Patients with diabetes showed higher rates of restenosis during follow-up than patients without diabetes (36-months estimate risk of restenosis: 21.2% diabetes vs 12.5% no diabetes; p < 0.05).

CONCLUSION

The presence of diabetes was associated with increased periprocedural risk, but no further additional risk emerged during longer term follow-up. Restenosis rates were higher among patients with diabetes.

Carotid stenting with proximal cerebral protection in symptomatic low-grade vulnerable recurrent carotid stenosis

Background

Although the management of carotid disease is well established for symptomatic lesions ⩾70%, carotid revascularization for symptomatic low-grade (⩽50%) stenosis is not actually supported by data from randomized clinical trials. Such patients may occasionally have recurrent neurological symptoms despite optimal medical treatment owing to vulnerable plaques. In such cases, carotid artery stenting (CAS) may represent an option for treatment but this has not been tested in clinical trials. This study analyzed early and long-term outcomes of CAS performed in patients with low-grade symptomatic recurrent carotid stenosis.

Methods

From a prospective registry of 322 carotid revascularization in symptomatic patients, 21 consecutive patients with low-grade symptomatic recurrent carotid stenosis who underwent CAS with proximal cerebral protection device Mo.Ma, after ruling out any other source of cerebral embolization, were involved in the study.All patients had suggestive evidence of unstable plaque or plaque ulceration.

Results

Procedural technical success rate was 100%. No 30-day stroke or death occurred, and no patients had recurrent neurological events related to the revascularized hemisphere during follow up. No 30-day local complications were reported. No late carotid occlusions were detected. There was one late death, and no stroke-related deaths. Survival rates were 100% at 1 year and 96% at 3 years.

Conclusions

This study shows that CAS is a well-tolerated, effective and durable treatment for patients with recurrent symptomatic low-grade carotid stenosis associated with a vulnerable plaque. Patients had excellent protection against further ischemic events and survived long enough.

Outcomes of mini-incision eversion carotid endarterectomy combined with nontouch isolation technique of the internal carotid artery

OBJECTIVE

We developed a mini-incision eversion carotid endarterectomy (CEA) procedure (the Jikei method CEA) to prevent perioperative embolic stroke. The aim of this study was to retrospectively analyze perioperative and midterm outcomes after the Jikei method CEA.

METHODS

We evaluated patients with the Jikei method CEA at our institution between January 2006 and June 2014. The primary end point was a major adverse event, which included death, stroke, intracranial hemorrhage, and myocardial infarction, within 30 days of CEA. Secondary end points were postoperative ipsilateral stroke and restenosis.

RESULTS

We retrospectively studied 120 lesions in 110 patients. The mean age was 72.2 ± 8.0 years. With regard to the 120 lesions, 56 lesions (46.7%) were symptomatic and 73 lesions (60.8%) showed ≥90% severe stenosis. The mean length of the skin incision was 3.2 ± 0.5 cm. The mean operative time, volume of blood loss, and internal carotid artery clamp time were 171.0 ± 50.7 minutes, 161.6 ± 110.8 mL, and 35.7 ± 10.8 minutes, respectively. There were three perioperative major adverse events (2.5%), including two strokes (1.7%) and one intracranial hemorrhage (0.8%) resulting from hyperperfusion syndrome. The median postoperative hospital stay was 6 days (range, 2-303 days). The mean follow-up was 3.9 ± 2.2 years. There was no case of ipsilateral stroke during the follow-up period. The freedom from ipsilateral stroke at 5 years was 98.3%. Three lesions (2.5%) developed restenosis. The freedom from restenosis was 97.2% at 5 years. The freedom from reintervention at 5 years was 99.0% because carotid artery stent placement was necessary in one patient with severe restenosis.

CONCLUSIONS

The Jikei method CEA was safe and effective in preventing perioperative and midterm stroke.

Cirse Quality Assurance Document and Standards for Classification of Complications: The Cirse Classification System

Interventional radiology provides a wide variety of vascular, nonvascular, musculoskeletal, and oncologic minimally invasive techniques aimed at therapy or palliation of a broad spectrum of pathologic conditions. Outcome data for these techniques are globally evaluated by hospitals, insurance companies, and government agencies targeting in a high-quality health care policy, including reimbursement strategies. To analyze effectively the outcome of a technique, accurate reporting of complications is necessary. Throughout the literature, numerous classification systems for complications grading and classification have been reported. Until now, there has been no method for uniform reporting of complications both in terms of definition and grading. The purpose of this CIRSE guideline is to provide a classification system of complications based on combining outcome and severity of sequelae. The ultimate challenge will be the adoption of this system by practitioners in different countries and health economies within the European Union and beyond.

The perioperative outcomes of eversion carotid endarterectomy in diabetic patients aged 80 years or older

BACKGROUND

Uncertainty exists about the influence of advanced age and diabetes mellitus on the clinical effect of carotid endarterectomy (CEA). This study analyzed the perioperative (30-day) outcomes of CEA in diabetic patients aged ≥80 years.

METHODS

Data of 1872 consecutive patients who underwent 2125 primary eversion CEAs from 1990 to 2014 at our institution were prospectively stored in a vascular surgery registry. Risk factors, medication, and indication for surgery were recorded. The 354 patients (387 CEAs) aged ≥80 years formed the study base; of whom, 207 (219 CEAs) were diabetic and 147 (168 CEAs) were not. A neurologist assessed all patients preoperatively, on waking from the anesthesia, and before discharge from the hospital. All procedures were eversion CEA performed by the same surgeon under general anesthesia with routine electroencephalographic monitoring for selective shunting.

RESULTS

Diabetic patients were more likely to have arterial hypertension (P = .033), cardiac disease (P = .038), peripheral aneurysmal/atherosclerotic disease (P = .046), and contralateral carotid occlusion (P = .042) than their nondiabetic counterparts. Overall, there were no deaths, two (0.51%) perioperative strokes (both in diabetic patients), and 13 nonfatal cardiac complications (3.3%), of which 10 occurred in diabetic patients, but the difference failed to reach statistical significance.

CONCLUSIONS

Findings from this study show that CEA is safe and effective for stroke prevention in diabetic patients aged ≥80 years, with a negligible incidence of perioperative adverse events and no deaths.

Treatment of Recurrent Carotid Stenosis: Angioplasty with Stenting versus Reoperative Carotid Surgery

Surgical treatment of recurrent carotid stenosis (RCS) requires additional decision making as compared with the treatment of primary carotid disease. The thromboembolic risk of the lesion may vary according to the time interval from the original carotid endarterectomy to the recurrence of stenosis. Percutaneous transluminal angioplasty with stenting (PTAS) has been offered as an alternative to reoperative carotid endarterectomy (RCEA). A retrospective analysis of a computerized registry identified 43 patients who underwent treatment for 50 recurrent carotid stenoses between 1986 and 1997, 28 by PTAS and 15 by RCEA. The time interval from previous endarterectomy until secondary treatment was less than 2 years for 16 arteries (32%) and more than 2 years for 34 arteries (68%). Indications for treatment were asymptomatic high-grade stenosis in 31 patients (72.1%), transient ischemic attack (TIA) in 10 patients (25.6%), and stroke in 1 patient (2.3%). Neurologic results in the PTAS group (28) included three patients who experienced TIAs (10.7%), five patients with strokes (17.9%), but no deaths. In the RCEA group (15), no patients experienced TIAs, one patient died from a fatal stroke (6.7%), and one patient had a cranial nerve injury (6.7%). Neurologic benefit provided by PTAS for the treatment of recurrent carotid stenosis cannot be identified when compared with RCEA in this limited series.

Impact of Carotid Endarterectomy Critical Pathway on Surgical Outcome and Hospital Stay

Carotid endarterectomy (CEA) is associated with substantial consumption of hospital days and other resources. Although surgical outcomes in their practice compared favorably with published benchmarks, the authors were concerned that postoperative stays were unnecessarily long and that patients were receiving unnecessary tests and pharmaceuticals. Recent studies suggest that within the bounds of safe practice, efforts to standardize care may increase quality and patient satisfaction and reduce consumption of resources. They examined their practice of CEA in an effort to discover the potential for quality improvement and decreased utilization of resources.

A CEA critical pathway (CP) was designed, the primary goal of which was elimination of a possibly unnecessary second postoperative hospital day for most patients and superfluous perioperative testing and medications. Data were recorded prospectively both for Pre-CP patients during the year prior to CP initiation and for subsequent CP patients during the subsequent 13-month period. CP patients were interviewed and the pathway was described prior to surgery.

Pre-CP and CP patients were indistinguishable with respect to indications for CEA and medical comorbidities. A single operative death occurred due to myocardial infarction (Pre-CP). Perioperative stroke and other complications occurred in similar numbers of Pre-CP and CP patients. CP resulted in a 0.5-day decrease in hospital stay overall. CP was also associated with a 22% decrease in direct costs. One early readmission for neck hematoma on postoperative day 2 (1 day postdischarge) might have been preventable. A second readmission on postoperative day 2 was secondary to a drug reaction and would likely have occurred prior to initiation of the CP as well.

CP resulted in significant decreases in resource utilization and with the possible exception of a single readmission did not appear to adversely affect outcome. Preoperative education and expectation that patients will be ready for discharge 1 day after CEA are critical to patient acceptance and satisfaction. Further modification of the CP may further decrease utilization of resources. CP is an excellent mechanism to understand how surgeons practice and it facilitates quality improvement.

Carotid Angioplasty: Is it Safe?

For 15 years, balloon angioplasty has been cautiously applied to carotid artery occlusive lesions. Procedural results have, by and large, been satisfactory, but the potential for significant neurologic complications and a dearth of controlled studies with long-term follow-up have impeded the development of carotid angioplasty until recently.

This review of the literature chronicles the slow but steady evolutionary pace of carotid angioplasty from its beginnings in 1980 to today's shifting focus to the use of stents. Based on these existing reports and significant personal experience, the advantages and risks of endoluminal carotid interventions are enumerated, along with suggested criteria for the application of carotid angioplasty.

Prospective randomized trial of ACUSEAL versus Vascu-Guard patching in carotid endarterectomy

BACKGROUND

Multiple studies have been conducted that demonstrate the superiority of patch angioplasty over primary closure for carotid endarterectomy (CEA). Patch angioplasty with polytetrafluorethylene patches (ACUSEAL) have shown results comparable to patch angioplasty with saphenous vein and polyester patches. This is a prospective randomized study to compare the clinical outcomes of CEA using ACUSEAL versus bovine pericardium patching (Vascu-Guard).

METHODS

Two hundred patients were randomized (1:1) to either ACUSEAL or Vascu-Guard patching. Demographic data/clinical characteristics were collected. Intraoperative hemostasis times and the frequency of reexploration for neck hematoma were recorded. All patients received immediate and 1-month postoperative duplex ultrasound studies, which were repeated at 6-month intervals. A Kaplan-Meier analysis was used to estimate the risk of restenosis and the stroke-free survival rates.

RESULTS

The demographics were similar in both groups, except for a higher incidence of current smokers in the ACUSEAL group and more patients with congestive heart failure in the Vascu-Guard group (P = 0.02 and 0.03, respectively). The mean operative internal carotid artery diameter and the mean arteriotomy length were similar in both groups. The mean hemostasis time was 4.90 min for ACUSEAL patching vs. 3.09 min for Vascu-Guard (P = 0.027); however, the mean operative times were similar for both groups (ACUSEAL 2.09 hr vs. Vascu-Guard 2.16 hr, P = 0.669). The incidence of reexploration for neck hematoma was higher in the Vascu-Guard group; 6.12% vs. 1.03% (P = 0.1183). The incidence of perioperative ipsilateral neurologic events was 3.09% for ACUSEAL patching vs. 1.02% for Vascu-Guard patching (P = 0.368). The mean follow-up period was 15 months. The respective freedom from ≥70% carotid restenosis at 1, 2, and 3 years were 100%, 100%, and 100% for ACUSEAL patching vs. 100%, 98%, and 98% for Vascu-Guard patching (P = 0.2478). The ipsilateral stroke-free rates at 1, 2, and 3 years were 96% for ACUSEAL and 99% for Vascu-Guard patching.

CONCLUSIONS

Although CEA patching with ACUSEAL versus Vascu-Guard differed in hemostasis time, the frequency of reexploration for neck hematomas was more frequent in the pericardial patch group; however, only 1 patient had documented suture line bleeding and the surgical reexploration rate is not likely to be patch related. There were not any significant differences in perioperative/late neurologic events and late restenosis in the 2 groups.

Durability of eversion carotid endarterectomy

OBJECTIVE

Carotid endarterectomy (CEA) remains the gold standard for treating carotid disease in selected symptomatic and asymptomatic patients, though carotid angioplasty and stenting has emerged as a safe alternative. The aim of this study was to assess the durability of CEA in a large series of patients followed up according to a strict clinical and ultrasonographic protocol.

METHODS

Over a 23-year period (1990-2012) a total of 1773 patients (1251 men and 522 women) with a mean age of 75.2 years (range, 31 to 96 years) who underwent 2007 consecutive primary eversion CEAs performed by the same surgeon under general anesthesia with electroencephalographic monitoring and selective shunting were prospectively followed up with ultrasonography at 1, 6, and 12 months, then yearly. A long-term follow-up (median, 11.2 years; mean, 12.9 years) was obtained for 1680 patients (94.8%). End points were perioperative (30-day) stroke and death and late carotid restenosis/occlusion rates.

RESULTS

More than two in three of the lesions (1446 of 2007, 72.1%) were symptomatic at the time of surgery, with a 25% rate of preoperative stroke. Preoperative antiplatelet or anticoagulant therapy was used by 1675 patients (94.4%), whereas 918 (51.8%) were receiving statin treatment. Overall, there were eight (0.4%) perioperative strokes and no deaths. During the follow-up, there were nine (0.47%) asymptomatic late carotid restenoses (six moderate [50%-69%] and three severe [≥ 70%]) and one (0.05%) carotid occlusion. Nine patients (0.47%) had late ipsilateral strokes, none of them related to restenosis/occlusion. Overall, there were 159 late deaths (9.4%).

CONCLUSIONS

The results of this study show that eversion CEA can be performed in symptomatic and asymptomatic patients with an extremely low perioperative stroke/death risk and a negligible incidence of late restenosis/occlusion, thus assuring a persistently good protection against the risk of cerebral ischemia.

Metabolic syndrome: A predictor of adverse outcomes after carotid revascularization

BACKGROUND

Metabolic syndrome (MetS) is rapidly increasing in prevalence and is associated with carotid plaque development and is a risk factor for stroke. The aim of this study is to describe the outcomes for patients with MetS after carotid revascularization (carotid endarterectomy [CEA] and carotid stenting [CAS]).

METHODS

A database of patients undergoing carotid revascularization for primary atherosclerotic lesions was queried from 1996 to 2006. MetS was defined as the presence of >or=3 of the following criteria: blood pressure >or=130 mm Hg/>or=90 mm Hg; Triglycerides >or=150 mg/dL; high-density lipoproteins (HDL) <or=50 mg/dL for women and <or=40 mg/dL for men; fasting blood glucose >or=110 mg/dL; or Body Mass Index (BMI) >or=30 kg/m(2). Multivariate and Kaplan-Meier analyses were performed to outcomes. The average follow-up period was 4.5 years. A major adverse event (MAE) was defined as the occurrence of stroke, myocardial infarction (MI), or death.

RESULTS

A total of 921 patients (mean age: 71 +/- 10 years; 64% male) underwent 750 CEAs and 171 CAS. Thirty-one percent were identified as having MetS, 48% were asymptomatic, 87% had hypertension, 27% had hyperlipidemia, 32% were considered diabetic, and 14% had chronic renal insufficiency. The morbidity and mortality rates for all patients were 16.9% and 1.1%, respectively. The 30-day combined stroke/death rate was 3.6%. The 30-day MAE rates were: 6.7% vs 3.3% for MetS vs No-MetS (P = .02). The 90-day MAE rates were 8.7% vs 4.9% for MetS vs No-MetS (P = .03). MetS patients were more likely to experience a complication than No-MetS patients (23% vs 14%, P = .001). By Kaplan-Meier analysis, there was no difference between MetS and No-MetS patients with respect to patency, restenosis, re-intervention, or survival, but a difference existed for freedom from stroke, MI, and MAE. The difference between stroke rates was maintained between MetS and No-MetS, when subgrouped by those with and without symptoms. For patients with diabetes mellitus (DM), those with MetS had a 68% and 410% higher risk of developing an MAE and MI, respectively. However, for patients without diabetes, MetS was not significantly associated with MAE, stroke, or MI. No factors were found to be significantly associated with risk of stroke in all cases (in all patients, patients with diabetes, and patients without diabetes).

CONCLUSION

MetS is prevalent among patients undergoing carotid revascularization. MetS patients are at a greater risk for perioperative morbidity as well as stroke, MI, and MAE during follow-up when compared to patients without MetS. Long-term stroke prevention is poor in the presence of MetS. MetS should be considered a significant risk factor for patients undergoing carotid revascularization.

Markers of inflammation in patients with symptomatic and asymptomatic carotid artery stenosis: a case-control study

OBJECTIVES

There is evidence that inflammation plays a role in the pathogenesis of atherosclerosis. We compared levels of inflammatory markers between patients undergoing carotid endarterectomy (CEA) and controls, and between patients with symptomatic and asymptomatic internal carotid artery (ICA) stenosis.

MATERIALS AND METHODS

A total of 180 patients with ICA stenosis were compared with 180 age-matched and sex-matched controls. The biomarkers evaluated were high-sensitivity C-reactive protein (hs-CRP), soluble intercellular adhesion molecule 1, soluble vascular cell adhesion molecule 1 (sVCAM-1), and interleukin-6 (IL-6).

RESULTS

The levels of hs-CRP, sVCAM-1, and IL-6 in the CEA group were significantly higher than in the control group (1.87 mg/mL vs 1.44 mg/mL, P = .011; 1408 ng/dL vs 672 ng/dL, P < .001; 11.9 pg/mL vs 6.3 pg/mL, P < .001). Multivariate linear regression analysis, adjusted for all clinical and physiologic parameters, showed a significant association between ICA stenosis and hs-CRP, sVCAM-1, and IL-6 concentrations. Analysis of symptomatic (n = 101) and asymptomatic (n = 79) ICA stenosis did not detect a difference in levels of these markers.

CONCLUSIONS

Our study suggests that inflammatory markers could serve as markers for ICA atherosclerosis but are not useful to identify carotid plaque at risk for symptomatic conversion.

[Mortality and morbidity of consecutive surgical carotid revascularisations in octogenarians]

AIM OF THE STUDY

Retrospective evaluation of the immediate and mid term mortality and morbidity of carotid surgical revascularisations in a population of octogenarians with severe carotid artery stenosis.

MATERIAL AND METHOD

Retrospective study of all patients 80 years old and more, consecutively operated for an internal carotid artery stenosis, from January 1991 to December 2003, in the Unit of Vascular Surgery of the Civil Hospices of Strasbourg. We analyzed the perioperative death and stroke rates at 30 days and the mid term survival.

RESULTS

We performed 81 carotid revascularisations on 70 patients. The mean age of the population studied was 83.5 (+/-2.8 years), (range 80-92). Twenty-four stenoses (29.6%) were symptomatic (23 transient ischemic accidents, 1 stroke), and 57 stenoses (70.4%) were asymptomatic. The mean degree of stenosis was 89.2+/-8.1% (based on NASCET evaluation). The main cardiovascular risk factor was arterial hypertension (95.7%). The overall perioperative death and stroke rate was 7.1%: 2 deaths, one of them related to a stroke, and 3 strokes (confidence interval: 2.4-15.9%). The perioperative death and stroke rate in the symptomatic stenosis group was 0%, and 8.8% in the asymptomatic stenosis group (p=0.163). No specific risk factor of neurologic events has been found except ASA 3 or higher (RR: 3.84 [1.2-12.1]). The mean follow up was 3.6 years (range 2-11.3), no patient was lost to follow-up. The Kaplan-Meier 5-year survival was 52%. The mean time to death was 3.5 years after the operation. Only 16.7% of these deaths were stroke-related.

CONCLUSIONS

Multicentric prospective studies, which have determined current recommendations for carotid surgery, did not include patients aged 79 years and older. In this particular population, the good results observed in our institution in the symptomatic carotid stenosis group would support the use of surgical treatment. The perioperative death and stroke rate observed for the asymptomatic group, clearly superior to current recommendations, suggests in our experience and especially for ASA> or =3, an individual evaluation to determinate the best indication.

Long-term survival and stroke-free survival after eversion carotid endarterectomy for asymptomatic severe carotid stenosis

BACKGROUND

Level 1 evidence supports carotid endarterectomy (CEA) as the standard treatment for severe (>70% lumen reduction) carotid stenosis in asymptomatic patients, though its safety and efficacy in high-risk patients remain controversial. Long-term survival and stroke-free survival after CEA may guide decisions concerning this procedure for asymptomatic patients, but this outcome has only been considered in few reports outside the large randomized trial setting. This study analyzed long-term survival and stroke-free survival after CEA and the impact of risk factors in a consecutive series of asymptomatic patients, including those with medical comorbidities and particular anatomical features believed to increase the perioperative morbidity and mortality of CEA.

METHODS

For over 10 years, data were prospectively collected for all patients who underwent CEA for asymptomatic severe carotid disease at our institution. All CEAs performed by the same surgeon involved eversion technique, with patients under deep general anesthesia and continuous perioperative electroencephalographic (EEG) monitoring for selective shunting. All patients had neurological follow-up and duplex ultrasound at 1, 6, and 12 months, and yearly thereafter. A complete follow-up (mean, 6.1 years; range, 0.1 to 10.6 years) was obtained in 348 patients (93%) with an overall 365 CEAs (93%). Survival analyses were performed using Kaplan-Meier life tables.

RESULTS

Among 374 patients undergoing 391 CEAs, there were no perioperative deaths or strokes. There were 17 (4.8%) late deaths, mainly cardiac-related (70%), and 2 (0.5%) non-fatal strokes. At 5 and 10 years, survival was 96.3% and 85.7%, and stroke-free survival was 95.6% and 84.8%, respectively. At multivariate analysis, diabetes mellitus (P = .002) and cardiac disease (P = .005) were independent predictors of a shorter long-term survival.

CONCLUSIONS

Eversion CEA proved safe and effective in a series of patients with asymptomatic severe carotid disease representing the typical population of daily clinical practice. Although long-term results were extremely favorable, excellent stroke-free survival was not translated into a longer patient survival.

Carotid Endarterectomy in Patients with Contralateral Carotid Artery Occlusion

The aim of this study was to evaluate the 30-day outcome of carotid endarterectomy in patients with contralateral carotid artery occlusion and compare it to that in patients with patent contralateral carotid artery. We compared 2,959 carotid endarterectomies performed in patients with patent contralateral internal carotid artery to 373 carotid endarterectomies performed in patients with occlusion of the contralateral carotid artery in the same institute between 1988 and 2004. Patient demographics, surgical and anesthesiological strategy, perioperative neurological and cardiac events, and deaths were compared. The patients were grouped and analyzed according to the presence or absence of symptoms and to their gender. No significant difference was shown in perioperative cardiological and neurological events and deaths in patients with contralateral carotid occlusion versus patients without contralateral carotid occlusion. Females had significant more neurological events than males, in both the asymptomatic (P < 0.001) and symptomatic (P = 0.02) groups. Concomitant occlusion of the contralateral carotid artery was not associated with increased risk of perioperative cardiological or neurological adverse events. However, female gender was associated with higher risk for adverse neurological events.

Raised plasma fibrinogen concentration in patients with abdominal aortic aneurysm

A feature associated with abdominal aortic aneurysms (AAA) is the presence of intraluminal thrombi (ILT). Elevated plasma fibrinogen concentrations predict a greater risk of thrombosis. Therefore, the authors assessed the relationship between fibrinogen levels, AAA size, and ILT. An age- and sex-matched case-control study was conducted. Demographic data and plasma samples were obtained from 110 patients with AAA and 110 controls. All subjects had an abdominal ultrasound scan to determine the size of the aneurysm and the percentage of the ILT occupying the lumen. Plasma fibrinogen concentrations were measured by the Clauss method. Fibrinogen concentrations were significantly higher in patients with AAA than in controls (median: 2.89 vs 2.53 g/L; p<0.01). Patients with AAA who were current smokers had a larger median AAA size (4.50 vs 4.30 cm; p<0.04) and greater percentage of the ILT (40% vs 30%) than those who did not smoke. Fibrinogen was positively correlated with AAA size (r =0.323; p<0.01) and the percentage of ILT occupying the lumen (r =0.358; p<0.05). Fibrinogen levels were higher in the AAA group. The authors also demonstrated positive correlations between the AAA size, ILT, and fibrinogen concentration. Smoking was associated with larger aneurysms and ILT. Fibrinogen may be a useful marker to monitor the progression of AAA.

Do device characteristics impact outcome in carotid artery stenting?

OBJECTIVES

The study was conducted to identify patient and procedural parameters that negatively impact the 30-day rates for stroke, death and transient ischemic attack (TIA) after carotid artery stenting (CAS) and that might be modified or further studied in future efforts to improve CAS.

METHODS

This was a retrospective investigation of a dual-center CAS database of 701 consecutive CAS patients (414 men; mean age, 72.4 +/- 8.4). A subset of patient-related, lesion-related, or procedure-related variables (age >or=80, left sided lesion, symptomatic, nicotine abuse, hypertension, diabetes mellitus, other peripheral vascular disease, hypercholesterolemia, embolic protection devices usage, predilation, ulcerated lesion, echolucent plaque, restenosis after surgery) were analyzed for association with occurrence of stroke, death, or TIA <or=30 days after CAS. The odds ratio (OR) and 95% confidence interval (CI) and P value were calculated for each variable to predict adverse outcome.

RESULTS

The overall combined rate of stroke, death, and TIA within this database was 3.7% at 30 days. In the total population of 701 patients, only the OR of 2.7 for hypercholesterolemia (95% CI, 1.0 to 7.3; P = .041) was found to be significant. Subgroup analysis of the 304 symptomatic patients (43%) showed that open-cell stent designs and concentric EPD designs yielded an OR of 4.1 (95% CI, 1.4 to 12, P = .0136) and 3.3 (95% CI, 1.016 to 10, P = .0525), respectively, for 30-day stroke/death/TIA within this database. Analysis of open-cell stent designs and concentric EPD designs in patients with echolucent lesions yielded an OR of 3.1 (95% CI,1.2 to 8.2, P = .0343) and 3.7 (95% CI, 1.3 to 10, P = .0174), respectively, for 30-day stroke/death/TIA.

CONCLUSIONS

We conclude that increased analysis of device design variables may be necessary. Particularly in symptomatic patients or with echolucent lesions, closed-cell design and eccentric filters seem superior. Prospective investigation comparing open-cell vs closed-cell stents and eccentric vs concentric filter devices may be warranted.

Natural history of carotid artery occlusion contralateral to carotid endarterectomy

BACKGROUND

The natural history of patients with carotid artery occlusion is controversial. A few studies have concluded that patients with internal carotid artery occlusion carry a high risk of neurologic events. None of these previously reported studies analyze the natural history of internal artery occlusion contralateral to carotid endarterectomy (CEA), except for a small series including a subset of patients from two randomized trials, the Asymptomatic Carotid Atherosclerosis Study and the North American Symptomatic Carotid Endarterectomy Trial. This study analyzes the natural history of patients with carotid artery occlusion contralateral to CEA, specifically assessing long-term neurologic events occurring in the hemisphere associated with the occluded carotid artery.

METHODS

Of the 599 CEAs in 544 patients that were included in two previously updated prospective studies, 63 patients had contralateral internal carotid artery occlusion, and their perioperative and long-term outcomes were evaluated. A Kaplan-Meier analysis was used to estimate the rate of freedom from late stroke occurring in the hemisphere ipsilateral to the occluded carotid artery. The stroke-free survival rate was also noted.

RESULTS

Mean follow-up was 58 months (range, 1 to 147 months). One perioperative stroke (1.6%) occurred, which was not in the cerebral hemisphere ipsilateral to the occluded carotid artery. Two late strokes (3.2%) and nine transient ischemic attacks (TIAs) (14.3%) occurred involving the hemisphere of the occluded carotid artery. There were also three late TIAs (4.8%) and no late strokes involving the hemisphere supplied by the operative site. There were a total of 14 late deaths. Fifteen patients had late > or =50% restenosis of the operative side. Six of these had neurologic events (TIA/stroke) involving the hemisphere of the occluded carotid artery, in contrast to five of 48 patients with no restenosis who had neurologic symptoms (P < .001). Freedom from late strokes in the hemisphere ipsilateral to the occluded carotid artery at 1, 3, 5, and 10 years was 98%, 96%, 96%, and 96%, respectively. The stroke-free survival rates at 1, 3, 5, and 10 years were 90%, 87%, 80%, and 59%, respectively.

CONCLUSIONS

The natural history of carotid artery occlusion contralateral to CEA is relatively benign. This may suggest a protective effect of carotid endarterectomy on the cerebral hemisphere ipsilateral to the carotid occlusion from late strokes.

Increased incidence of cerebral clamping ischemia during early contralateral carotid endarterectomy

OBJECTIVES

The aim of our study was to assess the influence of previous contralateral carotid endarterectomy (CEA) and of the timing of the procedures on cerebral clamping ischemia during the second operation in patients undergoing staged bilateral CEA.

METHODS

We reviewed the 251 patients who presented with bilateral carotid stenosis of > or =70% at the time of the first admission and underwent staged bilateral CEA between January 2001 and December 2004. Surgery was performed under locoregional anesthesia. Cerebral perfusion was monitored with mental status and contralateral motor function evaluation in awake patients. Selective carotid shunting was performed for patients who manifested neurologic deficits. Univariate and multivariate analyses were performed for the variables of interest.

RESULTS

Twenty-two patients (8.8%) required carotid shunting during the first procedure and 28 (11.1%) during the second one. Nine of the latter also had shunts during the first CEA, whereas 19 tolerated cross-clamping during the first operation. Among the patients who underwent contralateral CEA < or =30 days, 23 of 146 required carotid shunting; between 31 and 60 days, 4 of 73; and after 61 days, 1 of 32 (P = .023; univariate analysis). The chi2 for trend was statistically significant (P = .009). Patients operated on the second side < or =30 days had a nearly fourfold risk of shunting during the second procedure compared with patients operated on > or =31 days. The highest risk was observed in patients with a shunt during the first operation who underwent the second CEA < or =30 days. Multivariate analysis also identified the time intervals between CEAs and the need of shunting during the first procedure as independent risk factors (P = .042 and P < .001).

CONCLUSIONS

These data show an increased incidence of cerebral clamping ischemia during contralateral endarterectomy performed < or =30 days; whereas after longer intervals between CEAs, the need for shunting is significantly reduced.

High-grade symptomatic and asymptomatic carotid stenosis in the very elderly. A challenge for proponents of carotid angioplasty and stenting

Background

Carotid angioplasty and stenting (CAS) is often considered as the preferred treatment for severe carotid occlusive disease in patients labelled as "high risk", including those aged 80 or more. We analyzed 30-day stroke risk and death rates after carotid endarterectomy (CEA) for severe symptomatic or asymptomatic carotid disease in patients aged 80 or more, by comparison with the outcome of CAS reported in the recently- published literature.

Methods

A retrospective review was conducted on a prospectively compiled computerized database of all primary CEAs performed by a single surgeon at our institution from 1990 to 2003. Descriptive demographic data, risk factors, surgical details, perioperative strokes and deaths, and other complications were recorded.

Results

In all, 1260 CEAs were performed in 1099 patients; 1145 were performed in 987 patients less than 80 years old, and 115 were performed in 112 patients aged 80 or more. There were 11 perioperative strokes in the 1145 procedures in the younger group, for a stroke rate of 0.8%, and no strokes in the 115 procedures in the older group. The death rates were 0% for the octogenarians and 0.3% for the younger group.

Conclusion

The conviction that older age means higher risk needs to be revised. Patients aged 80 or more can undergo CEA with no more perioperative risks than younger patients. Proponents of CAS should bear this in mind before recommending CAS as the best therapeutic option for such patients.

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

Occlusion of the contralateral internal carotid artery (ICA) is considered to have a significant impact on the outcome of carotid endarterectomy (CEA). The purpose of this study was to review one center's experience concerning CEA opposite an occluded ICA, to see whether results differed from those obtained in patients with patent contralateral ICA in terms of relevant neurologic complication rate (RNCR, fatal + disabling stroke), stroke-free rate, and survival rate. From January 1997 to December 2002, 1,381 patients underwent a total of 1,445 CEAs at the Department of Vascular Surgery of Padua University. Patients were divided into two groups: group A included 144 patients with occlusion of the contralateral ICA and group B consisted of 1,237 patients with a patent contralateral ICA. There was no postoperative mortality in patients of group A, while in group B, two patients died as a result of myocardial infarction and cardiac failure and one died as a direct result of perioperative stroke. Postoperative disabling strokes occurred in one (0.7%) patient in group A and 10 (0.8%) patients in group B (p > 0.5). At 72 months, there were no statistical differences between the two groups in terms of RNCR, stroke-free rate, and late death. Our results show that contralateral carotid occlusion does not reduce the safety of CEA. The efficacy in terms of RNCR, stroke-free rate, and late survival is no different in patients with contralateral carotid occlusion.

Surgical vs medical treatment for isolated internal carotid artery elongation with coiling or kinking in symptomatic patients: A prospective randomized clinical study

BACKGROUND

Whether surgically correcting symptomatic carotid elongation with coiling or kinking in the absence of an atherosclerotic lesion of the carotid bifurcation (isolated elongation) is effective in preventing stroke remains a controversial issue. The hypothesis behind this study was that surgical correction of symptomatic isolated carotid elongation with coiling or kinking could yield better results, in terms of stroke prevention and freedom from late stroke or carotid occlusion, than medical treatment.

METHODS

We conducted a prospective clinical study randomly assigning symptomatic patients with isolated carotid elongation to undergo either elective surgery or medical treatment, with surgery reserved for any new onset or worsening of symptoms. The follow-up ranged from 1 month to 10 years (median, 5.9; mean, 6.2 years) and was obtained for all patients. The study end points were perioperative (30-day) stroke and mortality, late stroke, and stroke-related death and late carotid occlusions.

RESULTS

Ninety-two patients were randomly assigned for surgery and 90 for medical treatment. Overall, 139 carotid surgical corrections were performed in 129 patients. All 92 patients in the surgical arm had an elective operation; 10 of these patients later developed symptoms on the opposite side (7 hemispheric and 3 retinal transient ischemic attacks) and had contralateral internal carotid artery surgery. An additional 37 patients (41.1%) randomly assigned to medical treatment crossed over to the surgical group within a mean of 16.8 months after randomization due to new hemispheric symptoms or worsening nonhemispheric complaints. There were no perioperative strokes or deaths. The incidence of late hemispheric and retinal transient ischemic attacks was significantly lower in the surgical than in the medical group, respectively, 7.6% (7 of 92) vs 21.1% (19 of 90) (P = .01) and 3.2% (3 of 92) vs 12.2% (11 of 90) (P = .03). Late strokes, 2 (2.2%) of which were fatal, occurred only in the medical group (6 of 90, 6.6%; P = .01). Late carotid occlusions also developed only in the medical group (5 of 90, 5.5%; P = .02). All surgically treated carotid elongations were analyzed histologically and 78 (56.%) of 139 showed atypical and typical patterns of fibromuscular dysplasia.

CONCLUSIONS

The overall results of this trial indicate that surgical correction of symptomatic isolated carotid elongations with coiling or kinking is better for stroke prevention than medical treatment.

Initial experience with eversion carotid endarterectomy: Absence of a learning curve for the first 100 patients

OBJECTIVE

Eversion carotid endarterectomy (CEA) has been touted as superior to standard CEA with patch closure because of allegedly lower restenosis rates and greater technical ease of performance. The purpose of this study was to evaluate the early experience of one vascular surgeon beginning to use this technique.

METHODS

This was a retrospective study in an academic vascular surgical practice. The first 100 patients undergoing CEA via the eversion technique were compared with 100 contemporaneous patients who had standard CEA with patch closure. Residual (first examination within 3 months) or recurrent postoperative duplex scan stenosis, perioperative neurologic deficit, and mortality were analyzed by cumulative sum failure and Kaplan-Meier life-table analysis.

RESULTS

Operative indications were not significantly different between eversion and standard CEA patients (63% vs 60% asymptomatic, 10% vs 7% stroke, 4% vs 5% amaurosis, and 23% vs 28% transient ischemia). Intraoperative shunting was more commonly used during eversion CEA (87% vs 59%; P < .01). Perioperative neurologic deficits included amaurosis (n = 1) after eversion CEA and transient cerebral ischemia (n = 1) and retinal infarction (n = 1) after standard CEA, with one cardiac death each. By 36 months, one other patient in each group had experienced a transient ischemic event, but there were no strokes. Four carotids occluded within 36 months of eversion CEA, compared with one occlusion after standard CEA (not significant). Patients undergoing eversion CEA showed no difference in critical (>80%) residual or recurrent stenosis rates. However, after eversion CEA, a greater degree of greater than 50% recurrent stenosis was observed at 36 months (38% vs 6%; P < .001) despite similar residual stenosis rates. Cumulative sum failure analysis showed no plateau among patients undergoing eversion CEA, thus indicating the absence of a learning curve, at least within the first 100 patients.

CONCLUSIONS

Despite enthusiasm by advocates for eversion CEA, the recurrent greater than 50% stenosis rate remained high for the first 100 patients who underwent this technique, with no evidence of a learning curve. This observation implies that vascular surgeons considering adoption of this technique should monitor their own early results carefully.

Concomitant Brachiocephalic and Coronary Artery Disease: Outcome and Decision Analysis

BACKGROUND

In patients with coronary artery disease, concomitant brachiocephalic disease may affect outcome and influence decision making regarding operative staging, technique, and choice of conduit.

METHODS

Eighty consecutive patients (mean age, 59.3 years; 60.0% male) with concomitant brachiocephalic and coronary artery disease were identified either before (group A, n = 48) or after (group B, n = 32) coronary artery bypass grafting. Patients who had symptomatic brachiocephalic and coronary artery disease before surgery underwent concomitant brachiocephalic reconstruction and coronary artery bypass grafting using either all-vein coronary conduits (n = 41) or vein-and-internal mammary artery conduits (n = 7). Patients who had coronary-subclavian steal syndrome after coronary artery bypass (group B, n = 32) underwent either surgical (n = 5) or endovascular (n = 27) brachiocephalic reconstruction only.

RESULTS

All patients were asymptomatic after intervention. Operative mortality was 4.2% for group A and 3.1% for group B. The perioperative stroke rate was 2.1% for group A and 0% for group B. Actuarial 10-year freedom from specific events for group A was as follows: death 59.9 +/- 12.8%, brachiocephalic restenosis 100%, coronary-subclavian steal syndrome 100%, myocardial infarction 83.5 +/- 10.5%, stroke 82.1 +/- 9.9%, redo coronary artery bypass grafting 95.8 +/- 4.1%, other vascular operation 82.2 +/- 8.9%, and adverse cardiac outcome (death, redo coronary artery bypass grafting, or myocardial infarction) 52.9% +/- 13.2% (for patients with all-vein conduits) or 100% (for patients with vein-and-internal mammary artery conduits). At midterm follow-up (mean, 2.92 years), both the surgical and the endovascular treatment subgroups of group B had 100% brachiocephalic patency.

CONCLUSIONS

Long-term results in a limited population support continued evaluation of concomitant brachiocephalic reconstruction and coronary artery bypass grafting with use of the internal mammary artery conduit in an attempt to improve late survival in patients with concomitant disease. The excellent midterm brachiocephalic patency after either surgical or endovascular treatment of patients with coronary-subclavian steal syndrome supports continued evaluation of both methods.

Brachiocephalic reconstruction II: Operative and endovascular management of single-vessel disease

OBJECTIVE

Although the surgical management of brachiocephalic disease is well established, evolving endovascular techniques present new options for treatment. We explored the potential benefits and drawbacks of these interventions in terms of outcome.

METHODS

From 1966 to 2004, 391 consecutive patients (43.7% male; mean age, 61.9 years) with single-vessel brachiocephalic disease were treated with either operative bypass (group A; n = 229) or percutaneous transluminal angioplasty and stenting (group B; n = 162).

RESULTS

All patients were asymptomatic after surgery or endovascular intervention. Group A and group B had similar operative mortality (0.9% vs 0.6%) and stroke (1.3% vs 0%) rates. However, 5 years after the procedure, group A had significantly better freedom from graft or intervention failure (92.7% +/- 2.1%) than did group B (83.9% +/- 3.7%; P = .03, Kaplan-Meier analysis; P = .001, Cox regression analysis). At 10 years, group A had the following rates of actuarial freedom from specific events: death, 73.7% +/- 4.6%; myocardial infarction, 84.2% +/- 3.6%; stroke, 91.4% +/- 3.4%; graft failure, 88.1% +/- 3.3%; coronary revascularization, 69.8% +/- 5.1%; and other vascular operation, 70.7% +/- 4.6%. Endovascular intervention involved less initial cost (mean savings, $8787 per procedure), was less invasive, and did not necessitate general anesthesia. On satisfaction questionnaires, 96.5% of patients receiving an endovascular intervention and 95.1% of patients receiving operative bypass for single-vessel brachiocephalic disease subjectively rated their treatment as "good" or "very good."

CONCLUSIONS

Operative bypass and endovascular intervention for single-vessel brachiocephalic disease are both associated with acceptably low operative morbidity and mortality. Operative bypass produces significantly better mid-term freedom from graft or intervention failure than endovascular intervention and produces excellent long-term freedom from failure. Endovascular intervention offers tangible benefits regarding cost, level of invasiveness, and subjective patient satisfaction. Undetermined are the differences between the procedures regarding long-term durability, patterns of failure, efficacy as an adjunct to coronary artery bypass grafting, need for anticoagulation, efficacy as treatment for complex (multivessel) disease, and long-term cost.

Brachiocephalic reconstruction I: Operative and long-term results for complex disease

OBJECTIVES

Complex brachiocephalic disease involves multiple vessels and is frequently associated with multisystem atherosclerosis. We reviewed surgical outcome and examined the impact of this problem on decision making regarding operative staging, technique, and choice of conduit.

METHODS

Between 1966 and 2000, 157 consecutive patients (mean age, 54.0 years; 48.4% male) with innominate artery or multivessel brachiocephalic disease underwent operative reconstruction using either a transthoracic approach (group A, n = 113) or a less invasive, extrathoracic approach (group B, n = 44). Reconstruction required multiple distal anastomoses in 70 patients (44.6%), concomitant coronary artery bypass grafting (CABG) in 37 patients (23.6%), and concomitant carotid endarterectomy (CEA) in 26 patients (16.6%).

RESULTS

No significant differences were found between group A and group B when operative mortality (2.7% vs 2.3%) and stroke rates (2.7% vs 6.8%) were analyzed. However, 10 years after surgery, freedom from graft failure was significantly better in group A (94.4% +/- 4.4%) than in group B (60.3% +/- 13.4%) ( P = .002). Freedom from graft failure was adversely affected by nonaortic inflow ( P = .002) and axillo-axillary cervical grafts ( P = .0001). Mortality and stroke rates for subgroups having multiple distal anastomoses (2.9%, 2/70 and 4.3%, 3/70), concomitant CABG (5.4%, 2/37 and 0, 0/37), and concomitant CEA (3.8%, 1/26 and 3.8%, 1/26) were similar to those of other patients. For the entire patient group, 10-year rates of actuarial freedom from specific events were death, 68.8% +/- 6.0%; myocardial infarction, 86.7% +/- 4.5%; stroke, 87.0% +/- 4.4%; coronary revascularization, 88.0% +/- 3.6%, and other vascular operation, 79.9% +/- 4.4%.

CONCLUSIONS

Transthoracic arch reconstruction for complex brachiocephalic disease can be done with acceptably low morbidity and mortality similar to those of a less invasive, extrathoracic approach. Furthermore, the transthoracic approach is associated with significantly better long-term freedom from graft failure, possibly because it preserves aortic inflow to the great vessels. Nonetheless, the high frequency of late events in this relatively young patient population reflects the presence of multisystem atherosclerosis and suggests the need for close follow-up and lifestyle modification.

Prospective study of carotid endarterectomy with modified polytetrafluoroethylene (ACUSEAL) patching: Early and late results

OBJECTIVE

Carotid endarterectomies (CEAs) with standard polytetrafluoroethylene (PTFE) patching have been shown to have results comparable with those of autogenous vein patching; however, prolonged bleeding through needle holes in PTFE is a commonly recognized problem. This is the first study of CEA using a new hemostatic modified PTFE patch (GORE-TEX) analyzing the early and late outcomes.

METHODS

Two hundred consecutive CEAs were entered into this protocol. All patients had an immediate postoperative carotid duplex ultrasound scan that was repeated at 1 month and every 6 to 12 months thereafter. A Kaplan-Meier analysis was used to estimate the stroke-free survival and the risk of restenosis. The mean follow-up was 21 months (range, 1 to 48 months).

RESULTS

The perioperative stroke rate was 1.5% (1% ipsilateral and 0.5% contralateral, two minor strokes and one major stroke) with no perioperative mortality or perioperative carotid thrombosis. The incidence of perioperative transient ischemic attacks was 3.5% (2.5% ipsilateral and 1% contralateral). The mean hemostasis time after completion of the patching was 3 minutes, in contrast to 14 minutes for conventional PTFE (in a previous study). The rates of freedom from ipsilateral strokes at 1, 2, 3, and 4 years were 99%, 99%, 99%, and 99%, respectively. The cumulative stroke-free survival rates at 1, 2, 3, and 4 years were 98%, 96%, 93%, and 93%, respectively. The rates of freedom from > or =70% restenosis at 1, 2, 3, and 4 years were 97%, 97%, 94%, and 94%, respectively.

CONCLUSIONS

CEAs with a new modified PTFE patch are safe, have low perioperative stroke rates, are durable, and have an acceptable hemostasis time.

Carotid endarterectomy at the millennium: what interventional therapy must match

OBJECTIVES

Carotid endarterectomy (CEA) is supported by level 1 evidence as the standard treatment of severe carotid stenosis in both symptomatic and asymptomatic patients. As interventional techniques are emerging for treatment of this disease, this study was undertaken to provide a contemporary surgical standard for comparison to carotid stenting.

PATIENTS AND METHODS

During the interval 1989 to 1999, 2236 isolated CEAs were performed on 1897 patients (62% male, 36% symptomatic, 4.6% reoperative procedures). Study endpoints included perioperative events, patient survival, late incidence of stroke, anatomic durability of CEA, and resource utilization changes during the study. Variables associated with complications, long-term and stroke free survival, restenosis, and resource utilization were analyzed by univariate and multivariate analysis.

RESULTS

Perioperative complications occurred in 5.5% of CEA procedures, including any stroke/death (1.4%), neck hematoma (1.7%), cardiac complications (0.5%), and cranial nerve injury (0.4%). Actuarial survival at 5 and 10 years was 72.4% (95% confidence interval [CI] 69.3-73.5) and 44.7% (95% CI 41.7-47.9) respectively, with coronary artery disease (P < 0.0018), chronic obstructive pulmonary disease (P < 0.00018) and diabetes mellitus (P < 0.0011) correlating with decreased longevity. The age- and sex-adjusted incidence of any stroke during follow-up was reduced by 22% (upper 0.35, lower 0.08) of predicted with the patient classification of hyperlipidemia (P < 0.0045) as the only protective factor. Analysis of CEA anatomic durability during a median follow-up period of 5.9 years identified a 7.7% failure rate (severe restenosis/occlusion, 4.5%; or reoperative CEA, 3.2%) with elevated serum cholesterol (P < 0.017) correlating with early restenosis. Resource utilization diminished (first versus last 2-year interval periods) for average hospital length of stay from 10.3 +/- 1.5 days to 4.3 +/- 0.7 days (P < 0.01) and preoperative contrast angiography from 87% +/- 1.4% to 10.3% +/- 4%.

CONCLUSIONS

These data delineate the safety, durability, and effectiveness in long-term stroke prevention of CEA. They provide a standard to which emerging catheter-based therapies for carotid stenosis should be compared.

Durability of carotid endarterectomy for treatment of symptomatic and asymptomatic stenoses

PURPOSE

Although many studies have well established that carotid endarterectomy (CEA) is beneficial in selected patients with severe carotid disease, only a few large studies have focused on the durability of the surgical procedure. Carotid artery angioplasty and stenting (CAS) has recently been proposed as a potential alternative to CEA. We analyzed the incidence of late occlusion and recurrent stenosis after CEA.

METHODS

Over 13 years 1000 patients underwent 1150 CEA procedures to treat symptomatic and asymptomatic high-grade carotid stenosis. CEA procedures involving either traditional CEA with patching (n = 302) or eversion CEA (n = 848) were all performed by the same surgeon, with patients under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at 1, 6, and 12 months, and yearly thereafter. New neurologic events, late occlusions, and recurrent stenoses 50% or greater were recorded. Complete follow-up (mean, 6.2 years; range, 6-156 months) was obtained in 95% of patients (949 of 1000), for an overall average of 95% of procedures (1092 of 1150). Survival analysis was performed with the Kaplan-Meier life table method.

RESULTS

Perioperative (30-day) mortality rate was 0.3% (3 of 1000), and stroke rate was 0.9% (11 of 1150), with a combined mortality and stroke rate of 1.2%. The incidence of late occlusion and recurrent stenosis 70% or greater was 0.6% and 0.5%, respectively, with a combined occlusion and restenosis rate of 1.1%. Kaplan-Meier analysis showed that the rate of freedom from occlusion, restenosis 70% or greater, and combined occlusion and restenosis 70% or greater at 12 years was 99,4%, 99.5%, and 98.8%, respectively. Occlusion and restenosis developed asymptomatically.

CONCLUSIONS

CEA is a low-risk procedure for treating severe symptomatic and asymptomatic carotid disease, with excellent long-term durability. Proponents of CAS should bear this in mind before considering CAS as a routine alternative to CEA.

Perioperative stress response to carotid endarterectomy: The impact of anesthetic modality

OBJECTIVE

Surgery for extracranial carotid artery disease has been challenged by carotid angioplasty stenting because the latter is less invasive and avoids surgical trauma. In fact, the magnitude of the perioperative stress response evoked by carotid endarterectomy (CEA) has never been evaluated. Our aim was to determine the degree of surgical trauma caused by CEA and to define differences related to the use of locoregional or general anesthesia.

METHODS

We prospectively studied 113 consecutive CEAs performed on 109 patients admitted at a community institutional center. Patients were stratified for demographics and risk factors and operated on under locoregional (LA) or general anesthesia (GA) depending on both the surgeon preference and patient's compliance. Selective carotid shunting was performed for patients who manifested neurologic deficits under LA or had stump pressure values </=30 mm Hg under GA. Markers of the stress response, including cortisol, adrenocorticotropic hormone, prolactin, and C-reactive protein, were measured intraoperatively, before and after carotid artery cross-clamping (CACC), and postoperatively up to the third day after surgery. Hemodynamic variability was assessed during surgery and for 24 hours postoperatively. Operative times were also measured. Surgeons were considered as independent variables for stress response. Statistics were run by means of nonparametric tests and univariate and multivariate analysis with a linear regression model.

RESULTS

CEA was performed under GA in 63 cases (55.8%) and under LA in 50 (44.2%). The two groups were comparable in terms of demographics and risk factors. Intraoperatively, cortisol and adrenocorticotropic hormone levels were significantly higher in the LA group (both P <.001). CACC increased the intraoperative cortisol levels in both the GA (P =.019) and the LA groups (P =.006). However, in patients who underwent carotid shunting, this effect was abolished (GA group, P =.779; LA group, P = 1.0). During the early postoperative period there was no difference between the two groups. On postoperative day 1 the stress response was abolished in both groups. Prolactin levels increased intraoperatively in both the LA and GA groups and returned within preoperative values on postoperative day 1. Prolactin levels were higher in the GA group (P =.003 intraoperatively and P <.001 postoperatively). C-reactive protein significantly increased in both GA and LA groups on postoperative days 1 and 2 and started to decrease on day 3 with no differences between the two groups at any time. Hemodynamic variability and considered risk factors including individual surgeon were not significant variables. Gender-related differences were found only in prolactin secretion. The length of surgery had an impact for procedures that lasted >120 minutes. Three patients experienced an intraoperative neurologic event and had higher post-CACC cortisol values as compared to asymptomatic patients.

CONCLUSIONS

Intraoperative surgical stress was higher under LA and was blunted by carotid shunting under both LA and GA. Within 2 hours after surgery the anesthetic modality no longer had any impact on surgical trauma. The stress response to CEA, regardless of the type of anesthesia, was abolished within 24 hours. Intraoperative stress response, namely hypercortisolemia, directly correlated with subclinical and clinical cerebral hypoperfusion/ischemia during CACC. Hence, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events.

Subclavian artery stenting: factors influencing long-term outcome

This study provides extended follow-up of a nonrandomized series of symptomatic patients who underwent subclavian stent-supported angioplasty (SSA) with emphasis on preprocedure factors that may have influenced outcome. The endpoints of mortality and restenosis were analyzed using backward stepwise logistic regression with the following clinical variables: coronary artery disease, hypertension, hyperlipidemia, smoking, diabetes mellitus, chronic obstructive pulmonary disease, chronic renal insufficiency/failure, and hypothyroidism. Restenosis is reported based on prospective serial noninvasive studies and/or angiography. Mortality was evaluated by retrospective database review and inquiry to the State Department of Health and Human Services' statistical registry in patients who were lost to follow-up. Over a 9-year period (mean follow-up, 36.1 +/- 30.4 months; maximum observation, 109.5 months), 101 stents were placed in 91 consecutive patients (37 male, 54 female). The mean age at intervention was 62.03 +/- 9.3. The procedure was technically successful in 89 patients 97% (mean pre- and postoperative stenosis and pressure gradients were 90.2% +/- 9.4% vs. 3.7% +/- 6.6%, P < 0.001, and 59.9 +/- 35.2 vs. 0 mm Hg, P < 0.001, respectively), with 13 minor complications and no immediate major complications. One patient died of unrelated causes within 30 days. Per Kaplan-Meier method, for years 1 through 5, the rates of overall patency were 96%, 91%, 86%, 77%, and 72%; likewise, overall patient survival was 93%, 88%, 8%4, 81%, and 76%. No clear predictors for restenosis were discovered, although a trend toward higher recurrence was noted in women (18.5% in female vs. and 8.6% in male; P > 0.05), but the same were less likely to die during follow-up (P > 0.001). Also, the presence of hypothyroidism (P = 0.004) and increasing age (P = 0.068) were positively correlated with all-cause mortality. This study suggests that SSA is predictable, safe, and durable. The diagnosis of symptomatic subclavian disease is of prognostic importance, with age and male gender representing important predictors of all-cause long-term mortality. The strong association of increased mortality with hypothyroidism is difficult to discard and raises the question of a yet to be described thyroid steal phenomena.