Comparison of nonneurological events in high-risk patients treated by carotid angioplasty versus endarterectomy

The effect of clinical coronary disease severity on outcomes of carotid endarterectomy with and without combined coronary bypass

OBJECTIVE

The management of patients with carotid stenosis and symptomatic coronary artery disease (CAD) is challenging. This study assessed the impact of clinical coronary disease severity on carotid endarterectomy (CEA) with and without combined coronary artery bypass (CCAB).

METHODS

Using the Vascular Quality Initiative, patients with symptomatic CAD who underwent CCAB or isolated CEA (ICEA) from 2003 to 2017 were identified. Patients were stratified by CAD severity: stable angina (SA) and recent myocardial infarction/unstable angina (UA). Primary outcomes, including perioperative stroke, myocardial infarction (MI), and stroke/death/MI (SDM), were assessed between procedures within each CAD cohort.

RESULTS

There were 9098 patients identified: 887 CCAB patients (215 [24%] SA, 672 [76%] UA) and 8211 ICEA patients (6385 [78%] SA, 1826 [22%] UA). Overall, CCAB patients had higher rates of stroke (2.6% vs 1.3%; P = .002) and SDM (7.3% vs 3.5%, P < .001) but similar rates of MI (0.9% vs 1.6%; P = .12) compared with ICEA patients. In SA patients, no difference was seen in stroke (ICEA 1.2% vs CCAB 1.9%; P = .36), MI (1.3% vs 1.4%; P = .95), or SDM (2.9% vs 4.7%; P = .13). In UA patients, no difference was seen in stroke (ICEA 1.6% vs CCAB 2.8%; P = .06), but ICEA patients had higher rates of MI (2.4% vs 0.7%; P = .01) and CCAB patients had higher rates of SDM (8.2% vs 5.5%; P = .01). After logistic regression in the UA cohort, predictors of MI included ICEA (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-7.0; P = .04) and carotid symptomatic status (OR, 2.1; 95% CI, 1.1-3.8; P = .01); carotid symptomatic status also predicted stroke (OR, 2.0; 95% CI, 1.1-3.6; P = .03), but CCAB did not.

CONCLUSIONS

In patients with symptomatic CAD, both clinical CAD severity and operative strategy affect outcomes. In SA patients, CCAB does not increase perioperative morbidity. However, CCAB in UA patients prevents MI while not appreciably increasing stroke risk. This suggests that coronary revascularization before or concomitant with CEA should be considered in UA patients but that prioritizing coronary intervention is less important in SA patients.

Effects of Carotid Endarterectomy or Stenting on Blood Pressure in the International Carotid Stenting Study (ICSS)

Background and Purpose—

Arterial hypotension is more frequently observed early after carotid artery stenting (CAS) than after carotid endarterectomy (CEA), but their long-term effects on blood pressure (BP) are unclear. We compared the effects of CAS and CEA on BP up to 1 year after treatment in the International Carotid Stenting Study.

Methods—

Patients with symptomatic carotid stenosis were randomly allocated to CAS or CEA. Systolic and diastolic BP were recorded at baseline, at discharge, and at 1, 6, and 12 months. Antihypertensive medication use was recorded. A per-protocol analysis was performed. Patients with missing BP records were excluded. Between-group BP changes were compared and adjusted for baseline covariates with linear regression. Within-group BP changes were compared with the paired t test.

Results—

CAS (N=587) and CEA (N=637) were both associated with a decrease in BP at discharge, which was greater after CAS (mean difference in systolic BP between groups, 10.3 mm Hg; 95% CI, 7.3–13.3; P <0.0001; in diastolic BP, 4.1 mm Hg; 95% CI, 2.4–5.7; P <0.0001). During follow-up, BP changes were not different between groups. Adjustment for differences in baseline characteristics did not change the results. Fewer patients undergoing CAS used antihypertensive medication during follow-up than patients undergoing CEA (relative risk at 12 months, 0.91; 95% CI, 0.85–0.97; P =0.0073).

Conclusions—

CAS leads to a larger early decrease in BP than CEA, but this effect does not persist over time. CAS may lessen the requirement for antihypertensive medication more than CEA.

Clinical Trial Registration—

URL: www.controlled-trials.com . Unique identifier: ISRCTN25337470.

[Anesthesia in interventional neuroradiology]

Interventional neuroradiology procedures have become increasingly complex, requiring planning and coordination. Key roles are played by the anesthesiologist and the radiologist, as well as by technicians and nurses. This review aims to analyze the anesthesiologist's part in managing these procedures, from the start of the intervention through the immediate postoperative period. First concerns are to assure patient safety during transfer, maintain the airway, keep the patient immobile and hemodynamically stable, and manage anticoagulant and antiplatelet treatments. Rapid awakening must also be assured so that the patient's neurologic status can be assessed in situ. The anesthesiologist should treat any neurologic complications that develop and that might lead to emergency situations during the procedures.

Vasopressor use in the critical care unit for treatment of persistent post-carotid artery stent induced hypotension

INTRODUCTION

Hypotension is common following carotid artery stenting (CAS), and may be mediated by vagal stimulation and/or suppression of spinal sympathetic outflow. Both mixed alpha/beta agonists (dopamine (DA)), and more selective alpha- agonists (norepinephrine (NE) and phenylephrine (PE)), have been used, but the most effective treatment of post-CAS hypotension is unknown.

MATERIALS AND METHODS

We analyzed data for consecutive patients requiring vasopressor treatment of post-CAS hypotension. The treating physician made choice of vasopressor. Endpoints included infusion duration, coronary care unit (CCU) length of stay (LOS), and any major adverse events (death, stroke, myocardial infarction, arrhythmia).

RESULTS

During the study period, CAS stenting was performed in 623 patients. CCU admission in atropine non-responders for vasopressor treatment was required in 42 patients (6.7%). DA was used in 20 patients (48%), NE in 13 patients (31%), and PE in nine patients (21%). Vasopressor infusion time was 31.8 +/- 10.6 h for DA, compared with 23.8 +/- 8.1 h for NE (P = 0.052) and 22.1 +/- 6.1 h (P = 0.028) for PE. CCU LOS was 46.5 +/- 14.1 h for DA compared with 36.9 +/- 9.1 h for the NE and PE groups combined (P = 0.056). Major adverse events were more common in patients receiving DA than among patients receiving NE or PE (P = 0.04).

CONCLUSIONS

Compared with DA, treatment of post-CAS hypotension with a selective alpha-agonist (NE or PE) is associated with shorter drug infusion time, shorter CCU LOS, and fewer major adverse events.

Carotid artery stenting versus endarterectomy in relation to perioperative myocardial ischemia, troponin T release and major cardiac events

BACKGROUND

Carotid artery stenting (CAS) is less invasive than endarterectomy. This study examined differences in perioperative myocardial ischemia, troponin T release and clinical cardiac events in patients undergoing CAS compared with endarterectomy.

METHODS

In an observational study, CAS was performed in 24 and carotid endarterectomy in 44 patients. Before surgery, clinical risk factors were noted and dobutamine stress echocardiography was performed for cardiac risk assessment. Perioperative continuous 72-h 12-lead electrocardiographic monitoring was used for myocardial ischemia detection. Troponin T (>0.03 ng/ml) was measured on postoperative days 1, 3, 7 or before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted during hospital stay and during follow-up (mean: 1.2 years).

RESULTS

No significant differences were observed between patients with CAS and endarterectomy in terms of baseline clinical characteristics, dobutamine stress echocardiography results and cardiovascular medication. Perioperative myocardial ischemia was detected in nine patients (13%), perioperative troponin T release in seven patients (10%), early cardiac events in one patient (1%) and late cardiac events in three patients (4%). Significantly less perioperative myocardial ischemia was observed in patients with CAS compared with endarterectomy (0 versus 21%, P=0.02). Troponin T release was also significantly lower in CAS, compared with endarterectomy (0 versus 16%, P=0.04). Early (0 versus 2%, P=0.5) and late (0 versus 7%, P=0.2) cardiac events were lower after CAS, compared with endarterectomy, although these differences were not significant.

CONCLUSION

CAS is associated with a lower incidence of perioperative myocardial ischemia and troponin T release, compared with endarterectomy.

Noninvasive investigation of autonomic activity after carotid stenting or carotid endarterectomy

OBJECTIVE

Carotid artery stenting (CAS) has been introduced as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis. Both techniques seem to be associated with postoperative hemodynamic lability. Both may induce baroreceptor dysfunction, possibly leading to transient impairment of cardiovascular autonomic activity and resulting in hemodynamic instability. This instability might contribute to postoperative morbidity. To elucidate these phenomena, we studied the cardiac baroreflex and autonomic cardiovascular control after CAS and CEA.

METHOD

In 20 patients scheduled for CAS (n = 10) or CEA (n = 10), intra-arterial pressures and electrocardiograms were recorded during 10 minutes before and 8 and 24 hours after the procedure. Spontaneous cardiac baroreflex sensitivity was assessed using the sequence method and cross-spectral analysis. In addition, cardiovascular autonomic activity was investigated using spectral analysis of heart rate variability and systolic arterial pressure variability.

RESULTS

After CAS, we demonstrated an increase of the spontaneous baroreflex sensitivity median (interquartile range) from 5.6 (5.1 to 6.2) ms/mm Hg before the procedure to 8.8 (6.8 to 10.5) ms/mm Hg and 7.7 (3.9 to 8.6) ms/mm Hg (P < .001), 8 and 24 hours after the procedure. This was consistent with the increase of the high frequency component of heart rate variability reflecting cardiac parasympathetic activity and a decrease of the low frequency of systolic arterial pressure variability reflecting sympathetic vascular activity. The postoperative period was also associated with decreased systolic arterial pressure from 173 (162 to 190) mm Hg at baseline to 122 (109 to 143) mm Hg and 136 (121 to 143) mm Hg at 8 and 24 hours after CAS (P < .001). No changes in baroreflex sensitivity or in autonomic activity were observed after CEA.

CONCLUSIONS

These preliminary data suggest that CAS is associated with parasympathetic predominance postoperatively and may probably explain the lower systolic arterial pressure observed after CAS.

Reversible cerebral hyperperfusion syndrome after stenting of the carotid artery—Two case reports

Hyperperfusion syndrome can complicate carotid revascularization, be it endarterectomy or carotid artery stenting (CAS). Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion following CAS. We report two cases (female patients 72 and 81 years) presenting severe internal carotid stenosis (> 90%), who underwent presurgical and therapeutic intervention with CAS. Both patients developed hyperperfusion symptoms at 2 hours and at 30 minutes, respectively, following stenting, in both cases unilateral hyperperfusion was CCT confirmed. Case 1 was presenting with acute edema of the right hemisphere, case 2 with distended focal edema (left fronto-temporoparietally). Hyperperfusion syndrome and neurological symptoms retroceded in both cases (conservative therapy) and both patients returned to full activity (case 2 within 48 hours).

Assessment of short-term outcomes for protected carotid angioplasty with stents using recent evidence

BACKGROUND

Carotid artery stenosis is an important risk factor and etiology of stroke. Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid artery stenosis; however, there are potential benefits to adopting the use of carotid artery stenting (CAS) with protection devices. A number of large protected CAS (PCAS) trials are underway, but final results are still several years away. In the interim, numerous PCAS studies have recently been published, and the aim of this study was to combine the published results and examine the outcomes and safety of PCAS.

METHODS

Electronic, manual, and bibliographic searches of PubMed and PreMedline were conducted. Proportion differences were calculated for the periprocedural (30-day) outcomes of any stroke and any stroke or death.

RESULTS

More than 400 articles were identified. Only 26 studies met the inclusion criteria, resulting in the inclusion of 2,992 patients treated with PCAS. Within this patient group, the pooled perioperative PCAS rate of any type of stroke was 2.4% +/- 0.3% (95% confidence interval [CI]). The 30-day minor stroke rate was 1.1% +/- 0.2% (95% CI), and the 30-day major stroke rate was 0.6% +/- 0.2% (95% CI). The 30-day mortality rate was 0.9% +/- 0.4% (95% CI).

CONCLUSION

This study demonstrates relatively low rates of reported perioperative adverse events in PCAS. Selective use of PCAS to treat carotid artery stenosis in those at highest risk for surgical complications is appropriate until the randomized trials of CEA vs PCAS provide concurrent short- and long-term outcome data.