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Wu S, Wang H, Guo J, Zhang F, Pan D, Ning Y, Gu Y, Guo L. Comparative on the effectiveness and safety of different carotid endarterectomy techniques: a single-center Retrospective Study. J Cardiothorac Surg 2024; 19:338. [PMID: 38902703 PMCID: PMC11188523 DOI: 10.1186/s13019-024-02838-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) is a surgical procedure that can reduce the risk of stroke in patients with carotid artery stenosis. However, controversy still exists regarding the optimal surgical technique for CEA. OBJECTIVE To compare the safety and effectiveness of different techniques. METHODS Data on baseline characteristics as well as perioperative and postoperative complications from patients who underwent CEA at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, were retrospectively collected and analyzed. RESULTS A total of 262 CEA patients included in study, with a total of 265 CEA operations. The mean age of 69.95 ± 7.29 (range, 44-89) years. 65 (24.5%) patients underwent cCEA, 94 (35.5%) underwent pCEA, and 106 (40.0%) underwent eCEA. The use of shunt (1.9%) and the mean operation time were lower in eCEA group (P < 0.05). eCEA was also associated with a lower incidence of postoperative hypotension, whereas pCEA was associated with a lower incidence of postoperative hypertension (P < 0.05). There was no significant difference in clinical baseline characteristics, occurrence of perioperative complications, and survival whether restenosis-free, asymptomatic or overall. CONCLUSIONS This study found that all three surgical methods are equally safe for the treatment of carotid artery stenosis and are effective in preventing stroke.
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Affiliation(s)
- Sensen Wu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hui Wang
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Julong Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fan Zhang
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dikang Pan
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yachan Ning
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongquan Gu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Lianrui Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Jácome F, Costa-Pereira T, Dionísio A, Sousa J, Coelho A, Mansilha A. Contemporary open surgical approaches for the management of carotid stenosis: a comprehensive review. INT ANGIOL 2024; 43:348-357. [PMID: 39037369 DOI: 10.23736/s0392-9590.24.05228-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
This study aims to provide an overview on contemporary open surgical approaches for the management of carotid artery stenosis. A comprehensive literature search was performed to identify and categorize open surgery intervention techniques for the management of carotid artery stenosis, focusing on the benefits and drawbacks of each technique. Five surgical techniques for carotid endarterectomy (CEA) have been described: CEA with primary closure, CEA with patch closure, CEA by eversion technique, CEA by modified eversion technique and CEA by partial eversion. Evidence has reported significantly higher rates of perioperative complications after CEA with primary closure, including 30-days stroke rate and late restenosis. Although more recent techniques have been reported to provide superior outcomes, electing the best surgical technique is still a matter of debate. Also, CEA using a mini-skin incision has been associated to lower risk of cranial/cervical nerve injury and shorter length of hospital stay. The selection of the surgical intervention should be tailored and have into consideration individual patient characteristics, clinical considerations, surgeon preference and surgical team expertise. Further large-scale randomized clinical trials are needed to support more robust decisions on the choice of contemporary open surgical approaches to manage carotid stenosis.
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Affiliation(s)
- Filipa Jácome
- São João University Hospital Center, Porto, Portugal -
- Faculty of Medicine, University of Porto, Porto, Portugal -
| | - Tiago Costa-Pereira
- São João University Hospital Center, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Joel Sousa
- São João University Hospital Center, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Andreia Coelho
- Faculty of Medicine, University of Porto, Porto, Portugal
- Vila Nova de Gaia/Espinho Hospital Center, Vila Nova de Gaia, Portugal
| | - Armando Mansilha
- São João University Hospital Center, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
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Banks CA, Pearce BJ. Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications. Surg Clin North Am 2023; 103:645-671. [PMID: 37455030 DOI: 10.1016/j.suc.2023.05.003] [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: 07/18/2023]
Abstract
Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.
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Affiliation(s)
- Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA.
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Blecha M, DeJong M, Nam J, Penton A. Modifiable risk factors for occurrence of ipsilateral ischemic events after carotid endarterectomy beyond perioperative period. J Vasc Surg 2023; 77:538-547.e2. [PMID: 36181995 DOI: 10.1016/j.jvs.2022.09.021] [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: 07/28/2022] [Revised: 09/07/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The purpose of this study was to quantify the effects of several modifiable variables on the occurrence of stroke after the initial perioperative period for patients who had undergone carotid endarterectomy (CEA). METHODS The primary outcome for the present study was the development of an ischemic stroke or transient ischemic attack (TIA) in the cerebral hemisphere ipsilateral to CEA after the initial hospitalization. All CEAs in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEAs in the database. The exclusion criteria for the study were the lack of follow-up data for >30 days, concomitant coronary artery bypass surgery, concomitant proximal or distal carotid intervention at CEA, other arterial interventions at CEA, and stroke or TIA during the initial hospital admission, leaving 126,290 patients for analysis. We used the χ2 test for statistical analysis of the outcome of ipsilateral ischemic stroke or TIA after the initial CEA hospital admission to determine the relevant variables. Age was evaluated as an ordinal variable using the Student t test. Variables with P ≤ .05 on univariable analysis were included in the multivariable Cox regression time-to-event analysis for the primary outcome. Kaplan-Meier curves were constructed of the most significant variables on Cox regression as a visual aid. RESULTS The following variables achieved significance on Cox regression for an association with development of ipsilateral hemispheric ischemic events after the index CEA hospital admission: lack of patch placement at CEA site (hazard ratio [HR], 18.24; P < .0001), lack of antiplatelet therapy at long-term follow-up (LTFU; HR, 9.75; P < .0001), lack of statin therapy at LTFU (HR, 3.18; P < .001), lack of statin therapy at hospital discharge (HR, 1.25; P = .015), anticoagulation at LTFU (HR, 1.53; P < .001), development of >70% recurrent stenosis (HR, 2.15; P < .001), and shunt use at surgery (HR, 1.20; P = .007). Patients with patch placement at surgery and patients with confirmed antiplatelet therapy at LTFU had had 99.8% and 99.6% freedom from an ischemic event ipsilateral to the side of the CEA at LTFU, respectively. This finding is in contrast to the 5.7% and 4.7% positivity for ischemic events for those without patch placement at surgery and those not receiving antiplatelet therapy at LTFU, respectively (P < .0001 for both). CONCLUSIONS Performance of patch angioplasty arterial closure was remarkably protective against ipsilateral cerebral ischemic events at LTFU after CEA. Discharging and maintaining patients with antiplatelet and statin medication after CEA significantly reduces the incidence of future ipsilateral ischemic events. Thus, a significant opportunity exists for enhanced outcomes with improved implementation of these measures.
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Affiliation(s)
- Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Maywood, IL.
| | - Matthew DeJong
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Janice Nam
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Ashley Penton
- Department of Surgery, Loyola University Medical Center, Maywood, IL
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Abdel Rahim A, Elsamani K, Galal AM, Hammoda MI, Mittapalli D. Does the eversion technique have a lower early postoperative stroke rate than the conventional technique in carotid endarterectomy? Ann Med Surg (Lond) 2022; 81:104505. [PMID: 36147067 PMCID: PMC9486758 DOI: 10.1016/j.amsu.2022.104505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/20/2022] [Accepted: 08/21/2022] [Indexed: 11/20/2022] Open
Abstract
A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In carotid surgery, Does the eversion technique (ECEA) has an early postoperative lower stroke rate, As compared to conventional carotid endarterectomy (CCEA)? The outcome assessed was the stroke rate in the early potoperative period (30 days) in the two techniques. The best evidence confirmed that there is no statistically significant difference between ECEA and CCEA regarding the early postoperative stroke incidence. Eversion technique and conventional endarterectomy are the main surgical endarterectomy techniques in carotid artery disease. There is no difference between the Eversion and conventional endarterectomy techniques in early postoperative stroke rates. Lack of randomised controlled trials that compare the two techniques.
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Christoforou PD, Bakoyiannis CN, Konidari M, Georgopoulos S, Kotsis T. Doppler is a Safe Criterion for Ensuring the Implementation of Eversion Carotid Endarterectomy. Ann Vasc Dis 2021. [PMCID: PMC8752923 DOI: 10.3400/avd.oa.21-00065] [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: 11/23/2022] Open
Abstract
Objective: This is a prospective study concerning patients with symptomatic or asymptomatic significant carotid stenosis. Preoperative and intraoperative measurements of the peripheral extension of the carotid atherosclerotic plaque have been compared with postoperative measurements to identify a preoperative method that safely allows the performance of eversion carotid endarterectomy (ECEA). Materials and Methods: The study included 37 patients with symptomatic internal carotid stenosis greater than 70% and 43 patients with asymptomatic stenosis greater than 80%. Four methods were used for establishing criteria: preoperative Doppler examination, intraoperative measurement of the carotid atheroma before artery division, measurement of the removed plaque, and histological measurement of the plaque. Results: Preoperative Doppler examination is a method of estimating the actual distal extension of the internal carotid artery (ICA) atheroma, with correction as dictated by the following formula:AL= 0.6704+0.7685⋅Doppler In all cases, preoperative ultrasound measurements and intraoperative estimation confirmed the correct decision to proceed with the eversion technique. Conclusion: The peripheral extension of the atherosclerotic plaque of the ICA can be assessed with accuracy by preoperative Doppler study, which can be used with safety as a predicting criterion of the existence of healthy peripheral carotid tissue that allows the performance of the eversion endarterectomy technique.
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Affiliation(s)
- Panagitsa D. Christoforou
- Vascular Department, 2nd Clinic of Surgery, Aretaieion University Hospital, Athens Medical School, National and Kapodistrian University of Athens
| | - Chris N. Bakoyiannis
- Vascular Department, 1st Clinic of Surgery, Laiko General Hospital, Athens Medical School, National and Kapodistrian University of Athens
| | - Marianna Konidari
- 1st Department of Radiology, Aretaieion University Hospital, Athens Medical School, National and Kapodistrian University of Athens
| | - Sotirios Georgopoulos
- Vascular Department, 1st Clinic of Surgery, Laiko General Hospital, Athens Medical School, National and Kapodistrian University of Athens
| | - Thomas Kotsis
- Vascular Department, 2nd Clinic of Surgery, Aretaieion University Hospital, Athens Medical School, National and Kapodistrian University of Athens
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Moacdieh MP, Khan MA, Layman P, Elsayed N, Malas MB. Innovation in the open and endovascular treatment of carotid artery stenosis. Semin Vasc Surg 2021; 34:163-171. [PMID: 34911622 DOI: 10.1053/j.semvascsurg.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Munir P Moacdieh
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Maryam A Khan
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Peter Layman
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA 92093.
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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AbuRahma AF, Darling RC. Literature review of primary versus patching versus eversion as carotid endarterectomy closure. J Vasc Surg 2021; 74:666-675. [PMID: 33862187 DOI: 10.1016/j.jvs.2021.02.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Which type of closure after carotid endarterectomy (CEA), whether primary, patching, or eversion, will provide the optimal results has remained controversial. In the present study, we compared the results of randomized controlled trials (RCTs) and systematic meta-analyses of the various types of closure. METHODS We conducted a PubMed literature review search to find studies that had compared CEA with primary closure, CEA with patching, and/or eversion CEA (ECEA) during the previous three decades with an emphasis on RCTs, previously reported systematic meta-analyses, large multicenter observational studies (Vascular Quality Initiative data), and recent single-center large studies. RESULTS The results from RCTs comparing primary patching vs primary closure were as follows. Most of the randomized trials showed CEA with patching was superior to CEA with primary closure in lowering the perioperative stroke rates, stroke and death rates, carotid thrombosis rates, and late restenosis rates. These studies also showed no significant differences between the preferential use of several patch materials, including synthetic patches (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del], Acuseal [Gore Medical, Flagstaff, Ariz], polytetrafluoroethylene, or pericardial patches) and vein patches (saphenous or jugular). The results from observational studies comparing patching vs primary closure were as follows. The Vascular Study Group of New England data showed that the use of patching increased from 71% to 91% (P < .001). Also, the 1-year restenosis and occlusion (P < .01) and 1-year stroke and transient ischemic attack (P < .03) rates were significantly lower statistically with patch closure. The results from the RCTs comparing ECEA vs conventional CEA (CCEA) were as follows. Several RCTs that had compared ECEA with CCEA showed equivalency of CCEA vs ECEA (level 1 evidence) with patching in the perioperative carotid thrombosis and stroke rates. At 4 years after treatment, the incidence of carotid stenosis was lower for ECEA than for primary closure (3.6% vs 9.2%; P = .01) but was comparable between patching and eversion (1.5% for patching vs 2.8% for eversion). CONCLUSIONS Routine carotid patching or ECEA was superior to primary closure (level 1 evidence). We found no significant differences between the preferential use of several patch materials. The rates of significant post-CEA stenosis for CEA with patching was similar to that with ECEA, and both were superior to primary closure.
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
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Editor's Choice – Network Meta-Analysis of Carotid Endarterectomy Closure Techniques. Eur J Vasc Endovasc Surg 2021; 61:181-190. [DOI: 10.1016/j.ejvs.2020.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/09/2020] [Accepted: 10/07/2020] [Indexed: 11/22/2022]
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Stone DH, Giles KA, Kubilis P, Suckow BD, Goodney PP, Huber TS, Powell RJ, Cronenwett JL, Scali ST. Editor's Choice – Protamine Reduces Serious Bleeding Complications Associated with Carotid Endarterectomy in Asymptomatic Patients without Increasing the Risk of Stroke, Myocardial Infarction, or Death in a Large National Analysis. Eur J Vasc Endovasc Surg 2020; 60:800-807. [DOI: 10.1016/j.ejvs.2020.08.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/16/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
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Veraldi GF, Scorsone L, Mastrorilli D, Bruno S, Macrì M, Criscenti P, Onorati F, Faggian G, Bovo C, Mezzetto L. Carotid Endarterectomy with Modified Eversion Technique: Results of a Single Center. Ann Vasc Surg 2020; 72:627-636. [PMID: 33197539 DOI: 10.1016/j.avsg.2020.09.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) has a wide range of approaches based on personal expertise and preference. We evaluated our outcome with CEA with modified eversion technique (meCEA) under local anesthesia and whether the surgeon's experience could influence it. METHODS at our Institution, 837 patients underwent CEA across 8 years. Although the surgical technique was standardized, 2 groups were considered further: meCEA performed by a single Senior Operator (Group A) and meCEA performed by 4 young Consultants (Group B). RESULTS A selective shunting policy was needed in 5.1%, together with general anesthesia. Overall operative time was 63.9 ± 15.1 minutes (61.4 ± 12.5 and 66 ± 16.9 minutes in Group A and Group B respectively; P < 0.001) and cross-clamp time 19.3 ± 2.9 minutes (19.0 ± 3.2 vs. 19.5 ± 2.8, P = 0.009). At 30 days, 0.7% TIA and 0.8% strokes were recorded. No differences (p = N.S.) between the 2 study groups in terms of postoperative neurological complications, with postoperative ipsilateral strokes always < 1%. At a median imaging follow-up of 22.5 months, the overall percentage of restenosis was 3.7%, with no difference between the 2 groups (P = 0.954). Twenty-two patients (2.6%) underwent reintervention for significant restenosis, and none of them had an ipsilateral stroke or TIA. Freedom from reintervention for restenosis at 24 months was 97.9% in Group A and 95.9% in Group B, with no between-group difference (P = 0.14). At the median survival follow-up of 37 months, the overall survival rate at 24 months was 97.9%in Group A, and 97.9% in Group B, with no between-group difference (P = 0.070). CONCLUSIONS In our experience, CEA with a modified technique is safe and achieves comparable outcomes to those of other established techniques. The reported short cross-clamp time, also in less experienced hands, is an additional strength.
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Affiliation(s)
- Gian Franco Veraldi
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Lorenzo Scorsone
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy.
| | - Davide Mastrorilli
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Salvatore Bruno
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Marco Macrì
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Paolo Criscenti
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Francesco Onorati
- Department of Cardiac Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Giuseppe Faggian
- Department of Cardiac Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Chiara Bovo
- Medical Direction, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital and Trust of Verona, University of Verona - School of Medicine, Verona, Italy
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Catanese V, Esposito G, Beretta A, Barzaghi ME, Cusmai FA, Martelli E, Setti M. Ten-year single center experience with semi-eversion carotid endarterectomy: analysis of a cohort of patients with tips and tricks of our technique. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:521-523. [PMID: 32352249 DOI: 10.23736/s0021-9509.20.11389-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Vincenzo Catanese
- Department of Surgical, Microsurgical and Medical Sciences, University of Sassari, Sassari, Italy
| | - Giovanni Esposito
- Division of Vascular Surgery, Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy
| | - Alessandra Beretta
- Division of Vascular Surgery, Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy
| | - Maria E Barzaghi
- Division of Vascular Surgery, Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy
| | - Francesco A Cusmai
- Division of Vascular Surgery, Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy
| | - Eugenio Martelli
- Division of Vascular Surgery, S. Anna e S. Sebastiano Hospital, Caserta, Italy - .,Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Marco Setti
- Division of Vascular Surgery, Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy
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Ignatenko PV, Gostev AA, Saaia SB, Rabtsun AA, Cheban AV, Starodubtsev VB, Karpenko AA. [Autoarterial remodeling of the common carotid artery bifurcation in treatment of stenotic lesions]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:82-88. [PMID: 32240141 DOI: 10.33529/angio2020117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Carotid endarterectomy is the main operation carried out for prevention of ischaemic stroke in haemodynamically significant stenoses of the bifurcation of the common carotid artery. Despite the literature data demonstrating some advantages of eversion carotid endarterectomy over the classical technique there arises a series of complicated, as yet unsolved problems. This concerns the control of the distal portion of an atherosclerotic plaque in prolonged lesions of the internal carotid artery, the absence of a temporary bypass graft, necessity of prosthetic repair of the internal carotid artery in detachment of the distal border of the plaque. We suggested a new technique of carotid endarterectomy making it possible to widen visual removal of atheromatous masses from the internal carotid artery, to improve the control of the distal portion of the plaque in a prolonged lesion of the internal carotid artery. We carried out a comparative assessment of efficacy and safety of the new method of carotid endarterectomy versus the classical variant in a randomized study. The proposed technique of carotid endarterectomy turned out to be compatible by safety and demonstrated similar results with the classical carotid endarterectomy by the number of ischaemic strokes, transitory ischaemic attacks, and myocardial infarctions in the early and remote postoperative periods. When comparing the groups by efficiency, the primary efficacy endpoint, including cases of restenosis >50% according to the findings of ultrasonographic examination of the brachiocephalic arteries, all cases of ischaemic events (acute impairments of cerebral circulation, transitory ischaemic attacks), as well as the presence of the clinical picture of cranial nerve paresis demonstrated a significant advantage of the new technique versus the comparison group at the expense of a lower incidence of restenoses in the area of the operation during the whole period of follow up. In the group of autoarterial remodelling, the composite endpoint of outcomes occurred in 6 patients (6.1%) and in the group with the classic carotid endarterectomy - in 19 (19.6%) patients, p=0.005.
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Affiliation(s)
- P V Ignatenko
- National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - A A Gostev
- National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - Sh B Saaia
- National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - A A Rabtsun
- National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - A V Cheban
- National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - V B Starodubtsev
- National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
| | - A A Karpenko
- National Medical Research Centre named after Academician E.N. Meshalkin under the RF Ministry of Public Health, Novosibirsk, Russia
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Kotsis T, Christoforou P, Nastos K. Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy. Int J Angiol 2020; 29:33-38. [PMID: 32132814 DOI: 10.1055/s-0039-3400478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The technique of the eversion carotid endarterectomy (ECEA), as an alternative to the conventional endarterectomy with primary or patch angioplasty, is an established technique for managing internal carotid artery stenoses and recently its application has been upgraded through the European Society for Vascular Surgery guidelines (Recommendation 55: Class 1, Level A). However, the typical eversion method has been associated with postoperative hypertension due to loss of the baroreceptor reflex; the standard oblique transection at the bulb performed in the eversion endarterectomy interrupts either the baroreceptor sensoring tissue, which is mostly located in the adventitia at the medial portion of the proximal internal carotid artery, or even the proper Hering nerve, a branch of the glossopharyngeal nerve. These actions deregulate the natural negative feedback of the carotid baroreceptor. Guided by the anatomical location of the baroreceptor sensor we have elaborated a slight modification of the classical ECEA to maintain as much as possible of the viable carotid baroreceptor sensoring surface. By extending the oblique incision distal to the carotid bifurcation in the medial part of the internal carotid artery stem, an eyebrow-like part of the proximal internal carotid artery is maintained and the axis from the sensoring tissue to the nerve of Hering is protected and following the endarterectomy, postoperative arterial blood pressure levels are lower than in the classical ECEA due to the maintenance of the efficiency of the baroreceptor reflex. During the period from September 2016 to November 2018, carotid endarterectomy was performed in 57 patients. Twenty-eight of them underwent the typical ECEA and 29 patients had the modified eyebrow eversion carotid endarterectomy (me-ECEA). The changes of blood pressure baseline during the postoperative course in ECEA and me-ECEA group were analyzed and compared. Postoperative hypertension was defined as an elevation of systolic blood pressure (SBP) greater than 140 mm Hg. Patients who underwent typical ECEA had significantly higher postoperative blood pressure values compared with those who underwent me-ECEA. Actually, the mean postoperative SBP was 172.67 ± 24.59 mm Hg in the typical ECEA group compared with 160.86 ± 12.83 mm Hg in the me-ECEA group ( p = 0.023). The mean diastolic blood pressure in the ECEA group was 65.42 ± 11.39 mm Hg compared with 58.06 ± 9.06 mm Hg in the me-ECEA group ( p = 0.009). Our proposed me-ECEA technique seems to be related to lower rates of postoperative hypertension compared with the typical ECEA, probably due to the sparing of the main mass of the baroreceptor apparatus; this improved modification (me-ECEA) of the typical eversion procedure could represent an alternative ECEA technique with its inherent advantages.
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Affiliation(s)
- Thomas Kotsis
- Vascular Unit, 2nd Department of Surgery, National and Kapodistrian University of Athens Medical School, Aretaieion University Hospital, Athens, Greece
| | - Panagitsa Christoforou
- Vascular Unit, 2nd Department of Surgery, National and Kapodistrian University of Athens Medical School, Aretaieion University Hospital, Athens, Greece
| | - Konstantinos Nastos
- Vascular Unit, 2nd Department of Surgery, National and Kapodistrian University of Athens Medical School, Aretaieion University Hospital, Athens, Greece
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Davidovic LB, Tomic IZ. Eversion Carotid Endarterectomy : A Short Review. J Korean Neurosurg Soc 2020; 63:373-379. [PMID: 32114754 PMCID: PMC7218199 DOI: 10.3340/jkns.2019.0201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/29/2019] [Indexed: 11/27/2022] Open
Abstract
Carotid endarterectomy (CEA) is the main procedure in carotid surgery, as well as the most frequent vascular procedure. Two techniques of CEA are available : eversion and conventional plus patch angioplasty. Eversion CEA is anatomic procedure that reduces ischemic and total operative time. Simultaneous correction of the joined carotid kinking and coiling is possible, easy and safe, while the usage of patch is excluded. Thanks to oblique shape of anastomosis, eversion CEA is associated with low risk of long-term restenosis. The false anastomotic aneurysms occurrence is very rare, almost impossible after eversion CEA. However, the usage of carotid shunt during eversion CEA is not always simple, while proximal or distal extension of the carotid plaque can make eversion CEA more difficult and risky. Eversion CEA should be the first choice in carotid surgery. Conventional CEA is indicated in cases when carotid plaque is extended more than usual, as well as, if the usage of carotid shunt is necessary.
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Affiliation(s)
- Lazar B Davidovic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Ivan Z Tomic
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
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17
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Kazakov II, Iakovlev AO. [Surgical policy of managing patients with concomitant atherosclerotic lesions of the internal and common carotid arteries]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 25:124-130. [PMID: 31855209 DOI: 10.33529/angio2019404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM The purpose of this study was to investigate the natural course of stenosis of the common carotid artery (CCA) after carotid endarterectomy, as well as the long-term outcomes of various methods of reconstruction of the internal carotid artery (ICA) in patients with extended atherosclerotic lesions. PATIENTS AND METHODS Presented herein are the remote retrospective and prospective results of carotid endarterectomy in a total of 78 patients with concomitant atherosclerotic lesions of carotid arteries. Depending on the degree of CCA stenosis, the patients were divided into 2 groups. Group One (n=25): stenosis of the internal carotid artery (ICA) of more than 70% and haemodynamically insignificant (30-35% stenosis) but extended (from 3.0 to 5.0 cm (Q1, Me, Q3); 3.5 cm, 4.0 cm, 5.0 cm) stenosis of the CCA. These patients underwent carotid endarterectomy (CEA) from the ostium of the ICA, during which an atherosclerotic plaque was not completely removed from the CCA because the stenosis was extended but haemodynamically insignificant. Group Two (n=53): stenosis of the ICA of more than 70% and haemodynamically significant, extended (from 7.0 to 10.0 cm (Q1, Me, Q3); 7.5 cm, 8.0 cm, 9.0 cm) stenosis of the CCA. The patients of this group were subjected to various methods of operative intervention on the ICA and CCA: carotid endarterectomy (ECA) combined with open endarterectomy from the CCA with plasty using the primary suture (n=23); carotid endarterectomy and alloreconstruction of the CCA (n=10); simultaneous eversion endarterectomy from the ICA and CCA (n=20). The remote period of follow up of patients ranged from 14 to 24 months ((Q1, Me, Q3; 19 months, 22 months, 24 months). The differences were statistically insignificant (Mann-Whitney U-test, p=0.881). RESULTS In the remote postoperative period, 32% of Group One patients after previously performed carotid endarterectomy were found to have an increase in the degree of stenosis of the CCA up to a haemodynamically significant one (70% and more), thus suggesting progression of the atherosclerotic process. In Group Two patients, after plasty of the CCA with the primary suture, 21.7% of patients were diagnosed as having restenosis of the reconstruction zone up to 30%, with no neurological deficit. 20% of patients after carotid endarterectomy and alloreconstruction of the CCA were diagnosed as having restenosis of the reconstruction zone more than 70% and acute impairment of cerebral circulation with a lethal outcome. The patients after simultaneous eversion endarterectomy form the ICA and CCA in the intraoperative and postoperative periods had neither restenosis of the reconstruction zone nor neurological deficit. CONCLUSION 32% of patients after previously performed carotid endarterectomy with the presence of extended, but haemodynamically insignificant stenosis of the CCA (30-35% stenosis) in the postoperative period were found to have progression of the atherosclerotic lesion in the form of an increased degree of stenosis up to haemodynamically significant (more than 70%), thus requiring repeat reconstructive operation. Therefore, in patients presenting with concomitant atherosclerotic lesions of the carotid arteries it is appropriate to carry out operative intervention simultaneously on the ICA and CCA, which would make it possible to considerably improve the remote postoperative results of reconstructive interventions on the carotid basin in this cohort of patients. A comparative study of the outcomes of various methods of reconstruction of carotid arteries in patients with concomitant atherosclerotic lesions of the ICA and CCA demonstrated that simultaneous eversion endarterectomy from the ICA and CCA resulted in good postoperative parameters: absence of restenosis and neurological deficit in the remote period of follow up.
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Affiliation(s)
- Iu I Kazakov
- Regional Clinical Hospital, Tver, Russia; Tver State Medical University of the RF Ministry of Public Health, Tver, Russia
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18
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Dakour-Aridi H, Ou M, Locham S, AbuRahma A, Schneider JR, Malas M. Outcomes following Eversion versus Conventional Endarterectomy in the Vascular Quality Initiative Database. Ann Vasc Surg 2019; 65:1-9. [PMID: 31626932 DOI: 10.1016/j.avsg.2019.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/04/2019] [Accepted: 07/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although the majority of vascular surgeons perform conventional carotid endarterectomy (c-CEA), others prefer eversion CEA (e-CEA). Despite several randomized controlled trials and single center studies, the advantage of one technique over the other is still not clearly defined. The purpose of this study is to compare the postoperative outcomes and durability of c-CEA versus e-CEA in a nationally representative cohort. METHODS We performed a retrospective review of the Vascular Quality Initiative database between 2003 and 2018. Patients with prior ipsilateral carotid intervention (CEA and carotid artery stenting) and those undergoing concomitant procedures were excluded. Multivariable logistic and Cox-regression analyses were used to compare risk-adjusted perioperative and 1-year outcomes (stroke, death, and high-grade restenosis [>70%]) between c-CEA (using direct closure or patch angioplasty) and e-CEA. RESULTS A total of 95,726 CEA cases were included, of which 12,050 (12.6%) were e-CEA and the remaining (87.4%) were c-CEA. Patch angioplasty was used in 94.9% of c-CEA compared with 49.7% of e-CEA (P < 0.001). On univariable analysis, no difference in perioperative outcomes was noted between the 2 approaches except for higher rates of in-hospital dysrhythmia (1.5% vs. 1.3%) and postprocedural hemodynamic instability (27.3% vs. 24.3%) after c-CEA compared with e-CEA (all P < 0.05). On the other hand, e-CEA patients were more likely to return to the operating room for bleeding (1.3% vs. c-CEA: 0.9%, P < 0.001). The outcomes of e-CEA did not differ if the common carotid artery was closed primarily or with a patch. After adjusting for potential confounders and stratifying with respect to patch use, there was no significant difference in outcomes between e-CEA and c-CEA when a patch is used in both procedures. However, when no patching was performed, e-CEA was associated with lower stroke/death at 30 days (odds ratio 0.72, 95% confidence interval [CI] 0.54-0.95, P = 0.02) and at 1 year (hazard ratio 0.75, 95% CI 0.58-0.97, P = 0.03). CONCLUSIONS Both e-CEA and c-CEA are safe and durable techniques with similar stroke/death and restenosis rates up to 1-year of follow up, as long as c-CEA is performed with patch angioplasty. However, e-CEA is superior to c-CEA without patch angioplasty and is associated with 28% and 25% reduction in 30-day and 1-year stroke/death, respectively.
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Affiliation(s)
| | - Michael Ou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Ali AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV
| | - Joseph R Schneider
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mahmoud Malas
- Department of Surgery, University of California San Diego, La Jolla, CA.
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19
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Leopardi M, Dante A, Sbenaglia G, Maggipinto A, Ventura M. Short non-patch arteriotomy in carotid endarterectomy. INT ANGIOL 2019; 38:320-325. [DOI: 10.23736/s0392-9590.19.04095-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Sharma RK, Asiri AM, Yamada Y, Kawase T, Kato Y. Extracranial Internal Carotid Artery Aneurysm - Challenges in the Management: A Case Report and Review Literature. Asian J Neurosurg 2019; 14:970-974. [PMID: 31497143 PMCID: PMC6703024 DOI: 10.4103/ajns.ajns_292_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Extracranial internal carotid artery aneurysms (EICA) are rare. Incidence is <1% of all an arterial aneurysm. This aneurysm being rare but is important because it is associated with a high risk of neurological thromboembolic events, cranial nerve compression, and rupture. The causes of the EICA are congenital, trauma leading to the pseudoaneurysm, atherosclerosis, infections, and fibromuscular dysplasia. Here, we describe a case report of a 69-year-old female with progressive enlargement of the right neck mass accompanied by dyspnea on exertion. The patient had been diagnosed as right EICA and underwent the endovascular procedure as parent vessel occlusion 4 years ago. There was still enlargement of the size of the right neck mass and was causing troublesome to the patient. We performed selective embolization of the various feeders to the mass, but after this also, it was still enlarging. Three-dimensional reconstruction of the computed tomography scan showed fusiform dilatation of the right proximal EICA. We made the diagnosis of the thrombosed EICA and hence we planned to undergo surgical management. We performed removal of the intraluminal thrombus and ligation of the EICA. The size of the swelling decreased significantly.
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Affiliation(s)
- Rajan Kumar Sharma
- Department of Neurosurgery, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | | | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
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21
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Chait J, Nicoara M, Kibrik P, Ostrozhynskyy Y, Marks N, Rajaee S, Hingorani A, Ascher E. Early hemodynamic characteristics of eversion and patch carotid endarterectomies. J Ultrasound 2019; 22:433-436. [PMID: 31069757 DOI: 10.1007/s40477-019-00384-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/02/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is currently the gold standard in the operative management of carotid artery stenosis. While eversion and patch CEAs vary greatly in technique, various studies have determined equivalence with regard to clinical outcomes. However, the hemodynamic differences following each procedure are not known. This study aimed to investigate any early hemodynamic differences between eversion and patch CEAs. METHODS All CEAs performed at our institution from March 2012 to June 2018 were aggregated in a retrospective database by querying the 35301 CPT code from the electronic medical record system. Variables collected included gender, age, laterality of CEA, type of procedure, and pre- and post-operative duplex ultrasound (DUS) date and quantitative findings. Exclusion criteria included any procedure with incomplete data, a post-operative DUS > 90 days following the procedure, CEAs with concomitant bypass(es), isolated external carotid artery (ECA) endarterectomies, and re-do CEAs. RESULTS One hundred and seventy-one CEAs were performed in 161 unique patients. There were 101 males and 60 females, with an average age of 69.7 (38-96; ± 9.36). 63 CEAs were excluded from analysis: 51 due to incomplete data, eight with a > 90 day post-operative DUS, 2 isolated ECA endarterectomies, 1 CEA with a carotid-subclavian bypass, and 1 re-do CEA secondary to an infected patch. Twenty-seven eversion and 81 patch CEAs were included in analysis. There was no difference in procedure laterality or gender between the two cohorts (p > 0.05); however, patients who received an eversion CEA were older on average (73.3 vs 67.5; p = 0.002). Pre-operative peak systolic velocities (PSV) of the proximal internal carotid artery (ICA), distal ICA, and distal common artery (CCA) were all similar (p > 0.05). Post-operative DUS was performed at 17.0 and 12.9 days in the eversion and patch CEA cohorts, respectively (p = 0.12). Post-operative PSV and change in PSV were similar for all three aforementioned segments (p > 0.05). CONCLUSION Although eversion and patch CEAs vary greatly in technique and post-procedure anatomy, there was no significant difference in post-operative PSV or change in PSV at or around the carotid bifurcation.
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Affiliation(s)
- Jesse Chait
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA.
| | - Michael Nicoara
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Pavel Kibrik
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Yuriy Ostrozhynskyy
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Natalie Marks
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Sareh Rajaee
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Anil Hingorani
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
| | - Enrico Ascher
- Division of Vascular Surgery, NYU Langone Hospital-Brooklyn, Brooklyn, NY, USA
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22
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Elmallah AS, McGreal GT. Outcome of conventional and modified eversion carotid endarterectomy techniques in symptomatic and asymptomatic patients with significant carotid artery stenosis. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04775-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Texakalidis P, Tzoumas A, Giannopoulos S, Jonnalagadda AK, Jabbour P, Rangel-Castilla L, Machinis T, Rivet DJ, Reavey-Cantwell J. Risk Factors for Restenosis After Carotid Revascularization: A Meta-Analysis of Hazard Ratios. World Neurosurg 2019; 125:414-424. [PMID: 30822589 DOI: 10.1016/j.wneu.2019.02.065] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carotid artery restenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS) will occur in 3%-30% of cases. Restenosis can lead to more frequent clinical and imaging monitoring and the potential for reoperation. We sought to define the demographic, clinical, and radiographic characteristics that influence the restenosis risk after carotid revascularization. METHODS The present study was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. A random effects model meta-analysis of hazard ratios (HRs) was conducted. RESULTS Eighteen studies with 17,106 patients were included. Diabetes (HR, 1.68; 95% confidence interval [CI], 1.00-2.83; I2, 76.7%), dyslipidemia (HR, 1.77; 95% CI, 1.08-2.91; I2, 22.5%), female gender (HR, 1.50; 95% CI, 1.14-1.98, I2, 0%), chronic kidney disease (HR, 4.15; 95% CI, 1.69-10.19; I2, 44.5%), hypertension (HR, 1.99; 95% CI, 1.07-3.72; I2, 68%), smoking (HR, 1.65; 95% CI, 1.15-2.37; I2, 54.3%), and pretreatment stenosis >70% (HR, 1.04; 95% CI, 1.0-1.08; I2, 0%) showed a statistically significant increase in restenosis risk after carotid revascularization. Subgroup analyses of CEA and CAS showed that female gender and smoking status were significantly associated with recurrent stenosis after CEA but not after CAS. In contrast, hypertension was associated with restenosis after CAS but not after CEA. Patch endarterectomy (HR, 0.33; 95% CI, 0.22-0.50; I2, 0%) and symptomatic status at presentation in the CAS group (HR, 0.61; 95% CI, 0.41-0.90; I2, 0%) were associated with a decreased risk of restenosis. Antiplatelet use and coronary artery disease were not associated with restenosis risk. CONCLUSIONS Diabetes, dyslipidemia, female gender, renal failure, hypertension, and smoking were associated with an increased risk of restenosis, and patch endarterectomy and symptomatic status at presentation were associated with a decreased risk of carotid restenosis. Both female gender and current smoking status were only associated with recurrent stenosis after CEA, and hypertension was only associated with restenosis after CAS.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Andreas Tzoumas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Anil K Jonnalagadda
- Department of Cardiology, Medstar Washington Hospital Center, Washington District of Columbia, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Theofilos Machinis
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Dennis J Rivet
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Reavey-Cantwell
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
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Huizing E, Vos CG, van den Akker PJ, Schreve MA, de Borst GJ, Ünlü Ç. A systematic review of patch angioplasty versus primary closure for carotid endarterectomy. J Vasc Surg 2019; 69:1962-1974.e4. [PMID: 30792057 DOI: 10.1016/j.jvs.2018.10.096] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 10/09/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Guidelines recommend routine patching after carotid endarterectomy (CEA) on the basis of a lower restenosis rate and presumed lower procedural stroke rate than with primary repair. Underlying evidence is based on studies performed decades ago with perioperative care that significantly differed from current standards. Recent studies raise doubt about routine patching and have suggested that a more selective approach to patch closure (PAC) might be noninferior for procedural safety and long-term stroke prevention. The objective was to review the literature on the procedural safety and perioperative stroke prevention of PAC compared with primary closure (PRC) after CEA. METHODS MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched from January 1966 to September 2017. Two authors independently performed the search, study selection, assessment of methodologic quality, and data extraction. Articles were eligible if they compared PAC and PRC after CEA, were published in English, included human studies, and had a full text available. Methodologic quality for nonrandomized studies was assessed using the Methodological Index for Non-Randomized Studies score; randomized controlled trials were assessed using Grading of Recommendations Assessment, Development, and Evaluation. Nonrandomized studies with a score ≤15 were excluded. The primary outcome measure was 30-day stroke risk. Secondary outcome measures were long-term restenosis (>50%) and postoperative bleeding. RESULTS Twenty-nine articles met the inclusion criteria, 9 randomized studies and 20 nonrandomized studies, for a total of 12,696 patients and 13,219 CEAs. Overall 30-day stroke risk was higher in the PRC group (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-2.9). After exclusion of nonrandomized studies, this difference was not statistically significant anymore (OR, 1.8; 95% CI, 0.8-3.9). The restenosis rate was higher after PRC (OR, 2.2; 95% CI, 1.4-3.4). There were no differences in bleeding complications. Methodologic quality of the nonrandomized studies was moderate, and seven were excluded. Quality of the evidence according to Grading of Recommendations Assessment, Development, and Evaluation was moderate for restenosis, 30-day stroke, and bleeding. CONCLUSIONS In this systematic review, on the basis of moderate-quality evidence, perioperative stroke rate was lower after PAC compared with PRC. The rate of restenosis was higher after PRC, although the clinical significance of this finding in terms of long-term stroke prevention remained unclear.
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Affiliation(s)
- Eline Huizing
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands.
| | - Cornelis G Vos
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | - Gert J de Borst
- Department of Vascular Surgery, UMCU, Utrecht, The Netherlands
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
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Abstract
PURPOSE OF REVIEW Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis. RECENT FINDINGS Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise. 'Average surgical risk' patients with an asymptomatic carotid artery stenosis of 60-99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed 'high risk' for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.
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Djedovic M, Mujanovic E, Hadzimehmedagic A, Totic D, Vukas H, Vranic H. Comparison of Results Classical and Eversion Carotid Endarterectomy. Med Arch 2018; 71:89-92. [PMID: 28790536 PMCID: PMC5511541 DOI: 10.5455/medarh.2017.71.89-92] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Atherosclerosis blood vessels, be it on extra-cranial or intra-cranial circulation, the most common cause of incidents such as cerebro-vascular insult (ICV). Carotid endarterectomy (CEA) is a preventive operation to reduce the risk of stroke and it can be performed by eversion carotid endarterectomy (E-CEA) or a classical carotid endarterectomy (C-CEA). The aim of this study was to investigate the influence of the used techniques in basic perioperative results and the incidence of postoperative complications. MATERIALS AND METHODS It was retrospective-prospective study that involved 173 patients, with carotid stenosis, who underwent CEA, in the period of time December 2013 till December 2016. Subjects were divided into two groups in respect of technique: 90 patients were treated with E-CEA and 83 patients were treated with C-CEA. RESULTS Between two groups revealed a significant difference in favor of the patients from group E-CEA in the length of the surgery (92.56 ± 29.11 min. vs. 104.04 ± 18.01 min., P = 0.000), the time of clamping the carotid arteries (11.83 ± 1.81 min. vs. 23.69 ± 5:39 min., p = 0.000), the amount of post-operative drainage (25.33 ± 24.67 ml. vs. 36.14 ± 14:32 ml., p = 0.001), time spent in the intensive care unit (± 25.43 vs. 13:51 hours 34.54 ± 35.81 hours, p = 0.000), and the length of stay (4.60 ± 0.90 days vs. 5:42 ± 1.80 days, p = 0.001). In the patients of the group E-CEA, fewer number of individual postoperative complications without statistical significance: ICV (2.2% vs. 4.8%, p = 0.351), cardiac arrhythmia (2.2% vs. 4.8%, p = 0.351), transitory ischaemic attack (TIA) and cognitive disorder (2.2% vs. 7.2%, p = 0.117), mortality (1.1% vs. 1.2%, p = 0.954); and the total number of postoperative complications was significantly less in the same patients (7.77% vs. 18.7%, p = 0.042). CONCLUSION The results of this study clearly indicate that operating techniques affects the specified monitored outcomes of vascular treatment of carotid arteries in favor of E-CEA technique. It would be ideally that the conclusions of this study contribute to broader use of E-CEA in treatment of carotid stenosis.
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Affiliation(s)
- Muhamed Djedovic
- Clinic for Vascular Surgery, Clinical center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Amel Hadzimehmedagic
- Clinic for Vascular Surgery, Clinical center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Dragan Totic
- Clinic for Vascular Surgery, Clinical center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Haris Vukas
- Clinic for Vascular Surgery, Clinical center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Haris Vranic
- Clinic for Vascular Surgery, Clinical center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Outcomes of mini-incision eversion carotid endarterectomy combined with nontouch isolation technique of the internal carotid artery. J Vasc Surg 2017; 67:490-497. [PMID: 28943006 DOI: 10.1016/j.jvs.2017.07.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/03/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We developed a mini-incision eversion carotid endarterectomy (CEA) procedure (the Jikei method CEA) to prevent perioperative embolic stroke. The aim of this study was to retrospectively analyze perioperative and midterm outcomes after the Jikei method CEA. METHODS We evaluated patients with the Jikei method CEA at our institution between January 2006 and June 2014. The primary end point was a major adverse event, which included death, stroke, intracranial hemorrhage, and myocardial infarction, within 30 days of CEA. Secondary end points were postoperative ipsilateral stroke and restenosis. RESULTS We retrospectively studied 120 lesions in 110 patients. The mean age was 72.2 ± 8.0 years. With regard to the 120 lesions, 56 lesions (46.7%) were symptomatic and 73 lesions (60.8%) showed ≥90% severe stenosis. The mean length of the skin incision was 3.2 ± 0.5 cm. The mean operative time, volume of blood loss, and internal carotid artery clamp time were 171.0 ± 50.7 minutes, 161.6 ± 110.8 mL, and 35.7 ± 10.8 minutes, respectively. There were three perioperative major adverse events (2.5%), including two strokes (1.7%) and one intracranial hemorrhage (0.8%) resulting from hyperperfusion syndrome. The median postoperative hospital stay was 6 days (range, 2-303 days). The mean follow-up was 3.9 ± 2.2 years. There was no case of ipsilateral stroke during the follow-up period. The freedom from ipsilateral stroke at 5 years was 98.3%. Three lesions (2.5%) developed restenosis. The freedom from restenosis was 97.2% at 5 years. The freedom from reintervention at 5 years was 99.0% because carotid artery stent placement was necessary in one patient with severe restenosis. CONCLUSIONS The Jikei method CEA was safe and effective in preventing perioperative and midterm stroke.
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Symptomatic Carotid Artery Disease: Revascularization. Prog Cardiovasc Dis 2017; 59:601-611. [DOI: 10.1016/j.pcad.2017.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 04/16/2017] [Indexed: 02/02/2023]
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Musicant SE, Guzzetta VJ, Terramani TT, Greenwood KL, Chiodo WC, Heaney KM, Berthiaume SJ. Modified Eversion Carotid Endarterectomy (mECEA): Analysis of Clinical and Financial Outcomes. Ann Vasc Surg 2017; 42:16-24. [PMID: 28279725 DOI: 10.1016/j.avsg.2016.10.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 10/25/2016] [Accepted: 10/27/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Several carotid endarterectomy techniques have been described, including conventional carotid endarterectomy (CCEA) performed with patch repair and eversion carotid endarterectomy (ECEA) performed with transection of the internal carotid artery. We describe our simplified technique of modified eversion carotid endarterectomy (mECEA) with longitudinal arteriotomy limited to the carotid bulb, without transection of the internal carotid artery and present our analysis of its safety, efficacy, and cost effectiveness. METHODS A retrospective review of all carotid endarterectomies performed by 3 vascular surgeons over a 3-year period was completed. About 197 mECEA were performed during the study period. Follow-up data were obtained on 77.7% of patients. A comparison was made with the contemporary literature with respect to outcomes for both CCEA and ECEA. RESULTS Between January 2012 and December 2014, a total of 197 mECEA were performed. The perioperative stroke and death rates for those undergoing mECEA was 0.5% and 0.5%, respectively. Late stroke and death rates were 3.0% and 5.1%, respectively. Perioperative rate of myocardial infarction was 1.0%. Early restenosis rates of >70% occurred in 1.4%, whereas late restenosis of >70% occurred in 2.7%. Mean operating time for those undergoing mECEA was 57.9 min. Average costs savings for mECEA compared to CCEA were $5,835. CONCLUSIONS This simplified technique has comparable outcomes to those described in the contemporary literature for both CCEA and ECEA with respect to postoperative neurologic events as well as restenosis rates. In our institution, the short mean operative times with mECEA has led to reduced resource utilization.
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Affiliation(s)
- Scott E Musicant
- Division of Vascular Surgery, Department of Surgery, Sharp Grossmont Hospital Heart and Vascular Center, La Mesa, CA.
| | - Vincent J Guzzetta
- Division of Vascular Surgery, Department of Surgery, Sharp Grossmont Hospital Heart and Vascular Center, La Mesa, CA
| | - Thomas T Terramani
- Division of Vascular Surgery, Department of Surgery, Sharp Grossmont Hospital Heart and Vascular Center, La Mesa, CA
| | - Kristina L Greenwood
- Division of Vascular Surgery, Department of Surgery, Sharp Grossmont Hospital Heart and Vascular Center, La Mesa, CA
| | - Wendy C Chiodo
- Division of Vascular Surgery, Department of Surgery, Sharp Grossmont Hospital Heart and Vascular Center, La Mesa, CA
| | - Karen M Heaney
- Division of Vascular Surgery, Department of Surgery, Sharp Grossmont Hospital Heart and Vascular Center, La Mesa, CA
| | - Shelley J Berthiaume
- Division of Vascular Surgery, Department of Surgery, Sharp Grossmont Hospital Heart and Vascular Center, La Mesa, CA
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The modified operative technique of partial eversion carotid endarterectomy. J Vasc Surg 2017; 65:263-266. [DOI: 10.1016/j.jvs.2016.10.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 10/03/2016] [Indexed: 11/21/2022]
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Perioperative stroke after carotid endarterectomy: etiology and implications. Acta Neurochir (Wien) 2016; 158:2377-2383. [PMID: 27696001 DOI: 10.1007/s00701-016-2966-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is the procedure of choice for reducing the risk of stroke in both symptomatic and asymptomatic carotid artery stenoses. Stroke is associated with significant morbidity and mortality peri-operatively (2-3 %). Our primary aim is to evaluate the etiology of these strokes after CEA and their impact on morbidity by comparing the length of stay in the hospital. METHODS A total of 584 patients with documented neurological status evaluations who underwent CEAs were included in the study. Neurophysiological monitoring data was obtained during CEA for carotid stenosis included eight-channel electroencephalography (EEG) and upper extremity somatosensory evoked potentials (SSEPs). RESULTS Twenty-one (3.595 %) patients had strokes in the perioperative period and they were more likely to have left-sided surgery (p = 0.008), intraoperative monitoring (IOM) changes (p < 0.001), an intraoperative shunt placed (p = 0.0002) or a hospital stay longer than 5 days (p = 0.0042). Unilateral anterior circulation ischemic stroke were the most common in our series. In a logistic regression model, left-sided surgery was shown to be 4.78 times more likely to be associated with perioperative stroke (1.50-15.27; p = 0.008) while intraoperative shunts were 11.85 times more likely to have strokes (3.97-35.34; p < 0.0001). Patients with stenosis greater than 70 % were 6.67 times less likely to have a stroke (0.04-0.59; p = 0.007). CONCLUSIONS Ischemic anterior circulation strokes are the most common type of post-operative neurological changes in patients undergoing CEA. Intraoperative shunt placement was a strong predictor of perioperative strokes. Since shunts are only placed following intraoperative monitoring changes, SSEPs and EEG can therefore function as a biomarker of cerebral hypo-perfusion.
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Hosn MA, Adams B, Pederson M, Kresowik T, Pascarella L. Long-Term Effect of the Type of Carotid Endarterectomy on Blood Pressure. Ann Vasc Surg 2016; 39:204-208. [PMID: 27554699 DOI: 10.1016/j.avsg.2016.05.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/11/2016] [Accepted: 05/26/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The dissection of the carotid sinus nerve in eversion carotid endarterectomy (eCEA) has been hypothesized to cause an increase in postoperative blood pressure (BP). The objective of this study is to evaluate the effect of eCEA on BP and changes in BP medications over the course of year-long follow-up after eCEA compared with longitudinal incision carotid endarterectomy patch angioplasty (pCEA). METHODS A retrospective review of patients who underwent CEA between July 1, 2009 and June 30, 2014 in the Vascular Surgery Department at The University of Iowa Hospital and Clinics was conducted. Demographics, comorbidities, BP, and number, dosage, and type of antihypertensive medications were collected preoperatively, at 30 days, and at 12 months. The differences in BP and medications between pCEA and eCEA patients were compared. Demographic data and comorbidities were compared using t-tests and chi-squared analysis. Differences in BP and medication dosages were analyzed using multivariate analysis of variance. RESULTS In total, 363 CEA procedures were performed during the study period, of which 275 procedures were included in the final analysis. Thirty percent of the patients underwent eCEA. Fifty-four percent of the patients who underwent eCEA and 60% of the patients who underwent pCEA were symptomatic. Thirty-day mortality was 1.4% and 12-month mortality was 6.4% for the entire population. No postoperative neurologic deficits, including stroke, were observed. Analysis of BP did not yield a significant difference among preoperative, 30-day, and 12-month follow-up measurements (P = 0.893). There was no significant change to the number and total daily dose of BP medications preoperatively, at 30 days, or at 12 months. CONCLUSIONS There is no statistical difference in mortality, morbidity, and patency rates at 30 days and 12 months between pCEA and eCEA. eCEA is also not associated with long-term BP changes compared with pCEA.
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Affiliation(s)
- Maen Aboul Hosn
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | - Brian Adams
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Mark Pederson
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Timothy Kresowik
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Luigi Pascarella
- Division of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
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Abstract
Recurrent carotid stenosis is an ongoing process that may develop at or near the site of an operational or interventional procedure to treat an atheromatous stenosis. Although such a restenosis is most often initially without symptoms, as the disease progresses it may become symptomatic, and thus endanger the patient's life. Such patients are therefore candidates for revisional surgery. Extensive research investigation and numerous studies have incriminated several risk factors as predisposing conditions for recurrent carotid stenosis. The definite role of each predisposing factor, however, is still widely debated. Clarifying the extent of involvement of each factor in the pathogenesis of carotid restenosis is indeed demanding, as it would contribute enormously to the identification of the group of high-risk patients, and, therefore, determine the therapeutic approach in these patients.
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Affiliation(s)
- Christos D Liapis
- Department of Vascular Surgery, Athens University Medical School, Athens, Greece
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Radak DJ, Ilijevski NS, Nenezic D, Popov P, Vucurevic G, Gajin P, Jocic D, Kolar J, Radak S, Sagic D, Matic P, Milicic M, Otasevic P. Temporal Trends in Eversion Carotid Endarterectomy for Carotid Atherosclerosis: Single-Center Experience with 5,034 Patients. Vascular 2016; 15:205-10. [PMID: 17714636 DOI: 10.2310/6670.2007.00046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this article is to review our experience in surgical treatment of carotid atherosclerosis using eversion carotid endarterectomy (ECEA) in 5,034 patients, with particular attention to temporal changes in patients' characteristics, diagnostic approach, surgical technique, medical therapy, and outcome in the early (group A, 1991–1997) versus late (group B 1998–2004) period of ECEA. From January 1991 to December 2004, 5,034 primary ECEAs were performed for high-grade carotid stenosis. Patients treated for restenosis after previous carotid surgery were excluded from the analysis. Group A consisted of 1,714 patients who underwent surgery between 1991 and 1997, and group B consisted of 3,320 patients who underwent surgery between 1998 and 2004. Follow-up included routine clinical evaluation and noninvasive surveillance, with duplex scanning at 1 month after surgery, after 6 months, and annually afterward. Only 3% of patients in group A and 0.6% in group B were asymptomatic, with 23% and 47% of them having preoperative stroke, respectively. In group A, angiography was used for the final diagnosis in 78% of patients. In group B, duplex scanning was performed in 82% of patients and angiography in only 18% ( p < .001). Clamping time was shorter in the latter group (12.4 ± 3.1 vs 14.5 ± 4.1 min, p < .01). Introperative shunting and regional anesthesia were rarely performed in both groups (1.4% vs. 0.4%, p < .01, and 2% vs 0.3%, p < .001). Total and neurologic morbidity was significantly higher in group A than in group B (6.41% ± 0.47% vs 4.81% ± 0.53%, p < .001, and 2.14% ± 0.31% vs 1.23% ± 0.29%, p < .001, respectively). Total mortality was also higher in group A than in group B (1.92% ± 0.24% vs 1.36% ± 0.50%, p < .05), but although there was a trend toward lower neurologic mortality, it did not reach statistical significance (1.04% ± 0.5% vs 0.57% ± 0.25%, p = .074). There was a lower rate of nonsignificant restenosis (< 50%) in group B (2% vs 5%, p < .01), but the incidence of restenosis ≥ 50% was identical between the groups (5.5% for both). Our data show that ECEA is a reliable surgical technique for the treatment of atherosclerotic carotid disease. Temporal trends in our patients demonstrated a decline in periopertive mortality and morbidity, despite a higher incidence of preoperative stroke.
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Affiliation(s)
- Djordje J Radak
- Department of Vascular Surgery, Dedinje Cardiovascular Institute, and Belgrade University School of Medicine, Belgrade, Serbia
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Schneider JR, Hoel AW. Reply: To PMID 25925539. J Vasc Surg 2015; 62:1104-5. [PMID: 26410054 DOI: 10.1016/j.jvs.2015.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 06/01/2015] [Indexed: 11/18/2022]
Affiliation(s)
| | - Andrew W Hoel
- Division of Vascular Surgery, Northwestern University Fein berg School of Medicine, Chicago, Ill
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Ištvanić T, Vrselja Z, Brkić H, Radić R, Lekšan I, Curic G. Extended Eversion Carotid Endarterectomy: Computation of Hemodynamics. Ann Vasc Surg 2015; 29:1598-605. [PMID: 26319145 DOI: 10.1016/j.avsg.2015.05.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/14/2015] [Accepted: 05/26/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke prevention includes surgery for significant stenosis of internal carotid artery (ICA). Consensus on a standard approach lacks and one alternative approach is eversion carotid endarterectomy (eCEA). To overcome disadvantages of eCEA, we developed extended-eversion carotid endarterectomy (exeCEA). Aiming to investigate hemodynamics after different surgical approaches, we created computational fluid dynamics (CFD) models of exeCEA and eCEA with included progressing lumen narrowing, representation of artery restenosis at the incision line. METHODS Blood flow velocities, volume flow rates, and wall shear stress (WSS) were established in carotid arteries from models of eCEA and exeCEA with included increasing groove (1, 1.5, 2, and 2.5 mm) at the "incision line", under input pressure of 120 and 150 mm Hg. RESULTS For the corresponding restenosis grade, models of exeCEA had a larger orifice toward ICA, lower blood flow velocities and higher volume flow rates in ICA, with lower volume flow rates in external carotid artery. WSS values in ICA of exeCEA models were lower than in eCEA models, later reaching the thrombotic range. CONCLUSIONS CFD showed better hemodynamic properties in exeCEA models, indicating presented approach might be better at preserving brain perfusion.
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Affiliation(s)
- Tomislav Ištvanić
- Department of Vascular Surgery of Clinic for Surgery, University Hospital Osijek, Osijek, Croatia
| | - Zvonimir Vrselja
- Department of Radiology, University Hospital Osijek, Osijek, Croatia; Department of Anatomy and Neuroscience, Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Hrvoje Brkić
- Department of Biophysics, Medical Statistics and Medical Informatics, Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Radivoje Radić
- Department of Anatomy and Neuroscience, Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Igor Lekšan
- Department of Anatomy and Neuroscience, Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Goran Curic
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, Faculty of Medicine, University of Osijek, Osijek, Croatia.
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Benzing T, Wilhoit C, Wright S, McCann PA, Lessner S, Brothers TE. Standard duplex criteria overestimate the degree of stenosis after eversion carotid endarterectomy. J Vasc Surg 2015; 61:1457-63. [DOI: 10.1016/j.jvs.2015.01.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 01/20/2015] [Indexed: 11/25/2022]
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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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Abstract
Background:Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEAresults.Investigation:Brain imaging with CTor MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRAor CTangiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment.Indications:Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50 - 69% symptomatic stenosis, and those with asymptomatic stenosis ≥ 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions.Techniques:Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. “Eversion” endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis.Carotid angioplasty and stenting:Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA.Auditing:It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.
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Affiliation(s)
- J Max Findlay
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Emrecan B, Ozdemir AC, Onem G. Selective carotid endarterectomy and the advantages of conventional and eversion endarterectomy. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Bilgin Emrecan
- Department of Cardiac and Vascular Surgery; Pamukkale University; Denizli Turkey
| | - Ahmet Coskun Ozdemir
- Department of Cardiac and Vascular Surgery; Denizli Surgery Hospital; Denizli Turkey
| | - Gokhan Onem
- Department of Cardiac and Vascular Surgery; Pamukkale University; Denizli Turkey
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Lee JH, Suh BY. Comparative results of conventional and eversion carotid endarterectomy. Ann Surg Treat Res 2014; 87:192-6. [PMID: 25317414 PMCID: PMC4196435 DOI: 10.4174/astr.2014.87.4.192] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/31/2014] [Accepted: 04/15/2014] [Indexed: 11/30/2022] Open
Abstract
Purpose Comparative results of conventional carotid endarterectomy (cCEA) and eversion carotid endarterectomy (eCEA) have been reported in many studies. But in Korea, there have been no reports to compare the outcome of the two techniques. Thus, we investigated the results of eCEA compared to cCEA in Yeungnam University Medical Center. Methods A total of 120 subjects who underwent CEA were included in this study. Of them, cCEAs were performed in 63 patients and eCEAs were performed in 57 patients. We analyzed the results divided into the early (within 30 days after surgery), midterm (from 30 days up to 1 year after surgery) and late (over 1 year after surgery). Results Mean age of the patients was 65.9 ± 7.1 years in cCEA group and 66.8 ± 7.7 years in eCEA group (P = 0.523). Carotid shunt frequency was higher in the cCEA group (39.7% vs. 19.3%, P = 0.015). There were no statistical differences in the early complications with the exception of a significantly higher risk for new brain lesions in the cCEA group (34.9% vs. 14.0%, P = 0.008). The frequency of complication was same between cCEA group and eCEA group in the midterm. Although there was no statistical significance, the frequency of late complications was higher in the cCEA group compared to eCEA group. Mean follow-up duration was 29.4 ± 23.5 months. Conclusion These data showed that eCEA was an acceptable procedure and had some advantage compared to cCEA in the aspect of the early and late complication.
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Affiliation(s)
- Jae Hoon Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Bo Yang Suh
- Division of Vascular Surgery, Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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Georg Y, Psathas E, Alomran F, Gaudric J, Chiche L, Koskas F. Double Eversion Carotid Endarterectomy of Tandem Carotid Lesions. Ann Vasc Surg 2014; 28:1186-91. [DOI: 10.1016/j.avsg.2013.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 07/12/2013] [Accepted: 07/13/2013] [Indexed: 10/26/2022]
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Ozaki CK, Sobieszczyk PS, Ho KJ, McPhee JT, Gravereaux EC. Evidence-based carotid artery-based interventions for stroke risk reduction. Curr Probl Surg 2014; 51:198-242. [PMID: 24767101 DOI: 10.1067/j.cpsurg.2014.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/29/2014] [Indexed: 11/22/2022]
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Yasa H, Akyuz M, Yakut N, Aslan O, Akyuz D, Ozcem B, Tulukoğlu E, Gurbuz A. Comparison of two surgical techniques for carotid endarterectomy: conventional and eversion. Neurochirurgie 2014; 60:33-7. [PMID: 24673880 DOI: 10.1016/j.neuchi.2013.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 11/06/2013] [Accepted: 12/08/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The role of carotid endarterectomy for the treatment of atherosclerotic carotid bifurcation disease is now well established. The aim of this study was to compare durability, postoperative death, stroke, minor strokes, cranial nerve injuries, neck hematomas, myocardial infarctions, or surgical defects and restenosis at the operative site following short- and mid-term duration of the advantages eversion carotid endarterectomy (E-CEA) compared to conventional carotid endarterectomy (C-CEA). PATIENTS AND METHODS Between March 2003 and November 2012, primary CEAs were performed in 380 consecutive patients by the same surgical groups. These patients were evaluated retrospectively. C-CEA was performed in 202 patients, and E-CEA was performed in 178 patients. Carotid duplex ultrasonography was performed in all patients at 1, 6, 12 and 24 months after CEA to identify residual atherosclerotic carotid disease. RESULTS Mean age was 67.3±13.4 years in the E-CEA group and 64.8±14.8 years in the C-CEA group. Mean cross-clamping time in the E-CEA group was 9.54±2.6 minutes and 12.62±2.7 minutes for C-CEA group (P=0.236). Three postoperative strokes occurred (one after E-CEA and two after C-CEA). In the E-CEA group and C-CEA group respectively, carotid stenosis rates were found in 4 patients (2.24%) and in 5 (2.97%) at a follow-up period of 26 months. CONCLUSION Classical endarterectomy still remains the gold standard surgical technique for patients who are selected for coronary artery disease surgery. Nevertheless, we believe that eversion endarterectomy, which has some advantages, must be kept in mind as an alternative approach.
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Affiliation(s)
- H Yasa
- Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey.
| | - M Akyuz
- Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey.
| | - N Yakut
- Special Akut Cardiovascular Surgical Hospital, Izmir, Turkey.
| | - O Aslan
- Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey.
| | - D Akyuz
- Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey.
| | - B Ozcem
- Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey.
| | - E Tulukoğlu
- Special Akut Cardiovascular Surgical Hospital, Izmir, Turkey.
| | - A Gurbuz
- Ataturk Training and Research Hospital, Katip Celebi University, Izmir, Turkey.
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Ballotta E, Toniato A, Da Giau G, Lorenzetti R, Da Roit A, Baracchini C. Durability of eversion carotid endarterectomy. J Vasc Surg 2014; 59:1274-81. [PMID: 24423475 DOI: 10.1016/j.jvs.2013.11.088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 11/26/2013] [Accepted: 11/26/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) remains the gold standard for treating carotid disease in selected symptomatic and asymptomatic patients, though carotid angioplasty and stenting has emerged as a safe alternative. The aim of this study was to assess the durability of CEA in a large series of patients followed up according to a strict clinical and ultrasonographic protocol. METHODS Over a 23-year period (1990-2012) a total of 1773 patients (1251 men and 522 women) with a mean age of 75.2 years (range, 31 to 96 years) who underwent 2007 consecutive primary eversion CEAs performed by the same surgeon under general anesthesia with electroencephalographic monitoring and selective shunting were prospectively followed up with ultrasonography at 1, 6, and 12 months, then yearly. A long-term follow-up (median, 11.2 years; mean, 12.9 years) was obtained for 1680 patients (94.8%). End points were perioperative (30-day) stroke and death and late carotid restenosis/occlusion rates. RESULTS More than two in three of the lesions (1446 of 2007, 72.1%) were symptomatic at the time of surgery, with a 25% rate of preoperative stroke. Preoperative antiplatelet or anticoagulant therapy was used by 1675 patients (94.4%), whereas 918 (51.8%) were receiving statin treatment. Overall, there were eight (0.4%) perioperative strokes and no deaths. During the follow-up, there were nine (0.47%) asymptomatic late carotid restenoses (six moderate [50%-69%] and three severe [≥ 70%]) and one (0.05%) carotid occlusion. Nine patients (0.47%) had late ipsilateral strokes, none of them related to restenosis/occlusion. Overall, there were 159 late deaths (9.4%). CONCLUSIONS The results of this study show that eversion CEA can be performed in symptomatic and asymptomatic patients with an extremely low perioperative stroke/death risk and a negligible incidence of late restenosis/occlusion, thus assuring a persistently good protection against the risk of cerebral ischemia.
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Affiliation(s)
- Enzo Ballotta
- Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological, and Gastroenterological Sciences at the University of Padua, School of Medicine, Padova, Italy.
| | - Antonio Toniato
- Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological, and Gastroenterological Sciences at the University of Padua, School of Medicine, Padova, Italy
| | - Giuseppe Da Giau
- Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological, and Gastroenterological Sciences at the University of Padua, School of Medicine, Padova, Italy
| | - Renata Lorenzetti
- Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological, and Gastroenterological Sciences at the University of Padua, School of Medicine, Padova, Italy
| | - Anna Da Roit
- Vascular Surgery Group, 2nd Surgical Clinic, Department of Surgical, Oncological, and Gastroenterological Sciences at the University of Padua, School of Medicine, Padova, Italy
| | - Claudio Baracchini
- Department of Neurosciences at the University of Padua, School of Medicine, Padova, Italy
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LeSar CJ, Sprouse LR, Harris WB. Permissive hypertension during awake eversion carotid endarterectomy: a physiologic approach for cerebral protection. J Am Coll Surg 2014; 218:760-6. [PMID: 24655867 DOI: 10.1016/j.jamcollsurg.2013.12.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 12/30/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is often completed with general anesthesia and routine shunting; however, shunting is only required in a small group of at-risk patients to maintain adequate cerebral perfusion. Selective shunting during CEA is performed to normalize cerebral hemodynamics for patients determined to be at risk. Eversion CEA with selective shunting for neurologic dysfunction in patients that are awake/sedated is described, as well as routine use of permissive hypertension (PH), which uses standard cardiovascular medications to recruit the cerebral collateral network and reduce the need for shunting. STUDY DESIGN A retrospective review of all CEA procedures performed from July 2006 to April 2013 was conducted. Procedures were divided into 3 groups: pre-PH phase (group A), PH-test phase (group B), and routine PH phase (group C). Operative reports and anesthesia documentation were reviewed for clamp time, need for shunting, and mean hemodynamics during each case. RESULTS During the study period, 232 CEAs met inclusion criteria and were divided into 3 groups: group A (n = 75) was predominate reactionary shunting, group B (n = 41) was predominate reactionary blood pressure augmentation, and group C (n = 116) was pre-emptive PH. When combining groups A and B, the at-risk group consisted of 21 of 116 (18.1%) patients who had a neurologic compromise develop after clamping the internal carotid artery and required a shunt or altered blood pressure hemodynamics. In comparison with group C, routine use of PH pre-emptively before clamping as a standard intraoperative technique led to need for shunting in 1 of 116 (0.86%) (p ≤ 0.001) and significantly reduced operative time (p ≤ 0.0001). CONCLUSIONS Routine use of PH during clamp time can recruit the cerebral collateral network and substantially reduce the at-risk group and need for shunting in awake/sedated patients.
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Affiliation(s)
- Christopher J LeSar
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN.
| | - L Richard Sprouse
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN
| | - William B Harris
- Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN
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Carotid surgery in private practice: what kind of change in the last 15 years? Ann Vasc Surg 2013; 28:239-44. [PMID: 24011809 DOI: 10.1016/j.avsg.2013.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 01/24/2013] [Accepted: 02/01/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND This retrospective study analyzes and compares the results of patients undergoing carotid endarterectomy (CE) for atherosclerotic stenosis obtained by 2 surgeons during two 5-year periods. Group 1 (G1) represents the first period (January 1994-December 1998) and group 2 (G2) represents the second period (January 2006-December 2010). Our objective was to answer the 2 following questions: (1) Has the population changed between these 2 periods with regard to age, risk factors, and symptoms? (2) Have the techniques we used in G2--local anesthesia and eversion technique--improved the results? METHODS G1 included 682 CE procedures on 610 patients and G2 included 629 procedures on 592 patients. The following factors were analyzed in G1 and G2: distribution of age and sex, the main risk factors (diabetes and cardiovascular risk), symptomatology, the degree of stenosis, the preoperative computed tomography (CT) data, the type of anesthesia (general or local), the use of an intraoperative shunt, surgical techniques, postoperative patency, cardiac complications, central and peripheral neurologic complications, and reoperations. In conformity with the North American Symptomatic Carotid Endarterectomy Trial classifications, stenosis of >70% was included in this survey. Loops, tumors, aneurysms, and restenosis were excluded. Heparin (300 U.I./kg) was administered. Shunt placing was selective. The 3 most common techniques used were eversion, longitudinal CE with patch angioplasty, and CE with direct closure. Postoperative patency was controlled by intravenous digital angiography or duplex ultrasonography. Follow-up occurred until postoperative day 30. RESULTS Compared with G1, the incidence of arterial hypertension, diabetes, and coronary atherosclerosis treated by angioplasty increased significantly in G2; local anesthesia replaced general anesthesia in G2, and fewer intraoperative shunts were used (P = 0.034). The technique of direct closure of the arteriotomy was no longer used. In contrast to G1, in G2 no postoperative carotid thromboses (P = 1.8) and no lethal strokes (P = 5.44) were observed. The incidence of major adverse cardiovascular events on postoperative day 30 was 1.7% in G1 compared with 0.79% in G2. The combined mortality and morbidity rate--including reoperations and peripheral neurologic deficits--was 3.95% in G1 compared with 3.81% in G2. CONCLUSION Despite a major increase in risk factors, the combined use of local anesthesia and eversion technique, when technically feasible, improved our results in G2.
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Kamenskiy AV, Pipinos II, Dzenis YA, Gupta PK, Jaffar Kazmi SA, Mactaggart JN. A mathematical evaluation of hemodynamic parameters after carotid eversion and conventional patch angioplasty. Am J Physiol Heart Circ Physiol 2013; 305:H716-24. [PMID: 23812386 DOI: 10.1152/ajpheart.00034.2013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Carotid endarterectomy has a long history in stroke prevention, yet controversy remains concerning optimal techniques. Two methods frequently used are endarterectomy with patch angioplasty (CEAP) and eversion endarterectomy (CEE). The objective of this study was to compare hemodynamics-related stress and strain distributions between arteries repaired using CEAP and CEE. Mathematical models were based on in vivo three-dimensional arterial geometry, pulsatile velocity profiles, and intraluminal pressure inputs obtained from 16 patients with carotid artery disease. These data were combined with experimentally derived nonlinear, anisotropic carotid artery mechanical properties to create fluid-structure interaction models of CEAP and CEE. These models were then used to calculate hemodynamic parameters thought to promote recurrent disease and restenosis. Combining calculations of stress and strain into a composite risk index, called the integral abnormality factor, allowed for an overall comparison between CEAP and CEE. CEE demonstrated lower mechanical stresses in the arterial wall, whereas CEAP straightened the artery and caused high stress and strain concentrations at the suture-artery interface. CEAP produced a larger continuous region of oscillatory, low-shear, vortical flow in the carotid bulb. There was a more than two-fold difference in the integral abnormality factor, favoring CEE. In conclusion, in a realistically simulated carotid artery, fluid-structure interaction modeling demonstrated CEE to produce less mechanical wall stress and improved flow patterns compared with CEAP. Clinical validation with larger numbers of individual patients will ultimately be required to support modeling approaches to help predict arterial disease progression and comparative effectiveness of reconstruction methods and devices.
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Affiliation(s)
- Alexey V Kamenskiy
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Yuo TH, Roberts MS, Braithwaite RS, Chang CCH, Kraemer KL. Applying the payoff time framework to carotid artery disease management. Med Decis Making 2013; 33:1039-50. [PMID: 23784846 DOI: 10.1177/0272989x13491462] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND and OBJECTIVE Asymptomatic stenosis of the carotid arteries is associated with stroke. Carotid revascularization can reduce the future risk of stroke but can also trigger an immediate stroke. The objective was to model the generic relationship between immediate risk, long-term benefit, and life expectancy for any one-time prophylactic treatment and then apply the model to the use of revascularization in the management of asymptomatic carotid disease. METHODS In the "payoff time" framework, the possibility of losing quality-adjusted life-years (QALYs) because of revascularization failure is conceptualized as an "investment" that is eventually recouped over time, on average. Using this framework, we developed simple mathematical forms that define relationships between the following: perioperative probability of stroke (P); annual stroke rate without revascularization (r0); annual stroke rate after revascularization, conditional on not having suffered perioperative stroke (r1); utility levels assigned to the asymptomatic state (ua) and stroke state (us); and mortality rates (λ). RESULTS In patients whose life expectancy is below a critical life expectancy (CLE = P/(1-P)r0-r1, the "investment" will never pay off, and revascularization will lead to loss of QALYs, on average. CLE is independent of utilities assigned to the health states if a rank ordering exists in which ua > us. For clinically relevant values (P = 3%, r0 = 1%, r1 = 0.5%), the CLE is approximately 6.4 years, which is longer than published guidelines regarding patient selection for revascularization. CONCLUSIONS In managing asymptomatic carotid disease, the payoff time framework specifies a CLE beneath which patients, on average, will not benefit from revascularization. This formula is suitable for clinical use at the patient's bedside and can account for patient variability, the ability of clinicians who perform revascularization, and the particular revascularization technology that is chosen.
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Affiliation(s)
- Theodore H Yuo
- Division of Vascular Surgery, Pittsburgh, PA (THY).,RAND–University of Pittsburgh Health Institute, Pittsburgh, PA (THY)
| | - Mark S Roberts
- Center for Research on Health Care, Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA (MSR, CHC, KLK),Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (MSR)
| | - R Scott Braithwaite
- Section on Value and Effectiveness, Division of General Internal Medicine, Department of Medicine, School of Medicine, New York University, New York, NY (RSB)
| | - Chung-Chou H Chang
- Center for Research on Health Care, Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA (MSR, CHC, KLK),Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA (CHC)
| | - Kevin L Kraemer
- Center for Research on Health Care, Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA (MSR, CHC, KLK)
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Dalla Vecchia L, Barbic F, Galli A, Pisacreta M, Gornati R, Porretta T, Porta A, Furlan R. Favorable effects of carotid endarterectomy on baroreflex sensitivity and cardiovascular neural modulation: a 4-month follow-up. Am J Physiol Regul Integr Comp Physiol 2013; 304:R1114-20. [PMID: 23576607 DOI: 10.1152/ajpregu.00078.2013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Carotid surgery variably modifies carotid afferent innervation, thus affecting arterial baroreceptor sensitivity. Low arterial baroreflex sensitivity is a well-known independent risk factor for cardiovascular diseases. The aim of this study was to assess the 4-mo effects of carotid endarterectomy (CEA) on arterial baroreceptor sensitivity and cardiovascular autonomic profile in patients with unilateral carotid stenosis. We enrolled 20 patients (72 ± 8 yr) with unilateral >70% carotid stenosis. ECG, beat-by-beat blood pressure, and respiration were continuously recorded before and 126 ± 9 days after CEA, at rest and during a 75° head-up tilt. Both pharmacological (modified Oxford technique, BRS) and spontaneous (index α, spectral analysis) arterial baroreflex sensitivity were assessed. Cardiovascular autonomic profile was evaluated by plasma catecholamines and spectral indexes of cardiac sympathovagal modulation [low-frequency R-R interval (LFRR), low frequency-to high frequency ratio (LF/HF), high-frequency R-R interval (HFRR)] and sympathetic vasomotor control [low-frequency systolic arterial pressure (LFSAP)] obtained from heart rate and SAP variability. After CEA, both the index α and BRS were higher (P < 0.02) at rest. SAP variance decreased both at rest and during tilt (P < 0.02). Before surgery, tilt did not modify the autonomic profile compared with baseline. After CEA, tilt increased LF/HF and LFSAP and reduced HFRR compared with rest (P < 0.02). Four months after CEA was performed, arterial baroreflex sensitivity was enhanced. Accordingly, the patients' autonomic profile had shifted toward reduced cardiac and vascular sympathetic activation and enhanced cardiac vagal activity. The capability to increase cardiovascular sympathetic activation in response to orthostasis was restored. Baroreceptor sensitivity improvement might play an additional role in the more favorable outcome observed in patients after carotid surgery.
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