Editor's Choice – An Updated Systematic Review and Meta-analysis of Outcomes Following Eversion vs. Conventional Carotid Endarterectomy in Randomised Controlled Trials and Observational Studies

What Is the Best Technique for Treating Carotid Disease?

This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient's medical comorbidities and anatomic factors.

Comparative on the effectiveness and safety of different carotid endarterectomy techniques: a single-center Retrospective Study

BACKGROUND

Carotid endarterectomy (CEA) is a surgical procedure that can reduce the risk of stroke in patients with carotid artery stenosis. However, controversy still exists regarding the optimal surgical technique for CEA.

OBJECTIVE

To compare the safety and effectiveness of different techniques.

METHODS

Data on baseline characteristics as well as perioperative and postoperative complications from patients who underwent CEA at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, were retrospectively collected and analyzed.

RESULTS

A total of 262 CEA patients included in study, with a total of 265 CEA operations. The mean age of 69.95 ± 7.29 (range, 44-89) years. 65 (24.5%) patients underwent cCEA, 94 (35.5%) underwent pCEA, and 106 (40.0%) underwent eCEA. The use of shunt (1.9%) and the mean operation time were lower in eCEA group (P < 0.05). eCEA was also associated with a lower incidence of postoperative hypotension, whereas pCEA was associated with a lower incidence of postoperative hypertension (P < 0.05). There was no significant difference in clinical baseline characteristics, occurrence of perioperative complications, and survival whether restenosis-free, asymptomatic or overall.

CONCLUSIONS

This study found that all three surgical methods are equally safe for the treatment of carotid artery stenosis and are effective in preventing stroke.

Contemporary open surgical approaches for the management of carotid stenosis: a comprehensive review

This study aims to provide an overview on contemporary open surgical approaches for the management of carotid artery stenosis. A comprehensive literature search was performed to identify and categorize open surgery intervention techniques for the management of carotid artery stenosis, focusing on the benefits and drawbacks of each technique. Five surgical techniques for carotid endarterectomy (CEA) have been described: CEA with primary closure, CEA with patch closure, CEA by eversion technique, CEA by modified eversion technique and CEA by partial eversion. Evidence has reported significantly higher rates of perioperative complications after CEA with primary closure, including 30-days stroke rate and late restenosis. Although more recent techniques have been reported to provide superior outcomes, electing the best surgical technique is still a matter of debate. Also, CEA using a mini-skin incision has been associated to lower risk of cranial/cervical nerve injury and shorter length of hospital stay. The selection of the surgical intervention should be tailored and have into consideration individual patient characteristics, clinical considerations, surgeon preference and surgical team expertise. Further large-scale randomized clinical trials are needed to support more robust decisions on the choice of contemporary open surgical approaches to manage carotid stenosis.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Comparison Between Conventional and Patch Carotid Endarterectomy: A Single-Center Retrospective Study

OBJECTIVE

To compare perioperative and long-term safety and effectiveness between conventional carotid endarterectomy (cCEA) and patch carotid endarterectomy (pCEA) under current medical conditions.

METHODS

Data on baseline characteristics as well as perioperative and long-term postoperative complications from patients who underwent cCEA or pCEA at the Department of Vascular Surgery, Xuanwu Hospital of Capital Medical University, from 2013 to 2022, were retrospectively collected and analyzed.

RESULTS

A total of 248 CEA patients were included in our study. The majority of patients (87.3%) were male, and mean age was 63.6 ± 7.6 (range, 40-81) years; 104 patients (41.9%) underwent cCEA, while 144 (58.1%) underwent pCEA. Between the cCEA and pCEA groups, there were no significant differences in clinical baseline characteristics, occurrence of perioperative or long-term (median, 42.5 [range, 7 to 120] months) complications, and survival whether restenosis-free, asymptomatic or overall.

CONCLUSIONS

In a single-center experience, conventional and patch CEA approaches appear similarly safe and effective.

Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications

Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.

Eversion technique versus traditional carotid endarterectomy with patch angioplasty: a systematic review with meta-analyses and trial sequential analysis

Introduction

The use of an 'eversion' technique is not unequivocally proven to be superior to carotid endarterectomy with patch angioplasty. An up-to-date systematic review is needed for evaluation of benefits and harms of these two techniques.

Methods

RCTs comparing eversion technique versus endarterectomy with patch angioplasty in patients with a symptomatic and significant (≥50 %) stenosis of the internal carotid artery were enrolled. Primary outcomes were all-cause mortality rate, health-related quality of life and serious adverse events. Secondary outcomes included 30-day stroke and mortality rate, (a) symptomatic arterial occlusion or restenosis, and adverse events not critical for decision making.

Results

Four RCTs were included with 1272 surgical procedures for carotid stenosis; eversion technique n = 643 and carotid endarterectomy with patch closure n = 629. Meta-analysis comparing both techniques showed, with a very low certainty of evidence, that eversion technique might decrease the number of patients with serious adverse events (RR 0.47; 95% CI 0.34 to 0.64; p ≤ 0.01). However, no difference was found on the other outcomes. TSA demonstrated that the required information sizes were far from being reached for these patient-important outcomes. All patient-relevant outcomes were at low certainty of evidence according to GRADE.

Conclusions

This systematic review showed no conclusive evidence of any difference between eversion technique and carotid endarterectomy with patch angioplasty in carotid surgery. These conclusions are based on data obtained in trials with very low certainty according to GRADE and should therefore be interpreted cautiously. Until conclusive evidence is obtained, the standard of care according to ESVS guidelines should not be abandoned.

Update in Carotid Disease

This review of the literature analyzes publications over the past five years on various problems associated with carotid endarterectomy: 1. Is the eversion or classical technique of surgery with plastic repair of the reconstruction area with a patch more effective? 2. Carotid endarterectomy or carotid angioplasty with stenting is more optimal? 3. When should brain revascularization be performed after the development of ischemic stroke? 4. Should a temporary shunt be used to protect the brain during carotid endarterectomy? 5. How to prevent and treat different types of intraoperative ischemic strokes? 6. What tactics of treatment of patients with combined lesions of the carotid and coronary arteries is more effective? 7. What are the causes and methods of elimination of restenosis of the internal carotid artery known? 8. Is carotid endarterectomy safe in old age?

Partial Eversion Carotid Endarterectomy versus Conventional Techniques for Significant Carotid Stenosis

BACKGROUND

To compare the outcomes of patients who were submitted to partial carotid endarterectomy (P-CEA) to those of patients who underwent standard conventional CEA with patch closure (C-CEA) and eversion CEA (E-CEA) for a significant carotid stenosis.

METHODS

Data of patients who consecutively underwent CEA from January 2014 to December 2018 for a significant carotid stenosis were retrospectively collected. Primary outcomes included mortality and the occurrence of neurologic and cardiologic complications, both at 30 days and during follow-up. Secondary outcomes included the occurrence of perioperative local complications (i.e. cranial nerve injuries, hematomas) and restenosis during follow-up. P values < 0.5 were considered statistically significant.

RESULTS

Three-hundred twenty-seven patients (241 males, 74%) underwent CEA for carotid stenosis (28.6% symptomatic). P-CEA was performed in 202 patients (61.8%), while C-CEA and E-CEA were performed in 103 and 22 cases respectively. At 30 days, neurologic complications were not significantly different among the 3 groups (2.8% in the group of C-CEA, 2.4% after P-CEA and 0% in E-CEA patients, P = 0.81), neither during follow-up. Perioperative local complications also were not significantly different among the 3 groups (P = 0.16).

CONCLUSIONS

P-CEA had similar outcomes if compared to C-CEA and to E-CEA in terms of perioperative mortality, occurrence of neurologic and cardiologic complications, and occurrence of local complications. Also, in the long-term, P-CEA, C-CEA, and E-CEA were burdened by similar rates of mortality, neurologic, and cardiologic complications and restenosis.

Nationwide Outcome Analysis of Primary Carotid Endarterectomy in Symptomatic Patients Depending on Closure Technique and Patch Type

OBJECTIVE

Current European guidelines recommend both eversion carotid endarterectomy (CEA) and conventional CEA with routine patch closure, rather than routine primary closure. Polyester and polytetrafluoroethylene (PTFE) have been used as patch material for a long time. More recently, bovine pericardium has been used; however, there are few studies comparing long term results between bovine pericardium and other patch types. The aim of this study was to investigate the short and long term results after CEA depending on surgical technique and patch material.

METHODS

A registry based study on all primary CEAs (n = 9 205) performed for symptomatic carotid artery stenosis in Sweden from July 2008 to December 2019, cross linked with data from the Swedish stroke registry, Riksstroke, and chart review for evaluation of any events occurring during follow up. The primary endpoint was ipsilateral stroke < 30 days. Secondary endpoints included re-operations due to neck haematoma and < 30 day ipsilateral stroke, > 30 day ipsilateral stroke, all stroke > 30 days, and all cause mortality.

RESULTS

2 495 patients underwent eversion CEA and 6 710 conventional CEA for symptomatic carotid stenosis. The most commonly used patch material was Dacron (n = 3 921), followed by PTFE (n = 588) and bovine pericardium (n = 413). A total of 1 788 patients underwent conventional CEA with primary closure. Two hundred and seventy-three patients (3.0%) had a stroke < 30 days. Primary closure was associated with an increased risk of ipsilateral stroke and stroke or death <30 days: odds ratio 1.7 (95% confidence interval [CI] 1.2 - 2.4, p = .002); and 1.5 (95% CI 1.2 - 2.0), respectively. During follow up (median 4.2 years), 592 patients had any form of stroke and 1 492 died. There was no significant difference in long term risk of ipsilateral stroke, all stroke, or death depending on surgical technique or patch material.

CONCLUSION

There was an increased risk of ipsilateral stroke < 30 days in patients operated on with primary closure compared with eversion CEA and patch angioplasty. There was no difference between primary closure, different patch types, or eversion after the peri-operative phase.

Does the eversion technique have a lower early postoperative stroke rate than the conventional technique in carotid endarterectomy?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In carotid surgery, Does the eversion technique (ECEA) has an early postoperative lower stroke rate, As compared to conventional carotid endarterectomy (CCEA)? The outcome assessed was the stroke rate in the early potoperative period (30 days) in the two techniques. The best evidence confirmed that there is no statistically significant difference between ECEA and CCEA regarding the early postoperative stroke incidence.

•

Eversion technique and conventional endarterectomy are the main surgical endarterectomy techniques in carotid artery disease.

•

There is no difference between the Eversion and conventional endarterectomy techniques in early postoperative stroke rates.

•

Lack of randomised controlled trials that compare the two techniques.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clamped Carotid Dissection Can Reduce Postoperative Stroke After Carotid Endarterectomy

Background: The outcomes of carotid endarterectomy (CEA) are constantly reported in a multitude of studies; however, the specific causes of perioperative stroke have been scarcely investigated. The aim of the present study was to analyze and categorize the causes of perioperative strokes after CEA. Methods: All CEAs performed from 2006 to 2019 in a single center were collected. CEA was routinely performed under general anesthesia, with routine shunting and patching, using cerebral near-infrared spectroscopy monitoring. Carotid exposure technique was classified as either clamped-dissection (CD) or preclamping-dissection (PCD) if the carotid bifurcation was dissected after or prior to carotid clamping. Perioperative and 30-day strokes and their possible mechanisms were evaluated according to preoperative symptoms and surgical technique adopted. Results: Among 1760 CEAs performed, 30 (1.7%) perioperative strokes occurred. 14 (47%) were identified upon emergence from general anesthesia, and 16 (53%) were noted in the first 30 days following intervention. Stroke etiology was categorized as follows: technical (acute thrombosis or intimal flap or due to intraoperative complications), embolic (no recognized technical defect), hemorrhagic, or contralateral. Symptomatic patients had a significantly higher rate of any type of stroke than asymptomatic patients (3.8% vs 0.9%, P = .0001). CD was protective for postoperative stroke (0.9% vs 3.1%, P = .001) in both symptomatic and asymptomatic patients (2.5% vs 5.9%, P = .05; 0.4% vs 1.9%, P = .005), particularly for the cohort in which symptomatic patients (0.7% vs 3.2%, P = .04) suffered postoperative embolic stroke. Conclusion: Perioperative stroke in CEA may be multifactorial in etiology, including a result of technical errors. A CD technique may help reduce the incidence of perioperative stroke.

Long Term Restenosis Rate After Carotid Endarterectomy: Comparison of Three Surgical Techniques and Intra-Operative Shunt Use

OBJECTIVE

Closure of the artery during carotid endarterectomy (CEA) can be done with or without a patch, or performed with the eversion technique, while the use of intra-operative shunts is optional. The influence of these techniques on subsequent restenosis is uncertain. Long term carotid restenosis rates and risk of future ipsilateral stroke with these techniques were compared.

METHODS

Patients who underwent CEA in the International Carotid Stenting Study were divided into patch angioplasty, primary closure, or eversion endarterectomy. Intra-operative shunt use was reported. Carotid duplex ultrasound was performed at each follow up. Primary outcomes were restenosis of ≥ 50% and ≥ 70%, and ipsilateral stroke after the procedure to the end of follow up.

RESULTS

In total, 790 CEA patients had restenosis data at one and five years. Altogether, 511 (64.7%) had patch angioplasty, 232 (29.4%) primary closure, and 47 (5.9%) eversion endarterectomy. The cumulative incidence of ≥ 50% restenosis at one year was 18.9%, 26.1%, and 17.7%, respectively, and at five years it was 25.9%, 37.2%, and 30.0%, respectively. There was no difference in risk between the eversion and patch angioplasty group (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.45 - 1.81; p = .77). Primary closure had a higher risk of restenosis than patch angioplasty (HR 1.45, 95% CI 1.06 - 1.98; p = .019). The cumulative incidence of ≥ 70% restenosis did not differ between primary closure and patch angioplasty (12.1% vs. 7.1%, HR 1.59, 95% CI 0.88 - 2.89; p = .12) or between patch angioplasty and eversion endarterectomy (4.7%, HR 0.45, 95% CI 0.06 - 3.35; p = .44). There was no effect of shunt use on the cumulative incidence of restenosis. Post-procedural ipsilateral stroke was not more common in either of the surgical techniques or shunt use.

CONCLUSION

Restenosis was more common after primary closure than conventionally with a patch closure. Shunt use had no effect on restenosis. Patch closure is the treatment of choice to avoid restenosis.

Literature review of primary versus patching versus eversion as carotid endarterectomy closure

BACKGROUND

Which type of closure after carotid endarterectomy (CEA), whether primary, patching, or eversion, will provide the optimal results has remained controversial. In the present study, we compared the results of randomized controlled trials (RCTs) and systematic meta-analyses of the various types of closure.

METHODS

We conducted a PubMed literature review search to find studies that had compared CEA with primary closure, CEA with patching, and/or eversion CEA (ECEA) during the previous three decades with an emphasis on RCTs, previously reported systematic meta-analyses, large multicenter observational studies (Vascular Quality Initiative data), and recent single-center large studies.

RESULTS

The results from RCTs comparing primary patching vs primary closure were as follows. Most of the randomized trials showed CEA with patching was superior to CEA with primary closure in lowering the perioperative stroke rates, stroke and death rates, carotid thrombosis rates, and late restenosis rates. These studies also showed no significant differences between the preferential use of several patch materials, including synthetic patches (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del], Acuseal [Gore Medical, Flagstaff, Ariz], polytetrafluoroethylene, or pericardial patches) and vein patches (saphenous or jugular). The results from observational studies comparing patching vs primary closure were as follows. The Vascular Study Group of New England data showed that the use of patching increased from 71% to 91% (P < .001). Also, the 1-year restenosis and occlusion (P < .01) and 1-year stroke and transient ischemic attack (P < .03) rates were significantly lower statistically with patch closure. The results from the RCTs comparing ECEA vs conventional CEA (CCEA) were as follows. Several RCTs that had compared ECEA with CCEA showed equivalency of CCEA vs ECEA (level 1 evidence) with patching in the perioperative carotid thrombosis and stroke rates. At 4 years after treatment, the incidence of carotid stenosis was lower for ECEA than for primary closure (3.6% vs 9.2%; P = .01) but was comparable between patching and eversion (1.5% for patching vs 2.8% for eversion).

CONCLUSIONS

Routine carotid patching or ECEA was superior to primary closure (level 1 evidence). We found no significant differences between the preferential use of several patch materials. The rates of significant post-CEA stenosis for CEA with patching was similar to that with ECEA, and both were superior to primary closure.

Safe carotid endarterectomy: "one fits all strategy"

INTRODUCTION

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

AIM

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Eversion technique versus conventional endarterectomy with patch angioplasty in carotid surgery: protocol for a systematic review with meta-analyses and trial sequential analysis of randomised clinical trials

INTRODUCTION

Traditional carotid endarterectomy is considered to be the standard technique for prevention of a new stroke in patients with a symptomatic carotid stenosis. Use of patch angioplasty to restore the arterial wall after longitudinal endarterectomy is, to date, not unequivocally proven to be superior to eversion technique. A systematic review is needed for evaluation of benefits and harms of the eversion technique versus the traditional endarterectomy with patch angioplasty in patients with symptomatic carotid stenosis.

METHODS AND OUTCOMES

The review will be conducted according to this protocol following the recommendations of the 'Cochrane Handbook for Systematic Reviews' and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomised clinical trials comparing eversion technique versus endarterectomy with patch angioplasty in patients with a symptomatic stenosis of the internal carotid artery will be included. Primary outcomes are all-cause mortality rate, health-related quality of life and serious adverse events. Secondary outcomes are 30-day stroke and mortality rate, symptomatic arterial restenosis or occlusion and non-serious adverse events. The databases Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE will be searched (November 2019). We will primarily base our conclusions on meta-analyses of trials with overall low-risk of bias. We will use trial sequential analysis to assist the evaluation of imprecision in Grading of Recommendations, Assessment, Development and Evaluation. However, if pooled point estimates of all trials are similar to pooled point estimates of trials with overall low risk of bias and there is lack of a statistical significant interaction between estimates from trials with overall high risk of bias and trials with overall low risk of bias we will consider the trial sequential analysis adjusted precision of the estimate achieved in all trials as the result of our meta-analyses.

ETHICS AND DISSEMINATION

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

PROSPERO REGISTRATION NUMBER

CRD42019119361.

Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy

The technique of the eversion carotid endarterectomy (ECEA), as an alternative to the conventional endarterectomy with primary or patch angioplasty, is an established technique for managing internal carotid artery stenoses and recently its application has been upgraded through the European Society for Vascular Surgery guidelines (Recommendation 55: Class 1, Level A). However, the typical eversion method has been associated with postoperative hypertension due to loss of the baroreceptor reflex; the standard oblique transection at the bulb performed in the eversion endarterectomy interrupts either the baroreceptor sensoring tissue, which is mostly located in the adventitia at the medial portion of the proximal internal carotid artery, or even the proper Hering nerve, a branch of the glossopharyngeal nerve. These actions deregulate the natural negative feedback of the carotid baroreceptor. Guided by the anatomical location of the baroreceptor sensor we have elaborated a slight modification of the classical ECEA to maintain as much as possible of the viable carotid baroreceptor sensoring surface. By extending the oblique incision distal to the carotid bifurcation in the medial part of the internal carotid artery stem, an eyebrow-like part of the proximal internal carotid artery is maintained and the axis from the sensoring tissue to the nerve of Hering is protected and following the endarterectomy, postoperative arterial blood pressure levels are lower than in the classical ECEA due to the maintenance of the efficiency of the baroreceptor reflex. During the period from September 2016 to November 2018, carotid endarterectomy was performed in 57 patients. Twenty-eight of them underwent the typical ECEA and 29 patients had the modified eyebrow eversion carotid endarterectomy (me-ECEA). The changes of blood pressure baseline during the postoperative course in ECEA and me-ECEA group were analyzed and compared. Postoperative hypertension was defined as an elevation of systolic blood pressure (SBP) greater than 140 mm Hg. Patients who underwent typical ECEA had significantly higher postoperative blood pressure values compared with those who underwent me-ECEA. Actually, the mean postoperative SBP was 172.67 ± 24.59 mm Hg in the typical ECEA group compared with 160.86 ± 12.83 mm Hg in the me-ECEA group ( p  = 0.023). The mean diastolic blood pressure in the ECEA group was 65.42 ± 11.39 mm Hg compared with 58.06 ± 9.06 mm Hg in the me-ECEA group ( p  = 0.009). Our proposed me-ECEA technique seems to be related to lower rates of postoperative hypertension compared with the typical ECEA, probably due to the sparing of the main mass of the baroreceptor apparatus; this improved modification (me-ECEA) of the typical eversion procedure could represent an alternative ECEA technique with its inherent advantages.

Eversion Carotid Endarterectomy : A Short Review

Carotid endarterectomy (CEA) is the main procedure in carotid surgery, as well as the most frequent vascular procedure. Two techniques of CEA are available : eversion and conventional plus patch angioplasty. Eversion CEA is anatomic procedure that reduces ischemic and total operative time. Simultaneous correction of the joined carotid kinking and coiling is possible, easy and safe, while the usage of patch is excluded. Thanks to oblique shape of anastomosis, eversion CEA is associated with low risk of long-term restenosis. The false anastomotic aneurysms occurrence is very rare, almost impossible after eversion CEA. However, the usage of carotid shunt during eversion CEA is not always simple, while proximal or distal extension of the carotid plaque can make eversion CEA more difficult and risky. Eversion CEA should be the first choice in carotid surgery. Conventional CEA is indicated in cases when carotid plaque is extended more than usual, as well as, if the usage of carotid shunt is necessary.

Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients

Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I² test. I²>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I²=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I²=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I²=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I²=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I²=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I²=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I²=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I²=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I²=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I²=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I²=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I²=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.

A single-center experience in the eversion femoral endarterectomy

OBJECTIVES

Endarterectomy is the treatment of choice for arterial occlusive disease of the femoral bifurcation. Longitudinal arteriotomy and prosthetic patch angioplasty is the standard technique but, due to the increasing concerns with prosthetic-related infections and multidrug-resistant pathogens our group adopted an alternative approach. We present our experience with eversion femoral endarterectomy.

METHODS

All patients submitted to eversion femoral endarterectomy in a single institution during 2016-2019 were retrospectively analyzed. Patient demographics, surgical data, and complications were captured from medical records.

RESULTS

Nineteen patients, 84.2% male and a median age of 67 years (IQR 62-78) were submitted to eversion femoral endarterectomy with a median follow-up of 180 days (IQR 71-395). Seventeen (89.4%) patients were treated for chronic limb ischemia and the other two were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Most of the patients had smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). Only 3 patients (15.8%) were submitted exclusively to endarterectomy, 13 (68.4%) were submitted to endarterectomy as an adjuvant for peripheral endovascular treatment, 2 (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm, and 1 (5.3%) was complemented with thrombectomy of the femoro-popliteal sector. Primary patency rates were 100% and 87.5% (CI (38.7-98.1)) at 6 and 12 months, respectively. Primary-assisted and secondary patency rates were 100%. The 30-day mortality rate was 5.3% (n = 1) and complication rate 10.5% (n = 2). One patient complicated with acute renal disease related to rhabdomyolysis. Another patient developed a wound-related hematoma treated with surgical drainage, but died three days after consequent to ischemia-reperfusion injury.

CONCLUSIONS

Eversion femoral endarterectomy is a safe and feasible technique, with good patency results and respecting the concept of leaving nothing behind. A careful control of the proximal and distal endpoints is essential for the success of the technique.

Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy

BACKGROUND

Anesthesia modalities for carotid endarterectomy continue to vary nationally. We evaluated and compared short-term outcomes after carotid endarterectomy with general anesthesia (GA) and regional anesthesia (RA) in both symptomatic and asymptomatic patients.

METHODS

The 2011-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (PUFs) with merged Vascular Procedure-Targeted PUFs for carotid endarterectomy were queried for patients undergoing carotid endarterectomy. Postoperative complications, mortality, and hospital length of stay in patients undergoing GA or RA were compared.

RESULTS

A total of 14,447 patients were evaluated: 12,389 (85.7%) with GA and 2,058 (14.3%) with RA. The use of GA was inversely associated with patients' age (88.0% in patients aged 22-64 years vs. 83.4% in patients aged ≥80 years, P < 0.0001) and with symptomatic presentation (odds ratio [OR] = 1.25; 95% confidence interval [CI]: 1.13-1.38). There were no differences between GA and RA for in-hospital mortality, 30-day mortality, or postoperative complications of transient ischemic attack, stroke, bleeding, acute renal failure, or restenosis. However, rates of cranial nerve injury were significantly higher in GA than in RA (2.9% vs. 1.7%, respectively; P < 0.002) and confirmed by multivariable analysis (OR = 1.68; 95% CI: 1.19-2.39). Total operative time was also longer for GA than for RA (median: 115 minutes; Interquartile range (IQR): 89-145 versus median: 93 minutes; IQR: 76-119, respectively; P < 0.0001). Hospital length of stay was greater in GA than in RA (median: 1 day; IQR 1-2 vs. median: 1 day; IQR 1-1, respectively; P < 0.0001), as were 30-day readmission rates (6.7% vs. 5.4%, respectively; P = 0.02).

CONCLUSIONS

Iatrogenic nerve injury is a feared complication of carotid endarterectomy, especially in elective asymptomatic patients. RA reduces the rate of cranial nerve injury compared with GA. RA is also not inferior to GA for postoperative complications with the benefit of shorter operative times, lengths of hospital stay, and decreased 30-day readmission rates. Consideration should be given to more widespread adoption of this underused anesthesia modality.

[Meta-analysis of the results of eversion carotid endarterectomy and endarterectomy with patch plasty]

AIM

The study was aimed at comparing the results of eversion carotid endarterectomy and carotid endarterectomy with patch plasty in the immediate and remote postoperative periods.

MATERIALS AND METHODS

The literature was retrieved by means of electronic databases, with the dates of publications ranging from 1970 to 2019. According to the inclusion and exclusion criteria we selected the literature making it possible to carry out a meta-analysis in the immediate and remote postoperative periods. The results were obtained with the help of the Stata 14 software package. Eventually, we retrieved and analysed a total of 2139 articles. Of these, ten were included into the study and contained 3568 patients subjected to 3672 operations (eversion carotid endarterectomy - 1718 and carotid endarterectomy with a patch - 1954). The results of the meta-analysis were as follows: the mean time of carotid artery cross-clamping for eversion carotid endarterectomy was shorter than that for carotid endarterectomy with a patch (4.1±2.9 min); the frequency of using intraoperative temporary bypass in eversion carotid endarterectomy turned out to be significantly less compared with carotid endarterectomy with patch plasty - 13.5% (91/672) and 62.0% (492/793), OR=0.183, 95% CI: 0.136-0.254, p<0.001; the incidence rate of ischaemic stroke in the immediate and remote postoperative periods was significantly lower after eversion carotid endarterectomy than that after carotid endarterectomy with patch plasty - OR=0.452, 95% CI: 0258-0.792, p=0.005 and OR=0.300, 95% CI; 0.155-0.579, p=0.000. The development of restenosis in the immediate and remote postoperative periods was observed less often for eversion carotid endarterectomy compared with carotid endarterectomy with patch plasty - OR=0.604, 95% CI: 0.422-0.864, p=0.006.

CONCLUSION

Eversion carotid endarterectomy was associated with shorter time of carotid artery cross-clamping, lower frequency of intraoperative temporary bypass, lower number of cases of ischaemic stroke in the immediate and remote postoperative periods, as well as those of restenosis in the long-term postoperative period.

Bilateral Carotid Patch Infection Occurring 12 years Following Endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is the most commonly used invasive procedure for treatment of carotid stenosis. Different methods are used to close the arteriotomy including primary closure and patch repair with a graft. Prosthetic patch infection is a rare but serious complication of patch closure, and we will present a unique case of carotid patch infection (CPI) 12 years after implantation.

CASE

Patient is 76-year-old male ex-smoker with history of bilateral CEA with Dacron patch closure 12 years prior to presentation. He had a left neck draining sinus one year prior to presentation that was treated by patch excision and ICA ligation. He presented to us one year later with a right neck draining sinus tract, reaching the carotid sheath on CT scan. Surgery was done under EEG and NIRS oximetry with shunting. Excision of the patch with the involved ICA was done. CCA to distal ICA bypass was done by a reversed GSV graft. Intraoperative cultures of the patch grew Staphylococcus species coagulase negative, so the patient was discharged on antibiotics for one month. The patient had early postoperative swallowing difficulty that resolved over six weeks but no other complications. Patient was followed-up every three months and he was doing well on one-year follow-up.

DISCUSSION

Carotid patch infection is a well-documented complication of CEA with a prevalence between 0.27% and 1%. It most commonly presents as a pseudoaneurysm, draining sinus or neck swelling. The highest incidence is during the first year after the operation, and especially within the first three months postop due to contamination or wound infections; however, late presentations such as our case are rare. Bacterial cultures are positive in around 80% of the cases, growing mostly gram-positive cocci. Other organisms include Pseudomonas and Enterobacter. Management of CPI is challenging; difficulties include distal ICA control, friable arteries and adhesions to cranial nerves. Debridement with ligation of the vessel stump is an option, but may not be tolerated. Best outcomes are obtained with autogenous revascularization after debridement as was done in our case on the right side. Newer endovascular techniques may provide alternatives in urgent or high-risk situations, especially as staged procedures. This case is unique in its bilaterality and the longest time till presentation in the literature.

Outcomes following Eversion versus Conventional Endarterectomy in the Vascular Quality Initiative Database

BACKGROUND

Although the majority of vascular surgeons perform conventional carotid endarterectomy (c-CEA), others prefer eversion CEA (e-CEA). Despite several randomized controlled trials and single center studies, the advantage of one technique over the other is still not clearly defined. The purpose of this study is to compare the postoperative outcomes and durability of c-CEA versus e-CEA in a nationally representative cohort.

METHODS

We performed a retrospective review of the Vascular Quality Initiative database between 2003 and 2018. Patients with prior ipsilateral carotid intervention (CEA and carotid artery stenting) and those undergoing concomitant procedures were excluded. Multivariable logistic and Cox-regression analyses were used to compare risk-adjusted perioperative and 1-year outcomes (stroke, death, and high-grade restenosis [>70%]) between c-CEA (using direct closure or patch angioplasty) and e-CEA.

RESULTS

A total of 95,726 CEA cases were included, of which 12,050 (12.6%) were e-CEA and the remaining (87.4%) were c-CEA. Patch angioplasty was used in 94.9% of c-CEA compared with 49.7% of e-CEA (P < 0.001). On univariable analysis, no difference in perioperative outcomes was noted between the 2 approaches except for higher rates of in-hospital dysrhythmia (1.5% vs. 1.3%) and postprocedural hemodynamic instability (27.3% vs. 24.3%) after c-CEA compared with e-CEA (all P < 0.05). On the other hand, e-CEA patients were more likely to return to the operating room for bleeding (1.3% vs. c-CEA: 0.9%, P < 0.001). The outcomes of e-CEA did not differ if the common carotid artery was closed primarily or with a patch. After adjusting for potential confounders and stratifying with respect to patch use, there was no significant difference in outcomes between e-CEA and c-CEA when a patch is used in both procedures. However, when no patching was performed, e-CEA was associated with lower stroke/death at 30 days (odds ratio 0.72, 95% confidence interval [CI] 0.54-0.95, P = 0.02) and at 1 year (hazard ratio 0.75, 95% CI 0.58-0.97, P = 0.03).

CONCLUSIONS

Both e-CEA and c-CEA are safe and durable techniques with similar stroke/death and restenosis rates up to 1-year of follow up, as long as c-CEA is performed with patch angioplasty. However, e-CEA is superior to c-CEA without patch angioplasty and is associated with 28% and 25% reduction in 30-day and 1-year stroke/death, respectively.

[Advances in surgical treatment of ischemic cerebrovascular disease]

Restoration of cerebral blood flow is particularly important for the treatment of ischemic cerebrovascular disease. It is notable that surgical approaches play a unique role in treating this devastating disease. Among them, mechanical thrombectomy facilitates rapid and effective recanalization of occluded intracranial large vessels causing ischemic stroke, which contributes to improvement of cerebral perfusion in the ischemic penumbra; decompressive craniectomy is an important therapeutic option for acute massive cerebral infarction, and the timing of surgery determines the final clinical outcomes; for carotid endarterectomy in carotid-artery stenosis, individualized surgical plan is important for the safety and effectiveness of the operation; in the surgical revascularization of Moyamoya disease, precise evaluation of clinical and radiological characteristics, optimal surgical strategies and accuracy of intraoperative judgment will yield maximal therapeutic effects; and hybrid surgery is feasible for the therapy of complex ischemic cerebrovascular diseases, such as extracranial/intracranial arteries tandem stenosis and symptomatic chronic total occlusion of carotid artery. This paper reviews recent technical and clinical advances in the surgical treatment of ischemic cerebrovascular disease.

Early hemodynamic characteristics of eversion and patch carotid endarterectomies

OBJECTIVE

Carotid endarterectomy (CEA) is currently the gold standard in the operative management of carotid artery stenosis. While eversion and patch CEAs vary greatly in technique, various studies have determined equivalence with regard to clinical outcomes. However, the hemodynamic differences following each procedure are not known. This study aimed to investigate any early hemodynamic differences between eversion and patch CEAs.

METHODS

All CEAs performed at our institution from March 2012 to June 2018 were aggregated in a retrospective database by querying the 35301 CPT code from the electronic medical record system. Variables collected included gender, age, laterality of CEA, type of procedure, and pre- and post-operative duplex ultrasound (DUS) date and quantitative findings. Exclusion criteria included any procedure with incomplete data, a post-operative DUS > 90 days following the procedure, CEAs with concomitant bypass(es), isolated external carotid artery (ECA) endarterectomies, and re-do CEAs.

RESULTS

One hundred and seventy-one CEAs were performed in 161 unique patients. There were 101 males and 60 females, with an average age of 69.7 (38-96; ± 9.36). 63 CEAs were excluded from analysis: 51 due to incomplete data, eight with a > 90 day post-operative DUS, 2 isolated ECA endarterectomies, 1 CEA with a carotid-subclavian bypass, and 1 re-do CEA secondary to an infected patch. Twenty-seven eversion and 81 patch CEAs were included in analysis. There was no difference in procedure laterality or gender between the two cohorts (p > 0.05); however, patients who received an eversion CEA were older on average (73.3 vs 67.5; p = 0.002). Pre-operative peak systolic velocities (PSV) of the proximal internal carotid artery (ICA), distal ICA, and distal common artery (CCA) were all similar (p > 0.05). Post-operative DUS was performed at 17.0 and 12.9 days in the eversion and patch CEA cohorts, respectively (p = 0.12). Post-operative PSV and change in PSV were similar for all three aforementioned segments (p > 0.05).

CONCLUSION

Although eversion and patch CEAs vary greatly in technique and post-procedure anatomy, there was no significant difference in post-operative PSV or change in PSV at or around the carotid bifurcation.

A Single-center Retrospective Study with 5- and 10-year Follow-up of Carotid Endarterectomy with Patch Graft

Carotid endarterectomy (CEA) is widely used for cervical artery stenosis. In Japan, primary closure after endarterectomy has been a standard technique. Recently, the patch closure has been shown to be superior to the primary suture for the prevention of restenosis and ipsilateral stroke. This study evaluated the 5- and 10-year outcomes following CEA with patch graft closure in our institution. Between January 2000 and March 2013, 134 patients, who underwent CEA with patch graft closure were investigated in the current retrospective study. Among these patients, 102 CEAs in 97 patients were followed up for 5 years and 66 CEAs in 61 patients were for 10 years after the procedure. Restenosis was defined as >50% recurrent luminal narrowing at the endarterectomy site. In 5 years, symptomatic restenosis exhibited minor stroke in one patient at 58 months after CEA (restenosis rate 1.0%). The ipsilateral minor stroke occurred in three patients including the above case (2.9%). In 10 years, asymptomatic restenosis occurred in three patients in addition to the above symptomatic case (restenosis rate 6.1%), and the ipsilateral minor stroke occurred in four patients (6.1%). Carotid endarterectomy with patch graft exerted a high protective effect from restenosis up to 5 and 10 years in our institution. The number of carotid artery stenting is increasing all over the world but we speculated that the established surgical procedure of patched CEA prevented restenosis and ipsilateral stroke.

Comparing the Role of Mechanical Forces in Vascular and Valvular Calcification Progression

Calcification is a prevalent disease in most fully developed countries and is predominantly observed in heart valves and nearby vasculature. Calcification of either tissue leads to deterioration and, ultimately, failure causing poor quality of life and decreased overall life expectancy in patients. In valves, calcification presents as Calcific Aortic Valve Disease (CAVD), in which the aortic valve becomes stenotic when calcific nodules form within the leaflets. The initiation and progression of these calcific nodules is strongly influenced by the varied mechanical forces on the valve. In turn, the addition of calcific nodules creates localized disturbances in the tissue biomechanics, which affects extracellular matrix (ECM) production and cellular activation. In vasculature, atherosclerosis is the most common occurrence of calcification. Atherosclerosis exhibits as calcific plaque formation that forms in juxtaposition to areas of low blood shear stresses. Research in these two manifestations of calcification remain separated, although many similarities persist. Both diseases show that the endothelial layer and its regulation of nitric oxide is crucial to calcification progression. Further, there are similarities between vascular smooth muscle cells and valvular interstitial cells in terms of their roles in ECM overproduction. This review summarizes valvular and vascular tissue in terms of their basic anatomy, their cellular and ECM components and mechanical forces. Calcification is then examined in both tissues in terms of disease prediction, progression, and treatment. Highlighting the similarities and differences between these areas will help target further research toward disease treatment.

Hybrid Surgery for Nontaper or Nonstump Lesions in Symptomatic Subacute or Chronic Internal Carotid Occlusion: A Better Solution

BACKGROUND

Internal carotid artery occlusion (ICAO) causes transient ischemic attack and cerebral infarction. ICAO management remains clinically challenging. We discuss a hybrid treatment combining carotid endarterectomy and endovascular intervention (E-I) for patients with nontaper or nonstump lesions of symptomatic ICAO.

METHODS

We treated 32 patients with consecutive nontaper or nonstump ICAO with neurological symptoms with hybrid treatment or E-I. We analyzed the epidemiology, symptoms, angiographic morphology, technical success rate, and perioperative complications.

RESULTS

Of the 32 patients, 17 were treated with hybrid surgery and 15, E-I. The demographic data and lesion characteristics were similar between the 2 groups. The overall recanalization success rate was 71.9%. The rate for hybrid surgery was better than that for E-I (88.2% vs. 53.3%). The postoperative cerebral hyperperfusion rate showed no difference between the 2 groups (11.8% vs. 6.7%). Ipsilateral cerebral perfusion improved after treatment. The mean transition time and time to peak were greater than normal (normal values, <6 seconds and <8 seconds, respectively). Both increased significantly after treatment (mean transition time, 11.30 seconds vs. 7.25 seconds; time to peak, 19.30 seconds vs. 15.50 seconds). The incidence of perioperative complications from hybrid surgery was less than that with E-I (5.9% vs. 40.0%). Recurrent cerebrovascular events (5.9% vs. 13.3%) and the 3-month modified Rankin scale score (2.76 ± 0.66 vs. 2.93 ± 0.70) did not differ between the 2 groups.

CONCLUSIONS

Recanalization of nontaper or nonstump ICAO with hybrid treatment was more successful than that with E-I, with fewer perioperative complications. The carotid endarterectomy procedure enables easier wire crossing across the occlusion and reduces potential technology-related complications by requiring a shorter lesion and fewer dissections and minimizing the effect of calcification.