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Hommery-Boucher X, Fortin W, Beaudoin N, Blair JF, Stevens LM, Elkouri S. Safety of Shunting Strategies During Carotid Endarterectomy: A Vascular Quality Initiative Data Analysis. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00628-2. [PMID: 39038509 DOI: 10.1016/j.ejvs.2024.07.021] [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: 11/19/2023] [Revised: 06/24/2024] [Accepted: 07/16/2024] [Indexed: 07/24/2024]
Abstract
OBJECTIVE This study aimed to evaluate in hospital outcomes after carotid endarterectomy (CEA) according to shunt usage, particularly in patients with contralateral carotid occlusion (CCO) or recent stroke. Data from CEAs registered in the Vascular Quality Initiative database between 2012 and 2020 were analysed, excluding surgeons with < 10 CEAs registered in the database, concomitant procedures, re-interventions, and incomplete data. METHODS Based on their rate of shunt use, participating surgeons were divided in three groups: non-shunters (< 5%), selective shunters (5 - 95%), and routine shunters (> 95%). Primary outcomes of in hospital stroke, death, and stroke and death rate (SDR) were analysed in symptomatic and asymptomatic patients. RESULTS A total of 113 202 patients met the study criteria, of whom 31 147 were symptomatic and 82 055 were asymptomatic. Of the 1 645 surgeons included, 12.1% were non-shunters, 63.6% were selective shunters, and 24.3% were routine shunters, with 10 557, 71 160, and 31 579 procedures in each group, respectively. In the univariable analysis, in hospital stroke (2.0% vs. 1.9% vs. 1.6%; p = .17), death (0.5% vs. 0.4% vs. 0.4%; p = .71), and SDR (2.2% vs. 2.1% vs. 1.8%; p = .23) were not statistically significantly different among the three groups in the symptomatic cohort. The asymptomatic cohort also did not show a statistically significant difference for in hospital stroke (0.9% vs. 1.0% vs. 0.9%; p = .55), death (0.2% vs. 0.2% vs. 0.2%; p = .64), and SDR (1.0% vs. 1.1% vs. 1.0%; p = .43). The multivariable model did not show a statistically significant difference for the primary outcomes between the three shunting cohorts. On subgroup analysis, the SDRs were not statistically significantly different for patients with CCO (3.3% vs. 2.5% vs. 2.4%; p = .64) and those presenting with a recent stroke (2.9% vs. 3.4% vs. 3.1%; p = .60). CONCLUSION No statistically significant differences were found between three shunting strategies for in hospital SDR, including in patients with CCO or recent stroke.
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Affiliation(s)
| | - William Fortin
- Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Nathalie Beaudoin
- Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean-François Blair
- Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | | | - Stéphane Elkouri
- Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
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Bernau O, Beiles B, Khashram M. Editor's Choice -- Is Shunting Necessary in Patients with Contralateral Carotid Occlusion Undergoing Carotid Endarterectomy? Eur J Vasc Endovasc Surg 2024; 67:514-515. [PMID: 37087068 DOI: 10.1016/j.ejvs.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/23/2023] [Accepted: 04/18/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Oliver Bernau
- Faculty of Medicine, the University of Auckland, New Zealand.
| | - Barry Beiles
- Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, the University of Auckland, New Zealand
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Liang Z, Tang X, Chen Z. Carotid Artery Stenting for Patients With Carotid Stenosis and Contralateral Carotid Artery Occlusion: A 12-Year Experience. Ann Vasc Surg 2022; 92:118-123. [PMID: 36481673 DOI: 10.1016/j.avsg.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) has emerged as a potential alternative for treating patients with extracranial cerebrovascular diseases. Contralateral carotid artery occlusion (CCO) occurs in approximately 2.3% to 25% of patients with carotid artery stenosis. However, the association of a CCO with long-term outcomes after CAS remains unclear. Here, we aimed to evaluate the perioperative and long-term recovery and safety of patients with CCO after receiving CAS. METHODS We retrospectively collected the data of patients with CCO treated with CAS between 2010 and 2021. The primary end point was a nonfatal major stroke. The secondary end points included cerebral hemorrhage, nonfatal myocardial infarction, restenosis, acute renal insufficiency, stent-related complications, and death. Long-term outcomes were analyzed by Kaplan-Meier survival analysis using the following variables: symptomatic carotid stenosis, age, stent type, collateral flow status, and postdilation. RESULTS Seventy one consecutive patients with CCO who underwent CAS were included in the study. Of these, 61 patients (86%) were followed up for 9-134 months, with an average of 63.3 ± 30.4 months. In the perioperative period, 2 patients (2.8%) experienced stroke and 1 patient (1.4%) died due to cerebral hemorrhage combined with cerebral hernia. During follow-up, 2 patients (3.3%) developed stroke at 4 and 6 months each after CAS and 6 patients (9.8%) died (2 patients died due to myocardial infarction and 4 patients died due to either severe liver failure, car accident, cervical fracture, or unknown cause). Kaplan-Meier survival analysis showed that symptomatic carotid stenosis, age, stent type, and postdilation were not associated with long-term stroke (P<0.05). The inadequate collateral flow group showed a higher stroke rate than the control group (P = 0.009). CONCLUSIONS CAS is a safe and effective therapy for patients with CCO. Inadequate collateral flow is associated with a higher long-term rate of stroke. Our findings revealed that symptomatic carotid stenosis, age, stent type, and postdilation had no significant effect on outcome events after CAS.
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Affiliation(s)
- Zike Liang
- Department of Vascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaobin Tang
- Department of Vascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhong Chen
- Department of Vascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Ribieras AJ, Tabbara M, Rey J, Velazquez OC, Bornak A. Outcomes and role of shunting during carotid endarterectomy for symptomatic patients. J Vasc Surg 2022; 76:1289-1297. [PMID: 35810956 DOI: 10.1016/j.jvs.2022.06.096] [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: 04/19/2022] [Revised: 06/25/2022] [Accepted: 06/30/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Shunt placement during carotid endarterectomy (CEA) is often advocated to protect the ischemic penumbra in patients with symptomatic carotid stenosis. This study assesses the effect of shunt placement on postoperative stroke risk in symptomatic patients undergoing CEA. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program database (2016-2019) for CEA cases with complete CEA procedure-targeted data. Symptomatic patients were identified as having a preoperative diagnosis of stroke on presentation (DS), transient ischemic attack (TIA), amaurosis fugax (AF), or temporary monocular blindness (TMB). DS patients were further analyzed according to the severity of their stroke based on their modified Rankin Scale (mRS). To better assess the effect of shunt placement on stroke rate, we compared cases of CEA with patch angioplasty technique, with and without the use of intraoperative shunt. Patients who underwent carotid eversion or primary closure were excluded. Baseline demographics and perioperative outcomes were compared using Chi-square and Mann-Whitney U test. Multivariate analysis was performed to identify independent risk factors for postoperative stroke and cranial nerve injury. RESULTS We identified 4,652 cases of CEA with patch angioplasty in symptomatic patients, including 1,889 (40.6%) with shunt placement and 2,763 (59.4%) without. Age, race, and sex distributions were similar for both procedures. Compared to patients without shunt, those with shunt had significantly higher rates of emergency (9.1% vs 7.0%, P = .010) and non-elective surgery (40.3% vs 37.2%, P = .035), general anesthesia (97.0% vs 86.3%, P < .001), and bleeding disorders (27.2% vs 22.7%, P < .001). Thirty-day incidence of postoperative stroke was similar between patients who had shunt placement (3.2%) and those who did not (2.6%) (P = .219). Additionally, subgroup analysis failed to show any benefit of shunting on postoperative stroke regardless of preoperative symptoms or neurologic disability. In contrast, shunt placement was associated with increased rate of cranial nerve injury (4.1% vs 2.4%, P = .001). Multivariate analysis revealed that non-elective surgery (OR 1.99, 95% CI 1.36-2.91, P < .001) and DS (vs TIA/AF/TMB) (OR 1.64, 95% CI 1.12-2.41, P = .012) were predictive of 30-day postoperative stroke. After adjusting for confounders, shunt placement had no effect on stroke risk at 30 days but remained an independent risk factor for cranial nerve injury (aOR 1.87, 95% CI 1.32-2.64, P < .001). CONCLUSIONS In symptomatic patients undergoing CEA with patch angioplasty, shunting is associated with increased risk of cranial nerve injury without reduction in postoperative stroke risk.
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Affiliation(s)
- Antoine J Ribieras
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Marwan Tabbara
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Jorge Rey
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Omaida C Velazquez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Arash Bornak
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
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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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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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Franjić BD, Lovričević I, Brkić P, Dobrota D, Aždajić S, Hranjec J. Role of Doppler Ultrasound Analysis of Blood Flow Through the Ophthalmic and Intracranial Arteries in Predicting Neurologic Symptoms During Carotid Endarterectomy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2141-2156. [PMID: 33368431 DOI: 10.1002/jum.15599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/11/2020] [Accepted: 12/03/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Carotid endarterectomy (CEA) is frequently performed under locoregional anesthesia. The intraoperative clamping of the internal carotid artery (ICA) leads to cerebral hypoperfusion, which may in some patients result in the development of neurologic symptoms (NS). The objective of our study was to investigate whether there is an association between the preoperative ultrasound (US) Doppler flow in the ophthalmic artery (OA) and intracranial artery and the occurrence of these intraoperative NS. METHODS We compared 50 patients with NS and 150 patients without NS during CEA. We analyzed their preoperative blood flow characteristics by Doppler US and their clinical and demographic characteristics. RESULTS The contralateral ICA occlusion increased the likelihood of intraoperative NS (odds ratio [OR], 8.4; P < .001). Abnormal contralateral OA flow also increased the likelihood of NS (OR, 1.84; P < .001), whereas ipsilateral abnormal OA flow reduced it (OR, 0.73; P = .06). Increased flow in the ipsilateral anterior cerebral artery (ACA) increased the likelihood of NS (OR, 3.3), whereas reversed flow decreased it (OR, 0.1; P = .03). Inverse flow in the contralateral ACA increased the risk (OR, 5.4), whereas increased flow reduced it (OR, 0.2; P = .02). Male patients had a higher risk of NS (P = .09) as well as older patients (P = .05). Eight percent of the patients with NS developed a transient ischemic attack or stroke. CONCLUSIONS Doppler US analysis of the OA and ACA in combination with analysis of ICA stenosis may be a promising predictor of NS during ICA clamping. This, in turn, may warn the patient and the surgeon of an increased risk during surgery.
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Affiliation(s)
- Björn Dario Franjić
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ivo Lovričević
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Petar Brkić
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Duško Dobrota
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Stjepan Aždajić
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Jasmina Hranjec
- Department of Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
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Bozzani A, Arici V, Ticozzelli G, Pregnolato S, Boschini S, Fellegara R, Carando S, Ragni F, Sterpetti AV. Intraoperative Cerebral Monitoring During Carotid Surgery: A Narrative Review. Ann Vasc Surg 2021; 78:36-44. [PMID: 34537350 DOI: 10.1016/j.avsg.2021.06.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/16/2021] [Accepted: 06/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intra-operative neurological monitoring (IONM) during carotid endarterectomy (CEA) aims to reduce neurological morbidity of surgery. OBJECTIVE This narrative review analyses the role and results of different methods of IONM. METHODS review articles on PUBMED and Cochrane Library, by searching key words related to IONM and CEA, from 2000 up to date. RESULTS regional anesthesia in some centers represents the "gold standard". The most often used alternative techniques are: stump pressure, electroencephalogram, somatosensory evoked potentials, transcranical doppler ultrasound, near infrared spectroscopy and routine shunting. Every technique shows limitations. Regional anesthesia can make difficult prompt intubation when needed. Stump pressure shows a wide operative range. Electroencephalogram is unable to detect ischemia in sub-cortical regions of the brain. Somatosensory evoked potentials certainly demonstrate the presence of cerebral ischemia, but are no more specific or sensitive than the electroencephalogram. Transcranical doppler monitoring is undoubtedly operator-dependent and suffers from the limitations that the probe has to be placed relatively near to the surgical site and may impede the operator, especially if it needs constant adjustments; moreover, an acoustic window may not be found in 10% -20% of the subjects. Near infrared spectroscopy appears to have a high negative predictive value for cerebral ischemia, but has a poor positive predictive value and low specificity, because predominantly estimates venous oxygenation as this makes up about 80% of cerebral blood volume. The data on the use of Routine Shunting (RS) from RCTs are limited. CONCLUSIONS currently, with no clear consensus on monitoring technique, choice should be guided by local expertise and complication rates. With reflection, best practice may dictate that a standard technique is selected as suggested above and this remains the default position for individual practice. Nevertheless, current techniques for monitoring cerebral perfusion during CEA are associated with false negative and false positive resulting in inappropriate shunt insertion.
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Affiliation(s)
- Antonio Bozzani
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Vittorio Arici
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Ticozzelli
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sandro Pregnolato
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Boschini
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raffaele Fellegara
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Simona Carando
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Ragni
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Zhao W, Gao F, Wu C, Peng D, Jin X, Lou L, Sun W. Severe contralateral carotid stenosis or occlusion drive 30-day risk after carotid endarterectomy. Vascular 2021; 30:3-13. [PMID: 33596788 DOI: 10.1177/1708538121993619] [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
OBJECTIVES The significant effects on the treatment of severe carotid stenosis by carotid endarterectomy have been widely recognized. However, it is controversial whether patients with severe contralateral carotid stenosis or occlusion (SCSO) can benefit from carotid endarterectomy surgery. This study aimed to estimate the SCSO effects on early outcomes after carotid endarterectomy with selective shunting. METHODS Between August 2011 and October 2019, a total of 617 patients who underwent carotid endarterectomy with selective shunting were analyzed. SCSO was defined as >70% luminal narrowing of the contralateral extracranial carotid stenosis or occlusion. Of these patients, 116 were categorized into an SCSO group while the rest were assigned to the non-SCSO group. Primary study outcomes were the occurrence of major adverse events, defined as stroke, all-cause mortality, and myocardial infarction during the perioperative period after carotid endarterectomy. Traditional multivariable logistic regression model and logistic regression model adjusted for propensity scores were used to estimate the SCSO effects on primary outcomes. Interaction and stratified analyses were conducted according to age, sex, comorbidities (hypertension, diabetes), preoperative neurological deficit, preoperative symptoms, and shunt use. RESULTS Mean age was 68.5 ± 9.2 years (86.1% men). Overall major adverse events rate within 30 days was 2.5%. Major adverse events rates in SCSO and non-SCSO groups were 9.5% and 1.6%, respectively. This difference was statistically significant (p < 0.001). In multivariable regression analysis, patients with SCSO had a higher risk of major adverse events (non-SCSO vs. SCSO: aOR 5.05 [95% CI, 1.78-14.55]). In 342 propensity score matched patients, results were consistent (propensity score: aOR, 3.78 [95% CI, 1.13-12.64]). CONCLUSIONS SCSO is an independent predictor of 30-day major adverse events. Whether these patients with SCSO are suitable for carotid endarterectomy should be carefully considered.
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Affiliation(s)
- Wenyan Zhao
- General Practice Department, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Faliang Gao
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Cheng Wu
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Deqing Peng
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiao Jin
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Lin Lou
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Weijun Sun
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
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Dakour-Aridi H, Elsayed N, Malas M. Outcomes of Carotid Revascularization in Patients with Contralateral Carotid Artery Occlusion. J Am Coll Surg 2021; 232:699-708.e1. [PMID: 33601006 DOI: 10.1016/j.jamcollsurg.2020.12.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/29/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about the best revascularization procedure for patients with contralateral carotid artery occlusion (CCO). We aim to compare the outcomes of transcarotid artery revascularization (TCAR), carotid endarterectomy (CEA), and transfemoral carotid artery stenting (TFCAS) in patients with CCO. STUDY DESIGN Patients in the Vascular Quality Initiative dataset who underwent CEA, TFCAS, or TCAR, and had CCO between September 2016 and April 2020, were included. Multivariable logistic analysis was used to evaluate in-hospital outcomes. RESULTS The final cohort included 1,144 TCARs, 1,182 TFCAS, and 2,527 CEA procedures performed in patients with CCO. Compared with TFCAS, TCAR was associated with a significant reduction in the odds of in-hospital stroke or death (odds ratio [OR] 0.26; 95% CI: 0.12-0.59; p < 0.01). However, no significant difference in stroke was noted (OR 0.71; 95% CI 0.34-1.51; p = 0.38). These results persisted after stratifying with respect to symptomatic status (p values of interaction = 0.92 and 0.74, respectively). There was no significant difference between TCAR and CEA in odds of in-hospital stroke or death on multivariable adjustment (OR 0.57; 95% CI: 0.29-1.10, p = 0.10). The interaction between procedure type and symptomatic status in predicting in-hospital stroke was statistically significant (p = 0.04). In asymptomatic patients, TCAR was associated with a 50% to 60% reduction in the odds of stroke (p = 0.04). Yet, no significant differences were observed in symptomatic patients. CONCLUSIONS TCAR has lower odds of in-hospital stroke or death compared to TFCAS, independent of symptomatic status. Compared to CEA, TCAR seems to be a better option in asymptomatic patients, with lower odds of in-hospital stroke. Yet, no significant difference is observed in symptomatic patients.
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Affiliation(s)
- Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Mahmoud Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
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Moneta GL. Contralateral Carotid Artery Occlusion: Medical Therapy, Carotid Endarterectomy, Carotid Artery Stenting? J Am Coll Cardiol 2021; 77:845-847. [PMID: 33602465 DOI: 10.1016/j.jacc.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Gregory L Moneta
- Department of Surgery, Division of Vascular Surgery, Oregon Health & Science University, Knight Cardiovascular Institute, Portland, Oregon, USA.
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Surgical Management of a Patient with an Internal Carotid Artery Stenosis, Eagle Syndrome, and Internal Carotid Artery Tortuosity: A Case of Four Pathologies of the Carotid Arteries. EJVES Vasc Forum 2021; 50:37-39. [PMID: 33644775 PMCID: PMC7887635 DOI: 10.1016/j.ejvsvf.2021.01.002] [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: 10/16/2020] [Revised: 12/07/2020] [Accepted: 01/09/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction In 1937, W.W. Eagle first described two clinical cases of elongated styloid process causing compression of adjacent anatomical structures. A case of left internal carotid artery (ICA) stenosis, Eagle syndrome (bilateral), ICA tortuosity, and occlusion of the right carotid arteries is presented. Report A 67 year old man was referred following ischaemic stroke two months previously. Computed tomography (CT) revealed the pathologies described. Intervention was performed under general anaesthesia. The digastric muscle was transected, and the styloid process was resected. Carotid endarterectomy with end to end anastomosis between the crossed ends of the ICA was carried out using a temporary shunt due to occlusion of the contralateral carotid arteries. The patient was discharged on the third post-operative day. Discussion The case described shows that one stage surgical treatment of ICA stenosis, coiling, and Eagle syndrome gives good results.
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Casana R, Domanin M, Malloggi C, Tolva VS, Odero Jr A, Bissacco D, Trimarchi S, Silani V, Parati G. Influence of contralateral carotid artery occlusions on short- and long-term outcomes of carotid artery stenting: a retrospective single-center analysis and review of literature. INT ANGIOL 2020; 40:87-96. [PMID: 33274909 DOI: 10.23736/s0392-9590.20.04525-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In the current literature, correlations between a contralateral carotid artery occlusion (CCO) with mortality and major adverse cardiac or cerebrovascular events (MACCE) rates after carotid artery stenting (CAS) are often described with controversial conclusions. Moreover, long-term results of mortality, MACCE and restenosis rate are scarcely reported. This study examined the association between a CCO and the short- and long-term outcomes after CAS. METHODS One hundred and forty-six patients with CCO and without (No-CCO) who underwent between 2010 and 2017 to a CAS procedure in a single institution were retrospectively evaluated. The primary aim of the study was to evaluate mortality and MACCE rates in the short-term (defined as the occurrence during hospitalization and within 30-day) and after 3-year follow-up. The secondary aim of the study was to examine the restenosis rates in the short- and long-term period. RESULTS The overall success of CAS was 99.3% and the 30-day all-cause mortality rate was 0.7% (one death). About MACCE, there were no major strokes in the CCO groups and 1 (1.4%) in the No-CCO group (P=1.00). The rate of 30-day minor strokes was 1.4% (1 patient) in the CCO group and 2.7% (2 patients) in the No-CCO group (P=1.00). In the 3-year follow-up, death occurred in 11 CCO vs. 6 No-CCO patients, respectively (15.1% vs. 8.2%, P=0.30). Regarding MACCE, major stroke occurred in 6 CCO vs. 2 No-CCO patients (8.2% vs. 2.7%, P=0.27), minor stroke in 6 CCO vs. 6 No-CCO (8.2% vs. 8.2%, P=1.0) and myocardial infarction in 6 CCO (8.2%) vs. 3 No-CCO patients (8.2 vs. 4.1%, P=0.49), respectively. Regarding the 30-day restenosis rate, it was observed in one patient (1.4%) in the CCO group while no cases were recorded in the No-CCO group, respectively (P=1.00). In the 3-year follow-up, greater than >50% restenosis was observed in 7 patients (9.6%) in the CCO group and in one patient (1.4%) in the No-CCO group (P=0.06), respectively. Kaplan-Meier survival analysis revealed that CCO patients had a lower 3-year freedom from restenosis rate with respect to the No-CCO group (87.6% vs. 98.6%, P=0.024). A Cox regression model on 3-year restenosis highlighted female gender and hypertension to be statistically significant predictors of restenosis. CONCLUSIONS Patients with a preexisting CCO did not show a significative increased risk of procedural adverse events after CAS both in the immediate and long-term follow-up, but on the long term they are more likely to experience restenosis. CCO condition should be considered always as a clinical manifestation of a more aggressive carotid atherosclerosis.
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Affiliation(s)
- Renato Casana
- Department of Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy - .,Laboratory of Research in Vascular Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy -
| | - Maurizio Domanin
- Vascular Surgery Unit, IRCCS, Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| | - Chiara Malloggi
- Laboratory of Research in Vascular Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Valerio S Tolva
- Department of Vascular and Endovascular Surgery, Policlinico di Monza, Monza, Monza-Brianza, Italy
| | - Andrea Odero Jr
- Department of Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Daniele Bissacco
- Vascular Surgery Unit, IRCCS, Ospedale Maggiore Policlinico, Milan, Italy
| | - Santi Trimarchi
- Vascular Surgery Unit, IRCCS, Ospedale Maggiore Policlinico, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| | - Vincenzo Silani
- Department of Neurology-Stroke and Neuroscience, IRCCS Istituto Auxologico Italiano, Ospedale San Luca, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, Università di Milano-Bicocca, Monza, Monza-Brianza, Italy
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Carotid endarterectomy with concomitant distal endovascular intervention is associated with increased rates of stroke and death. J Vasc Surg 2020; 73:960-967.e1. [PMID: 32707384 DOI: 10.1016/j.jvs.2020.07.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/08/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) with concomitant distal endovascular intervention (CEA+D) is infrequently necessary but has often been used as a salvage maneuver when complications occur during CEA. The present study aimed to determine whether preoperative risk factors associated with CEA requiring CEA+D exist and to evaluate the outcomes compared with isolated CEA. METHODS The Vascular Quality Initiative CEA registry was used to identify patients who had undergone CEA or CEA+D for asymptomatic or symptomatic carotid stenosis from 2013 to 2019. Data regarding distal intervention included whether angioplasty or stenting of the distal internal carotid artery (ICA) and/or bifurcation had been required. However, information regarding the indication or whether the intervention had been planned was not included. The χ2 test and analysis of variance were used to evaluate the categorical and continuous perioperative variables. Variables with P < .20 on univariate analysis were included in the multivariable analysis to assess for preoperative predictors of the need for CEA+D and the association with perioperative stroke. RESULTS From 2013 to 2019, 327 CEA+D cases were identified and compared with 105,192 isolated CEA cases. The CEA+D patients were more likely to have undergone previous ipsilateral CEA (CEA, 1.8%; CEA+D, 4.9%; P < .01) and contralateral ICA occlusion (CEA, 4.6%; CEA+D, 11.0%; P < .01) but were less likely to have had ipsilateral stenosis ≥70% (CEA, 88.3%; CEA+D, 80.6%; P < .01). The preoperative factors associated with the need for CEA+D on multivariable analysis included previous peripheral vascular intervention, American Society of Anesthesiologists class ≥4, contralateral ICA occlusion, low-volume surgeon, and previous ipsilateral CEA. CEA+D was associated with significantly increased rates of stroke in both asymptomatic (CEA+D, 3.9%; CEA, 0.9%; P < .01) and symptomatic (CEA+D, 9.4%; CEA, 1.9%; P < .01) patients. CEA+D was associated with decreased rates of 30-day survival in both asymptomatic (CEA+D, 98.3%; CEA, 99.4%; P = .02) and symptomatic (CEA+D, 94.8%; CEA, 99.1%; P < .01) cohorts. On multivariable analysis, CEA+D remained significantly associated with stroke (odds ratio, 3.17; 95% confidence interval, 1.80-5.60; P < .01). Other factors significantly associated with perioperative stroke included procedure length >135 minutes, diabetes, hypertension, shunt for indication, symptomatic status, previous ipsilateral CEA, contralateral ICA occlusion, urgent or emergent procedure, intravenous medications for hemodynamic instability, and re-exploration at the initial operation. CONCLUSIONS Although markers of more significant cardiovascular disease burden were associated with the use of CEA+D, their power to predict CEA+D use was limited. In cases in which CEA+D was used, CEA+D was associated with significantly greater rates of perioperative stroke and mortality compared with isolated CEA for both asymptomatic and symptomatic patients, which could be useful for framing the expected outcomes after these procedures.
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Chia MC, Wallace GA, Cheng BT, Ho KJ, Eskandari MK. Identifying a Safe Carotid Stump Pressure Threshold for Selective Shunting During Carotid Endarterectomy. Ann Vasc Surg 2020; 69:158-162. [PMID: 32554199 DOI: 10.1016/j.avsg.2020.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is no current consensus on the best criteria for selective shunting during carotid endarterectomy (CEA). The choice of continuous neurologic assessment during awake CEA, intraoperative electroencephalogram, or carotid stump pressure monitoring as the basis for shunt placement is primarily dependent on surgeon preference. Our goal is to define a safe stump pressure threshold as a guide for selective shunting. METHODS The study is a single-surgeon retrospective review of consecutive patients who underwent CEA under general anesthesia with selective shunting based on intraoperative stump pressure measurements from 2001 to 2019. Demographic and periprocedural variables were analyzed using standard statistical techniques. RESULTS Among 399 patients, 68% were male with a mean age of 70. One-third of the patients were symptomatic, with amaurosis fugax in 12%, transient ischemic attack in 7%, and stroke in 16%. In total, 60 (15%) patients underwent shunting: 34 for a confirmed preoperative acute ischemic stroke, 22 for a stump pressure <30 mm Hg, and 4 for other indications. Overall 30-day death, ischemic ipsilateral stroke, myocardial infarction, and cranial nerve palsy rates were 0.5%, 0.8%, 1.8%, and 1.0%, respectively. No strokes occurred due to hypoperfusion, and all stroke symptoms resolved prior to discharge with a mean length of stay of 1.6 days. CONCLUSIONS This is one of the largest contemporary series of CEA using a 30 mm Hg threshold for selective shunting that demonstrated exceedingly low 30-day death and stroke events. Intraoperative carotid stump pressure measurements are a useful guide for selective shunting and reduction in perioperative stroke complications after CEA.
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Affiliation(s)
- Matthew C Chia
- Division of Vascular Surgery, Department of Surgery, Feinberg School of Medicine, Chicago, IL
| | - Gabriel A Wallace
- Division of Vascular Surgery, Department of Surgery, Feinberg School of Medicine, Chicago, IL
| | - Brian T Cheng
- Division of Vascular Surgery, Department of Surgery, Feinberg School of Medicine, Chicago, IL
| | - Karen J Ho
- Division of Vascular Surgery, Department of Surgery, Feinberg School of Medicine, Chicago, IL
| | - Mark K Eskandari
- Division of Vascular Surgery, Department of Surgery, Feinberg School of Medicine, Chicago, IL.
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Schneider JR, Wilkinson JB, Rogers TJ, Verta MJ, Jackson CR, Hoel AW. Results of carotid endarterectomy in patients with contralateral internal carotid artery occlusion from the Mid-America Vascular Study Group and the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2020; 71:832-841. [DOI: 10.1016/j.jvs.2019.05.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 05/04/2019] [Indexed: 11/17/2022]
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Kokkinidis DG, Chaitidis N, Giannopoulos S, Texakalidis P, Haider MN, Aronow HD, Giri JS, Armstrong EJ. Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients. J Endovasc Ther 2020; 27:334-344. [PMID: 32066317 DOI: 10.1177/1526602820904163] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I2 test. I2>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I2=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I2=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I2=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I2=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I2=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I2=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I2=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I2=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I2=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I2=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA.,Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nikos Chaitidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Pavlos Texakalidis
- Division of Neurological Surgery, Emory University Hospital, Atlanta, GA, USA
| | - Moosa N Haider
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, USA
| | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Jay S Giri
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Levin SR, Farber A, Goodney PP, Schermerhorn ML, Patel VI, Arinze N, Cheng TW, Jones DW, Rybin D, Siracuse JJ. Shunt intention during carotid endarterectomy in the early symptomatic period and perioperative stroke risk. J Vasc Surg 2020; 72:1385-1394.e2. [PMID: 32035768 DOI: 10.1016/j.jvs.2019.11.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/21/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Whether recent stroke mandates planned shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with postoperative outcomes of CEAs performed after acute stroke. METHODS The Vascular Quality Initiative database (2010-2018) was queried for CEAs performed within 14 days of an ipsilateral stroke. Surgeons who prospectively planned to shunt either shunted routinely per their usual practice or shunted selectively for preoperative indications. Surgeons who prospectively planned not to shunt either shunted selectively for intraoperative indications or did not shunt. Univariable and multivariable analyses compared shunting approaches. RESULTS There were 5683 CEAs performed after acute ipsilateral stroke. Surgeons planned to shunt in 56.1% of cases. Patients whose surgeons planned to shunt vs planned not to shunt were more likely to have severe contralateral stenosis (8.8% vs 6.9%; P = .008), to receive general anesthesia (97.5% vs 89.1%; P < .001), and to undergo conventional CEA (94% vs 81.8%; P < .001). Unadjusted outcomes were similar between the cohorts for operative duration (124.3 ± 48.1 minutes vs 123.6 ± 47 minutes; P = .572) and 30-day stroke (3.4% vs 3%; P = .457), myocardial infarction (1.1% vs 0.8%; P = .16), and mortality (1.6% vs 1.3%; P = .28). On multivariable analysis, planning to shunt vs planning not to shunt was associated with similar risk of 30-day stroke (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82-1.67; P = .402). On subgroup analysis, in 38.4% patients, no shunt was placed, whereas the remainder received routine shunts (44.4%), preoperatively indicated shunts (11.6%), and intraoperatively indicated shunts (5.5%). Compared with no shunting, shunting by surgeons who routinely shunt was associated with a similar stroke risk (OR, 1.39; 95% CI, 0.91-2.13; P = .129), but shunting by surgeons who selectively shunt on the basis of preoperative indications (OR, 2.11; 95% CI, 1.22-3.63; P = .007) or intraoperative indications (OR, 3.34; 95% CI, 1.86-6.01; P < .001) was associated with increased stroke risk. Prior coronary revascularization independently predicted increased intraoperatively indicated shunting (OR, 1.37; 95% CI, 1.05-1.8; P = .022). CONCLUSIONS In CEAs performed after acute ipsilateral stroke, there is no difference in postoperative stroke risk when surgeons prospectively plan to shunt or not to shunt. Shunting is often not necessary; however, when shunting is performed, routine shunters achieve better outcomes.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Center, New York, NY
| | - Nkiruka Arinze
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
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Carotid stenting and endarterectomy and contralateral carotid occlusion. J Vasc Surg 2019; 70:824-831. [DOI: 10.1016/j.jvs.2018.12.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 12/12/2018] [Indexed: 11/21/2022]
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20
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Xin WQ, Zhao Y, Ma TZ, Gao YK, Wang WH, Wang HY, Yang XY. Comparison of postoperative results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid artery occlusion: A meta-analysis. Vascular 2019; 27:595-603. [PMID: 31027468 DOI: 10.1177/1708538119841232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The purpose of this study was to conduct a meta-analysis to systematically compare the safety and efficacy of carotid endarterectomy and carotid artery stenting in contralateral carotid occlusion patients who needed reperfusion. Methods This study retrieved potential academic articles comparing results between carotid endarterectomy and carotid artery stenting for patients with contralateral carotid occlusion from the MEDLINE database, the PubMed database the EMBASE database, and the Cochrane Library from January 1990 to May 2018. The reference articles for the identified studies were carefully reviewed to ensure that all available documents were represented in the study. Results Four retrospective cohort study involving 6252 patients with contralateral carotid occlusion were included in our meta-analysis. During 30-day follow-up, there is significant difference in post-procedure mortality (odds ratio (OR) = 0.476, 95% confidence interval (CI) (0.306–0.740), P = 0.001); no significant differences are not found in post-procedure stroke (risk difference (RD) = 0.002, 95%CI (–0.007 to 0.011); P = 0.631), myocardial infarction (RD = 0.003, 95%CI (–0.002 to 0.008); P = 0.301), and transient cerebral ischemia (RD = 1.059, 95%CI (–0.188 to 5.964); P = 0.948). Conclusions Carotid endarterectomy was associated with a lower incidence of mortality compared to carotid artery stenting for patients with contralateral carotid occlusion. Regarding stroke, myocardial infarction, and transient ischemic attack, there was no significant difference between the two groups. More randomized controlled trials and prospective cohorts are necessary to help further clarify the ideal approach for these patients.
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Affiliation(s)
- Wen-Qiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, R.P. China
| | - Yan Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, R.P. China
| | - Tie-Zhu Ma
- Department of Neurology, Characteristic Medical Center of Chinese Armed Police Force, Tianjin, R.P. China
| | - Yi-Kuan Gao
- Department of Neurosurgery, Central Hospitol of Yongzhou, Yongzhou, Tianjin, R.P. China
| | - Wei-Han Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, R.P. China
| | - Hong-Yu Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, R.P. China
| | - Xin-Yu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, R.P. China
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Influence of Contralateral Carotid Occlusion on Outcomes After Carotid Endarterectomy: A Meta-Analysis. J Stroke Cerebrovasc Dis 2018; 27:2587-2595. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/09/2018] [Accepted: 05/19/2018] [Indexed: 11/23/2022] Open
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Early Outcomes of Routine Delayed Shunting in Carotid Endarterectomy for Asymptomatic Patients. Eur J Vasc Endovasc Surg 2018; 56:334-341. [DOI: 10.1016/j.ejvs.2018.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022]
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Lomivorotov VV, Shmyrev VA, Moroz GB. Volatile Anesthesia for Carotid Endarterectomy: Friend or Foe for the Brain? J Cardiothorac Vasc Anesth 2018; 32:1709-1710. [DOI: 10.1053/j.jvca.2018.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Indexed: 11/11/2022]
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Severe contralateral carotid stenosis or occlusion does not have an impact on risk of ipsilateral stroke after carotid endarterectomy. J Vasc Surg 2018; 67:1744-1751. [DOI: 10.1016/j.jvs.2017.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 09/22/2017] [Indexed: 11/21/2022]
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Pascot R, Parat B, Le Teurnier Y, Godet G, Gauvrit JY, Gouëffic Y, Steinmetz E, Cardon A, Kaladji A. Predictive Factors of Silent Brain Infarcts after Asymptomatic Carotid Endarterectomy. Ann Vasc Surg 2018; 51:225-233. [PMID: 29772320 DOI: 10.1016/j.avsg.2018.02.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 02/03/2018] [Accepted: 02/19/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimization of medical treatment regularly challenges the role of carotid surgery for asymptomatic patients. Current research seeks to determine which of these patients will benefit most from surgery. The goal of this study was to identify in a multicenter study, using magnetic resonance imaging (MRI), the risk factors for postoperative silent cerebral ischemic lesions after carotid surgery for asymptomatic stenosis. METHODS The multicenter, retrospective study included patients with asymptomatic severe carotid stenosis suitable for surgical treatment and who did not have a history of cerebral ischemia. A diffusion MRI scan was performed the day before and in the 3 days after the procedure. An analysis by an independent neuroradiologist determined the presence of preoperative silent ischemia and the appearance of new lesions postoperatively. The analysis also took into account the plaque type, lesions of supra-aortic trunks, the circle of Willis, the type of surgery, and anesthesia, shunt use, and clamp time. RESULTS Between April 2011 and November 2015, 141 patients were included. The mean degree of carotid stenosis in the patients who underwent surgery was 78.2% ± 6.5, with 9 (6.4%) cases of contralateral stenosis ≥70% and 6 (4.3%) of which were thrombosis. The circle of Willis was incomplete in 23 (16.3%) patients. Twenty-one (14.9%) plaques were of high embolic risk. The preoperative MRI found 34 (24.1%) patients with embolic ischemic lesions. The majority of procedures were eversions performed under general anesthesia, 7 (5%) required a shunt, and the mean clamp time was 39 ± 16 min. The postoperative MRI revealed that 10 (7%) patients had a new ischemic lesion on the operated side. None of these lesions were symptomatic. On multivariate analysis, the risk factors for appearance of a new ischemic lesion on the operated side were significant severe stenosis of the vertebral artery ipsilateral to the lesion (odds ratio [OR] = 9.2, 95% confidence interval [CI] [2.1-39.8], P = 0.003) and insertion of a shunt (OR = 9.1, 95% CI [1.1-73.1], P = 0.039). The 30-day follow-up showed one death at D4 due to hemorrhagic stroke on the operated side and one contralateral stroke. None of the study patients had a myocardial infarction. CONCLUSIONS In this multicenter study, the rate of silent ischemic lesions in asymptomatic carotid surgery showed 43.3% of preoperative silent ischemic lesions and 9.2% of new silent lesions after surgery. The use of a shunt and presence of ipsilateral vertebral stenosis are risk factors for perioperative embolism.
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Affiliation(s)
- Rémy Pascot
- Department of Vascular Surgery, Rennes University Hospital, Rennes, France
| | - Benjamin Parat
- Department of Neuroradiology, Rennes University Hospital, Rennes, France
| | - Yann Le Teurnier
- Department of Anesthesiology and Intensive Care, Nantes University Hospital, Nantes, France
| | - Gilles Godet
- Department of Anesthesiology and Intensive Care, Rennes University Hospital, Rennes, France
| | - Jean-Yves Gauvrit
- Department of Neuroradiology, Rennes University Hospital, Rennes, France
| | - Yann Gouëffic
- Department of Vascular Surgery, Nantes University Hospital, Nantes, France
| | - Eric Steinmetz
- Department of Vascular Surgery, Dijon University Hospital, Dijon, France
| | - Alain Cardon
- Department of Vascular Surgery, Rennes University Hospital, Rennes, France
| | - Adrien Kaladji
- Department of Vascular Surgery, Rennes University Hospital, Rennes, France; INSERM, U1099, Rennes, France; Signal and Image Processing Laboratory (LTSI), University of Rennes 1, Rennes, France.
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Nejim B, Dakour Aridi H, Locham S, Arhuidese I, Hicks C, Malas MB. Carotid artery revascularization in patients with contralateral carotid artery occlusion: Stent or endarterectomy? J Vasc Surg 2017; 66:1735-1748.e1. [DOI: 10.1016/j.jvs.2017.04.055] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
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Kong J, Li J, Ye Z, Fan X, Wen J, Zhang J, Liu P. Carotid Endarterectomy with Routine Shunt for Patients with Contralateral Carotid Occlusion. Ann Thorac Cardiovasc Surg 2017; 23:227-232. [PMID: 28794387 DOI: 10.5761/atcs.oa.17-00017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This study aimed to report the clinical features and early and long-term outcomes of patients treated with carotid endarterectomy (CEA) combined with a routine shunt for carotid stenosis with the occlusion of the contralateral carotid artery (CCO), and to compare them with patients without contralateral occlusion (NO-CCO). A retrospective analysis included 301 patients who had carotid artery stenosis treated with CEA using a routine shunt. Of these patients, 35 patients and 266 patients were categorized into a CCO group and NO-CCO group, respectively. Demographics and short-term and long-term outcomes were documented and compared. The demographic characteristics were not significantly different between the two groups. The periprocedural mortality, stroke rate, and rate of periprocedural myocardial infarction were not significantly different between both groups. The mean follow-up period for long-term outcomes was 34.45 ± 22.99 months, and the Kaplan-Meier analysis showed no statistical difference between both groups regarding stroke, myocardial infarction, and mortality. CEA combined with the routine shunt is an effective and durable procedure for carotid artery stenosis patients with CCO.
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Affiliation(s)
- Jie Kong
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jinyong Li
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Zhidong Ye
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xueqiang Fan
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianyan Wen
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianbin Zhang
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Peng Liu
- Graduate School of Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
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Piffaretti G, Tarallo A, Franchin M, Bacuzzi A, Rivolta N, Ferrario M, Ferraro S, Bossi M, Castelli P, Tozzi M. Outcome Analysis of Carotid Cross-Clamp Intolerance during Carotid Endarterectomy under Locoregional Anesthesia. Ann Vasc Surg 2017; 43:249-257. [DOI: 10.1016/j.avsg.2016.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/12/2016] [Accepted: 11/28/2016] [Indexed: 10/19/2022]
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Pothof AB, Soden PA, Fokkema M, Zettervall SL, Deery SE, Bodewes TCF, de Borst GJ, Schermerhorn ML. The impact of contralateral carotid artery stenosis on outcomes after carotid endarterectomy. J Vasc Surg 2017; 66:1727-1734.e2. [PMID: 28655552 DOI: 10.1016/j.jvs.2017.04.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/01/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with contralateral carotid occlusion (CCO) have been excluded from randomized clinical trials because of a deemed high risk for adverse neurologic outcomes with carotid endarterectomy (CEA). Evidence for this rationale is limited and conflicting. Therefore, we aimed to compare outcomes after CEA between patients with and without CCO and varying degrees of contralateral carotid stenosis (CCS). METHODS We identified patients undergoing CEA from 2003 to 2015 in the Vascular Study Group of New England (VSGNE) registry. Patients were stratified by preoperative symptom status and presence of CCO. Multivariable analysis was used to account for differences in demographics and comorbidities. Our primary outcome was 30-day stroke/death risk. RESULTS Of 15,487 patients we identified who underwent CEA, 10,377 (67%) were asymptomatic. CCO was present in 914 patients, of whom 681 (75%) were asymptomatic. Overall, the 30-day stroke/death was 2.0% for symptomatic patients (CCO: 2.6%) and 1.1% for asymptomatic patients (CCO: 2.3%). After adjustment, including symptom status, CCO was associated with higher 30-day stroke/death (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.3; P = .001), any in-hospital stroke (OR, 2.8; 95% CI, 1.7-4.6; P < .001), in-hospital ipsilateral stroke (OR, 2.2; 95% CI, 1.2-4.0; P = .02), in-hospital contralateral stroke (OR, 5.1; 95% CI, 2.2-11.4; P < .001), and prolonged length of stay (OR, 1.6; 95% CI, 1.3-1.9; P < .001). CCS of 80% to 99% was only associated with a prolonged length of stay (OR, 1.3; 95% CI, 1.1-1.6; P = .01), not with in-hospital stroke. Neither CCO nor CCS was associated with 30-day mortality. CONCLUSIONS Although CCO increases the risk of 30-day stroke/death, in-hospital strokes, and prolonged length of stay after CEA, the 30-day stroke/death rates in symptomatic and asymptomatic patients with CCO remain within the recommended thresholds set by the 14 societies' guideline document. Thus, CCO should not qualify as a high-risk criterion for CEA. Moreover, there is no evidence that patients with CCO have lower stroke/death rates after carotid artery stenting than after CEA. We believe that CEA remains a valid and safe option for patients with CCO and that CCO should not be applied as a criterion to promote carotid artery stenting per se.
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Affiliation(s)
- Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Margriet Fokkema
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Perini P, Bonifati DM, Tasselli S, Sogaro F. Routine Shunting During Carotid Endarterectomy in Patients With Acute Watershed Stroke. Vasc Endovascular Surg 2017; 51:288-294. [DOI: 10.1177/1538574417708130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim: To evaluate the protective role of routine shunting in patients with acute watershed stroke (WS) undergoing carotid endarterectomy (CEA). Methods: A total of 138 patients with symptomatic carotid stenosis (SCS) who underwent CEA after acute ischemic stroke from March 2008 to March 2015 were included in this study. Transient ischemic attacks were excluded. These patients were divided into 2 groups according to the topographic pattern of the stroke on magnetic resonance imaging: group 1, territorial strokes (TS) caused by emboli of carotid origin, and group 2, WS caused by a hemodynamic mechanism related to an SCS. Primary end points were 30-day mortality and postoperative neurological morbidity. The insertion of a Pruitt carotid shunt was performed systematically. Results: Ninety (65.2%) patients presented a TS of carotid origin and were included in group 1, and 48 (34.8%) of the 138 patients had a WS related to an SCS and were included in group 2. The median time between clinical onset of the cerebral ischemic event and surgery was 9 days (range: 0-89 days). Postoperative mortality was 0%. Seven (5.1%) patients had an aggravation of the neurological status during the postoperative period, of whom 2 presented a complete regression of the symptoms in less than 1 hour (definitive postoperative neurologic morbidity: 3.6%). Postoperative neurologic morbidity rate was significantly higher in the TS group (7 of 90; 7.8%) compared to the WS group (0 of 48; P = .04). No other independent predictive factor of neurologic morbidity after CEA for an SCS was found. Conclusions: Our results suggest that routine shunting should be considered in case of acute WS since it may play a protective role. Further studies are eagerly awaited to better define the timing and the best treatment option for both acute WS and TS related to an SCS in order to reduce postoperative neurologic morbidity.
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Affiliation(s)
- Paolo Perini
- Unit of Vascular Surgery, Cardiovascular Department, S. Chiara Hospital, Trento, Italy
| | | | - Sebastiano Tasselli
- Unit of Vascular Surgery, Cardiovascular Department, S. Chiara Hospital, Trento, Italy
| | - Filippo Sogaro
- Unit of Vascular Surgery, Cardiovascular Department, S. Chiara Hospital, Trento, Italy
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The perioperative outcomes of eversion carotid endarterectomy in diabetic patients aged 80 years or older. J Vasc Surg 2016; 64:348-353. [PMID: 26993375 DOI: 10.1016/j.jvs.2016.01.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/29/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Uncertainty exists about the influence of advanced age and diabetes mellitus on the clinical effect of carotid endarterectomy (CEA). This study analyzed the perioperative (30-day) outcomes of CEA in diabetic patients aged ≥80 years. METHODS Data of 1872 consecutive patients who underwent 2125 primary eversion CEAs from 1990 to 2014 at our institution were prospectively stored in a vascular surgery registry. Risk factors, medication, and indication for surgery were recorded. The 354 patients (387 CEAs) aged ≥80 years formed the study base; of whom, 207 (219 CEAs) were diabetic and 147 (168 CEAs) were not. A neurologist assessed all patients preoperatively, on waking from the anesthesia, and before discharge from the hospital. All procedures were eversion CEA performed by the same surgeon under general anesthesia with routine electroencephalographic monitoring for selective shunting. RESULTS Diabetic patients were more likely to have arterial hypertension (P = .033), cardiac disease (P = .038), peripheral aneurysmal/atherosclerotic disease (P = .046), and contralateral carotid occlusion (P = .042) than their nondiabetic counterparts. Overall, there were no deaths, two (0.51%) perioperative strokes (both in diabetic patients), and 13 nonfatal cardiac complications (3.3%), of which 10 occurred in diabetic patients, but the difference failed to reach statistical significance. CONCLUSIONS Findings from this study show that CEA is safe and effective for stroke prevention in diabetic patients aged ≥80 years, with a negligible incidence of perioperative adverse events and no deaths.
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Perioperative and follow-up results in carotid artery stenting with contralateral carotid occlusion. Jpn J Radiol 2016; 34:523-8. [PMID: 27230906 DOI: 10.1007/s11604-016-0554-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Contralateral carotid occlusion (CCO) increases the risk of carotid endarterectomy (CEA). We determined the outcome of carotid angioplasty and stenting (CAS), an alternative to CEA, in the setting of CCO through an independent analysis of imaging and clinical outcome. MATERIALS AND METHODS Medical records of 26 consecutive patients with CCO who underwent CAS by a single operator using the same procedural protocol (with distal protection and closed-cell stents) were retrospectively evaluated. National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) scores before and after CAS, periprocedural complications, and the restenosis rate were analyzed by independent stroke neurologists who were not involved in the care of the patients. RESULTS The median mRS score for the 26 patients was 1 (range 0-5) before and after CAS. All of the patients underwent clinical and imaging follow-up (mean 19.5 ± 14.3 and 11.6 ± 11.2 months, respectively). Thirty-day mortality/permanent morbidity rates were 0 %. One patient had hyperperfusion syndrome and was managed medically without sequelae; however, he had stent occlusion after 30 days, resulting in a decline in his mRS from 4 (preprocedure) to 5. Otherwise, there was no decline in mRS during the post-discharge follow-up. CONCLUSION According to an independent analysis of this single-operator series, CAS is safe and effective for the treatment of patients with CCO.
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Clinical Outcomes after Carotid Endarterectomy in Patients with Contralateral Carotid Occlusion. Ann Vasc Surg 2016; 32:83-7. [DOI: 10.1016/j.avsg.2015.10.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/15/2015] [Accepted: 10/23/2015] [Indexed: 11/18/2022]
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De Santis F, Chaves Brait CM, Pattaro C, Cesareo V, Di Cintio V. A Prospective Nonrandomized Study on Carotid Surgery Performed under General Anesthesia without Intraoperative Cerebral Monitoring. J Stroke Cerebrovasc Dis 2015; 25:136-43. [PMID: 26493333 DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/27/2015] [Accepted: 09/09/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess our experience of carotid surgery habitually performed under general anesthesia without intraoperative intracerebral monitoring, and following a pre-established perioperative protocol, which includes extensive use of an intraoperative shunt (IOS). METHODS This study included 311 consecutive carotid operations performed over 32 months. This patient cohort represents 14% of our total experience in carotid surgery (2219 operations, major stroke/mortality rate: 1.4%). The IOS was inserted routinely in the presence of intraoperative blood pressure instability during cross-clamping and when the predictable clamping time might have exceeded 20 minutes. A moderate and stable hypertension was maintained throughout surgery without IOS. RESULTS Overall, 120 (38.6%) endarterectomies were performed with primary closure, 73 (23.5%) with eversion technique, 113 (36.3%) with patch angioplasty, and 5 (1.6%) with other techniques. Out of 113 patch angioplasties, 111 (98.2%) were performed with an IOS. This was utilized in only 3 cases of direct carotid reconstructions or other carotid endarterectomy techniques (1.5%). Overall, the IOS placement rate was 36.7%. Postoperatively, 2 major strokes (.64%), 2 minor strokes (.64%), 4 hyperperfusion syndromes (1.3%), and no mortality were recorded. No cases of cross-clamp ischemia/shunt-related perioperative strokes were observed. CONCLUSIONS The low perioperative stroke rate reported in this prospective study proves the advantages of wide use of IOS during carotid surgery. This coupled with a large experience in carotid surgery and close monitoring and support of blood pressure, are the major determinants of these results that demonstrate the low risk of shunt-related complications for surgeons who regularly utilize an IOS.
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Affiliation(s)
| | | | - Cristian Pattaro
- Institute of Genetic Medicine, European Academy of Bolzano/Bozen (EURAC), Italy
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Jaffer U, Normahani P, Harrop-Griffiths W, Standfield NJ. Pre-operative methods to predict need for shunting during carotid endarterectomy. Int J Surg 2015; 23:5-11. [PMID: 26386385 DOI: 10.1016/j.ijsu.2015.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/09/2015] [Accepted: 09/06/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To establish whether pre-operative investigations are able to predict cerebral tolerance to carotid cross clamping during carotid endarterectomy (CEA). METHODS A search of the MEDLINE database from 1950 to 2015 was made in combination with manual cross-referencing using the search strategy: ("carotid" [all fields] AND "endarterectomy" [all fields]) AND "preoperative" [all fields]) AND "clamping" [all fields]) AND ("MRA" [all fields] OR "MRI" [all fields] OR "CT" [all fields] OR "CTA" [all fields] OR "EEG" [all fields] OR "Doppler" [all fields] OR "angiography" [all fields]). A total of 20 studies were identified as eligible for inclusion. RESULTS 3D Time of Flight MRA and acetazolomide stress SPECT imaging have been reported to have a negative predictive value of 96% and 94% respectively for the need for intraoperative shunting during carotid endarterectomy. CONCLUSIONS There is some evidence to suggest that pre-operative imaging investigations can reliably identify which patients undergoing CEA will not require carotid shunting for neurological protection. However, this evidence is limited and there is a need for more rigorous studies to be conducted.
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Affiliation(s)
- Usman Jaffer
- Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK.
| | - Pasha Normahani
- Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - William Harrop-Griffiths
- Department of Anesthesia, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK; The Association of Anesthetists of UK & Eire, UK
| | - Nigel J Standfield
- Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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Choi BM, Park SK, Shin S, Cho YP, Kwon TW, Choi YJ, Lee EK, Noh GJ. Neurologic Derangement and Regional Cerebral Oxygen Desaturation Associated With Patency of the Circle of Willis During Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2015; 29:1200-5. [PMID: 26384627 DOI: 10.1053/j.jvca.2015.05.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To explore the relationship between the maximal fractional decrease of regional cerebral oxygen saturation (rSO2) in neurologic derangement and the patency of the circle of Willis and contralateral carotid artery stenosis. DESIGN A prospective observational study. SETTINGS A tertiary-care university hospital PARTICIPANTS This study enrolled 307 patients undergoing carotid endarterectomy under regional anesthesia. INTERVENTIONS No interventions. MEASUREMENTS AND MAIN RESULTS Magnetic resonance angiography and carotid color-duplex ultrasound were performed, and the rSO2 was recorded. The relationship between the maximal fractional decrease of rSO2 from preclamp baseline against shunt insertion and patency of the circle of Willis was analyzed by a 2-way analysis of variance. Receiver operating characteristic analysis of the maximal fractional decrease of rSO2 also was performed to calculate the cut-off value for detecting neurologic derangement. In addition, probability of shunt insertion was estimated by logistic regression. Patency of the circle of Willis did not influence the maximal fractional decrease of rSO2. When both anterior and posterior circulations were nonpatent, the degree of contralateral carotid artery stenosis (Contra) was 54.7%±29.0% versus 40.7%±26.0% in patients with versus without shunting, respectively (p<0.05). The cut-off value of rSO2 for predicting shunt insertion was 25.8%, regardless of the patency of the circle of Willis. Probability of shunt insertion for nonpatent anterior circulation = exp(-2.02+0.02×Contra)/[1+exp(-2.02+0.02×Contra)]. CONCLUSIONS The rSO2 can be used to predict shunt insertion, regardless of the patency of the circle of Willis. The probability of shunt insertion increased with increasing degree of contralateral carotid artery stenosis in the absence of anterior circulation in the circle of Willis.
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Affiliation(s)
| | - Soo-kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung Shin
- Surgery, Division of Vascular Surgery
| | | | | | | | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, Republic of Korea
| | - Gyu-Jeong Noh
- Clinical Pharmacology and Therapeutics/Anesthesiology and Pain Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea.
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Hokari M, Nakayama N, Kazumata K, Osanai T, Nakamura T, Yasuda H, Ushikoshi S, Shichinohe H, Abumiya T, Kuroda S, Houkin K. Surgical Outcomes for Cervical Carotid Artery Stenosis: Treatment Strategy for Bilateral Cervical Carotid Artery Stenosis. J Stroke Cerebrovasc Dis 2015; 24:1768-74. [PMID: 25956627 DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/31/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid stenting (CAS) are beneficial procedures for patients with high-grade cervical carotid stenosis. However, it is sometimes difficult to manage patients with bilateral carotid stenosis. To decide the treatment strategy, one of the most important questions is whether contralateral stenosis increases the risk of patients undergoing CEA. METHODS This retrospective study included 201 patients with carotid stenosis who underwent a total of 219 consecutive procedures (CEA 189/CAS 30). We retrospectively analyzed outcomes in patients with carotid stenosis who were treated with either CEA or CAS and evaluated whether or not contralateral lesions increases the risk of patients undergoing CEA or CAS. Furthermore, we retrospectively verified our treatment strategy for bilateral carotid stenosis. RESULTS The incidences of perioperative complications were 5.3% in the CEA patients and 6.7% in the CAS patients, respectively. There was no significant difference between these 2 groups. The existences of contralateral occlusion and/or contralateral stenosis were not associated with perioperative complications in both the groups. There were 32 patients with bilateral severe carotid stenosis (>50%). Of those, 13 patients underwent bilateral revascularizations; CEA followed by CEA in 8, CEA followed by CAS in 3, CAS followed by CEA + coronary artery bpass grafting in 1, and CAS followed by CAS in 1. CONCLUSIONS Our date showed that the existence of contralateral carotid lesion was not associated with perioperative complications, and most of our cases with bilateral carotid stenosis initially underwent CEA.
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Affiliation(s)
- Masaaki Hokari
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Naoki Nakayama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ken Kazumata
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshiya Osanai
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshitaka Nakamura
- Department of Neurosurgery, Azabu Neurosurgical Hospital, Sapporo, Japan
| | - Hiroshi Yasuda
- Department of Neurosurgery, Hokkaido Medical Center, Sapporo, Japan
| | | | - Hideo Shichinohe
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takeo Abumiya
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Schneider JR, Helenowski IB, Jackson CR, Verta MJ, Zamor KC, Patel NH, Kim S, Hoel AW. A comparison of results with eversion versus conventional carotid endarterectomy from the Vascular Quality Initiative and the Mid-America Vascular Study Group. J Vasc Surg 2015; 61:1216-22. [PMID: 25925539 PMCID: PMC4930669 DOI: 10.1016/j.jvs.2015.01.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 01/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is usually performed with eversion (ECEA) or conventional (CCEA) technique. Previous studies report conflicting results with respect to outcomes for ECEA and CCEA. We compared patient characteristics and outcomes for ECEA and CCEA. METHODS Deidentified data for CEA patients were obtained from the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) database for years 2003 to 2013. Second (contralateral) CEA, reoperative CEA, CEA after previous carotid stenting, or CEA concurrent with cardiac surgery were excluded, leaving 2365 ECEA and 17,155 CCEA for comparison. Univariate analysis compared patients, procedures, and outcomes. Survival analysis was also performed for mortality. Multivariate analysis was used selectively to examine the possible independent predictive value of variables on outcomes. RESULTS Groups were similar with respect to sex, demographics, comorbidities, and preoperative neurologic symptoms, except that ECEA patients tended to be older (71.3 vs 69.8 years; P < .001). CCEA was more often performed with general anesthesia (92% vs 80%; P < .001) and with a shunt (59% vs 24%; P < .001). Immediate perioperative ipsilateral neurologic events (ECEA, 1.3% vs CCEA, 1.2%; P = .86) and any ipsilateral stroke (ECEA, 0.8% vs CCEA, 0.9%; P = .84) were uncommon in both groups. ECEA tended to take less time (median 99 vs 114 minutes; P < .001). However, ECEA more often required a return to the operating room for bleeding (1.4% vs 0.8%; P = .002), a difference that logistic regression analysis showed was only partly explained by differential use of protamine. Life-table estimated 1-year freedom from any cortical neurologic event was similar (96.7% vs 96.7%). Estimated survival was similar comparing ECEA with CCEA at 1 year (96.7% vs 95.9%); however, estimated survival tended to decline more rapidly in ECEA patients after ∼2 years. Cox proportional hazards modeling confirmed that independent predictors of mortality included age, coronary artery disease, chronic obstructive pulmonary disease, and smoking, but also demonstrated that CEA type was not an independent predictor of mortality. The 1-year freedom from recurrent stenosis >50% was lower for ECEA (88.8% vs 94.3%, P < .001). However, ECEA and CCEA both had a very high rate of freedom from reoperation at 1 year (99.5% vs 99.6%; P = .67). CONCLUSIONS ECEA and CCEA appear to provide similar freedom from neurologic morbidity, death, and reintervention. ECEA was associated with significantly shorter procedure times. Furthermore, ECEA obviates the expenses, including increased operative time, associated with use of a patch in CCEA, and a shunt, more often used in CCEA in this database. These potential benefits may be reduced by a slightly greater requirement for early return to the operating room for bleeding.
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Affiliation(s)
- Joseph R Schneider
- Vascular Surgery and Interventional Radiology Partners of Cadence Physician Group, a part of Northwestern Medicine, Winfield and Geneva, Ill; Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Irene B Helenowski
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Cheryl R Jackson
- Vascular Surgery and Interventional Radiology Partners of Cadence Physician Group, a part of Northwestern Medicine, Winfield and Geneva, Ill
| | - Michael J Verta
- Vascular Surgery and Interventional Radiology Partners of Cadence Physician Group, a part of Northwestern Medicine, Winfield and Geneva, Ill; Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Kimberly C Zamor
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Nilesh H Patel
- Vascular Surgery and Interventional Radiology Partners of Cadence Physician Group, a part of Northwestern Medicine, Winfield and Geneva, Ill
| | - Stanley Kim
- Vascular Surgery and Interventional Radiology Partners of Cadence Physician Group, a part of Northwestern Medicine, Winfield and Geneva, Ill
| | - Andrew W Hoel
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Hans SS, Catanescu I. Selective shunting for carotid endarterectomy in patients with recent stroke. J Vasc Surg 2015; 61:915-9. [DOI: 10.1016/j.jvs.2014.11.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
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Capoccia L, Sbarigia E, Rizzo AR, Pranteda C, Menna D, Sirignano P, Mansour W, Esposito A, Speziale F. Contralateral occlusion increases the risk of neurological complications associated with carotid endarterectomy. Int J Vasc Med 2015; 2015:942146. [PMID: 25705519 PMCID: PMC4326273 DOI: 10.1155/2015/942146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/07/2015] [Accepted: 01/07/2015] [Indexed: 11/17/2022] Open
Abstract
Objective. To report on the incidence and factors associated with the development of perioperative neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO) and to compare results between those patients and the whole group of patients submitted to CEA at our vascular division from 1997 to 2012. Methods. Our nonrandomized prospective experience including 1639 patients consecutively submitted to CEA was retrospectively reviewed. 136 patients presented a CO contralateral to the treated carotid stenosis. Outcomes considered for analysis were perioperative neurological death rates, major and minor stroke rates, and a combined endpoint of all neurological complications. Results. CO patients more frequently were male, smokers, younger, and symptomatic (P < 0.001), presented with a preoperative brain infarct and associated peripheral arterial disease (P < 0.0001), and presented with higher perioperative major stroke rate than patients without CO (4.4% versus 1.2%, resp., P = 0.009). Factors associated with the highest neurological risk in CO patients were age >74 years and preoperative brain infarct (P = 0.03). The combination of the abovementioned factors significantly increased complication rates in CO patients submitted to CEA. Conclusions. In our experience CO patients were at high risk for postoperative neurological complications particularly when presenting association of advanced age and preoperative brain infarction.
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Affiliation(s)
- Laura Capoccia
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Enrico Sbarigia
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Anna Rita Rizzo
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Chiara Pranteda
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Danilo Menna
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Wassim Mansour
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Andrea Esposito
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
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Ricotta JJ, Upchurch GR, Landis GS, Kenwood CT, Siami FS, Tsilimparis N, Ricotta JJ, White RA. The influence of contralateral occlusion on results of carotid interventions from the Society for Vascular Surgery Vascular Registry. J Vasc Surg 2014; 60:958-64; discussion 964-5. [PMID: 25260471 DOI: 10.1016/j.jvs.2014.04.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 04/10/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Data on the influence of contralateral carotid occlusion (CCO) on carotid endarterectomy (CEA) are conflicting and are absent for carotid artery stenting (CAS). This study evaluated the influence of CCO on CEA and CAS. METHODS We evaluated patients with and without CCO in the Society for Vascular Surgery Vascular Registry. Primary outcome was a composite of periprocedural death, stroke, or myocardial infarction (MI) (major adverse cardiovascular events [MACE]) and its individual components. Further analysis was done to identify the influence, if any, of symptom status on outcomes. RESULTS There were 1128 CAS and 666 CEA patients with CCO. CAS patients were more often symptomatic with a greater incidence of coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and New York Heart Association class >III. Absolute risk of periprocedural MACE (2.7% for CAS vs. 4.2% for CEA), death (1.1% for CAS vs. 0.7% for CEA), stroke (2.1% for CAS vs. 3.1% for CEA), and MI (0.3% for CAS vs. 0.6% for CEA) was statistically equivalent for both. This equivalence was maintained when patients with CCO were segregated according to symptom status and after adjusting for periprocedural risk. There were 16,646 patients without contralateral occlusion (5698 CAS; 10,948 CEA). Patients without contralateral occlusion with CEA have better outcomes in periprocedural MACE (1.8% for patients without contralateral occlusion vs 4.2% for patients with CCO), and stroke (1.1% for patients without contralateral occlusion vs. 3.1% for patients with CCO) (P < .0001 for both). In CAS patients, CCO did not significantly affect periprocedural MACE (3.2% for patients without contralateral occlusion vs. 2.7% for patients with CCO), death (0.8% for patients without contralateral occlusion vs. 1.0% for patients with CCO), stroke (2.3% for patients without contralateral occlusion vs. 2.1% for patients with CCO), or MI (0.6% for patients without contralateral occlusion vs. 0.3% for patients with CCO). In CEA patients, CCO increased MACE, primarily by increasing stroke rates in asymptomatic (0.7% vs. 2.0%; P = .0095) and symptomatic (1.7% vs. 4.9%; P = .0012) patients. CONCLUSIONS Although CEA is preferred in patients without contralateral occlusion, regardless of symptom status, based on lower rates of periprocedural MACE, death, and stroke, the benefit of CEA is lost in patients with CCO because of increased stroke rates in CCO patients after CEA but not after CAS regardless of symptom status. The results of CAS and CEA in patients with CCO are equivalent and within acceptable American Heart Association guidelines.
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Affiliation(s)
| | - Gilbert R Upchurch
- Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va
| | | | - Christopher T Kenwood
- Department of Vascular Surgery and Endovascular Therapy, New England Research Institutes, Inc, Watertown, Mass
| | - Flora S Siami
- Department of Vascular Surgery and Endovascular Therapy, New England Research Institutes, Inc, Watertown, Mass.
| | | | | | - Rodney A White
- Harbor University of California Los Angeles (UCLA), Los Angeles, Calif
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Hokari M, Isobe M, Asano T, Itou Y, Yamazaki K, Chiba Y, Iwamoto N, Isu T. Treatment strategy for bilateral carotid stenosis: 2 cases of carotid endarterectomy for the symptomatic side followed by carotid stenting. J Stroke Cerebrovasc Dis 2014; 23:2851-2856. [PMID: 25280820 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/03/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022] Open
Abstract
Since the introduction of carotid stenting (CAS), a combined treatment for bilateral lesions using carotid endarterectomy (CEA) and CAS has been developed. However, there has been only 1 report about CEA then CAS. Herein we describe 2 patients with bilateral severe carotid stenosis who were treated by CEA for the symptomatic side and CAS for the contralateral asymptomatic side. A 71-year-old man underwent CEA for the symptomatic side. Although the patient suffered hyperperfusion syndrome after CEA, he recovered fully after 3 weeks of rehabilitation. Two months later, CAS was performed for the asymptomatic side, and he was discharged with no deficit. A 67-year-old man underwent CEA for the symptomatic side. The patient developed no postoperative neurologic deficits except for hoarseness. Four weeks later, CAS was performed for the contralateral asymptomatic side. After the procedure, however, severe hypotension occurred, and treatment by continuous injection of catecholamine was necessary to maintain systematic blood pressure. The patient was ultimately discharged with no deficit. The combined therapy of CAS for the asymptomatic side and then CEA for the symptomatic side has been recommended by several authors. However, one of the problems of this strategy is the higher incidence of postprocedural hemodynamic complications, and hypotension after CAS may be dangerous for the symptomatic hemisphere. We suggest a combined therapy using CEA for the symptomatic side and then CAS for the asymptomatic side can be 1 beneficial treatment option for patients with bilateral carotid stenosis without coronary artery disease.
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Affiliation(s)
- Masaaki Hokari
- Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro-shi, Hokkaido, Japan.
| | - Masanori Isobe
- Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro-shi, Hokkaido, Japan
| | - Takeshi Asano
- Department of Neurosurgery, Asahikawa Red Cross Hospital, Asahikawa-shi, Hokkaido, Japan
| | - Yasuhiro Itou
- Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro-shi, Hokkaido, Japan
| | - Kazuyoshi Yamazaki
- Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro-shi, Hokkaido, Japan
| | - Yasuhiro Chiba
- Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro-shi, Hokkaido, Japan
| | - Naotaka Iwamoto
- Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro-shi, Hokkaido, Japan
| | - Toyohiko Isu
- Department of Neurosurgery, Kushiro Rousai Hospital, Kushiro-shi, Hokkaido, Japan
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Bennett KM, Scarborough JE, Cox MW, Shortell CK. The impact of intraoperative shunting on early neurologic outcomes after carotid endarterectomy. J Vasc Surg 2014; 61:96-102. [PMID: 25135874 DOI: 10.1016/j.jvs.2014.06.105] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/11/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the need for intraoperative shunting during carotid endarterectomy (CEA) is intensely debated, relatively few studies have compared the neurologic outcomes of patients undergoing CEA with or without shunts. The objective of our analysis was to determine the impact of intraoperative shunting during CEA on the incidence of postoperative stroke. METHODS The 2012 CEA-targeted American College of Surgeons National Surgical Quality Improvement Program database was used for this analysis. The preoperative and operative characteristics of patients undergoing CEA with or without intraoperative shunting were compared. From this overall sample, propensity score techniques were then used to match patients with or without intraoperative shunting for a number of variables, including age, degree of ipsilateral and contralateral carotid stenosis, presence of several anatomic or physiologic risk factors, anesthesia modality, and use of patch angioplasty vs primary arteriotomy closure. The 30-day postoperative mortality and combined stroke/transient ischemic attack (TIA) rates of this matched cohort were then compared. A similar analysis was also performed on a subgroup of patients with severe stenosis or occlusion of the contralateral carotid artery. RESULTS A total of 3153 patients were included for initial analysis (2023 "no-shunt" patients vs 1130 "shunt" patients). From this overall sample, propensity score matching yielded a cohort of 1072 patients with or without intraoperative shunt placement who were well matched for all known patient- and procedure-related factors. There was no significant difference in the incidence of postoperative stroke/TIA between the two groups of this matched cohort (3.4% in the no-shunt group vs 3.7% in the shunt group; P = .64). Analysis of a similarly well matched subgroup of patients with severe stenosis or occlusion of the contralateral carotid artery demonstrated a statistically nonsignificant increase in the incidence of postoperative stroke/TIA with the use of intraoperative shunting (4.9% in the no-shunt group vs 9.8% in the shunt group; P = .08). CONCLUSIONS There is no clinical benefit to intraoperative shunting during CEA, even in patients who may be at high risk for intraoperative cerebral hypoperfusion due to severe stenosis or occlusion of the contralateral carotid artery.
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Affiliation(s)
- Kyla M Bennett
- Department of Surgery, Duke University Medical Center, Durham, NC.
| | | | - Mitchell W Cox
- Department of Surgery, Duke University Medical Center, Durham, NC
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Chongruksut W, Vaniyapong T, Rerkasem K. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev 2014; 2014:CD000190. [PMID: 24956204 PMCID: PMC7032624 DOI: 10.1002/14651858.cd000190.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. This may improve outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2009. OBJECTIVES To assess the effect of routine versus selective or no shunting during carotid endarterectomy, and to assess the best method for selecting people for shunting. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 8), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013) and Index to Scientific and Technical Proceedings (1980 to August 2013). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field. SELECTION CRITERIA Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. DATA COLLECTION AND ANALYSIS Three review authors independently performed the searches and applied the inclusion criteria. For this update, we identified two new relevant randomised controlled trials. MAIN RESULTS We included six trials involving 1270 participants in the review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. In general, reporting of methodology in the included studies was poor. For most studies, the blinding of outcome assessors and the report of prespecified outcomes were unclear. For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. No significant difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring, However, this analysis was inadequately powered to reliably detect the effect. There was no significant difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited. AUTHORS' CONCLUSIONS This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. Large scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.
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Affiliation(s)
- Wilaiwan Chongruksut
- Chiang Mai UniversityDepartment of Surgery, Faculty of MedicineChiang MaiThailand50200
| | - Tanat Vaniyapong
- Chiang Mai UniversityDepartment of Surgery, Faculty of MedicineChiang MaiThailand50200
| | - Kittipan Rerkasem
- Chiang Mai UniversityDepartment of Surgery, Faculty of MedicineChiang MaiThailand50200
- Chiang Mai UniversityCenter for Applied Science, Research Institute of Health SciencesChiang MaiThailand
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Ullery BW, Kalapatapu V. Bilateral reperfusion injury after carotid endarterectomy with contralateral carotid occlusion. Vascular 2014; 23:188-92. [DOI: 10.1177/1708538114538254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cerebral hyperperfusion syndrome represents a clinical spectrum characterized by severe unilateral headache, acute changes in mental status, vomiting, seizures, focal neurologic deficits, and, in its most severe form, intracranial hemorrhage. With the exception of one early case report, reperfusion injury to the brain following carotid endarterectomy has been reported only ipsilateral to the side of surgery. We report the unique case of a patient with symptomatic severe right internal carotid artery stenosis and contralateral carotid occlusion who underwent carotid endarterectomy complicated by cerebral hyperperfusion syndrome and associated bilateral intracranial hemorrhage.
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Affiliation(s)
- Brant W Ullery
- Division of Vascular Surgery, Stanford University, Stanford, USA
| | - Venkat Kalapatapu
- Department of Surgery, Philadelphia Veterans Affairs Medical Center, Philadelphia, USA
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Carotid endarterectomy using a "home-constructed" shunt for patients intolerant to cross-clamping. Surg Today 2014; 45:284-9. [PMID: 24748515 DOI: 10.1007/s00595-014-0896-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 02/14/2014] [Indexed: 10/25/2022]
Abstract
PURPOSES There is a small minority of patients with occlusive carotid artery disease, who are at high-risk for general anesthesia because of their intolerance to carotid flow blockage, even if only for seconds, without neurologic deficit. Even <30 s of temporary clamping of the carotid arteries to deploy a shunt may prove eventful in this patient group. We define safe carotid endarterectomy after the insertion of a novel shunt that we made from simple medical equipment in this patient population. METHODS Among 65 patients who underwent carotid endarterectomy between March 2010 and December 2012, 5 (7.7 %; 3 men and 2 women; age range 56-77 years) could not tolerate carotid clamping. We used an alternative carotid shunt, made by us from simple equipment in our clinic, during surgery for these patients. RESULTS Two patients had bilateral lesions and the remainder had unilateral disease. The degree of stenosis ranged from 70 to 95 %. Temporary carotid clamping resulted in neurologic events, such as loss of consciousness in all and tremor in one, in <10 s (range, from immediately to 8 s after clamping). Full neurologic function was regained 15-30 s after releasing the clamps. All of the patients tolerated the procedures well with the support of our novel shunt. Shunt flow was adequate in all patients and no neurologic deterioration occurred after carotid clamping. The mean carotid clamp time was 28.11 ± 14.19 min. There was no mortality and all patients were followed up for a mean period of 9.3 ± 3.6 months, uneventfully. CONCLUSIONS An alternative, simple shunt, which is easily constructed in the operating room or clinic, using an angiocatheter, a three-way stopcock, and a serum line can provide adequate cerebral flow and permit safe carotid endarterectomy for those rare patients with carotid artery stenosis, who cannot tolerate even seconds of carotid occlusion.
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Kang J, Conrad MF, Patel VI, Mukhopadhyay S, Garg A, Cambria MR, LaMuraglia GM, Cambria RP. Clinical and anatomic outcomes after carotid endarterectomy. J Vasc Surg 2014; 59:944-9. [DOI: 10.1016/j.jvs.2013.10.059] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 10/08/2013] [Accepted: 10/09/2013] [Indexed: 10/25/2022]
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Triple-balloon shunt placement for carotid endarterectomy: a novel intraluminal shunt designed to preserve the internal and external carotid blood flow. World Neurosurg 2014; 82:239.e5-8. [PMID: 24549016 DOI: 10.1016/j.wneu.2014.01.020] [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: 05/25/2013] [Revised: 10/08/2013] [Accepted: 01/29/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To report a newly developed intraluminal triple-balloon shunt designed to preserve the blood flow of both the internal carotid artery (ICA) and the external carotid artery (ECA) during carotid endarterectomy in patients with a previous ipsilateral extracranial-intracranial bypass, in whom hemodynamic cerebral ischemia might be caused by cross-clamping at the ICA as well as the ECA. METHODS The novel device consists of 3 silicone tubes equipped with balloons at each end. The design facilitates insertion proximally to the common carotid artery and distally to both the ICA and the ECA. RESULTS The new shunt tube was used in 3 patients, each of whom had previously undergone ipsilateral superficial temporal artery-middle cerebral artery bypass for proximal middle cerebral artery occlusion. The blood flow of the middle cerebral artery and anterior cerebral artery was supplied independently from the ECA via the bypass and from the ICA, respectively. There were no shunt-related complications. CONCLUSIONS This novel shunt device can be used safely and effectively in cases requiring preservation of the blood supply to both the ICA and the ECA during carotid endarterectomy.
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Yang SS, Kim YW, Kim DI, Kim KH, Jeon P, Kim GM, Chung CS, Lee KH. Impact of contralateral carotid or vertebral artery occlusion in patients undergoing carotid endarterectomy or carotid artery stenting. J Vasc Surg 2013; 59:749-55. [PMID: 24360588 DOI: 10.1016/j.jvs.2013.10.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 09/05/2013] [Accepted: 10/06/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the impact of contralateral carotid occlusion (CCO) and/or vertebral artery occlusion (VAO) on the development of early postoperative neurologic complications after carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS A retrospective analysis was conducted using a database of patients who underwent CEA (n = 698) or CAS (n = 455) at a single institution. Excluded were 44 CEAs synchronously performed with coronary artery bypass grafting and 76 CASs performed without an embolic protective device (n = 69) or that resulted in technical failures (n = 7). All CEAs were the conventional type and performed under general anesthesia, and carotid shunts were routinely used. Patients were categorized into three groups according to patency of the contralateral carotid and vertebral arteries: Group I (no CCO or VAO); Group II (CCO with or without VAO); Group III (with VAO but no CCO). CCO or VAO were diagnosed with two or more carotid imaging studies including duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, or conventional carotid angiography. Patient groups were compared with demographics, preoperative symptomatic status, and frequencies of early (<30 days) symptomatic neurologic complications (ESNCs) including transient ischemic attack and stroke. Postprocedural stroke alone was separately compared. Univariate (χ(2) or Fisher's exact test) and multivariate analysis (multiple logistic regression) were conducted to determine predictors of ESNC or postprocedural stroke. RESULTS ESNCs and postprocedural stroke developed significantly more often with CAS compared with CEA (ESNC, 2.6% vs 8.1%; P < .001; stroke, 1.3% vs 6.8%; P < .001). In group II, the frequency of ESNCs was higher (6.8% vs 1.8%; P = .044), but the frequency of postprocedural stroke was not significantly higher (2.3% vs 0.9%; P = .405) in the CEA group. By multivariate analysis, the presenting symptom of stroke (odds ratio, 3.612; 95% confidence interval, 1.288-10.130; P = .015) and group II (odds ratio, 7.242; 95% confidence interval, 1.727-30.374; P = .007) were independent risk factors of ESNC following CEA but not CAS. When we analyzed the risk factor for postprocedural stroke alone, the presenting symptom of stroke was the only risk factor, while presence of CCO or VAO was not. CONCLUSIONS CAS was followed by a significantly higher frequency of ESNC and postprocedural stroke compared with CEA. By subgroup analysis, CCO was a risk factor for ESNC but not for postprocedural stroke alone in patients undergoing CEA. Unilateral or bilateral VAO was not associated with a higher rate of ESNC or stroke in CEA or CAS.
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Affiliation(s)
- Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Keon-ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chin-Sang Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kwang-Ho Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Touzé E, Trinquart L, Felgueiras R, Rerkasem K, Bonati LH, Meliksetyan G, Ringleb PA, Mas JL, Brown MM, Rothwell PM. A Clinical Rule (Sex, Contralateral Occlusion, Age, and Restenosis) to Select Patients for Stenting Versus Carotid Endarterectomy. Stroke 2013; 44:3394-400. [DOI: 10.1161/strokeaha.113.002756] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Compared with carotid endarterectomy (CEA), carotid angioplasty and stenting (CAS) is associated with a higher risk of procedural stroke or death especially in patients with symptomatic stenosis. However, after the perioperative period, risk is similar with both treatments, suggesting that CAS could be an acceptable option in selected patients.
Methods—
We performed systematic reviews of observational studies of procedural risks of CEA or CAS and extracted data on 9 predefined risk factors (age, contralateral carotid occlusion, coronary artery disease, diabetes mellitus, sex, hypertension, peripheral artery disease, and type and side of stenosis). We calculated pooled relative risks of procedural stroke or death. Factors with differential effects on risk of CAS versus CEA were identified by interaction tests and used to derive a rule. The rule was tested using individual patient data from randomized trials of CAS versus CEA from the Carotid Stenting Trialists’ Collaboration (CSTC).
Results—
We identified 170 studies. The effects of sex, contralateral occlusion, age, and restenosis (SCAR) on the procedural risk of stroke or death differed. Patients with contralateral occlusion or restenosis and women <75 years were at relatively low risk for CAS (SCAR negative), with all others being high risk (SCAR positive). Among the 3049 patients in the CSTC validation, 694 (23%) patients were SCAR negative. The pooled RR of procedural stroke and death with CAS versus CEA was 0.93 (0.49–1.77;
P
=0.83) in SCAR-negative and 2.41 (1.68–3.45;
P
<0.0001) in SCAR-positive patients (
P
[interaction]=0.05).
Conclusions—
The SCAR rule is potentially useful to identify patients in whom CAS has a similar risk of perioperative stroke or death to CEA.
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Affiliation(s)
- Emmanuel Touzé
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Ludovic Trinquart
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Rui Felgueiras
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Kittipan Rerkasem
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Leo H. Bonati
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Gayané Meliksetyan
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Peter A. Ringleb
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Jean-Louis Mas
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Martin M. Brown
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
| | - Peter M. Rothwell
- From the Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S894, Service de Neurologie, Hôpital Sainte-Anne, Paris, France (E.T., G.M., J.-L.M.); Université de Caen Basse Normandie, INSERM UMR-S U919, Service de Neurologie, CHU Côte de Nacre, Caen, France (E.T.); French Cochrane Centre, Université Paris Descartes, Sorbonne Paris Cité, INSERM U738, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, Centre d’Epidémiologie Clinique, Paris, France (L.T.); Neurology Department, Hospital
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