1
|
Ciaramella MA, Liang P, Hamdan AD, Wyers MC, Schermerhorn ML, Stangenberg L. Bailout Distal Internal Carotid Artery Stenting after Carotid Endarterectomy: Indications, Technique, and Outcomes. Ann Vasc Surg 2024; 105:218-226. [PMID: 38599489 DOI: 10.1016/j.avsg.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/11/2024] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. METHODS We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. RESULTS Six patients were identified during the study period. All were male with an age range of 63 to 82 years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2 days (range 1-7 days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17 months. CONCLUSIONS Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.
Collapse
Affiliation(s)
- Michael A Ciaramella
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Allen D Hamdan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mark C Wyers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Lars Stangenberg
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
2
|
Paraskevas KI, Mikhailidis DP, Ringleb PA, Brown MM, Dardik A, Poredos P, Gray WA, Nicolaides AN, Lal BK, Mansilha A, Antignani PL, de Borst GJ, Cambria RP, Loftus IM, Lavie CJ, Blinc A, Lyden SP, Matsumura JS, Jezovnik MK, Bacharach JM, Meschia JF, Clair DG, Zeebregts CJ, Lanza G, Capoccia L, Spinelli F, Liapis CD, Jawien A, Parikh SA, Svetlikov A, Menyhei G, Davies AH, Musialek P, Roubin G, Stilo F, Sultan S, Proczka RM, Faggioli G, Geroulakos G, Fernandes E Fernandes J, Ricco JB, Saba L, Secemsky EA, Pini R, Myrcha P, Rundek T, Martinelli O, Kakkos SK, Sachar R, Goudot G, Schlachetzki F, Lavenson GS, Ricci S, Topakian R, Millon A, Di Lazzaro V, Silvestrini M, Chaturvedi S, Eckstein HH, Gloviczki P, White CJ. An international, multispecialty, expert-based Delphi Consensus document on controversial issues in the management of patients with asymptomatic and symptomatic carotid stenosis. J Vasc Surg 2024; 79:420-435.e1. [PMID: 37944771 DOI: 10.1016/j.jvs.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. METHODS Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. RESULTS Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. CONCLUSIONS The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Division of Surgery and Interventional Science, Department of Surgical Biotechnology, University College London Medical School, University College London (UCL) and Department of Clinical Biochemistry, Royal Free Hospital Campus, UCL, London, United Kingdom
| | | | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Alan Dardik
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Pavel Poredos
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Andrew N Nicolaides
- Vascular Screening and Diagnostic Center, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus; Department of Vascular Surgery, Imperial College, London, United Kingdom
| | - Brajesh K Lal
- Department of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Vascular Surgery, Baltimore VA Medical Center, Baltimore, MD; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Armando Mansilha
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard P Cambria
- Division of Vascular and Endovascular Surgery, St. Elizabeth's Medical Center, Boston, MA
| | - Ian M Loftus
- St George's Vascular Institute, St George's University London, London, United Kingdom
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Ales Blinc
- Division of Internal Medicine, Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sean P Lyden
- Department of Vascular Surgery, The Cleveland Clinic, Cleveland, OH
| | - Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX
| | - J Michael Bacharach
- Department of Vascular Medicine and Endovascular Intervention, North Central Heart Institute and the Avera Heart Hospital, Sioux Falls, SD
| | | | - Daniel G Clair
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Clark J Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS Multimedica Hospital, Castellanza, Italy
| | - Laura Capoccia
- Vascular Surgery Division, Department of Surgery, SS. Filippo e Nicola Hospital, Avezzano, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/ Columbia University Irving Medical Center, New York, NY; Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Alexei Svetlikov
- Division of Vascular and Endovascular Surgery, North-Western Scientific Clinical Center of Federal Medical Biological Agency of Russia, St Petersburg, Russia
| | - Gabor Menyhei
- Department of Vascular Surgery, University of Pecs, Pecs, Hungary
| | - Alun H Davies
- Department of Surgery and Cancer, Section of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Gary Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/ Brookwood, Baptist Medical Center, Birmingham, AL
| | - Francesco Stilo
- Vascular Surgery Division, Department of Medicine and Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
| | - Robert M Proczka
- First Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland, Lazarski University Faculty of Medicine, Warsaw, Poland
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - George Geroulakos
- Department of Vascular Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Fernandes E Fernandes
- Faculty of Medicine, Lisbon Academic Medical Center, University of Lisbon, Portugal, Hospital da Luz Torres de Lisboa, Lisbon, Portugal
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery, University Hospital of Toulouse, Toulouse, France
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Piotr Myrcha
- Department of General and Vascular Surgery, Faculty of Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL
| | - Ombretta Martinelli
- Faculty of Medicine, Sapienza University of Rome, Rome, Italy; Vascular Surgery Unit, "Umberto I." Hospital, Rome, Italy
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Ravish Sachar
- North Carolina Heart and Vascular Hospital, UNC-REX Healthcare, University of North Carolina, Raleigh, NC
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Felix Schlachetzki
- Department of Neurology, University Hospital of Regensburg, Regensburg, Germany
| | | | - Stefano Ricci
- Neurology Department-Stroke Unit, Gubbio-Gualdo Tadino and Citta di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civil de Lyon, Bron, France
| | - Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Universita Campus Bio-Medico di Roma, Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Christopher J White
- Department of Medicine and Cardiology, Ochsner Clinical School, University of Queensland, Brisbane, Australia; Department of Cardiology, The John Ochsner Heart and Vascular Institute, New Orleans, LA
| |
Collapse
|
3
|
Elsayed N, Locham S, Janssen C, Patel R, Gaffey A, Kashyap VS, Stoner M, Malas MB. Impact of Routine Intracerebral Completion Angiography on Outcomes After TransCarotid Artery Revascularization. J Vasc Surg 2022; 75:1958-1965. [PMID: 35063610 DOI: 10.1016/j.jvs.2021.12.074] [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: 09/26/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Completion intracerebral angiography (CIA) following transcarotid artery revascularization (TCAR) aims to identify distal embolization after stenting and serve as a measure of intraoperative quality control. Nevertheless, there is no general evidence regarding the benefit of performing routine CIA. The aim of this study was to evaluate the potential risk and benefit of routine CIA. METHODS We retrospectively reviewed the Vascular Quality Initiative (VQI) database for transcarotid artery revascularization between 2016-2021. Patients were divided into two groups: patients with no CIA performed and those with completion angiography performed. The primary outcome was in-hospital stroke or death. Secondary outcomes included stroke, death, myocardial infarction (MI) and return to the operating room (RTOR). Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier. RESULTS A total of 18,155 patients who underwent TCAR were identified, 63.7% of them had routine CIA performed. Patients who had routine CIA were more likely to have contralateral carotid occlusion and general anesthesia. After adjusting for potential confounders, we found no difference in the risk of stroke or death (aOR): 1.03, 95%CI (0.8-1.3), P=.820), stroke/TIA (aOR, 1, 95%CI (0.8-1.3), P=.998), stroke (aOR: 1.1, 95%CI (0.8-1.4), P=.452), death (aOR: 0.98, 95%CI (0.6-1.6), P=.953), MI (aOR: 0.78, 95%CI (0.5-1.2), P=.240), or RTOR (aOR: 1.5, 95%CI (0.6-3.8), P=.412) between patients who had CIA compared to those who did not. A sub-analysis of patients who had new occlusion detected on CIA (69 patients, 0.6%; 19 not treated and 50 treated) indicated higher risk of stroke or death in patients with treated new occlusions (OR: 7.1, 95%CI (2.9-17.3), P<.001) and stroke/TIA (aOR, 5.8, 95%CI (2.3-14.7), P<.001) compared to patients who had no CIA. However, no difference in stroke/death (OR: 3.3, 95%CI (0.37-29.5), P=.283) or stroke/TIA (aOR, 3.1, 95%CI (0.3-29.4), P=.327) was found in patients with non-treated new occlusions compared to patients who had no CIA. CONCLUSIONS In this retrospective study, routine performance of completion cerebral angiography was not beneficial with no significant differences in in-hospital stroke or death detected. Detection of new lesions on completion cerebral angiography was rare. Moreover, identifying new occlusions following intracranial angiography was associated with higher odds of stroke or death when these new lesions are treated. Further studies are needed to define the etiology of worse outcomes in patients undergoing intervention for lesions discovered on completion cerebral angiogram and delineate optimal timing for further imaging and intervention.
Collapse
Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California
| | - Satinderjit Locham
- Division of Vascular and Endovascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Claire Janssen
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California
| | - Rohini Patel
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California
| | - Ann Gaffey
- University of Pennsylvania Health System, Division of Vascular Surgery and Endovascular Therapy, Philadelphia, PA
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Michael Stoner
- Division of Vascular and Endovascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California.
| |
Collapse
|
4
|
Madden NJ, Calligaro KD, Dougherty MJ, Maloni K, Troutman DA. Completion Arteriogram Following Carotid Endarterectomy Yields Lower Perioperative Stroke Rate. Vasc Endovascular Surg 2021; 56:29-32. [PMID: 34601982 DOI: 10.1177/15385744211048310] [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
Introduction: Completion imaging following carotid endarterectomy (CEA) remains controversial. We present our experience performing routine completion arteriography (CA). Methods: A retrospective review of our prospectively maintained institutional database was performed for patients undergoing isolated CEA. Results: 1439 isolated CEAs with CA were performed on 1297 patients. CEA was for asymptomatic lesions in 70% (1003) of cases. There were no complications related to arteriography. An abnormal arteriogram documented significant abnormalities in the internal carotid artery (ICA) and prompted revision in 1.7% (24/1439) of cases: 20 unsatisfactory distal endpoints of the endarterectomy (12 residual stenoses, 7 intimal flaps, and 1 dissection), 3 kinks or stenoses within the body of the patch, and 1 thrombus. Of the 20 distal endpoint lesions, stent deployment was used in 17 cases and patch revision in 3 cases. The other 4 cases were treated by patch angioplasty (3) or thrombectomy (1). None suffered a perioperative stroke. The overall 30-day stroke, death, and combined stroke/death rate for the 1439 patients in our series was 1.5% (22), .5% (7), and 1.9% (27), respectively. The combined stroke/death rate for asymptomatic lesions was 1.1% (11/1003) and for symptomatic lesions was 2.5% (11/436). Of the 22 strokes in the entire series (all with normal CA), 15 were non-hemorrhagic strokes ipsilateral to the CEA; 14 were confirmed to have widely patent endarterectomy sites by CT-A (13) or re-exploration and repeat arteriography (1). The occluded site was re-explored and underwent thrombectomy, but no technical problems were identified. The remaining strokes were hemorrhagic (4 reperfusion syndrome and 1 surgical site bleeding) or contralateral to the CEA (2). Conclusion: Although not all patients in this series who underwent intraoperative revision due to abnormal CA might have suffered a stroke, performing this simple and safe study may have halved our overall perioperative stroke rate from 3.2% to 1.5%.
Collapse
Affiliation(s)
- Nicholas J Madden
- Section of Vascular Surgery, 6572Pennsylvania Hospital, Philadelphia, PA, USA
| | - Keith D Calligaro
- Section of Vascular Surgery, 6572Pennsylvania Hospital, Philadelphia, PA, USA
| | - Matthew J Dougherty
- Section of Vascular Surgery, 6572Pennsylvania Hospital, Philadelphia, PA, USA
| | - Krystal Maloni
- Section of Vascular Surgery, 6572Pennsylvania Hospital, Philadelphia, PA, USA
| | - Douglas A Troutman
- Section of Vascular Surgery, 6572Pennsylvania Hospital, Philadelphia, PA, USA
| |
Collapse
|
5
|
Knappich C, Lang T, Tsantilas P, Schmid S, Kallmayer M, Haller B, Eckstein HH. Intraoperative completion studies in carotid endarterectomy: systematic review and meta-analysis of techniques and outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1201. [PMID: 34430642 PMCID: PMC8350645 DOI: 10.21037/atm-20-2931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 10/16/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Declining perioperative stroke and death rates over the past 3 decades have been paralleled by an increasing use of intraoperative completion studies (ICS) following carotid endarterectomy (CEA). Techniques applied include angiography, intraoperative duplex ultrasound (IDUS), flowmetry, and angioscopy. This systematic review and meta-analysis is aiming on providing an overview of techniques and corresponding outcomes. METHODS A PubMed based systematic literature review comprising the years 1980 through 2020 was performed using predefined keywords to identify articles on different ICS techniques. Pooled analyses and meta-analyses estimating risk ratios (RR) and 95% confidence intervals (CI) were performed to compare outcomes of different ICS modes to nonapplication of any ICS. I2 values were assessed to quantify study heterogeneities. RESULTS Identification of 34 studies including patients undergoing CEA with angiography (n=53,218), IDUS (n=20,030), flowmetry (n=16,812), and angioscopy (n=2,291). Corresponding rates of perioperative stroke were 1.5%, 1.8%, 3.6%, and 1.5%, perioperative stroke or death occurred in 1.7%, 1.9%, 2.2%, and 2.0%. Intraoperative surgical revision rates were 6.2%, 5.9%, and 7.9% after CEA with angiography, IDUS, and angioscopy, respectively. Compared to nonapplication of any ICS, the pooled analysis revealed angiography to be significantly associated with lower rates of stroke (RR 0.47; 95% CI, 0.36-0.62; P<0.0001) and stroke or death (RR 0.76; 95% CI, 0.70-0.83; P<0.0001). IDUS was significantly associated with lower rates of stroke (RR 0.56; 95% CI, 0.43-0.73; P<0.0001) and stroke or death (RR 0.83; 95% CI, 0.74-0.93; P=0.0018), whereas angioscopy showed a significant association with a lower stroke rate (RR 0.48; 95% CI, 0.033-0.68; P=0.0001), but no effect on the combined stroke or death rate. Angioscopy was associated with a higher intraoperative revision rate compared to angiography (RR 1.29; 95% CI, 1.07-1.54; P=0.006). The meta-analyses confirmed lower perioperative stroke or death rates for angiography (RR 0.83; 95% CI, 0.76-0.91) and IDUS (RR 0.86; 95% CI, 0.76-0.98) compared to non-application of any ICS, whereas flowmetry showed no significant association. CONCLUSIONS This study represents the first systematic literature review and meta-analysis on usage of ICSs in CEA. Data strongly indicate a significant beneficial effect of angiography, IDUS, and angioscopy on perioperative CEA outcomes. Any carotid surgeon should consider implementation of ICSs in his routine armamentarium.
Collapse
Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Lang
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Pavlos Tsantilas
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sofie Schmid
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| |
Collapse
|
6
|
AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
| |
Collapse
|
7
|
Normahani P, Khan B, Sounderajah V, Poushpas S, Anwar M, Jaffer U. Applications of intraoperative Duplex ultrasound in vascular surgery: a systematic review. Ultrasound J 2021; 13:8. [PMID: 33606080 PMCID: PMC7895879 DOI: 10.1186/s13089-021-00208-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/03/2021] [Indexed: 11/10/2022] Open
Abstract
Objective This review aims to summarise the contemporary uses of intraoperative completion Duplex ultrasound (IODUS) for the assessment of lower extremity bypass surgery (LEB) and carotid artery endarterectomy (CEA). Methods We performed a systematic literature search using the databases of MEDLINE. Eligible studies evaluated the use of IODUS during LEB or CEA. Results We found 22 eligible studies; 16 considered the use of IODUS in CEA and 6 in LEB. There was considerable heterogeneity between studies in terms of intervention, outcome measures and follow-up. In the assessment of CEA, there is conflicting evidence regarding the benefits of completion imaging. However, analysis from the largest study suggests a modest reduction in adjusted risk of stroke/mortality when using IODUS selectively (RR 0.74, CI 0.63–0.88, p = 0.001). Evidence also suggests that uncorrected residual flow abnormalities detected on IODUS are associated with higher rates of restenosis (range 2.1% to 20%). In the assessment of LEB, we found a paucity of evidence when considering the benefit of IODUS on patency rates or when considering its utility as compared to other imaging modalities. However, the available evidence suggests higher rates of thrombosis or secondary intervention in grafts with uncorrected residual flow abnormalities (up to 36% at 3 months). Conclusions IODUS can be used to detect defects in both CEA and LEB procedures. However, there is a need for more robust prospective studies to determine the best scanning strategy, criteria for intervention and the impact on clinical outcomes.
Collapse
Affiliation(s)
- Pasha Normahani
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK. .,St Marys Hospital, Level 2, Patterson Building, Paddington, W21NY, UK.
| | - Bilal Khan
- Department of General Surgery, Kingston Hospital, London, UK
| | | | - Sepideh Poushpas
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Muzaffar Anwar
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Usman Jaffer
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
8
|
Dakour-Aridi H, Ibrahim EA, Mathlouthi A, Naazie I, Cronenwett JL, Malas MB. Practice patterns in the use of completion imaging after carotid endarterectomy. J Vasc Surg 2020; 73:151-160.e2. [PMID: 32623109 DOI: 10.1016/j.jvs.2020.05.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/29/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of intraoperative completion imaging (completion carotid duplex ultrasound or angiography) to confirm the technical adequacy of carotid endarterectomy (CEA) remains a matter of controversy. The purpose of this study was to describe vascular surgeons' practice patterns in the use of completion imaging after CEA and to study the association between completion imaging and postoperative stroke/death and high-grade restenosis (>70%). METHODS Patients who underwent CEA without concomitant procedures in the Vascular Quality Initiative database between 2003 and 2018 were included. Surgeons' practice patterns were defined on the basis of the distribution of completion imaging use among annual CEA cases per surgeon. Multivariable and Cox proportional hazards models were used to study the association between different practice patterns of completion imaging and perioperative and 1-year outcomes after CEA. RESULTS Of 98,055 CEA cases, 26,716 (27.3%) were performed with completion imaging. Compared with cases in which completion imaging was not performed, completion imaging was associated with increased rates of immediate re-exploration (3.5% vs 0.9%; odds ratio [OR], 3.84; 95% confidence interval [CI], 2.74-5.38; P < .001), overall return to the operating room (RTOR; 1.6% vs 1.2%; OR, 1.24; 95% CI, 1.08-1.42; P < .01), and longer operative time (median [interquartile range], 105 minutes [82-132] vs 119 minutes [92-148]; P < .001). Of 1920 surgeons in our cohort, 45% never performed completion imaging, whereas 26% rarely performed completion imaging (for ≤20% of annual CEA cases), 9.5% performed it selectively (21%-79% of annual CEAs), and 19.6% used completion imaging routinely (≥80% of annual CEAs). Rarely performing completion imaging had higher rates of immediate re-exploration (6.5% vs 0.9%; OR, 7.2; 95% CI, 5.7-9.2; P < .001), in-hospital stroke (4.0% vs 1.1%; adjusted OR [aOR], 3.4; 95% CI, 2.6-4.6; P < .001), RTOR for bleeding (1.9% vs 0.9%; aOR, 2.1; 95% CI, 1.5-2.9; P < .001), and neurologic events (1.5% vs 0.4%; aOR, 3.6; 95% CI, 2.2-5.9; P < .001) compared with not performing completion imaging. It was also associated with increased stroke/death and repeated revascularization at 30 days and significant restenosis at 1 year. On the other hand, performance of selective and routine completion imaging was associated with increased immediate re-exploration (selective: aOR, 3.2 [95% CI, 1.9-5.5; P < .001]; routine: aOR, 3.7 [95% CI, 2.5-5.6; P < .001]) without any increase in in-hospital, 30-day, and 1-year adverse outcomes compared with cases performed without completion imaging. CONCLUSIONS The performance of selective or routine completion imaging during CEA is safe and is not associated with increased adverse events compared with not using intraoperative completion imaging. However, rarely performing completion imaging is associated with a significant increase in the odds of perioperative stroke/death and RTOR, possibly because of unnecessary re-exploration for minor defects. The operator's experience and establishing a criterion for fixing residual defects are important to avoid unnecessary re-exploration.
Collapse
Affiliation(s)
- Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, Calif
| | - EzzElDien A Ibrahim
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, Calif
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, Calif
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, Calif
| | - Jack L Cronenwett
- Section of Vascular Surgery and The Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, Calif.
| |
Collapse
|
9
|
Spanos K, Nana P, Kouvelos G, Batzalexis K, Matsagkas MM, Giannoukas AD. Completion imaging techniques and their clinical role after carotid endarterectomy: Systematic review of the literature. Vascular 2020; 28:794-807. [PMID: 32493183 DOI: 10.1177/1708538120929793] [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: 11/17/2022]
Abstract
BACKGROUND Completion imaging has been suggested for the intraoperative quality control assessment of the carotid endarterectomy technical success, in order to immediately resolve pathologic findings and accordingly improve patients' outcome. The aim of this study was to present existing evidence of different completion imaging techniques after carotid endarterectomy and their role on clinical outcome. MATERIAL AND METHODS A systematic review was performed searching in MEDLINE, CENTRAL, and Cochrane databases including studies reporting on completion imaging techniques after carotid endarterectomy. RESULTS A total of 12,378 patients in 35 studies (20 retrospective and 15 prospective) underwent a completion imaging technique after carotid endarterectomy: in 19 studies, 5340 patients underwent arteriography; in 5 studies, 2095 angioscopy; in 21 studies, 5722 DUS; and in 2 studies, 150 patients underwent transcranial Doppler. Ten studies assessed > 1 imaging technique. The mean age was 67 ± 7 years old (69% males) with common co-morbidities to be hypertension (74%), smoking (64%), and hyperlipidemia (54%). Almost half of the patients (4949; 44%) were treated for symptomatic disease. In 1104 (9.7%) patients, a major defect was identified intra-operatively, while in 329 patients (2.9%), a minor defect. Common pathological findings were the presence of mural thrombus, carotid dissection, residual stenosis, and intimal flaps. An immediate re-intervention was undertaken in 75% (790/1053) of the patients to treat a major intra-operative imaging finding. In patients with re-intervention, only 2.3% (14/609) had an intra-operative stroke and 0.8% (5/609), a transient ischemic attack, while only 1.4% (8/575) had a stroke and 0.2% a transient ischemic attack (1/575) during 30-day post-operative period. No intra-operative death was reported. In the same period, the restenosis rate of internal and common carotid artery was 0.5% (3/575) and 0.2% (1/575), respectively. CONCLUSION Completion imaging techniques can detect defects in almost 10% of patients that may lead to immediate intra-operative surgical revision with low intra-operative stroke/transient ischemic attack rate and low early carotid restenosis. During the 30-day follow-up period, in those patients, the incidence of stroke/transient ischemic attack may be low but present. This review cannot provide any evidence on which completion imaging technique is better, and the clinical impact conferred by each technique in the absence of a randomized control studies.
Collapse
Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Petroula Nana
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Batzalexis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Miltiadis M Matsagkas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
10
|
Zanow J, Settmacher U, Schüle S. [Intraoperative completion diagnostics in open vascular surgery]. Chirurg 2020; 91:461-465. [PMID: 32185427 DOI: 10.1007/s00104-020-01155-1] [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: 11/24/2022]
Abstract
Intraoperative imaging diagnostics during open vascular surgical procedures aim to enhance diagnostic certainty during the operation, ensure quality control documentation and reduce avoidable complications; however, the evidence for the various diagnostic imaging procedures with respect to improvement of perioperative outcome is not confirmed for carotid endarterectomy or for infrainguinal bypass surgery. Nevertheless, an intraoperative diagnostic control is principally recommended. The advantage of intraoperative imaging is confirmed and essential for the surgical reconstruction of bypass occlusions and acute thromboembolic occlusions.
Collapse
Affiliation(s)
- J Zanow
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - U Settmacher
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - S Schüle
- Klinik für Allgemein‑, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| |
Collapse
|
11
|
Brooke BS, Beck AW, Kraiss LW, Hoel AW, Austin AM, Ghaffarian AA, Cronenwett JL, Goodney PP. Association of Quality Improvement Registry Participation With Appropriate Follow-up After Vascular Procedures. JAMA Surg 2019; 153:216-223. [PMID: 29049809 DOI: 10.1001/jamasurg.2017.3942] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Benjamin S. Brooke
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City
| | - Adam W. Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama- Birmingham
| | - Larry W. Kraiss
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City
| | - Andrew W. Hoel
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrea M. Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Amir A. Ghaffarian
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City
| | - Jack L. Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Philip P. Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire,Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| |
Collapse
|
12
|
Wieker CM, Harcos K, Ronellenfitsch U, Demirel S, Bruijnen H, Böckler D. Impact of routine completion angiography on outcome after carotid endarterectomy. J Vasc Surg 2019; 69:824-831. [DOI: 10.1016/j.jvs.2018.06.210] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/25/2018] [Indexed: 11/25/2022]
|
13
|
Bostock IC, Zarkowsky DS, Hicks CW, Stone DH, Malas MB, Goodney PP. Outcomes and Risk Factors Associated with Prolonged Intubation after EVAR. Ann Vasc Surg 2018; 50:167-172. [PMID: 29481928 DOI: 10.1016/j.avsg.2017.11.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/01/2017] [Accepted: 11/19/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Time to discharge has decreased for aortic surgery since the advent of endovascular aortic aneurysm repair (EVAR), partially due to improved perioperative management. We aimed to investigate outcomes and risk factors associated with prolonged intubation following EVAR. METHODS The Vascular Study Group of New England (VSGNE) database was queried to select all patients who underwent elective EVAR between January 2003 and December 2014. Patients who were not extubated in the operating room were classified as having prolonged intubation. Patients requiring prolonged intubation were compared with those extubated in the operating room using t-test and chi-square statistics. Kaplan-Meier survival analyses estimated all-cause mortality. Independent predictors associated with prolonged intubation, including postoperative pneumonia or respiratory failure, were examined using multivariable logistic regression. RESULTS A total of 3,979 patients were identified within the elective EVAR VSGNE data set, among whom 5.2% required prolonged intubation. Patients with prolonged intubation were older, more frequently female, non-Hispanic, had larger aneurysms, and had a more frequent diagnoses of diabetes, congestive heart failure, coronary artery disease, ejection fraction < 50%, and chronic obstructive pulmonary disease (all P < 0.05). Respiratory complications occurred in 25.5% of patients with prolonged intubation vs. 1.8% of patients who were extubated in the operating room (P < 0.001). Kaplan-Meier survival estimates suggested patients requiring prolonged intubation after EVAR had significantly lower survivals than those who extubated in the operating room (P < 0.05). On multivariable analysis, independent risk factors associated with prolonged intubation included subjective lack of fitness for open procedure (OR: 4.8, 95% confidence interval [CI]: 3.5-8.7), ejection fraction < 50% (1.8, 1.3-2.8), and ASA class >3 (1.5, 1.1-1.7). CONCLUSIONS Prolonged intubation following EVAR is associated with increased risk of postoperative respiratory complications, as well as decreased long-term survival. High-risk patients for prolonged intubation, including those deemed subjectively unfit for an open procedure, ejection fraction < 50% and ASA class >3, may not benefit from an elective EVAR.
Collapse
Affiliation(s)
- Ian C Bostock
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Devin S Zarkowsky
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA
| | - Caitlin W Hicks
- Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, MD
| | - David H Stone
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mahmoud B Malas
- Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, MD
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| |
Collapse
|
14
|
Chan K, Abouzamzam A, Woo K. Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative. Ann Vasc Surg 2017; 42:11-15. [PMID: 28323231 PMCID: PMC5559870 DOI: 10.1016/j.avsg.2016.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 11/10/2016] [Accepted: 11/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The objective of this study was to examine the variation in practice patterns and associated outcomes for carotid endarterectomy (CEA) within the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe), a regional quality group of the Vascular Quality Initiative. METHODS All cases entered in the CEA registry by the So Cal VOICe were included in the study. RESULTS From September 2010 through September 2015, 1,110 CEA cases were entered by 9 centers in the So Cal VOICe. Six hundred seventy-seven patients (61%) were male with mean age of 73 years. Nine hundred eighty-eight (89%) were hypertensive, 655 (59%) were prior or current smokers, 389 (35%) were diabetics, and 233 (21%) had coronary artery disease. Eight hundred twenty-one (74%) patients were asymptomatic (no history of ipsilateral neurologic event). The percentage of asymptomatic patients varied across the 9 centers from 57% to 91%. Preoperatively, 344 (31%) underwent cardiac stress test, center variation 13-75%, 500 (45%) underwent only duplex, center variation 11-72%. Intraoperatively, 600 (54%) underwent routine shunting, whereas 67 (6%) were shunted for an indication, and 444 (40%) were not shunted. Wound drainage was used in 422 (38%) cases, center variation 2-98%. Completion imaging by duplex and/or angiogram was performed in 766 (69%) cases, center variation 0-100%. Postoperatively, 11 (1%) patients had a new ipsilateral postoperative neurologic event, center variation 0-1.3%, 6 (0.5%) had a postoperative myocardial infarction, center variation 0-1.3%, and 8 (0.7%) required return to operating room for bleeding, center variation 0-1.3%. CONCLUSIONS Despite wide variation in practice patterns surrounding CEA in the So Cal VOICe, postoperative complications were uniformly low. Further work will focus on identifying practices that can be modified to improve cost-effectiveness while maintaining excellent outcomes.
Collapse
Affiliation(s)
- Kaelan Chan
- Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ahmed Abouzamzam
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA
| | - Karen Woo
- Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA.
| |
Collapse
|
15
|
Sen AN, Fridley J, Sebastian S, Duckworth EAM. Intraoperative Computed Tomography Angiography: A Novel Completion Imaging Modality for Carotid Endarterectomy. Oper Neurosurg (Hagerstown) 2017; 13:739-745. [DOI: 10.1093/ons/opw036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 03/30/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Intraoperative computed tomography angiography (ICTA) is a novel completion imaging modality for carotid endarterectomy (CEA). No studies exist in the literature describing ICTA use in CEA.
OBJECTIVE
To evaluate the feasibility and efficacy of ICTA as a method of immediately evaluating the technical results of CEA.
METHODS
Twenty-three consecutive CEAs were performed by a single neurosurgeon over an 8-month period. Of this series, 12 utilized ICTA for completion imaging, 10 utilized duplex ultrasonography (US), and 1 utilized no intraoperative completion imaging. Electronic medical records were reviewed to assess demographics, CTA results, US results, and need for revisions.
RESULTS
Patients included 13 men (62%) and 8 women (38%). All patients had symptomatic internal carotid artery stenosis. Polytetrafluoroethylene (PTFE) patch angioplasty was used in 16 cases (70%). Average operative times were comparable between cases that utilized CTA and US, 180 and 175 min, respectively. Major technical defects were identified in one of the 12 cases utilizing ICTA and none of the 10 cases utilizing intraoperative US. The technical defect was revised without subsequent neurological complication. One patient had a postoperative intracerebral hemorrhage requiring surgical evacuation. Fifteen patients were followed for up to 3 months with no postoperative stroke or transient ischemic attacks.
CONCLUSION
ICTA is a potentially safe and effective completion imaging modality compared to traditional alternatives, enabling the identification of technical deficits intraoperatively. While no statistically significant difference in operative times were noted between intraoperative CTA and US use, numerous steps must be taken to maximize the efficiency of ICTA.
Collapse
Affiliation(s)
- Anish N Sen
- Department of Neurosurgery, Baylor Col-lege of Medicine, Houston, Texas
| | - Jared Fridley
- Department of Neurosurgery, Baylor Col-lege of Medicine, Houston, Texas
| | - Sherly Sebastian
- Department of Neurosurgery, Baylor Col-lege of Medicine, Houston, Texas
| | | |
Collapse
|
16
|
Knappich C, Kuehnl A, Tsantilas P, Schmid S, Breitkreuz T, Kallmayer M, Zimmermann A, Eckstein HH. Intraoperative Completion Studies, Local Anesthesia, and Antiplatelet Medication Are Associated With Lower Risk in Carotid Endarterectomy. Stroke 2017; 48:955-962. [DOI: 10.1161/strokeaha.116.014869] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/21/2017] [Accepted: 01/27/2017] [Indexed: 01/05/2023]
Abstract
Background and Purpose—
In Germany, all surgical and endovascular procedures on the carotid bifurcation must be documented in a statutory nationwide quality assurance database. We aimed to analyze the association between procedural and perioperative variables and in-hospital stroke or death rates after carotid endarterectomy.
Methods—
Between 2009 and 2014, overall 142 074 elective carotid endarterectomy procedures for asymptomatic or symptomatic carotid artery stenosis were documented in the database. The primary outcome of this secondary data analysis was in-hospital stroke or death. Major stroke or death, stroke, and death, each until discharge were secondary outcomes. Adjusted relative risks (RRs) were assessed by multivariable multilevel regression analyses.
Results—
The primary outcome occurred in 1.8% of patients, with a rate of 1.4% in asymptomatic and 2.5% in symptomatic patients, respectively. In the multivariable analysis, lower risks of stroke or death were independently associated with local anesthesia (versus general anesthesia: RR, 0.85; 95% confidence interval [CI], 0.75–0.95), carotid endarterectomy with patch plasty compared with primary closure (RR, 0.71; 95% CI, 0.52–0.97), intraoperative completion studies by duplex ultrasound (RR, 0.74; 95% CI, 0.63–0.88) or angiography (RR, 0.80; 95% CI, 0.71–0.90), and perioperative antiplatelet medication (RR, 0.83; 95% CI, 0.71–0.97). No shunting and a short cross-clamp time were also associated with lower risks; however, these are suspected to be confounded.
Conclusions—
Local anesthesia, patch plasty compared with primary closure, intraoperative completion studies by duplex ultrasound or angiography, and perioperative antiplatelet medication were independently associated with lower in-hospital stroke or death rates after carotid endarterectomy.
Collapse
Affiliation(s)
- Christoph Knappich
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Andreas Kuehnl
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Pavlos Tsantilas
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Sofie Schmid
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Thorben Breitkreuz
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Michael Kallmayer
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Alexander Zimmermann
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| | - Hans-Henning Eckstein
- From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.)
| |
Collapse
|
17
|
Bensley RP, Beck AW. Using the Vascular Quality Initiative to improve quality of care and patient outcomes for vascular surgery patients. Semin Vasc Surg 2015; 28:97-102. [DOI: 10.1053/j.semvascsurg.2015.09.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
18
|
Weinstein S, Mabray MC, Aslam R, Hope T, Yee J, Owens C. Intraoperative sonography during carotid endarterectomy: normal appearance and spectrum of complications. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:885-894. [PMID: 25911722 DOI: 10.7863/ultra.34.5.885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Carotid endarterectomy is a commonly performed procedure for prevention of stroke related to carotid stenosis. Intraoperative sonography is used to identify potentially correctable technical defects during carotid endarterectomy. The main risk of endarterectomy is perioperative stroke, and great effort has been put into trying to reduce this risk through various surgical techniques and evaluation of the surgical bed. Postoperative carotid thrombosis, or thombo-embolization from the arterectomy site, remains a common cause of perioperative stroke and is often related to technical defects in the arterial reconstruction procedure. Re-exploration and repair of any imperfections have the potential to improve outcomes. Intraoperative imaging can identify potentially occult lesions, provide the option for correction, and thus reduce chance of stroke. Familiarity with the spectrum of intraoperative sonographic findings helps correctly identify residual intimal dissection flaps, plaque, thrombi, and stenosis, which may require immediate surgical revision. Our objective is to illustrate the spectrum of intraoperative findings and their importance.
Collapse
Affiliation(s)
- Stefanie Weinstein
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California USA
| | - Marc C Mabray
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California USA
| | - Riz Aslam
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California USA
| | - Tom Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California USA
| | - Judy Yee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California USA
| | - Christopher Owens
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California USA
| |
Collapse
|
19
|
Tan TW, Rybin D, Kalish JA, Doros G, Hamburg N, Schanzer A, Cronenwett JL, Farber A. Routine use of completion imaging after infrainguinal bypass is not associated with higher bypass graft patency. J Vasc Surg 2014; 60:678-85.e2. [DOI: 10.1016/j.jvs.2014.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
|
20
|
Budincevic H, Ivkosic A, Martinac M, Trajbar T, Bielen I, Csiba L. Asymptomatic dissecting intimal lesions of common carotid arteries after carotid endarterectomy. Surg Today 2014; 45:1227-32. [PMID: 25160766 DOI: 10.1007/s00595-014-1018-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 08/12/2014] [Indexed: 01/01/2023]
Abstract
PURPOSE Carotid endarterectomy is a standard treatment for symptomatic high-degree internal carotid artery stenosis. The aim of this article is to present possible intimal lesions after carotid endarterectomy. These lesions could be manifested as intimal flaps, intimal steps or dissections with or without occlusion or stenosis of the artery. METHODS The evaluation of the frequency and characteristics of the asymptomatic dissecting intimal lesions of the common carotid arteries was performed in a sample of 100 patients who underwent endarterectomy for symptomatic high-grade stenosis of the internal carotid artery. RESULTS We found five patients with asymptomatic dissecting intimal lesions of the common carotid arteries. CONCLUSION The most common causes of these intimal lesions were shunting and prolongation of the clamping time. Routine carotid ultrasound follow-up exams are necessary because of the potential need for a change in the antithrombotic therapy or due to a need to perform an endovascular treatment.
Collapse
Affiliation(s)
- Hrvoje Budincevic
- Stroke and Intensive Care Unit, Department of neurology, University Hospital "Sveti Duh", Sveti Duh 64, 10000, Zagreb, Croatia.
| | - Ante Ivkosic
- Department of surgery, University Hospital "Sveti Duh", Sveti Duh 64, 10000, Zagreb, Croatia
| | - Miran Martinac
- Department of surgery, University Hospital "Sveti Duh", Sveti Duh 64, 10000, Zagreb, Croatia
| | - Tomislav Trajbar
- Department of surgery, University Hospital "Sveti Duh", Sveti Duh 64, 10000, Zagreb, Croatia
| | - Ivan Bielen
- Department of neurology, University Hospital "Sveti Duh", Sveti Duh 64, 10000, Zagreb, Croatia
| | - Laszlo Csiba
- Department of neurology, Medical and Health Science Center, University of Debrecen, Nagyerdei Körút 98, P.O. Box 48, Debrecen, Hungary
| |
Collapse
|
21
|
Fokkema M, de Borst GJ, Nolan BW, Indes J, Buck DB, Lo RC, Moll FL, Schermerhorn ML. Clinical relevance of cranial nerve injury following carotid endarterectomy. Eur J Vasc Endovasc Surg 2013; 47:2-7. [PMID: 24157257 DOI: 10.1016/j.ejvs.2013.09.022] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/22/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The benefit of carotid endarterectomy (CEA) may be diminished by cranial nerve injury (CNI). Using a quality improvement registry, we aimed to identify the nerves affected, duration of symptoms (transient vs. persistent), and clinical predictors of CNI. METHODS We identified all patients undergoing CEA in the Vascular Study Group of New England (VSGNE) between 2003 and 2011. Surgeon-observed CNI rate was determined at discharge (postoperative CNI) and at follow-up to determine persistent CNI (CNIs that persisted at routine follow-up visit). Hierarchical multivariable model controlling for surgeon and hospital was used to assess independent predictors for postoperative CNI. RESULTS A total of 6,878 patients (33.8% symptomatic) were included for analyses. CNI rate at discharge was 5.6% (n = 382). Sixty patients (0.7%) had more than one nerve affected. The hypoglossal nerve was most frequently involved (n = 185, 2.7%), followed by the facial (n = 128, 1.9%), the vagus (n = 49, 0.7%), and the glossopharyngeal (n = 33, 0.5%) nerve. The vast majority of these CNIs were transient; only 47 patients (0.7%) had a persistent CNI at their follow-up visit (median 10.0 months, range 0.3-15.6 months). Patients with perioperative stroke (0.9%, n = 64) had significantly higher risk of CNI (n = 15, CNI risk 23.4%, p < .01). Predictors for CNI were urgent procedures (OR 1.6, 95% CI 1.2-2.1, p < .01), immediate re-exploration after closure under the same anesthetic (OR 2.0, 95% CI 1.3-3.0, p < .01), and return to the operating room for a neurologic event or bleeding (OR 2.3, 95% CI 1.4-3.8, p < .01), but not redo CEA (OR 1.0, 95% CI 0.5-1.9, p = .90) or prior cervical radiation (OR 0.9, 95% CI 0.3-2.5, p = .80). CONCLUSIONS As patients are currently selected in the VSGNE, persistent CNI after CEA is rare. While conditions of urgency and (sub)acute reintervention carried increased risk for postoperative CNI, a history of prior ipsilateral CEA or cervical radiation was not associated with increased CNI rate.
Collapse
Affiliation(s)
- M Fokkema
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; University Medical Center Utrecht, Utrecht, The Netherlands
| | - G J de Borst
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - B W Nolan
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - J Indes
- Yale Medical Center, New Haven, CT, USA
| | - D B Buck
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; University Medical Center Utrecht, Utrecht, The Netherlands
| | - R C Lo
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - F L Moll
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - M L Schermerhorn
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | | |
Collapse
|
22
|
Ricco JB, Forbes TL. Trans-atlantic debate: the role of completion imaging following carotid artery endarterectomy. Eur J Vasc Endovasc Surg 2013; 45:423. [PMID: 23734373 DOI: 10.1016/j.ejvs.2013.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
|
24
|
Samson R. Part Two: Against the Motion. Completion Angiography is Unnecessary Following Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2013; 45:420-2. [DOI: 10.1016/j.ejvs.2013.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
25
|
Ricco JB, Schneider F, Illuminati G. Part One: For the Motion. Completion Angiography Should be Used Routinely Following Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2013; 45:416-9. [DOI: 10.1016/j.ejvs.2013.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
Editors' commentary. J Vasc Surg 2013; 57:1438-9. [PMID: 23601599 DOI: 10.1016/j.jvs.2013.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
27
|
Cronenwett JL, Kraiss LW, Cambria RP. The Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2012; 55:1529-37. [DOI: 10.1016/j.jvs.2012.03.016] [Citation(s) in RCA: 253] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 03/17/2012] [Accepted: 03/18/2012] [Indexed: 11/25/2022]
|