1
|
Padmanaban V, Caldwell C, Milne I, Hazard SW, Harbaugh RE, Church EW. Carotid endarterectomy using regional anesthesia: technique and considerations. Front Surg 2024; 11:1421624. [PMID: 38903863 PMCID: PMC11187481 DOI: 10.3389/fsurg.2024.1421624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
Background Carotid endarterectomy (CEA) is one of the most effective operations in minimizing stroke risk in both symptomatic and asymptomatic patients with carotid stenosis in the United States. Awake CEA with regional anesthesia may decrease both perioperative complications and length of hospital stay. Techniques of performing awake CEA is not often described in published literature. Objective To describe our experience with CEA using regional anesthesia with a focus on patient selection, anatomic variations, and surgical technique including cervical regional block. We particularly focus on nuances of the awake approach. Methods CEA using regional anesthesia is described in detail. Results Successful use of regional anesthesia during CEA without complication. Conclusion Regional anesthesia for CEA is an advantageous approach for cervical plaque removal in appropriate patients. Thoughtful patient selection, as well as understanding of anatomy and its variants, is required. Potential advantages and disadvantages are discussed.
Collapse
Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Catherine Caldwell
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Indigo Milne
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Sprague W. Hazard
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
- Department of Anesthesia and Perioperative Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Robert E. Harbaugh
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Ephraim W. Church
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| |
Collapse
|
2
|
Pereira-Macedo J, Duarte-Gamas L, Pereira-Neves A, de Andrade JJP, Rocha-Neves J. Short-term outcomes after selective shunt during carotid endarterectomy: a propensity score matching analysis. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:71-78. [PMID: 37696419 DOI: 10.1016/j.neucie.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/28/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION AND OBJECTIVES Carotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. MATERIAL AND METHODS From January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. RESULTS Ninety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien-Dindo ≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). CONCLUSIONS In this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien-Dindo ≥ 2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.
Collapse
Affiliation(s)
- Juliana Pereira-Macedo
- Department of Surgery, Centro Hospitalar do Médio-Ave, Vila Nova de Famalicão, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal.
| | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - António Pereira-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
| | - José José Paulo de Andrade
- Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
| |
Collapse
|
3
|
Levin SR, King EG, Farber A, Cheng TW, Rybin D, Siracuse JJ. Unplanned Shunting Is Associated with Higher Stroke Risk after Eversion Carotid Endarterectomy. Ann Vasc Surg 2022; 87:362-368. [PMID: 35803457 DOI: 10.1016/j.avsg.2022.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/20/2022] [Accepted: 05/31/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Shunting during eversion carotid endarterectomy (eCEA) may be technically challenging. Whether shunting practice patterns modify perioperative stroke risk after eCEA is unclear. We aimed to compare eCEA outcomes based on shunting practice. METHODS The Vascular Quality Initiative (2011-2019) was queried for eCEAs performed for symptomatic and asymptomatic carotid stenosis. Univariable and multivariable analyses compared outcomes based on whether shunting was routine practice, preoperatively-indicated, intraoperatively-indicated, or not performed. RESULTS There were 13,207 eCEAs identified. Average age was 71.4 years and 59.4% of patients were male sex. Ipsilateral carotid stenosis was >80% in 45.6% and there was severe contralateral carotid stenosis in 8.6%. Early ipsilateral symptoms within 14 days of eCEA were transient ischemic attack in 5.6% and stroke in 7%. The majority of cases were performed under general anesthesia (82.7%). Electroencephalogram monitoring and stump pressures were utilized in 30.9% and 14.7%, respectively. Shunting was routine (25.4%), preoperatively-indicated (1.9%), intraoperatively-indicated (4.7%), or not implemented (68%). Preoperatively-indicated shunting was more often performed in patients with early symptomatic carotid stenosis or severe contralateral carotid stenosis. After routine shunting, preoperatively-indicated shunting, intraoperatively-indicated shunting, and no shunting, median operative duration was 110, 101, 112, and 97 min, respectively (P < 0.001), and ipsilateral perioperative stroke prevalence was 0.6%, 1.2%, 1.9%, and 0.7%, respectively (P = 0.004). On multivariable analysis, longer operative time was associated with routine shunting (MR 1.17, 95% CI 1.15-1.19, P < 0.001), preoperatively-indicated shunting (MR 1.09, 95% CI 1.04-1.15, P < 0.001), and intraoperatively-indicated shunting (MR 1.12, 95% CI 1.09-1.16, P < 0.001) compared with no shunting. Compared with no shunting, routine shunting (OR 0.91, 95% CI 0.54-1.54, P = 0.74) and preoperatively-indicated shunting (OR 1.53, 95% CI 0.47-4.99, P = 0.48) were not associated with stroke; however, intraoperatively-indicated shunting was associated with increased stroke (OR 2.74, 95% CI 1.41-5.3, P = 0.003). Shunting type was not associated with perioperative mortality. CONCLUSIONS Intraoperatively-indicated shunting during eCEA was associated with longest operative duration and increased perioperative stroke risk. Surgeon familiarity with shunting and planning to shunt in advance may permit more expeditious shunting and prevent stroke.
Collapse
Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| |
Collapse
|
4
|
Moehl K, Shandal V, Anetakis K, Paras S, Mina A, Crammond D, Balzer J, Thirumala PD. Predicting transient ischemic attack after carotid endarterectomy: The role of intraoperative neurophysiological monitoring. Clin Neurophysiol 2022; 141:1-8. [DOI: 10.1016/j.clinph.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 05/17/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022]
|
5
|
Zagzoog N, Elgheriani A, Attar A, Takroni R, Aljoghaiman M, Klotz L, Vandervelde C, Darling C, Farrokhyar F, Martyniuk A, Algird A. Comprehensive comparison of carotid endarterectomy primary closure and patch angioplasty: A single-institution experience. Surg Neurol Int 2022; 13:1. [PMID: 35127201 PMCID: PMC8813614 DOI: 10.25259/sni_1013_2021] [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] [Received: 10/06/2021] [Accepted: 12/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA. Methods: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients’ baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured. Results: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82–1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort. Conclusion: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.
Collapse
Affiliation(s)
- Nirmeen Zagzoog
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Ali Elgheriani
- Department of Internal Medicine, University of Manitoba, Manitoba, Canada
| | - Ahmed Attar
- Department of Neurology, McMaster University, Hamilton, Canada,
- King Abdullah International Medical Research Center, Jeddeah, Saudi Arabia,
| | - Radwan Takroni
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Majid Aljoghaiman
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Klotz
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Chloe Darling
- Fleming School of Nursing, Trent University, Peterborough, Ontario, Canada
| | - Forrough Farrokhyar
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Martyniuk
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Almunder Algird
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
6
|
Dakour-Aridi H, Gaber MG, Khalid M, Patterson R, Malas MB. Examination of the interaction between method of anesthesia and shunting with carotid endarterectomy. J Vasc Surg 2020; 71:1964-1971. [DOI: 10.1016/j.jvs.2019.08.248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/06/2019] [Indexed: 10/25/2022]
|
7
|
Rocha-Neves JM, Pereira-Macedo J, Dias-Neto MF, Andrade JP, Mansilha AA. Benefit of selective shunt use during carotid endarterectomy under regional anesthesia. Vascular 2020; 28:505-512. [DOI: 10.1177/1708538120922098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. Methods From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. Results Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found ( P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group ( P < 0.001 and P = 0.0001, respectively). Conclusions Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.
Collapse
Affiliation(s)
- João M Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina F Dias-Neto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Paulo Andrade
- Department of Biomedicine – Unity of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Armando A Mansilha
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| |
Collapse
|
8
|
Kordzadeh A, Abbassi OA, Prionidis I, Shawish E. The Role of Carotid Stump Pressure in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Dis 2020; 13:28-37. [PMID: 32273919 PMCID: PMC7140166 DOI: 10.3400/avd.ra.19-00100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This review evaluates the carotid stump pressure (CSP)’s role as a single parameter at any given pressure as an indicator for selective shunting, or vice versa, in carotid endarterectomy (CEA). A systematic review of literature in MEDLINE and the Cochrane Library from 1969 to 2019 was conducted. The primary end point was set at 0 to 30-day mortality, ischemic stroke (IS), transient ischemic attack (TIA), and a secondary point at recognition of an optimal CSP pressure. The data was subjected to meta-analytics. The odds ratio (OR) was reported at 95% confidence interval (CI). This study has been registered with PROSPERO: CRD42019119851. The pooled analysis on the primary endpoint of IS demonstrated higher incidence of stroke in shunted CEAs solely based on CSP measurement alone (OR, 0.14, 95%CI: 0.08–0.24, I2=48%, p<0.001). Sub group analysis demonstrated similar patterns at 25 mmHg (OR, 0.06, 95%CI: 0.01–0.5, p<0.01), 30 mmHg (OR, 0.07, 95%CI: 0.01–0.63, p=0.02) and 40 mmHg (OR, 0.23, 95%CI: 0.09–0.57, p<0.01). This effect on end points of mortality and TIA demonstrated no benefit in either direction. CSP, as a single criterion, is not a reliable parameter in reduction of TIA, mortality, and IS at any given pressure range.
Collapse
Affiliation(s)
- Ali Kordzadeh
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Omar Ahmed Abbassi
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Ioannis Prionidis
- Mid Essex Hospitals Services NHS Trust, Department of Vascular, Endovascular and Renal Access Surgery, Broomfield Hospital
| | - Emad Shawish
- Department of Vascular Surgery, Royal Shrewsbury and Telford Hospitals NHS Trust
| |
Collapse
|
9
|
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]
|
10
|
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.
Collapse
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.
| |
Collapse
|
11
|
Karthaus EG, Vahl A, Kuhrij LS, Elsman BHP, Geelkerken RH, Wouters MWJM, Hamming JF, de Borst GJ. The Dutch Audit of Carotid Interventions: Transparency in Quality of Carotid Endarterectomy in Symptomatic Patients in the Netherlands. Eur J Vasc Endovasc Surg 2018; 56:476-485. [PMID: 30077438 DOI: 10.1016/j.ejvs.2018.05.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/31/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Dutch Audit for Carotid Interventions (DACI) registers all patients undergoing interventions for carotid artery stenosis in the Netherlands. This study describes the design of the DACI and results of patients with a symptomatic stenosis undergoing carotid endarterectomy (CEA). It aimed to evaluate variation between hospitals in process of care and (adjusted) outcomes, as well as predictors of major stroke/death after CEA. METHODS All patients with a symptomatic stenosis, who underwent CEA and were registered in the DACI between 2014 and 2016 were included in this cohort. Descriptive analyses of patient characteristics, process of care, and outcomes were performed. Casemix adjusted hospital procedural outcomes as (30 day/in hospital) mortality, stroke/death, and major stroke/death, were compared with the national mean. A multivariable logistic regression model (backward elimination at p > 0.10) was used to identify predictors of major stroke/death. RESULTS A total of 6459 patients, registered by 52 hospitals, were included. The majority (4,832, 75%) were treated <2 weeks after their first hospital consultation, varying from 40% to 93% between hospitals. Mortality, stroke/death, and major stroke/death were, respectively, 1.1%, 3.6%, and 1.8%. Adjusted major stroke/death rates for hospital comparison varied between 0 and 6.5%. Nine hospitals performed significantly better, none performed significantly worse. Predictors of major stroke/death were sex, age, pulmonary disease, presenting neurological symptoms, and peri-operative shunt. CONCLUSION CEA in The Netherlands is associated with an overall low mortality and (major) stroke/death rate. Whereas the indicator time to intervention varied between hospitals, mortality and (major) stroke/death were not significantly distinctive enough to identify worse practices and therefore were unsuitable for hospital comparison in the Dutch setting. Additionally, predictors of major stroke/death at population level could be identified.
Collapse
Affiliation(s)
- Eleonora G Karthaus
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands; Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Anco Vahl
- Department of Surgery, OLVG, Amsterdam, The Netherlands; Department of Clinical Epidemiology, OLVG, Amsterdam, The Netherlands
| | - Laurien S Kuhrij
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Robert H Geelkerken
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Faculty of Technical Sciences, University of Twente, Enschede, The Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Surgery, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | | | | | | |
Collapse
|
12
|
Baram A, Majeed G, Subhi Abdel-Majeed A. Carotid endarterectomy: neither shunting nor patching technique. Asian Cardiovasc Thorac Ann 2018; 26:446-450. [PMID: 30005581 DOI: 10.1177/0218492318788777] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The role of carotid shunting in carotid endarterectomy is controversial. Many studies have concluded that patch angioplasty is preferable to primary closure, while others found that it had no value. The aim of this study was to report the results of our first series of patients undergoing carotid endarterectomy with a non-shunting technique and primary closure of the arteriotomy. Methods From October 2014 to October 2017, 63 patients with unilateral or bilateral carotid artery stenosis underwent carotid endarterectomy. There were 48 males and 15 females, the mean age was 63.16 years, and all were symptomatic. Conventional endarterectomy was performed without a shunt in all cases. All arteriotomies were closed primarily. We analysed the early and late outcomes of this procedure with at least 18 months of follow-up. Results Diabetes was the most frequent comorbidity. Most of the patients had a history of transient ischemic attack (49.2%) or stroke (44.4%). All patients had significant (moderate to severe) carotid artery stenosis. Postoperatively, 2 (3.2%) patients developed ischemic stroke, one (1.6%) suffered hypoglossal nerve injury, and one had a postoperative cervical hematoma. During follow-up, one patient developed asymptomatic total occlusion of the endartrectomized carotid artery at 18 months. Conclusion Carotid endarterectomy without shunting is a safe procedure. The short- and longer-term outcomes are not significantly inferior to those of the routine or selective shunting technique, and the rate of restenosis is not higher than that of patch angioplasty closure.
Collapse
Affiliation(s)
- Aram Baram
- 1 Department of Thoracic and Cardiovascular Surgery, Sulaimani Teaching Hospital, Sulaymaniyah, Iraq
| | - Goran Majeed
- 2 Kurdistan Board for Medical Specialization, Cardiothoracic and Vascular Surgery, Sulaimani DOH, Sulaymaniyah, Iraq
| | - Allaa Subhi Abdel-Majeed
- 2 Kurdistan Board for Medical Specialization, Cardiothoracic and Vascular Surgery, Sulaimani DOH, Sulaymaniyah, Iraq
| |
Collapse
|
13
|
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.
Collapse
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.
| |
Collapse
|
14
|
Radak D, Tanaskovic S, Sagic D, Antonic Z, Gajin P, Babic S, Neskovic M, Matic P, Kovacevic V, Nenezic D, Ilijevski N. A Novel Antegrade Approach for Simultaneous Carotid Endarterectomy and Angioplasty of Proximal Lesions in Patients with Tandem Stenosis of Supraaortic Arch Vessels. Ann Vasc Surg 2017; 44:368-374. [DOI: 10.1016/j.avsg.2017.05.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/01/2017] [Accepted: 05/07/2017] [Indexed: 11/26/2022]
|
15
|
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]
|
16
|
Kawamura Y, Maruyama D, Akagi Y, Iihara K. Effective Intraluminal Shunt in Carotid Endarterectomy for Carotid Artery Near Occlusion: Technical Report. World Neurosurg 2017; 106:813-818. [PMID: 28739521 DOI: 10.1016/j.wneu.2017.07.078] [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: 06/06/2017] [Revised: 07/13/2017] [Accepted: 07/14/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Carotid artery near occlusion is a critical degree of stenosis whereby blood flow is decreased and the distal cervical and intracranial internal carotid arteries (ICAs) are prone to collapse. Considering the diminished perfusion and risk of progression to total occlusion and periocclusive embolism, we performed carotid endarterectomy for carotid artery near occlusion. METHODS Accurate evaluation of tandem stenosis or patency of the poststenotic ICA in carotid artery near occlusion is often difficult preoperatively. Thus we performed carotid endarterectomy in a hybrid operating room where intraoperative digital subtraction angiography (DSA) and endovascular angioplasty or stenting for distal lesions can be performed if necessary. In addition, to evaluate the distal ICA intraoperatively, we used an intraluminal shunt for shunt angiography, with injection of contrast material through the shunt tube, as a replacement for conventional DSA. Furthermore, an intraluminal shunt held the collapsed lumen open and provided a scaffold for suturing, which prevented postoperative stenosis of the distal ICA. CONCLUSION The present report is intended to underline the merits of intraluminal shunt as a replacement for conventional DSA and as a scaffold for suturing.
Collapse
Affiliation(s)
- Yoichiro Kawamura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Daisuke Maruyama
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yojiro Akagi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| |
Collapse
|
17
|
Bennett KM, Kent KC, Schumacher J, Greenberg CC, Scarborough JE. Targeting the most important complications in vascular surgery. J Vasc Surg 2017; 65:793-803. [DOI: 10.1016/j.jvs.2016.08.107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/18/2016] [Indexed: 11/16/2022]
|
18
|
Cho JW, Jeon YH, Bae CH. Selective Carotid Shunting Based on Intraoperative Transcranial Doppler Imaging during Carotid Endarterectomy: A Retrospective Single-Center Review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:22-8. [PMID: 26889442 PMCID: PMC4757393 DOI: 10.5090/kjtcs.2016.49.1.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/16/2015] [Accepted: 09/30/2015] [Indexed: 11/25/2022]
Abstract
Background Carotid endarterectomy (CEA) with selective shunting is the surgical method currently used to treat patients with carotid artery disease. We evaluated the incidence of major postoperative complications in patients who underwent CEA with selective shunting under transcranial Doppler (TCD) at our institution. Methods The records of 45 patients who underwent CEA with TCD-based selective shunting under general anesthesia from November 2009 to June 2015 were reviewed. The risk factors for postoperative complications were analyzed using univariate and multivariate analysis. Results Preoperative atrial fibrillation was observed in three patients. Plaque ulceration was detected in 10 patients (22.2%) by preoperative computed tomography imaging. High-level stenosis was observed in 16 patients (35.5%), and 18 patients had contralateral stenosis. Twenty patients (44.4%) required shunt placement due to reduced TCD flow or a poor temporal window. The 30-day mortality rate was 2.2%. No cases of major stroke were observed in the 30 days after surgery, but four cases of minor stroke were noted. Univariate analysis showed that preoperative atrial fibrillation (odds ratio [OR], 40; p=0.018) and ex-smoker status (OR, 17.5; p=0.021) were statistically significant risk factors for a minor stroke in the 30-day postoperative period. Analogously, multivariate analysis also found that atrial fibrillation (p<0.001) and ex-smoker status (p=0.002) were significant risk factors for a minor stroke in the 30-day postoperative period. No variables were identified as risk factors for 30-day major stroke or death. No wound complications were found, although one (2.2%) of the patients suffered from a hypoglossal nerve injury. Conclusion TCD-based CEA is a safe and reliable method to treat patients with carotid artery disease. Preoperative atrial fibrillation and ex-smoker status were found to increase the postoperative risk of a small embolism leading to a minor neurologic deficit.
Collapse
Affiliation(s)
- Jun Woo Cho
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine
| | - Yun-Ho Jeon
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine
| | - Chi Hoon Bae
- Department of Cardiovascular and Thoracic Surgery, Catholic University of Daegu School of Medicine
| |
Collapse
|