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Brisard L, El Batti S, Borghese O, Maurel B. Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score. J Clin Med 2023; 12:7520. [PMID: 38137589 PMCID: PMC10743399 DOI: 10.3390/jcm12247520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.
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Affiliation(s)
- Laurent Brisard
- Department of Anesthesiology and Critical Care, Laënnec Hospital, University Hospital of Nantes, F-44000 Nantes, France;
| | - Salma El Batti
- Department of Vascular and Endovascular Surgery, Hôpital Européen Georges Pompidou—Hôpitaux de Paris, Université de Paris Cité, F-75015 Paris, France;
| | - Ottavia Borghese
- Department of Cardiac and Vascular Surgery, L’Institut du Thorax, Nantes University Hospital, F-44093 Nantes, France;
| | - Blandine Maurel
- Department of Cardiac and Vascular Surgery, L’Institut du Thorax, Nantes University Hospital, F-44093 Nantes, France;
- Inserm UMR 1087/CNRS UMR 6291, L’Institut du Thorax, Université de Nantes, F-44000 Nantes, France
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Li F, Zhang R, Di X, Niu S, Rong Z, Liu C, Ni L. Diabetes mellitus and adverse outcomes after carotid endarterectomy: A systematic review and meta-analysis. Chin Med J (Engl) 2023; 136:1401-1409. [PMID: 37334731 PMCID: PMC10278750 DOI: 10.1097/cm9.0000000000002730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND There is still uncertainty regarding whether diabetes mellitus (DM) can adversely affect patients undergoing carotid endarterectomy (CEA) for carotid stenosis. The aim of the study was to assess the adverse impact of DM on patients with carotid stenosis treated by CEA. METHODS Eligible studies published between 1 January 2000 and 30 March 2023 were selected from the PubMed, EMBASE, Web of Science, CENTRAL, and ClinicalTrials databases. The short-term and long-term outcomes of major adverse events (MAEs), death, stroke, the composite outcomes of death/stroke, and myocardial infarction (MI) were collected to calculate the pooled effect sizes (ESs), 95% confidence intervals (CIs), and prevalence of adverse outcomes. Subgroup analysis by asymptomatic/symptomatic carotid stenosis and insulin/noninsulin-dependent DM was performed. RESULTS A total of 19 studies (n = 122,003) were included. Regarding the short-term outcomes, DM was associated with increased risks of MAEs (ES = 1.52, 95% CI: [1.15-2.01], prevalence = 5.1%), death/stroke (ES = 1.61, 95% CI: [1.13-2.28], prevalence = 2.3%), stroke (ES = 1.55, 95% CI: [1.16-1.55], prevalence = 3.5%), death (ES = 1.70, 95% CI: [1.25-2.31], prevalence =1.2%), and MI (ES = 1.52, 95% CI: [1.15-2.01], prevalence = 1.4%). DM was associated with increased risks of long-term MAEs (ES = 1.24, 95% CI: [1.04-1.49], prevalence = 12.2%). In the subgroup analysis, DM was associated with an increased risk of short-term MAEs, death/stroke, stroke, and MI in asymptomatic patients undergoing CEA and with only short-term MAEs in the symptomatic patients. Both insulin- and noninsulin-dependent DM patients had an increased risk of short-term and long-term MAEs, and insulin-dependent DM was also associated with the short-term risk of death/stroke, death, and MI. CONCLUSIONS In patients with carotid stenosis treated by CEA, DM is associated with short-term and long-term MAEs. DM may have a greater impact on adverse outcomes in asymptomatic patients after CEA. Insulin-dependent DM may have a more significant impact on post-CEA adverse outcomes than noninsulin-dependent DM. Whether DM management could reduce the risk of adverse outcomes after CEA requires further investigation.
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Affiliation(s)
- Fengshi Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Rui Zhang
- Department of Breast Oncoplastic Surgery, Hunan Cancer Hospital & The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410031, China
| | - Xiao Di
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Shuai Niu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Zhihua Rong
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Changwei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Leng Ni
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Xodo A, Barbui F, Desole A, Pilon F, Zaramella M, Milite D. Bypass and other modified reconstruction techniques for 'challenging' carotid cases: A comparison with conventional endarterectomy. Vascular 2023:17085381231174946. [PMID: 37172198 DOI: 10.1177/17085381231174946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA. METHODS A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30 days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis. RESULTS A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed. CONCLUSIONS Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues.
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Affiliation(s)
- Andrea Xodo
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
| | - Federico Barbui
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
| | - Alessandro Desole
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
| | - Fabio Pilon
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
| | | | - Domenico Milite
- Division of Vascular and Endovascular Surgery, "San Bortolo" Hospital, Vicenza, Italy
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Kazantsev A, Korotkikh A, Lider R, Lebedev O, Sirotkin A, Palagin P, Mukhtorov O, Shmatov D, Artyukhov S, Ageev I, Rogova A, Kalichkin I, Beglaryan J, Snigur A, Belov Y. Results of carotid endarterectomy with the use of temporary shunts with reduced retrograde pressure in the internal carotid artery - analysis of the multicenter Russian register. Indian J Thorac Cardiovasc Surg 2023; 39:244-250. [PMID: 37124591 PMCID: PMC10140191 DOI: 10.1007/s12055-023-01487-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 02/25/2023] Open
Abstract
Aim The aim of the study was to assess the role of a temporary carotid shunt in patients undergoing carotid endarterectomy. Materials and methods This was a retrospective, multicentric (n = 159) study carried out between January 2005 and October 2020. The study included 3114 patients undergoing carotid endarterectomy who had a reduced retrograde internal carotid artery pressure (<60% of systolic blood pressure). A temporary carotid shunt was used in 1328 patients and 1786 patients underwent carotid endarterectomy without a shunt. Results The in-hospital outcomes were comparable in terms of the incidence of deaths, myocardial infarctions, and stroke between the two groups. However, asymptomatic strokes (confirmed on computed tomography) occurred more frequently in the group where the temporary shunt was used (34 (2.5%) vs. 10 (0.55%), p < 0.0001). The composite endpoints of adverse events were also higher in the group where a temporary shunt was used (44 (3.3%) vs. 28 (1.5%), p = 0.002). The risk of symptomatic stroke (both fatal and non-fatal) was higher in the group where a temporary shunt was not used, though this was statistically not significant. Logistic regression analysis identified diabetes mellitus and stenosis (81-90%) of the contralateral internal carotid artery to be important predictors for stroke. Conclusion Temporary carotid shunts during carotid endarterectomy were associated with increased rates of asymptomatic stroke. There were no statistically significant differences in the incidence of non-fatal or fatal stroke, myocardial infarction, and mortality.
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Affiliation(s)
- Anton Kazantsev
- Kostroma Regional Clinical Hospital Named After E.I. Korolev, Kostroma, Russian Federation
| | - Alexander Korotkikh
- Clinic of Cardiac Surgery of the Amur State Medical Academy of the Ministry of Health of Russia, Blagoveshchensk, Russia
| | - Roman Lider
- Kemerovo State Medical University of the Ministry of Health of the Russian Federation, Kemerovo, Russian Federation
| | - Oleg Lebedev
- Kostroma Regional Clinical Hospital Named After E.I. Korolev, Kostroma, Russian Federation
| | - Alexey Sirotkin
- Kostroma Regional Clinical Hospital Named After E.I. Korolev, Kostroma, Russian Federation
| | - Petr Palagin
- Kostroma Regional Clinical Hospital Named After E.I. Korolev, Kostroma, Russian Federation
| | - Otabek Mukhtorov
- Kostroma Regional Clinical Hospital Named After E.I. Korolev, Kostroma, Russian Federation
| | - Dmitriy Shmatov
- Clinic of High Medical Technologies Named After N.I. Pirogov St. Petersburg State University, Saint Petersburg, Russian Federation
| | - Sergey Artyukhov
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russian Federation
| | - Ivan Ageev
- Kemerovo State Medical University of the Ministry of Health of the Russian Federation, Kemerovo, Russian Federation
| | - Alexandra Rogova
- Kemerovo State Medical University of the Ministry of Health of the Russian Federation, Kemerovo, Russian Federation
| | - Ivan Kalichkin
- Kemerovo State Medical University of the Ministry of Health of the Russian Federation, Kemerovo, Russian Federation
| | - Jasmine Beglaryan
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russian Federation
| | - Alla Snigur
- North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russian Federation
| | - Yuri Belov
- Russian Scientific Center of Surgery named after Academician B.V. Petrovsky, Moscow, Russian Federation
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Squizzato F, Spertino A, Lupia M, Grego F, Gerosa G, Tarantini G, Piazza M, Antonello M. Prevalence, risk factors, and clinical effect of coronary artery disease in patients with asymptomatic bilateral carotid stenosis. J Vasc Surg 2023; 77:1182-1191.e1. [PMID: 36464015 DOI: 10.1016/j.jvs.2022.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE In the present report, we have described the prevalence, risk factors, and clinical effects of coronary artery disease (CAD) for patients with asymptomatic bilateral carotid stenosis. METHODS We conducted a single-center, retrospective cohort study of consecutive patients referred for bilateral carotid stenosis >70% (2014-2021). All the patients had undergone systematic coronary angiography. Depending on the anatomic and clinical characteristics, the patients had undergone combined carotid endarterectomy (CEA) plus coronary artery bypass grafting, coronary percutaneous intervention followed by CEA or carotid artery stenting (CAS), or staged bilateral CEA with cardiac best medical therapy. The cumulative 30-day stroke/myocardial infarction (MI) rate after cardiac and bilateral carotid interventions and long-term survival and freedom from cardiovascular mortality were assessed. RESULTS A total of 167 patients with bilateral carotid stenosis >70% had undergone preoperative coronary angiography, identifying severe CAD in 108 patients (65.1%). Echocardiographic abnormalities (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.03-5.78; P = .04) and prior coronary intervention (OR, 11.94; 95% CI, 2.99-63.81; P = .001) were significantly associated with severe CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). The cumulative MI rate was 4.8%; 5.6% for the patients with severe CAD and 1.7% for those without severe CAD (P = .262). The cumulative stroke rate was 1.8%; 1.8% for those with severe CAD and 1.7% for those without severe CAD (P = 1.00). The overall stroke/MI rate was 6.6%; 8.3% for those with severe CAD and 3.3% for patients without severe CAD (P = .33). Patients with severe CAD deemed untreatable for coronary bypass or percutaneous intervention had a higher risk of perioperative stroke/MI (OR, 1.24; 95% CI, 1.00-2.83; P = .04). At 10 years, overall survival was 67.1% (95% CI, 57%-79%), and freedom from cardiovascular mortality was 78.5% (95% CI, 69%-89%). Patients with untreatable CAD maintained a higher risk of 10-year mortality (hazard ratio, 5.5; 95% CI, 1.6-19.9; P < .01). CONCLUSIONS In the present study, the prevalence of CAD in patients with bilateral carotid stenosis was high, especially for those with abnormal echocardiographic findings. CAD was potentially treatable in 80% of patients, and staged or simultaneous CAD treatment was performed with an acceptable stroke/MI complication rate for these patients. The presence of untreatable CAD was associated with worsened early and long-term outcomes, questioning the benefit of carotid interventions for this subset of patients.
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Affiliation(s)
- Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Andrea Spertino
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Mario Lupia
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Franco Grego
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gino Gerosa
- Division of Cardiac Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Division of Cardiology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Kazantsev AN, Korotkikh AV, Unguryan VM, Belov YV. Update in Carotid Disease. Curr Probl Cardiol 2023; 48:101676. [PMID: 36828045 DOI: 10.1016/j.cpcardiol.2023.101676] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
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?
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Affiliation(s)
- Anton Nikolaevich Kazantsev
- Kostroma Regional Clinical Hospital named after Korolev E.I., Kostroma, Russian Federation; Kostroma oncological dispensary, Kostroma, Russian Federation.
| | - Alexander Vladimirovich Korotkikh
- Clinic of Cardiac Surgery of the Amur State Medical Academy of the Ministry of Health of Russia, Blagoveshchensk, Russian Federation
| | | | - Yuriy Vladimirovich Belov
- First Moscow State Medical University named after Sechenov, Moscow, Russian Federation; Federal State Budgetary Scientific Institution Russian Scientific Center for Surgery named after Academician B.V. Petrovsky, Moscow, Russian Federation
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Squizzato F, Siracuse JJ, Shuja F, Colglazier J, Balachandran Wilkins P, Goodney PP, Sands Brooke B, DeMartino RR. Impact of Shunting Practice Patterns During Carotid Endarterectomy for Symptomatic Carotid Stenosis. Stroke 2022; 53:2230-2240. [PMID: 35321557 DOI: 10.1161/strokeaha.121.037657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND We aimed to assess the effect of surgeons' shunting practice and shunt use on the early outcomes of carotid endarterectomy (CEA) in recently symptomatic patients. METHODS We conducted a retrospective observational study based on a multicenter national prospective database. The Vascular Quality Initiative database (2010-2019) was queried for CEAs performed within 14 days after an ipsilateral stroke or transient ischemic attack. Surgeons were gauged as routine shunters if they shunted in >95% of CEAs, otherwise were classified as selective shunters. In-hospital stroke and death rates were compared between routine and selective shunters, stratifying by type of index event (transient ischemic attack versus stroke) and timing of CEA (≤2 versus >2 days). RESULTS Thirteen thousand four hundred sixty-nine CEAs were performed after a transient ischemic attack (43%) or stroke (57%), 3186 (24%) by routine shunters, and 10 283 (76%) by selective shunters. Comparing routine and selective shunters, in-hospital stroke (1.9% versus 2.4%; P=0.09) and death (0.4% versus 0.5%; P=0.73) rates were similar. A lower stroke rate (1.5% versus 4.2%; P=0.02) was achieved by routine shunters for CEA performed <2 days after an ischemic stroke. Among selective shunters, a higher stroke rate occurred in case of shunt use (2.9% versus 2.3%; P<0.01), mainly due to cases presenting with stroke (3.5% versus 2.4%; P<0.01) but not transient ischemic attack (1.8% versus 1.5%; P=0.57). Awake anesthesia was adopted in 7.8% of cases by selective shunters and in 0.8% by routine shunters, without impact on the perioperative stroke rate (1.8% versus 2.3%; P=0.349). CONCLUSIONS In this large national cohort, the overall outcomes of CEA were similar between routine and selective shunters. A lower postoperative stroke rate was achieved by routine shunters in CEA performed <2 days after an ischemic stroke. Among selective shunters, intraoperatively indicated shunting determined an increased stroke rate, likely due to intraoperative hypoperfusion. These data may guide the decision regarding timing of CEA and shunting intention in symptomatic patients.
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Affiliation(s)
- Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (F. Squizzato, F. Shuja, J.C., P.B.W., R.R.D.).,Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (F. Squizzato)
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, MA (J.J.S.)
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (F. Squizzato, F. Shuja, J.C., P.B.W., R.R.D.)
| | - Jill Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (F. Squizzato, F. Shuja, J.C., P.B.W., R.R.D.)
| | - Parvathi Balachandran Wilkins
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (F. Squizzato, F. Shuja, J.C., P.B.W., R.R.D.)
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, PA (P.P.G.)
| | | | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (F. Squizzato, F. Shuja, J.C., P.B.W., R.R.D.)
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8
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Baram A, Mohammed ZA, Al-Bajalan SJ, Falah F. Five-year outcome of non-shunting and primary closure technique during carotid endarterectomy: a longitudinal cohort study. J Int Med Res 2022; 50:3000605221076925. [PMID: 35422155 PMCID: PMC9016544 DOI: 10.1177/03000605221076925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective The long-term outcomes of primary carotid artery closure after carotid
endarterectomy (CEA) have not been sufficiently studied. This prospective
study was performed to analyze the 5-year outcomes of the non-shunting and
primary arterial repair technique for CEA. Methods This study involved 150 patients who underwent CEA with the primary arterial
closure technique without arterial shunting and completed 5 years of
follow-up. Results The patients comprised 107 men and 43 women. The 30-day postoperative course
was uneventful in 147 (98.0%) patients; however, cerebrovascular accidents
occurred in 3 (2.0%) patients. With respect to the long-term results, most
cases of restenosis at 5 years were <50%. Two patients developed
asymptomatic total internal carotid artery occlusion. Eleven deaths occurred
(mortality rate of 7.3%); one death (0.7%) occurred in the first 30
days. Conclusion Primary arteriotomy closure provides very good long-term patency. Routine use
of patch closure is unnecessary.
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Affiliation(s)
- Aram Baram
- Professor of Cardiovascular and Thoracic Surgery, Department of Surgery, College of Medicine, University of Sulaimani, Department of Thoracic and Cardiovascular Surgery, Sulaimani Shar Teaching Hospital, Al Sulaymaniyah, Iraq/Kurdistan region
| | - Zana A. Mohammed
- Consultant Neurologist, Department of Medicine, College of Medicine, University of Sulaimani, Department of Neurology, Sulaimani Shar Teaching Hospital, Al Sulaymaniyah, Iraq/Kurdistan region
| | - Sarwer Jamal Al-Bajalan
- Consultant Neurologist, Department of Medicine, College of Medicine, University of Sulaimani, Department of Neurology, Sulaimani Shar Teaching Hospital, Al Sulaymaniyah, Iraq/Kurdistan region
| | - Fitoon Falah
- Cardiovascular Surgeon, Slemani Center for Heart Disease, Slemani Directorate of Health, Ministry of Health, Kurdistan Regional Government
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Prevalence and Prognostic Impact of Carotid Artery Disease in Patients Undergoing TAVI. Ann Vasc Surg 2022; 84:61-68. [PMID: 35341937 DOI: 10.1016/j.avsg.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the prevalence of atherosclerotic carotid artery disease (ACAD) in patients undergoing transcatheter aortic valve implantation (TAVI) and postoperative cerebrovascular and evaluate its prognostic impact on post-operative cerebrovascular incidents (CVA). METHODS Retrospective review of all consecutive patients with severe symptomatic aortic valve stenosis (AVS) who underwent TAVI at a single tertiary university hospital (January 2008-December 2018). Patients with AVS scheduled for TAVI and concomitant carotid stenosis were evaluated for prophylactic carotid revascularization (carotid endarterectomy, CEA or carotid artery stenting, CAS). RESULTS 771 consecutive patients (mean age 80 years, 52% males), were treated by TAVI procedures. Carotid stenosis >70% was detected in 69 patients (9%); it was unilateral in 47 (68%) and bilateral in 22 (32%). Prophylactic carotid revascularization was performed before TAVI in 45 patients (31%): in 63.1% of patients (30/47) with unilateral carotid stenosis >70%, and in 68.1% (15/22) with bilateral carotid stenosis >70%. Postoperative CVA following TAVI procedures were recorded in 25 patients (3.2%): 22 cases of stroke (2.8%) and 3 cases of transient ischemic attack (0.4%). At multiple logistic regression, only bilateral carotid stenosis >70% (OR 1.16, CI 95% 1.03-1.31; p=.0009) was found as independent predictors of periprocedural CVA. CONCLUSIONS In patients with severe symptomatic AVS undergoing TAVI, carotid stenosis was frequently observed. Unilateral carotid stenosis >70% did not show a significant association with early CVA following TAVI. However, in the cohort of patients with bilateral carotid stenosis >70%, a significant association with postoperative CVA was observed.
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Pini R, Faggioli G, Palermo S, Fronterrè S, Alaidroos M, Vacirca A, Gallitto E, Gargiulo M. Clamped Carotid Dissection Can Reduce Postoperative Stroke After Carotid Endarterectomy. Vasc Endovascular Surg 2021; 56:138-143. [PMID: 34663108 DOI: 10.1177/15385744211052218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, Diagnostic and Experimental Medicine, University of Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, Diagnostic and Experimental Medicine, University of Bologna, Italy
| | - Sergio Palermo
- Department of Vascular Surgery, Diagnostic and Experimental Medicine, University of Bologna, Italy
| | - Sara Fronterrè
- Department of Vascular Surgery, Diagnostic and Experimental Medicine, University of Bologna, Italy
| | - Moad Alaidroos
- Department of Vascular Surgery, Diagnostic and Experimental Medicine, University of Bologna, Italy
| | - Andrea Vacirca
- Department of Vascular Surgery, Diagnostic and Experimental Medicine, University of Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, Diagnostic and Experimental Medicine, University of Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, Diagnostic and Experimental Medicine, University of Bologna, Italy
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11
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Squizzato F, Xodo A, Taglialavoro J, Zavatta M, Grego F, Antonello M, Piazza M. Early outcomes of routine delayed shunting in carotid endarterectomy for symptomatic patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:573-581. [PMID: 34308613 DOI: 10.23736/s0021-9509.21.11845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The role of shunting during carotid endarterectomy (CEA) in symptomatic patients is unclear. The aim was to evaluate early outcomes of CEA with routine "delayed" shunt insertion, for patients with symptomatic carotid stenosis. METHODS we conducted a single-center retrospective review of symptomatic patients undergoing CEA (2009-2020). All CEAs were performed under general anesthesia using a standardized technique, based on delayed routine shunt insertion after plaque removal. Primary endpoints were 30-days mortality and stroke. A logistic regression was performed to identify clinical and procedural factors predictors of post-operative stroke. A literature systematic review was conducted using the terms "carotid endarterectomy" "stroke", "transient ischemic attack", "symptomatic carotid stenosis", and "shunt". RESULTS two-hundred-sixty-three CEAs were performed for TIA (n=178, 47%) or acute ischemic stroke (n=85, 32%). Mean delay of surgery was 6±19 days, and early CEA (<48 hours) was performed in 98 cases (37%). Conventional CEA was performed in 171 patients (67%), eversion CEA in 83 (33%). Early (30-days) mortality was 0.3%. Stroke/death rate was 2.3%. Female sex (OR 5.14, 95%CI 1.32-24.93; P=.023), use of anticoagulants (OR 10.57, 95%CI 2.67-51.86; P=.001), preoperative stroke (OR 5.34, 95%CI 1.62-69.21; P=.006), and the presence of preoperative CT/MRI cerebral ischemic lesions (OR 5.96, 95%CI 1.52-28.59; P=.013) were associated with early neurological complications. Statin medication (OR 0.18, 95%CI 0.04-0.71; P=.019) and CEA timing <2 days (OR 0.14, 95%CI 0.03-0.55; P=.005) were protective from postoperative stroke. CEA outcomes were independent from time period (P=.201) and operator's volume (P=.768). Four studies described the CEA outcomes with routine shunting in symptomatic patients, with a large variability in the selection of patients, surgical technique, and description of the results. CONCLUSIONS Routine delayed shunting after plaque removal seems to be a safe and effective technique, that contributed to maintain a low complication rate in neurologically symptomatic patients. Statin use and expedited timing were associated with improved outcomes using this technique.
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Affiliation(s)
- Francesco Squizzato
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Andrea Xodo
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Jacopo Taglialavoro
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Marco Zavatta
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Franco Grego
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy
| | - Michele Piazza
- Vascular and Endovascular Surgery Division, Department Of Cardiac, Thoracic Vascular Sciences and Public Health, School of Medicine, Padova University, Padua, Italy -
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D'Oria M, Ziani B, Damiano Pipitone M, Manganotti P, Mucelli RP, Gorgatti F, Riccitelli F, Zamolo F, Fisicaro M, Lepidi S. Prognostic interaction between age and sex on outcomes following carotid endarterectomy. VASA 2021; 50:453-461. [PMID: 34102866 DOI: 10.1024/0301-1526/a000957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: The aim of this study was to assess the prognostic interaction between age and sex on peri-operative and follow-up outcomes following elective carotid endarterectomy (CEA) for asymptomatic and symptomatic carotid stenosis. Patients and methods: A retrospective review of all patients admitted to a single vascular unit who underwent elective CEA between January, 2015 and December, 2019 was performed. The primary endpoints of the study were overall survival (from index operation) and cumulative stroke rate at thirty days. Results: A total of 383 consecutive patients were included in this study; of these 254 (66.4%) were males. At baseline, males were younger (mean age 73.4±11 vs. 76.3±10 years, p=.01) and with lower proportion of octogenarians (20.4% vs. 28.7%, p=.05). The rate of stroke in symptomatic and asymptomatic patients (males vs. females) were as follows: a) whole cohort 1.9% vs. 2% (p=1.00) and 2.7% vs. 1.3% (p=.66), respectively; b) ≥80 years old 3.7% vs. 0% (p=1.00) and 4% vs. 5.9% (p=1.00), respectively; c) <80 years old 1.2% vs. 3.3% (p=.47) and 2.5% vs. 0% (p=.55), respectively. The 3-year survival estimates were significantly lower for males (84% vs. 92%, p=.03). After stratification by age groups, males maintained inferior survival rates in the strata aged <80 years (85% vs. 97%, p=.005), while no differences were seen in the strata aged ≥80 years (82% vs. 79%, p=.92). Using multivariate Cox proportional hazards, age (HR: 2.1, 95% CI: 1.29-3.3, p=.002) and male gender (HR: 2.5, 95% CI: 1.16-5.5, p=.02) were associated with increased hazards of all-cause mortality. Conclusions: In this study of elective CEA for asymptomatic and symptomatic carotid stenosis, similar peri-operative neurologic outcomes were found in both males and females irrespective of age. Despite being usually older, females have superior long-term survival rates.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | | | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine Surgery and Health Sciences, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Roberta Pozzi Mucelli
- Radiology Unit, Department of Medicine Surgery and Health Sciences, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Filippo Gorgatti
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Francesco Riccitelli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Francesca Zamolo
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Maurizio Fisicaro
- Cardiovascular Health Services Centre, Cardiovascular Department, Maggiore Hospital ASUGI, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
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13
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Veraldi GF, Scorsone L, Mastrorilli D, Bruno S, Macrì M, Criscenti P, Onorati F, Faggian G, Bovo C, Mezzetto L. Carotid Endarterectomy with Modified Eversion Technique: Results of a Single Center. Ann Vasc Surg 2020; 72:627-636. [PMID: 33197539 DOI: 10.1016/j.avsg.2020.09.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) has a wide range of approaches based on personal expertise and preference. We evaluated our outcome with CEA with modified eversion technique (meCEA) under local anesthesia and whether the surgeon's experience could influence it. METHODS at our Institution, 837 patients underwent CEA across 8 years. Although the surgical technique was standardized, 2 groups were considered further: meCEA performed by a single Senior Operator (Group A) and meCEA performed by 4 young Consultants (Group B). RESULTS A selective shunting policy was needed in 5.1%, together with general anesthesia. Overall operative time was 63.9 ± 15.1 minutes (61.4 ± 12.5 and 66 ± 16.9 minutes in Group A and Group B respectively; P < 0.001) and cross-clamp time 19.3 ± 2.9 minutes (19.0 ± 3.2 vs. 19.5 ± 2.8, P = 0.009). At 30 days, 0.7% TIA and 0.8% strokes were recorded. No differences (p = N.S.) between the 2 study groups in terms of postoperative neurological complications, with postoperative ipsilateral strokes always < 1%. At a median imaging follow-up of 22.5 months, the overall percentage of restenosis was 3.7%, with no difference between the 2 groups (P = 0.954). Twenty-two patients (2.6%) underwent reintervention for significant restenosis, and none of them had an ipsilateral stroke or TIA. Freedom from reintervention for restenosis at 24 months was 97.9% in Group A and 95.9% in Group B, with no between-group difference (P = 0.14). At the median survival follow-up of 37 months, the overall survival rate at 24 months was 97.9%in Group A, and 97.9% in Group B, with no between-group difference (P = 0.070). CONCLUSIONS In our experience, CEA with a modified technique is safe and achieves comparable outcomes to those of other established techniques. The reported short cross-clamp time, also in less experienced hands, is an additional strength.
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Affiliation(s)
- Gian Franco Veraldi
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Lorenzo Scorsone
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy.
| | - Davide Mastrorilli
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Salvatore Bruno
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Marco Macrì
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Paolo Criscenti
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Francesco Onorati
- Department of Cardiac Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Giuseppe Faggian
- Department of Cardiac Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Chiara Bovo
- Medical Direction, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
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14
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Squizzato F, Antonello M, Taglialavoro J, Prosdocimi L, Grego F, Lupia M, Piazza M. Clinical Impact of Routine Cardiology Consultation Prior to Elective Carotid Endarterectomy in Neurologically Asymptomatic Patients. Eur J Vasc Endovasc Surg 2020; 59:536-544. [DOI: 10.1016/j.ejvs.2019.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 09/13/2019] [Accepted: 11/06/2019] [Indexed: 01/29/2023]
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15
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Piazza M, Zavatta M, Lamaina M, Taglialavoro J, Squizzato F, Grego F, Antonello M. Corrigendum to "Early outcomes of routine delayed shunting in carotid endarterectomy for asymptomatic patients" Eur J Vasc Endovasc Surg 56 (2018) 334-341. Eur J Vasc Endovasc Surg 2019; 57:606. [PMID: 30709698 DOI: 10.1016/j.ejvs.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michele Piazza
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padua, Italy.
| | - Marco Zavatta
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padua, Italy
| | - Margherita Lamaina
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padua, Italy
| | - Jacopo Taglialavoro
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padua, Italy
| | - Francesco Squizzato
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padua, Italy
| | - Franco Grego
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padua, Italy
| | - Michele Antonello
- Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padua, Italy
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