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Haywood NS, Ratcliffe SJ, Zheng X, Mao J, Farivar BS, Tracci MC, Malas MB, Goodney PP, Clouse WD. Operative and long-term outcomes of combined and staged carotid endarterectomy and coronary bypass. J Vasc Surg 2023; 77:1424-1433.e1. [PMID: 36681256 PMCID: PMC10353412 DOI: 10.1016/j.jvs.2023.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/31/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Optimal temporal surgical management of significant carotid stenosis and coronary artery disease remains unknown. Carotid endarterectomy (CEA) and coronary artery bypass (CABG) are performed concurrently (CCAB) or in a staged (CEA-CABG or CABG-CEA) approach. Using the Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network-Medicare-linked dataset, this study compared operative and long-term outcomes after CCAB and staged approaches. METHODS The Vascular Quality Initiative-Vascular Implant Surveillance and Interventional Outcomes Coordinated Registry Network dataset was used to identify CEAs from 2011 to 2018 with combined CABG or CABG within 45 days preceding or after CEA. Patients were stratified based on concurrent or staged approach. Primary outcomes were stroke, myocardial infarction (MI), all-cause mortality, stroke and death as composite (SD) and all as composite within 30 days from the last procedure as well as in the long term. Univariate analysis and risk-adjusted analysis using inverse propensity weighting were performed. Kaplan-Meier curves of stroke, MI, and death were created and compared. RESULTS There were 1058 patients included: 643 CCAB and 415 staged (309 CEA-CABG and 106 CABG-CEA). Compared with staged patients, those undergoing CCAB had a higher preoperative rate of congestive heart failure (24.8% vs 18.4%; P = .01) and decreased renal function (14.9% vs 8.5%; P < .01), as well as fewer prior neurological events (23.5% vs 31.4%; P < .01). Patients undergoing CCAB had similar weighted rate of 30-day stroke (4.6% vs 4.1%; P = .72), death (7.0% vs 5.0%; P = .32), and composite outcomes (stroke and death, 9.8% vs 8.5%; P = .56; stroke, death, and MI, 14.7% vs 17.4%; P = .31), but a lower weighted rate of MI (5.5% vs 11.5%; P < .01) vs the staged cohort. Long-term adjusted risks of stroke (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.54-1.36; P = .51) and mortality (HR, 1.02; 95% CI, 0.76-1.36; P=.91) were similar between groups, but higher risk of MI long-term was seen in those staged (HR, 1.49; 95% CI, 1.07-2.08; P = .02). CONCLUSIONS In patients undergoing CCAB or staged open revascularization for carotid stenosis and coronary artery disease, the staged approach had an increased risk of postoperative cardiac event, but the short- and long-term rates of stroke and mortality seem to be comparable. Adverse cardiovascular event risk is high between operations when staged and should be a consideration when selecting an approach. Although factors leading to staged sequencing performance need further clarity, CCAB seems to be safe and should be considered an equally reasonable option.
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Affiliation(s)
- Nathan S Haywood
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Sarah J Ratcliffe
- Department of Biostatistics, University of Virginia, Charlottesville, VA
| | - Xinyan Zheng
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Behzad S Farivar
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret C Tracci
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Mahmoud B Malas
- Department of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Philip P Goodney
- Department of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Department of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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Li B, Eisenberg N, Howe KL, Forbes TL, Roche-Nagle G. The impact of sex on outcomes following carotid endarterectomy. Ann Vasc Surg 2022; 88:210-217. [PMID: 36029946 DOI: 10.1016/j.avsg.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Previous studies have demonstrated significant sex differences in vascular surgery outcomes. We assessed stroke or death rates following carotid endarterectomy (CEA) in women vs. men. METHODS The Vascular Quality Initiative (VQI) was used to identify all patients who underwent CEA between 2010-2019. Demographic, clinical, and procedural characteristics were recorded and differences between women vs. men were assessed using independent t-test and chi-square test. The primary outcomes were 30-day and 1-year stroke or death. Associations between sex and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis. RESULTS 52,137 women and 79,974 men underwent CEA in VQI sites during the study period. Women were younger (70.3 vs. 70.5 years, p < 0.001) and more likely to have hypertension (89.2% vs. 88.9%, p < 0.05) and diabetes (36.2% vs. 35.8%, p < 0.001), but less likely to be diagnosed with coronary artery disease (23.2% vs. 31.0%, p < 0.001). A greater proportion of men were receiving cardiovascular risk reduction medications and had symptomatic carotid stenosis (28.5% vs. 26.7%, p < 0.001). Women had shorter procedure times (113 vs. 122 minutes, p < 0.001) and were less likely to receive electroencephalography neuromonitoring (27.9% vs. 28.8%, p < 0.001), drain (35.9% vs. 37.3%, p < 0.001), and protamine (67.4% vs. 68.0%, p < 0.01). Stroke or death at 30 days (1.9% vs. 1.8%, p = 0.60) and 1 year (HR 0.98 [95% CI 0.94 - 1.01], p = 0.20) were similar between groups, which persisted in asymptomatic patients (HR 0.97 [95% CI 0.93 - 1.01], p = 0.17) and symptomatic patients (HR 0.99 [95% CI 0.93 - 1.05], p = 0.71). The similarities in 1-year stroke or death rates existed in both the US (HR 0.96 [95% CI 0.92 - 1.01], p = 0.09) and Canada (HR 1.21 [95% CI 0.47 - 3.11], p = 0.70). CONCLUSIONS Despite sex differences in clinical and procedural characteristics, women and men have similar 30-day and 1-year outcomes following carotid endarterectomy.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn L Howe
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Chuatrakoon B, Nantakool S, Rerkasem A, Orrapin S, Howard DP, Rerkasem K. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev 2022; 6:CD000190. [PMID: 35731671 PMCID: PMC9216235 DOI: 10.1002/14651858.cd000190.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. The shunt may improve the outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2002, 2009, and 2014. OBJECTIVES To assess the effect of routine versus selective or no shunting, and to assess the best method for selective shunting on death, stroke, and other complications in people undergoing carotid endarterectomy under general anaesthesia. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched April 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2021, Issue 4), MEDLINE (1966 to April 2021), Embase (1980 to April 2021), and the Science Citation Index Expanded (SCI-EXPANDED) (1980 to April 2021). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and handsearched relevant journals, conference proceedings, and reference lists. SELECTION CRITERIA Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. DATA COLLECTION AND ANALYSIS Three independent review authors performed data extraction, selection, and analysis. A pooled Peto odds ratio (OR) and 95% confidence interval (CI) were computed for all outcomes of interest. Best and worse case scenarios were also calculated in case of unavailable data. Two authors independently assessed risk of bias, and quality of evidence using GRADE. MAIN RESULTS No new trials were found for this updated review. Thus, six trials involving 1270 participants are included in this latest review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Only three trials comparing routine shunting and no shunting were eligible for meta-analysis. Major findings of this comparison found that the routine shunting had less risk of stroke-related death within 30 days of surgery (best case) than no shunting (Peto odds ratio (OR) 0.13, 95% confidence interval (CI) 0.02 to 0.96, I2 not applicable, P = 0.05, low-quality evidence), the routine shunting group had a lower stroke rate within 24 hours of surgery (Peto odds ratio (OR) 0.15, 95% CI 0.03 to 0.78, I2 = not applicable, P = 0.02, low-quality evidence), and ipsilateral stroke within 30 days of surgery (best case) (Peto OR 0.41, 95% CI 0.18 to 0.97, I2 = 52%, P = 0.04, low-quality evidence) than the no shunting group. No difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring. However, this analysis was inadequately powered to reliably detect the effect. There was no difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited. AUTHORS' CONCLUSIONS This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy when performed under general anaesthesia. Large-scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.
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Affiliation(s)
- Busaba Chuatrakoon
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Sothida Nantakool
- Environmental - Occupational Health Sciences and Non Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Amaraporn Rerkasem
- Environmental - Occupational Health Sciences and Non Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Dominic Pj Howard
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kittipan Rerkasem
- Environmental - Occupational Health Sciences and Non Communicable Diseases Research Group, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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5
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Zagzoog N, Elgheriani A, Attar A, Takroni R, Aljoghaiman M, Klotz L, Vandervelde C, Darling C, Farrokhyar F, Martyniuk A, Algird A. Comprehensive comparison of carotid endarterectomy primary closure and patch angioplasty: A single-institution experience. Surg Neurol Int 2022; 13:1. [PMID: 35127201 PMCID: PMC8813614 DOI: 10.25259/sni_1013_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA. Methods: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients’ baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured. Results: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82–1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort. Conclusion: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.
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Affiliation(s)
- Nirmeen Zagzoog
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Ali Elgheriani
- Department of Internal Medicine, University of Manitoba, Manitoba, Canada
| | - Ahmed Attar
- Department of Neurology, McMaster University, Hamilton, Canada,
- King Abdullah International Medical Research Center, Jeddeah, Saudi Arabia,
| | - Radwan Takroni
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Majid Aljoghaiman
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Klotz
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Chloe Darling
- Fleming School of Nursing, Trent University, Peterborough, Ontario, Canada
| | - Forrough Farrokhyar
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Martyniuk
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Almunder Algird
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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Bell PRF. Open Surgery has not had its Day. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2001.12098598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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7
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Martin GH, Saqib NU, Safi HJ. Treatment of an Infected, Bovine Pericardial Carotid Patch: Excision and Reconstruction with a Superficial Femoral Arterial Interposition Graft. Ann Vasc Surg 2020; 70:565.e1-565.e5. [PMID: 32768534 DOI: 10.1016/j.avsg.2020.07.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/20/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
Carotid patch infection is a rare complication but one often associated with severe morbidity, including hemorrhage, stroke, cranial nerve injury, and mortality. We present a case of a gram-negative bacterial infection of a bovine pericardial carotid patch. Treatment ultimately required patch explantation and reconstruction with a femoral arterial interposition graft.
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Affiliation(s)
- Gordon H Martin
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX.
| | - Naveed U Saqib
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
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8
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Agacayak KS, Guler R, Sezgin Karatas P. Relation Between the Incidence of Carotid Artery Calcification and Systemic Diseases. Clin Interv Aging 2020; 15:821-826. [PMID: 32581522 PMCID: PMC7276320 DOI: 10.2147/cia.s256588] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background The aim of this study is to investigate the relationship of carotid artery calcifications detected in panoramic radiographs of patients aged 60 or older with isolated systemic diseases. Patients and Methods From October 2018 to December 2019, 867 panoramic radiographs of patients, who applied to Dicle University Faculty of Dentistry for various dental reasons, were collected for examination. Of these 867 panoramic radiographs, 444 panoramic radiographs were included in this study. Medical data were collected from the archival records of the dental school. Results The study population consisted of 240 female (54.1%) and 204 male (45.9%) patients. Their mean age was 66 ± 7.3 (range: 60–92) years. Only 39 (8.8%) of the 444 patients had atherosclerotic plaques. Of the 39 patients with carotid artery calcification, 13 (33.3%) were male and 26 (66.7%) were female. As a result of statistical analysis, carotid artery calcification compared to other systemic diseases was found to be significantly more common in patients with hypertension (p = 0.009). Conclusion Carotid artery calcifications detected coincidentally in standard panoramic radiographs of dental patients may be important markers for preventing serious risks such as coronary artery disease, stroke, and death. The relationship between carotid artery calcifications found on dental panoramic radiographs and hypertension was significant. Therefore, it seems that detection of carotid artery calcifications on panoramic images of hypertension patients must be considered by dentists.
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Affiliation(s)
- Kamil Serkan Agacayak
- Department of Oral and Maxillofacial Surgery, Dicle University School of Dentistry, Diyarbakır, Turkey
| | - Rıdvan Guler
- Department of Oral and Maxillofacial Surgery, Dicle University School of Dentistry, Diyarbakır, Turkey
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Editor's Choice – Prognostic Role of Pre-Operative Symptom Status in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 59:516-524. [DOI: 10.1016/j.ejvs.2020.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/16/2019] [Accepted: 01/16/2020] [Indexed: 01/10/2023]
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10
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Dulai M, Tawfick W, Hynes N, Sultan S. Female Gender as a Risk Factor for Adverse Outcomes After Carotid Revascularization. Ann Vasc Surg 2019; 60:254-263. [PMID: 31200032 DOI: 10.1016/j.avsg.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 02/20/2019] [Accepted: 03/15/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND We aim to identify gender differences in complications after carotid surgery. Our primary endpoint is the incidence of perioperative stroke, myocardial infarction, and mortality. Secondary endpoints include restenosis and reintervention rates. METHODS All patients undergoing carotid endarterectomy from July 2003 to May 2016 were reviewed. The Society for Vascular Surgery carotid reporting standards were used as a guideline for data collection. RESULTS Over 13 years, 9,585 patients with carotid disease were referred to our institution. A total of 690 procedures were performed (633 carotid endarterectomies, 54 carotid angioplasties and stenting, and 3 bypasses). Of these 633 carotid endarterectomy procedures, 31.8% (201) were in women and 68.2% (432) were in men. In the perioperative period, female gender was found to be an independent predictor of stroke (odds ratio [OR]: 8.597, 95% confidence interval [CI]: 0.967-76.429, P = 0.041), restenosis (OR: 2.103, 95% CI: 1.445-3.060, P < 0.001), and reintervention (OR: 6.448, 95% CI: 1.313-31.667, P = 0.019). Mortality and cardiac morbidity did not significantly differ between genders. Ten-year stroke-free survival was 98.0% in women and 99.1% in men (logrank P = 0.259). Ten-year restenosis-free survival was 77.6% (45 of 201) in women and 89.4% (45 of 425) in men (logrank P < 0.001). Ten-year reintervention-free survival was 97.0% in women and 99.5% in men (logrank P = 0.008). Female gender was not an independent predictor of myocardial infarction (P = 0.713) and mortality (P = 0.856), respectively. The mean follow-up time was 47.06 ± 37.48 months with a median follow-up time of 43 months (interquartile range: 14.0-72.5). CONCLUSIONS Female gender was an independent predictor of postoperative stroke, restenosis, and reintervention. Symptom status at the time of surgery and type of closure of the arteriotomy did not influence development of stroke in female patients.
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Affiliation(s)
- Makinderjit Dulai
- Western Vascular Institute Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Galway, Ireland
| | - Wael Tawfick
- Western Vascular Institute Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland
| | - Sherif Sultan
- Western Vascular Institute Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Galway, Ireland; Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland.
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Extrakranielle Karotisstenose beim herzchirurgischen Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0250-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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12
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Vinogradov RA, Pykhteev VS, Martirosova KI, Lashevich KA. [Perioperative complications prognosis in carotid endarterectomy]. Khirurgiia (Mosk) 2018:82-85. [PMID: 29376964 DOI: 10.17116/hirurgia2018182-85] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- R A Vinogradov
- Research Institute - Ochapovsky Regional Clinical Hospital # 1, Krasnodar, Russia; Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| | - V S Pykhteev
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
| | - K I Martirosova
- Pirogov Russian National Research Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - K A Lashevich
- Kuban State Medical University of Healthcare Ministry of the Russian Federation, Krasnodar, Russia
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Huntress LA, Nassiri N, Shafritz R, Rahimi SA. Transcervical Carotid Stent Placement in the Setting of a Hostile Neck and a Type III Aortic Arch. Vasc Endovascular Surg 2017; 51:346-349. [DOI: 10.1177/1538574417710601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Previous radical neck dissection and neck irradiation pose considerable operative risks in patients requiring carotid endarterectomy for symptomatic carotid disease. Carotid stenting is an acceptable alternative for these patients but carries a higher risk of cerebrovascular accidents especially in patients with type III aortic arch anatomy. Herein, we present a technically challenging case of a patient with an irradiated neck and a history of radical neck dissection who presented with a symptomatic high-grade left internal carotid artery stenosis in the setting of a type III aortic arch. He was treated via a hybrid approach for carotid artery stenting.
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Affiliation(s)
| | - Naiem Nassiri
- Division of Vascular Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Randy Shafritz
- Division of Vascular Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum A. Rahimi
- Division of Vascular Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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14
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Wang GJ, Beck AW, DeMartino RR, Goodney PP, Rockman CB, Fairman RM. Insight into the cerebral hyperperfusion syndrome following carotid endarterectomy from the national Vascular Quality Initiative. J Vasc Surg 2016; 65:381-389.e2. [PMID: 27707618 DOI: 10.1016/j.jvs.2016.07.122] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/24/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral hyperperfusion syndrome (CHS), characterized by severe ipsilateral headache, seizures, and intracranial hemorrhage, is a rare, poorly understood complication that can be fatal following carotid endarterectomy (CEA). The purpose of the study was to determine the factors associated with CHS as captured in the Vascular Quality Initiative. METHODS Analysis was conducted on 51,001 procedures captured from the CEA module of the Vascular Quality Initiative from 2003 to 2015. Preoperative, operative, and postoperative variables were considered for inclusion in logistic regression analyses to determine possible associations with CHS. The relative contribution of each variable to the overall model was determined using dominance analysis. RESULTS The mean age was 70.2 ± 9.4 years; there were 39.6% female patients, 93.1% of white race, with 29.6% of CEAs being performed for symptomatic status. The overall rate of CHS was 0.18% (n = 94), with 55.1% occurring in asymptomatic and 44.9% occurring in symptomatic patients with an associated mortality rate of 38.2%. Multivariable analysis including preoperative variables showed that female gender (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.09-2.51; P = .019), <1 month major ipsilateral stroke (OR, 5.36; 95% CI, 2.35-12.22; P < .001), coronary artery disease (OR, 1.77; 95% CI, 1.15-2.71; P = .009), and contralateral stenosis ≥70% (OR, 1.54; 95% CI, 1.00-2.36; P = .050) were independently associated with CHS and that <1 month major stroke was the most important contributor to the model. With the additional inclusion of operative and postoperative variables, female gender (OR, 1.75; 95% CI, 1.14-2.67; P = .010), <1 month ipsilateral major stroke (OR, 3.20; 95% CI, 1.32-7.74; P = .010), urgency (OR, 2.25; 95% CI, 1.38-3.67; P = .001), re-exploration (OR, 2.98; 95% CI, 1.27-6.97; P = .012), postoperative hypertension (OR, 4.09; 95% CI, 2.65-6.32; P < .001), postoperative hypotension (OR, 3.21; 95% CI, 1.97-5.24; P < .001), dysrhythmias (OR, 3.23; 95% CI, 1.64-6.38; P = .001), and postoperative myocardial infarction (OR, 2.84; 95% CI, 1.21-6.67; P = .017) were significantly associated with CHS, with postoperative blood pressure lability and cardiac complications having the strongest associations with CHS. CONCLUSIONS The risk of CHS was highest in female patients and in those with a recent major stroke, coronary artery disease, and contralateral stenosis ≥70%. In addition, in adjusting for operative and postoperative variables, CHS was most significantly associated with postoperative blood pressure lability and cardiac complications. These data lend insight into a high-risk population for this devastating complication.
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Affiliation(s)
- Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
| | - Adam W Beck
- Division of Vascular Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | | | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchock Medical Center, Lebanon, NH
| | - Caron B Rockman
- Division of Vascular Surgery, NYU Langone Medical Center, New York, NY
| | - Ronald M Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
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15
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Lepore MR, Jordan WD, Fisher WS, Voellinger DC, Redden D, McDowell HA. Treatment of Recurrent Carotid Stenosis: Angioplasty with Stenting versus Reoperative Carotid Surgery. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449803200602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgical treatment of recurrent carotid stenosis (RCS) requires additional decision making as compared with the treatment of primary carotid disease. The thromboembolic risk of the lesion may vary according to the time interval from the original carotid endarterectomy to the recurrence of stenosis. Percutaneous transluminal angioplasty with stenting (PTAS) has been offered as an alternative to reoperative carotid endarterectomy (RCEA). A retrospective analysis of a computerized registry identified 43 patients who underwent treatment for 50 recurrent carotid stenoses between 1986 and 1997, 28 by PTAS and 15 by RCEA. The time interval from previous endarterectomy until secondary treatment was less than 2 years for 16 arteries (32%) and more than 2 years for 34 arteries (68%). Indications for treatment were asymptomatic high-grade stenosis in 31 patients (72.1%), transient ischemic attack (TIA) in 10 patients (25.6%), and stroke in 1 patient (2.3%). Neurologic results in the PTAS group (28) included three patients who experienced TIAs (10.7%), five patients with strokes (17.9%), but no deaths. In the RCEA group (15), no patients experienced TIAs, one patient died from a fatal stroke (6.7%), and one patient had a cranial nerve injury (6.7%). Neurologic benefit provided by PTAS for the treatment of recurrent carotid stenosis cannot be identified when compared with RCEA in this limited series.
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Affiliation(s)
| | | | | | | | | | - Holt A. McDowell
- Department of Surgery, University of Alabama at Birmingham, Alabama
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16
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Goldman KA, Singhal A, Kahn SP, Davidson JT, Patel N, Patel T, Patel M. Carotid Artery Endarterectomy in the Octogenarian: A Community Hospital Experience. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449903300503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Between May 1995 and April 1998 three vascular surgeons performed 310 consecutive primary carotid endarterectomies (CEAs) in a 224-bed community hospital. Seventy-six CEAs were performed in octogenarians (Group 1) and 234 CEAs were performed in nonoctogenarians (Group 2). Demographic information, indication for surgery, and outcomes were compared. There were no strokes or deaths in Group 1; there was a single death and three strokes in Group 2. The overall rates of death, stroke, and combined stroke and death were 0.3%, 1%, and 1% respectively. No statistically significant difference existed in rates of morbidity and mortality in Groups 1 and 2. On follow-up (mean = 18 months), 94% of the patients were alive without stroke, 5% were dead, and 1% were alive with stroke. These data demonstrate that CEA can be performed safely in the octogenarian in the community hospital setting.
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Affiliation(s)
- Kenneth A. Goldman
- The Medical Center at Princeton, Department of Surgery, Princeton, New Brunswick, New Jersey
| | - Arun Singhal
- University of Medicine and Dentistry of New Jersey, Department of Surgery, New Brunswick, New Jersey
| | | | - J. Thomas Davidson
- The Medical Center at Princeton, Department of Surgery, Princeton, New Brunswick, New Jersey
| | | | | | - Munjal Patel
- University of Medicine and Dentistry of New Jersey, Department of Surgery, New Brunswick, New Jersey
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17
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Nguyen L, Liles DR, Lin PH, Bush RL. Hormone Replacement Therapy and Peripheral Vascular Disease in Women. Vasc Endovascular Surg 2016; 38:547-56. [PMID: 15592636 DOI: 10.1177/153857440403800609] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Women have been shown to have a lower incidence of vascular disease when compared to men. However, the incidence of vascular disease increases as women progress through menopause and reaches an incidence similar to that of men later in life. Women with peripheral vascular disease often have a delay in diagnosis, a higher incidence of asymptomatic disease, and poorer outcome after interventions. The differences in outcome have been attributed to a number of factors such as anatomic and hormonal differences. It is thought that estrogen deficiency is at least partially responsible for the increased risk of developing vascular disease after menopause, and thus hormone replacement therapy has been considered as a method to prevent progression of vascular disease. Conclusions drawn from a number of recent studies have resulted in a divergent view of hormone replacement therapy (HRT). This article explores the risk of peripheral vascular disease in women and the current state of research on hormone replacement therapy. The aims of this review are to present current perspectives on gender differences in the pathogenesis and outcomes of peripheral arterial disease (PAD). The effect of estrogen on atherogenesis, the role it plays in modulating the vascular endothelium, and the current evidence of the effects of HRT on vascular pathology is discussed. The most recent HRT clinical trials and present evidence for the benefits and risks of postmenopausal hormone replacement therapy are summarized. The effect of these issues on treatment practices is explained and suggestions are made for future directions of HRT and PAD research.
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Affiliation(s)
- Liz Nguyen
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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18
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Archie JP. Restenosis After Carotid Endarterectomy in Patients with Paired Vein and Dacron Patch Reconstruction. ACTA ACUST UNITED AC 2016; 35:419-27. [PMID: 16222380 DOI: 10.1177/153857440103500601] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This is an analysis of restenosis after bilateral carotid endarterectomy (CEA) with saphenous vein patch reconstruction on one side and Dacron patch reconstruction on the other. The possibility that differences in reconstruction geometry between vein and Dacron patched sides effected restenosis outcomes was evaluated as was the value of serial common carotid wall thickness measurements in predicting restenosis. Between 1990 and 1997, 33 bilateral CEA were performed within one year on 22 men and 11 women using a greater saphenous vein patch on one side and a knitted Dacron patch on the other. Interoperative post-CEA geometry was measured. Follow-up was by duplex scans that included wall thickness measurements in the endarterectomized common carotid bulb. Over a mean follow-up of 43 months 10 (30%) Dacron patched and one (3%) vein patched CEA developed?25% restenosis (p=0.001), seven (21%) Dacron patched and no vein patched CEA developed >50% restenosis (p=0.01) and four (12%) Dacron patched and no vein patched CEA developed >70% restenosis (p =0.1 1). The Kaplan-Meier cumulative >25% restenosis rates for Dacron and vein patched CEA were 22% and 0% at 2 years and 41% and 5% at 5 years respectively (p=0.002). The cumulative >50% restenosis rates for Dacron and vein patched CEA were 16% and 0% at 2 years and 34% and 0% at 5 years respectively (p = 0.003). The cumulative?70% restenosis rates for Dacron and vein patched CEA were 8% and 0% at 2 years and 20% and 0% at 5 years respectively (p = 0.02). For both patients with and without recurrent stenosis the mean within patient between sides differences of the diameters of the internal carotid, internal carotid bulb, common carotid bulb, and common carotid arteries and the lengths of the internal carotid and total patch segments were not significantly different and all were less than 5%. Common carotid bulb wall thickness measured at the time of identification of the nine unilateral Dacron patched CEA restenosis was 1.5 ±0.5 mm compared to 1.4 +0.4 mm (m ± 1 SD) for the contralateral vein patched CEA (p = 0.45 by paired t test). Dacron patched CEA have a significantly higher incidence of mild, moderate and severe restenosis than do saphenous vein patched CEA independent of systemic risk factors. The within patient equality of Dacron and vein patched carotid reconstruction geometry in patients with unilateral restenosis indicates that patch material is the major local risk factor, not adverse hemodynamics produced by variance in geometry. Common carotid bulb wall thickness measurements after CEA are not predictors or indicators of recurrent stenosis.
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Affiliation(s)
- J P Archie
- Carolina Cardiovascular Surgical Associates and Wake Medical Center, Raleigh, NC 27610, USA
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19
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Carotid Revascularization Using Endarterectomy or Stenting Systems (CARESS): Phase I Clinical Trial. J Endovasc Ther 2016; 10:1021-30. [PMID: 14723574 DOI: 10.1177/152660280301000601] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To determine whether carotid stenting with embolic protection is equivalent to carotid endarterectomy (CEA) in a broad risk population of patients with symptomatic and asymptomatic carotid stenosis. Methods: A prospective, multicenter Phase I trial was conducted comparing standard CEA to carotid stenting systems (CSS) in patients with symptomatic (≥50%) and asymptomatic (≥75%) carotid stenosis. Patients were enrolled using selection criteria reflective of broad clinical practice. The enrollment ratio at each clinical site was designed to be 2:1 (CEA to CSS) to achieve a planned enrollment of 450 patients: 300 in the CEA arm and 150 in the CSS cohort, which would ensure adequate precision with a coefficient of variation ≤0.35. The primary endpoint for comparison was 30-day all-cause mortality and nonfatal stroke. Results: Between April 2001 and December 2002, 14 clinical sites enrolled 439 patients, of which 397 (247 men; mean age 71 years, range 44–89) were treated: 254 with CEA and 143 patients with CSS (ratio 1.8 to 1.0). More than 90% of patients had >75% stenosis; ∼68% of patients were asymptomatic. There were no significant differences in baseline patient characteristics between the treatment groups with the exception of a more frequent history of prior CEA (30% CSS versus 11% for CEA, p<0.0001) and prior carotid stent placement in the CSS group (6% versus 0% for CEA, p = 0.0002). There was no significant difference in the 30-day combined all-cause mortality and stroke rate by Kaplan-Meier estimate between CEA (2%) and CSS (2%). There was no significant difference in the secondary endpoint of combined 30-day all-cause mortality, stroke, and myocardial infarction between CEA (3%) and CSS (2%). Conclusions: This study suggests that the 30-day risk of stroke or death following carotid stenting with cerebral protection is equivalent to standard carotid endarterectomy in a broad risk population of patients with carotid stenosis.
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20
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New G, Roubin GS, Iyer SS, Lawrence EJ, Oetgen M, Al-Mubarek N, Moussa I, Moses JW, Vitek JJ. Outpatient Carotid Artery Stenting: A Case Report. J Endovasc Ther 2016. [DOI: 10.1177/152660289900600403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To report a case of carotid artery stenting for asymptomatic carotid restenosis performed in an outpatient setting. Methods and Results: A 68-year-old man with right carotid restenosis after repeat carotid endarterectomy underwent carotid angioplasty and stenting on an ambulatory basis. The procedure to implant a Smart stent required 45 minutes; the femoral access site was closed with a puncture closure device. The patient experienced no sequelae to this procedure and is well 6 months after treatment. Conclusions: Outpatient delivery of percutaneous carotid stenting may be feasible in appropriately selected patients.
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Affiliation(s)
- Gishel New
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
| | - Gary S. Roubin
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
| | - Sriram S. Iyer
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
| | - Emily J. Lawrence
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
| | - Matthew Oetgen
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
| | - Nadim Al-Mubarek
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
| | - Issam Moussa
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
| | - Jeffrey W. Moses
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
| | - Jiri J. Vitek
- Lenox Hill Heart and Vascular Institute of New York, New York, New York, USA
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21
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Abbott AL, Bladin CF, Levi CR, Chambers BR. What Should We Do with Asymptomatic Carotid Stenosis? Int J Stroke 2016; 2:27-39. [DOI: 10.1111/j.1747-4949.2007.00096.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.
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Affiliation(s)
- Anne L. Abbott
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
| | - Christopher F. Bladin
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
| | - Christopher R. Levi
- Department of Neuroscience, John Hunter Hospital, Lookout Road, Lambton Heights, Newcastle, NSW, 2035, Australia
| | - Brian R. Chambers
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
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22
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Luebke T, Brunkwall J. Meta- analysis and meta-regression analysis of the associations between sex and the operative outcomes of carotid endarterectomy. BMC Cardiovasc Disord 2015; 15:32. [PMID: 25956903 PMCID: PMC4432947 DOI: 10.1186/s12872-015-0029-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/21/2015] [Indexed: 12/26/2022] Open
Abstract
Background Subgroup analyses from randomized controlled trials (RCT) of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis suggest less benefit in women compared to men, due partly to higher age-independent peri-operative risk. However, a meta-analysis of case series and databases focussing on CEA-related gender differences has never been investigated. Methods A systematic review of all available publications (including case series, databases and RCTs) reporting data on the association between sex and procedural risk of stroke and/or death following CEA from 1980 to 2015 was investigated. Pooled Peto odds ratios of the procedural risk of stroke and/or death were obtained by Mantel-Haenszel random-effects meta-analysis. The I2 statistic was used as a measure of heterogeneity. Potential publication bias was assessed with the Egger test and represented graphically with Begg funnel plots of the natural log of the OR versus its standard error. Additional sensitivity analyses were undertaken to evaluate the potential effect of key assumptions and study-level factors on the overall results. Meta-regression models were formed to explore potential heterogeneity as a result of potential risk factors or confounders on outcomes. A tria sequential analysis (TSA) was performed with the aim to maintain an over- all 5 % risk of type I error, being the standard in most meta- analyses and systematic reviews. Results 58 articles reported combined stroke and mortality rates within 30 days of treatment. In the unselected overall meta-analysis, the incidence of stroke and death in the male and female groups differed significantly (Peto OR, 1,162; 95 % CI, 1.067-1.266; P = .001), revealing a worse outcome for female patients. Moderate heterogeneity among the studies was identified (I2 = 36 %), and the possibility of publication bias was low (P = .03). In sensitivity analyses the meta-analysis of case series with gender aspects as a secondary outcome showed a significantly increased risk for 30-day stroke and death in women compared to men (Peto OR, 1.390; 95 % CI, 1.148-1.684; P = .001), In contrast, meta-analysis of databases (Peto OR, 1.025; 95 % CI, 0.958-1.097; P = .474) and case series with gender related outcomes as a primary aim (Peto OR, 1.202; 95 % CI, 0.925-1.561; P = .168) demonstrated no increase in operative risk of stroke and death in women compared to men. Conclusions Metanalyses of case series and databases dealing with CEA reveal inconsistent results regarding gender differences related to CEA-procedure and should not be transferred into clinical practice.
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Affiliation(s)
- Thomas Luebke
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
| | - Jan Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germay.
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23
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Dragas M, Koncar I, Opacic D, Ilic N, Maksimovic Z, Markovic M, Ercegovac M, Simic T, Pljesa-Ercegovac M, Davidovic L. Fluctuations of serum neuron specific enolase and protein S-100B concentrations in relation to the use of shunt during carotid endarterectomy. PLoS One 2015; 10:e0124067. [PMID: 25859683 PMCID: PMC4393266 DOI: 10.1371/journal.pone.0124067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/25/2015] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the changes in serum neuron specific enolase and protein S-100B, after carotid endarterectomy performed using the conventional technique with routine shunting and patch closure, or eversion technique without the use of shunt. Materials and Methods Prospective non-randomized study included 43 patients with severe (>80%) carotid stenosis undergoing carotid endarterectomy in regional anesthesia. Patients were divided into two groups: conventional endarterectomy with routine use of shunt and Dacron patch (csCEA group) and eversion endarterectomy without the use of shunt (eCEA group). Protein S-100B and NSE concentrations were measured from peripheral blood before carotid clamping, after declamping and 24 hours after surgery. Results Neurologic examination and brain CT findings on the first postoperative day did not differ from preoperative controls in any patients. In csCEA group, NSE concentrations decreased after declamping (P<0.01), and 24 hours after surgery (P<0.01), while in the eCEA group NSE values slightly increased (P=ns), accounting for a significant difference between groups on the first postoperative day (P=0.006). In both groups S-100B concentrations significantly increased after declamping (P<0.05), returning to near pre-clamp values 24 hours after surgery (P=ns). Sub-group analysis revealed significant decline of serum NSE concentrations in asymptomatic patients shunted during surgery after declamping (P<0.05) and 24 hours after surgery (P<0.01), while no significant changes were noted in non-shunted patients (P=ns). Decrease of NSE serum levels was also found in symptomatic patients operated with the use of shunt on the first postoperative day (P<0.05). Significant increase in NSE serum levels was recorded in non-shunted symptomatic patients 24 hours after surgery (P<0.05). Conclusion Variations of NSE concentrations seemed to be influenced by cerebral perfusion alterations, while protein S-100B values were unaffected by shunting strategy. Routine shunting during surgery for symptomatic carotid stenosis may have the potential to prevent postoperative increase of serum NSE levels, a potential marker of brain injury.
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Affiliation(s)
- Marko Dragas
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- * E-mail:
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dragan Opacic
- Faculty of Health, Medicine and Life Sciences, Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | - Nikola Ilic
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zivan Maksimovic
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miroslav Markovic
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Ercegovac
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Neurology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Tatjana Simic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Institute of Medical and Clinical Biochemistry, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Pljesa-Ercegovac
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Institute of Medical and Clinical Biochemistry, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Lazar Davidovic
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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24
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Aydin E, Ozen Y, Sarikaya S, Yukseltan I. Simultaneous coronary artery bypass grafting and carotid endarterectomy can be performed with low mortality rates. Cardiovasc J Afr 2014; 25:130-3. [PMID: 25000443 PMCID: PMC4120123 DOI: 10.5830/cvja-2014-018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/10/2014] [Indexed: 11/24/2022] Open
Abstract
Introduction There is controversy over the best approach for patients with concomitant carotid and coronary artery disease. In this study, we report on our experience with simultaneous carotid endarterectomy (CEA) and coronary artery bypass graft (CABG) surgery in our clinic in the light of data in the literature. Methods Between January 1996 and January 2009, a total of 110 patients (86 males, 24 females; mean age 65.11 ± 7.81 years; range 44–85 years), who were admitted to the cardiovascular surgery clinic at our hospital, were retrospectively analysed. All patients underwent simultaneous CEA and CABG. Demographic characteristics of the patients and a history of previous myocardial infarction (MI), hypertension, diabetes mellitus, hyperlipidaemia, peripheral arterial disease and smoking were recorded. Results One patient (0.9%) with major stroke died due to ventricular fibrillation. Peri-operative neurological complications were observed in seven patients (6%). Complications were persistent in two patients. Four patients (3%) had postoperative major stroke, whereas three patients (2%) had transient hemiparesis. No peri-operative myocardial infarction was observed. Conclusion Simultaneous CEA and CABG can be performed with low rates of mortality and morbidity.
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Affiliation(s)
- Ebuzer Aydin
- Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey.
| | - Yucel Ozen
- Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
| | - Sabit Sarikaya
- Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
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25
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Chongruksut W, Vaniyapong T, Rerkasem K. Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting). Cochrane Database Syst Rev 2014; 2014:CD000190. [PMID: 24956204 PMCID: PMC7032624 DOI: 10.1002/14651858.cd000190.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. This may improve outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2009. OBJECTIVES To assess the effect of routine versus selective or no shunting during carotid endarterectomy, and to assess the best method for selecting people for shunting. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 8), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013) and Index to Scientific and Technical Proceedings (1980 to August 2013). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field. SELECTION CRITERIA Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy. DATA COLLECTION AND ANALYSIS Three review authors independently performed the searches and applied the inclusion criteria. For this update, we identified two new relevant randomised controlled trials. MAIN RESULTS We included six trials involving 1270 participants in the review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. In general, reporting of methodology in the included studies was poor. For most studies, the blinding of outcome assessors and the report of prespecified outcomes were unclear. For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. No significant difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring, However, this analysis was inadequately powered to reliably detect the effect. There was no significant difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited. AUTHORS' CONCLUSIONS This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. Large scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.
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Affiliation(s)
- Wilaiwan Chongruksut
- Chiang Mai UniversityDepartment of Surgery, Faculty of MedicineChiang MaiThailand50200
| | - Tanat Vaniyapong
- Chiang Mai UniversityDepartment of Surgery, Faculty of MedicineChiang MaiThailand50200
| | - Kittipan Rerkasem
- Chiang Mai UniversityDepartment of Surgery, Faculty of MedicineChiang MaiThailand50200
- Chiang Mai UniversityCenter for Applied Science, Research Institute of Health SciencesChiang MaiThailand
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Patching plus extended exposure and tacking of the common carotid cuff may reduce the late incidence of recurrent stenosis after carotid endarterectomy. J Vasc Surg 2013; 58:926-34.e1-2. [DOI: 10.1016/j.jvs.2013.04.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 04/10/2013] [Accepted: 04/10/2013] [Indexed: 11/20/2022]
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Mohan PP, Hamblin MH. Comparison of endovascular and open repair of ruptured abdominal aortic aneurysm in the United States in the past decade. Cardiovasc Intervent Radiol 2013; 37:337-42. [PMID: 23756880 DOI: 10.1007/s00270-013-0665-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 05/16/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study is national-level comparison of the endovascular (EVAR) and open repair (OAR) of ruptured abdominal aortic aneurysm (AAA) in the United States from 2001 to 2010. METHODS The data were obtained from nationwide inpatient sample from the Department of Health and Human Services. Ruptured AAA treated by OAR or EVAR were selected using combination ICD-9 codes. RESULTS There were 42,126 cases of ruptured AAA of which 8,140 (19.3%) were repaired by EVAR. EVAR patients were older (74.1 vs. 72.8 years, p < 0.001) and had higher incidence of comorbidities compared with OAR group. EVAR patients had lower in-hospital mortality (25.9 vs. 39.1%, p < 0.001) and shorter hospital stay (10.4 vs. 13.7 days, p < 0.001). More patients were discharged home following EVAR (36.8 vs. 21.5%, p < 0.001). There was reduced need for institutional rehabilitation following EVAR (26.3 vs. 29.1%, p < 0.001). Females had significantly higher mortality compared with males after both EVAR (32.2 vs. 24.1%, p < 0.001) and OAR (46.2 vs. 36.9%, p < 0.001). The hospital mortality (41.3-25.8%, p < 0.001) and mean length of stay (11.8-9.7 days, p < 0.01) of EVAR steadily improved over the study period. CONCLUSIONS National level comparison of data from the past decade shows that in suitable cases, EVAR for ruptured AAA is associated with reduced hospital mortality, shorter hospital stay, and reduced need for rehabilitation. EVAR outcomes showed consistent improvement with time. Regardless of the type of repair, women had higher mortality compared with men.
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Affiliation(s)
- Prasoon P Mohan
- Diagnostic and Interventional Radiology, St. Francis Hospital, 355 Ridge Avenue, Evanston, IL, 60202, USA,
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Galyfos G, Sigala F, Tsioufis K, Bakoyiannis C, Lagoudiannakis E, Manouras A, Zografos G, Filis K. Postoperative Cardiac Damage After Standardized Carotid Endarterectomy Procedures in Low- and High-Risk Patients. Ann Vasc Surg 2013; 27:433-40. [DOI: 10.1016/j.avsg.2012.06.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 06/03/2012] [Accepted: 06/14/2012] [Indexed: 10/26/2022]
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Cho J, Lee KK, Yun WS, Kim HK, Hwang YH, Huh S. Selective shunt during carotid endarterectomy using routine awake test with respect to a lower shunt rate. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 84:238-44. [PMID: 23577319 PMCID: PMC3616278 DOI: 10.4174/jkss.2013.84.4.238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 01/09/2013] [Accepted: 02/12/2013] [Indexed: 12/05/2022]
Abstract
PURPOSE To evaluate shunt rate and discuss the resultsrelated to selective shunt placement during carotid endarterectomy (CEA) using routine awake test. METHODS Patients with CEA from 2007 to 2011 were retrospectively reviewed from prospectively collected data. The need for shunt placement was determined by the awake test, based on the alteration in the neurologic examination. We collected data by using the clinical records and imaging studies, and investigated factors related to selective shunt such as collateral circulation and contralateral internal carotid artery (ICA) stenosis. RESULTS There were 45 CEAs under regional anesthesia with the awake test in 44 patients. The mean age was 61.8 ± 7.1 years old. There were 82.2% (37/45) of males, and 68.9% (31/45) of symptomatic patients. Selective shunt placement had been performed in only two (4.4%) patients. Among them fewer cases (4%) had severe (stenosis >70%) contralateral ICA lesions, and more cases (91%) of complete morphology of the anterior or posterior circulation in the circle of Willis. There was no perioperative stroke, myocardial infarctionor death, and asymptomatic new brain lesions were detected in 4 patients (9%), including 2 cases of selective shunt placement. CONCLUSION CEA under routine awake test could besafe and feasible method with low shunt placement rate in selected patients.
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Affiliation(s)
- Jayun Cho
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kyung Keun Lee
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Woo-Sung Yun
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyung-Kee Kim
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Huh
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
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Bekelis K, Moses Z, Missios S, Desai A, Labropoulos N. Indications for treatment of recurrent carotid stenosis. Br J Surg 2013; 100:440-7. [DOI: 10.1002/bjs.9027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2012] [Indexed: 11/07/2022]
Abstract
Abstract
Background
There is significant variation in the indications for intervention in patients with recurrent carotid artery stenosis. The aim of the present study was to describe these indications in a contemporary cohort of patients.
Methods
This was a systematic review of all peer-reviewed studies reporting on the indications for carotid intervention in patients with recurrent stenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS) that were published between 1990 and 2012.
Results
There were 50 studies reporting on a total of 3524 patients undergoing a carotid procedure; of these, 3478 underwent CEA as the initial intervention. Reintervention was by CEA in 2403 patients and by CAS in 1121. Only 54·7 per cent of the patients were treated for any symptoms and, importantly, just 444 (23·1 per cent of 1926 symptomatic patients) underwent intervention for documented ipsilateral symptoms. None of the studies reported whether the patients were evaluated for other sources of emboli. The remaining 45·3 per cent of patients had asymptomatic restenosis and in the majority of the studies were treated when the degree of stenosis exceeded 80 per cent. The time to repeat intervention was significantly longer in patients with recurrent atherosclerosis, in asymptomatic patients and in patients undergoing CEA.
Conclusion
The reported criteria for retreatment of carotid stenosis were not rigorous and there is still significant ambiguity surrounding the indications for intervention.
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Affiliation(s)
- K Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, USA
| | - Z Moses
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - S Missios
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, USA
| | - A Desai
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, USA
| | - N Labropoulos
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, New York, USA
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Imanimoghaddam M, Rah Rooh M, Mahmoudi Hashemi E, Javadzade Blouri A. Doppler sonography confirmation in patients showing calcified carotid artery atheroma in panoramic radiography and evaluation of related risk factors. J Dent Res Dent Clin Dent Prospects 2012; 6:6-11. [PMID: 22991627 PMCID: PMC3442447 DOI: 10.5681/joddd.2012.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Accepted: 10/18/2011] [Indexed: 12/02/2022] Open
Abstract
Background and aims
The purpose of this study was to identify patients at the risk of cerebrovascular attack (CVA) by detecting calcified carotid artery atheroma (CCAA) in panoramic radiography and evaluating their risk factors.
Materials and methods
A total of 960 panoramic radiographs of patients above 40 years old were evaluated. Doppler Sonography (DS) was performed for patients who showed calcified carotid artery atheroma (CCAA) in panoramic radiogra-phy in order to determine the presence of CCAA and the degree of stenosis. Cardiovascular risk factors in both groups of patients with CCAA (12 subjects) and without CCAA (3 subjects) were compared using a questionnaire filled out by the patients. Statistical analysis including Fisher and independent t-test applied for data analysis.
Results
Fifteen patients (30 sides) showed calcification in their panoramic radiographs, and underwent DS which revealed CCAA in 16 sides (12 patients). Two patients (13.33%) showed stenosis greater than 70%. Among the risk factors, only age showed a significant association with the occurrence of carotid calcified atheroma (P=0.026).
Conclusion Considering the results, dentists should refer especially elderly patients with radiographically identified atheromas for further examinations, as asymptomatic CCAA might be associated with high degrees of stenosis.
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Affiliation(s)
- Mahrokh Imanimoghaddam
- Dental Research Center, Mashhad University of Medical Sciences, Mashhad, Iran ; Associate Professor, Department of Oral and Maxillofacial Radiology, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
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Bouziane Z, Nourissat G, Duprey A, Albertini JN, Favre JP, Barral X. Carotid Artery Surgery: High-Risk Patients or High-Risk Centers? Ann Vasc Surg 2012; 26:790-6. [DOI: 10.1016/j.avsg.2011.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 09/11/2011] [Accepted: 09/13/2011] [Indexed: 10/28/2022]
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Kim TY, Choi JB, Kim KH, Kim MH, Shin BS, Park HK. Routine Shunting is Safe and Reliable for Cerebral Perfusion during Carotid Endarterectomy in Symptomatic Carotid Stenosis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:95-100. [PMID: 22500279 PMCID: PMC3322192 DOI: 10.5090/kjtcs.2012.45.2.95] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 09/14/2011] [Accepted: 10/16/2011] [Indexed: 12/03/2022]
Abstract
Background The purpose of this report is to describe the perioperative outcomes of standard carotid endarterectomy (CEA) with general anesthesia, routine shunting, and tissue patching in symptomatic carotid stenoses. Materials and Methods Between October 2007 and July 2011, 22 patients with symptomatic carotid stenosis (male/female, 19/3; mean age, 67.2±9.4 years) underwent a combined total of 23 CEAs using a standardized technique. The strict surgical protocol included general anesthesia and standard carotid bifurcation endarterectomy with routine shunting. The 8-French Pruitt-Inahara shunt was used in all the patients. Results During the ischemic time, the shunts were inserted within 2.5 minutes, and 5 patients (22.7%) revealed ischemic cerebral signals (flat wave) in electroencephalographic monitoring but recovered soon after insertion of the shunt. The mean shunting time for CEA was 59.1±10.3 minutes. There was no perioperative mortality or even minor stroke. All patients woke up in the operating room or the operative care room before being moved to the ward. One patient had difficulty swallowing due to hypoglossal nerve palsy, but had completely recovered by 1 month postsurgery. Conclusion Routine shunting is suggested to be a safe and reliable method of brain perfusion and protection during CEA in symptomatic carotid stenoses.
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Affiliation(s)
- Tae Yun Kim
- Department of Thoracic and Cardiovascular Surgery, Division of Neurology, Chonbuk National University Hospital, Chonbuk National University Medical School, Korea
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Women derive less benefit from elective endovascular aneurysm repair than men. J Vasc Surg 2012; 55:906-13. [DOI: 10.1016/j.jvs.2011.11.047] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 11/03/2011] [Accepted: 11/04/2011] [Indexed: 11/22/2022]
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Baracchini C, Saladini M, Lorenzetti R, Manara R, Da Giau G, Ballotta E. Gender-based outcomes after eversion carotid endarterectomy from 1998 to 2009. J Vasc Surg 2012; 55:338-45. [DOI: 10.1016/j.jvs.2011.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 08/17/2011] [Accepted: 08/18/2011] [Indexed: 10/15/2022]
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Open and Endovascular Management of Concomitant Severe Carotid and Coronary Artery Disease: Tabular Review of the Literature. Ann Vasc Surg 2012; 26:125-40. [DOI: 10.1016/j.avsg.2011.02.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 01/10/2011] [Accepted: 02/09/2011] [Indexed: 11/20/2022]
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Grootenboer N, Hunink M, Hoeks S, Hendriks J, van Sambeek M, Poldermans D. The Impact of Gender on Prognosis After Non-cardiac Vascular Surgery. Eur J Vasc Endovasc Surg 2011; 42:510-6. [DOI: 10.1016/j.ejvs.2011.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 06/15/2011] [Indexed: 11/30/2022]
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Aburahma AF, Mousa AY, Stone PA. Shunting during carotid endarterectomy. J Vasc Surg 2011; 54:1502-10. [PMID: 21906905 DOI: 10.1016/j.jvs.2011.06.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/02/2011] [Accepted: 06/08/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of shunting during carotid endarterectomy (CEA) is controversial. While some surgeons advocate routine shunting, others prefer selective shunting or no shunting. Several large series have documented excellent results of CEA with routine shunting or without shunts. Others reported similar results with selective shunting using transcranial Doppler (TCD), electroencephalogram (EEG) monitoring, carotid stump pressure (SP), cervical block anesthesia (CBA), and somatosensory evoked potential (SSEP). In this study, we review the available evidence supporting shunting, nonshunting, and selective shunting during CEA. METHODS An electronic PubMed/MEDLINE search was conducted to identify all published CEA studies between January 1990 and December 2010, that analyzed the perioperative outcome of routine shunting, routine nonshunting, routine versus selective shunting, selecting shunting versus avoiding a shunt, and selective shunting based on EEG, TCD, SP, CBA, and SSEP. RESULTS The mean reported perioperative stroke rate for CEAs with routine shunting was 1.4% and for routine nonshunt was 2%. Meanwhile, the mean perioperative stroke rates for selecting shunting were 1.6% using EEG, 4.8% using TCD, 1.6% using SP, 1.8% using SSEP, and 1.1% for CBA. Similar results were noted for perioperative stroke and death rates. CONCLUSIONS The use of routine shunting and selective shunting was associated with a low stroke rate. Both methods are acceptable, and the individual surgeon should select the method with which they are more comfortable.
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Affiliation(s)
- Ali F Aburahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV 25304, USA.
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Gupta PK, Pipinos II, Miller WJ, Gupta H, Shetty S, Johanning JM, Longo GM, Lynch TG. A Population-Based Study of Risk Factors for Stroke After Carotid Endarterectomy Using the ACS NSQIP Database. J Surg Res 2011; 167:182-91. [DOI: 10.1016/j.jss.2010.10.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 08/19/2010] [Accepted: 10/13/2010] [Indexed: 11/30/2022]
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Naylor AR, Bown MJ. Stroke after Cardiac Surgery and its Association with Asymptomatic Carotid Disease: An Updated Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2011; 41:607-24. [PMID: 21396854 DOI: 10.1016/j.ejvs.2011.02.016] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 02/13/2011] [Indexed: 11/19/2022]
Affiliation(s)
- A R Naylor
- The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester LE2 7LX, UK.
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Dick AM, Brothers T, Robison JG, Elliott BM, Kratz JM, Toole JM, Crumbley AJ, Crawford FA. Combined Carotid Endarterectomy and Coronary Artery Bypass Grafting Versus Coronary Artery Bypass Grafting Alone: A Retrospective Review of Outcomes at Our Institution. Vasc Endovascular Surg 2011; 45:130-4. [DOI: 10.1177/1538574410393752] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: It remains controversial whether patients with concomitant carotid and coronary disease should undergo operative repair separately or in combination. Methods: Patients with documented cerebrovascular disease undergoing coronary artery bypass grafting (CABG) alone were matched by propensity scoring with patients undergoing combined carotid endarterectomy (CEA)/CABG procedures and compared for the occurrence of stroke, myocardial infarction (MI), and mortality. Results: Of the 4943 patients undergoing CABG, 908 had known cerebrovascular disease. Among these, 134 underwent concomitant CEA, and these were propensity matched with 134 patients undergoing CABG only. No differences were observed in the perioperative risks of stroke (4% vs 3%, odds ratio [OR] 1.5, 95% confidence interval [CI] 0.4-5.5), MI (0.7% vs 0.7%, not significant [NS]), or combined cardiovascular events (6% vs 10%, OR 0.5, 95% CI [0.2-1.3]), although mortality (1% vs 8%, OR 0.2, 95% CI [0.04-0.8] was higher with CABG only. Discussion: Addition of CEA to CABG did not significantly alter the risk of perioperative stroke relative to propensity-matched patients undergoing CABG alone.
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Affiliation(s)
- Amanda M. Dick
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Brothers
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA,
| | - Jacob G. Robison
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Bruce M. Elliott
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - John M. Kratz
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - J. Matthew Toole
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Arthur J. Crumbley
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Fred A. Crawford
- Divisions of Vascular Surgery and Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
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Ploeg AJ, Flu HC, Lardenoye JHP, Hamming JF, Breslau PJ. Assessing the quality of surgical care in vascular surgery; moving from outcome towards structural and process measures. Eur J Vasc Endovasc Surg 2011; 40:696-707. [PMID: 20889355 DOI: 10.1016/j.ejvs.2010.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 05/08/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study presents a review of studies reporting on quality of care in vascular surgery. The aim of this study was to provide insight in quality improvement initiatives in vascular surgery. DESIGN Original data were collected from MEDLINE and EMBASE databases. Inclusion criteria were: description of one of the three factors of quality of care, e.g. process, outcome or structure and prospectively described. All articles identified were ascribed to a domain of quality of care. RESULTS 57 prospective articles were included, drawn from 859 eligible reports. Structure as an indicator of quality of care was described in 19 reports, process in 7 reports and outcome in 31 reports. Most studies based on structural measures considered the introduction of a clinical pathway or a registration system. Reports based on process measures showed promising results. Outcome as clinical indicator mainly focussed on identifying risk factors for morbidity, mortality or failure of treatment. CONCLUSIONS Structure and process indicators are evaluated scarcely in vascular surgery. Many studies in vascular surgery have been focussed on outcomes as indicator of quality of care, but a shift towards process measures should be considered as focus of attention in the future.
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Affiliation(s)
- A J Ploeg
- Leiden University Medical Center (LUMC), Department of Vascular Surgery, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Calvillo-King L, Xuan L, Zhang S, Tuhrim S, Halm EA. Predicting risk of perioperative death and stroke after carotid endarterectomy in asymptomatic patients: derivation and validation of a clinical risk score. Stroke 2010; 41:2786-94. [PMID: 21051669 DOI: 10.1161/strokeaha.110.599019] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE National guidelines on carotid endarterectomy (CEA) for asymptomatic patients state that the procedure should be performed with a ≤ 3% risk of perioperative death or stroke. We developed and validated a multivariate model of risk of death or stroke within 30 days of CEA for asymptomatic disease and a related clinical prediction rule. METHODS We analyzed asymptomatic cases in a population-based cohort of CEAs performed in Medicare beneficiaries in New York State. Medical records were abstracted for sociodemographics, neurologic history, disease severity, diagnostic imaging data, comorbidities, and deaths and strokes within 30 days of surgery. We used multivariate logistic regression to identify independent predictors of perioperative death or stroke. The CEA-8 clinical risk score was derived from the final model. RESULTS Among the 6553 patients, the mean age was 74 years, 55% were male, 62% had coronary artery disease, and 22% had a history of distant stroke or transient ischemic attack. The perioperative rate of death or stroke was 3.0%. Multivariable predictors of perioperative events were female sex (odds ratio [OR] = 1.5; 95% CI, 1.1 to 1.9), nonwhite race (OR = 1.8; 95% CI, 1.1 to 2.9), severe disability (OR = 3.7; 95% CI, 1.8 to 7.7), congestive heart failure (OR = 1.6; 95% CI, 1.1 to 2.4), coronary artery disease (OR = 1.6; 95% CI, 1.2 to 2.2), valvular heart disease (OR = 1.5; 95% CI, 1.1 to 2.3), a distant history of stroke or transient ischemic attack (OR = 1.5; 95% CI, 1.1 to 2.0), and a nonoperated stenosis ≥ 50% (OR = 1.8; 95% CI, 1.3 to 2.3). The CEA-8 risk score stratified patients with a predicted probability of death or stroke rate from 0.6% to 9.6%. CONCLUSIONS Several sociodemographic, neurologic severity, and comorbidity factors predicted the risk of perioperative death or stroke in asymptomatic patients. The CEA-8 risk score can help clinicians calculate a predicted probability of complications for an individual patient to help inform the decision about revascularization.
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Affiliation(s)
- Linda Calvillo-King
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390-8889, USA
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Abstract
Severe asymptomatic carotid stenosis is associated with a stroke risk of approximately 2% per annum. Aggressive management of risk factors is recommended, including cessation of smoking, and treatment of hypertension, diabetes, and hypercholesterolemia. Patients should be treated with antiplatelet agents. Carotid endarterectomy (CEA) in patients with greater than or equal to 60% stenosis reduces the risk of stroke by approximately 1% per annum overall. The benefit is greatest for men and younger patients. There may be no benefit for women or for older patients. Carotid angioplasty and stenting is not recommended as an alternative to CEA until there is clinical trial evidence of efficacy in asymptomatic stenosis, except in some patients with technical contraindications to CEA. There is no evidence that patients with asymptomatic severe carotid stenosis should undergo carotid revascularization prior to other surgical procedures, including coronary bypass surgery.
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Affiliation(s)
- Brian R Chambers
- National Stroke Research Institute, Department of Medicine, University of Melbourne, Austin Health, 300 Waterdale Road, Heidelberg Heights, 3081, Victoria, Australia.
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Long-Term Results of Eversion Carotid Endarterectomy. Ann Vasc Surg 2010; 24:92-9. [DOI: 10.1016/j.avsg.2009.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 06/01/2009] [Accepted: 06/23/2009] [Indexed: 11/23/2022]
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Dorigo W, Pulli R, Marek J, Troisi N, Pratesi G, Innocenti AA, Pratesi C. Carotid endarterectomy in female patients. J Vasc Surg 2009; 50:1301-6; discussion 1306-7. [PMID: 19782512 DOI: 10.1016/j.jvs.2009.07.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 06/29/2009] [Accepted: 07/01/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate early and late results of carotid endarterectomy (CEA) in female patients in a large single center experience. METHODS Over a 12-year period ending in December 2007, 4009 consecutive primary and secondary CEAs in 3324 patients were performed at our institution. All patients were prospectively enrolled in a dedicated database containing pre-, intra-, and postoperative parameters. Patients were female in 1200 cases (1020 patients; Group 1) and male in the remaining 2809 (2304 patients, Group 2). Early results in terms of intraoperative neurological events and 30-day stroke and death rates were analyzed and compared. Follow-up results were analyzed with Kaplan Meier curves and compared with log-rank test. RESULTS Patients of Group 1 were more likely to have hyperlipemia, diabetes, and hypertension; patients of Group 2 were more likely to be smokers and to have concomitant coronary artery disease (CAD) and peripheral arterial disease (PAD). There were no differences in terms of clinical status or degree of stenosis. Patients of Group 2 had a significantly higher percentage of contralateral carotid artery occlusion than patients in Group 1 (6.9% and 3.9%, respectively; P < .001). Thirty-day stroke and death rates were similar in the two groups (1.2% for both groups). Univariate analysis demonstrated the presence of CAD, PAD, diabetes, and contralateral carotid artery occlusion to significantly affect 30-day stroke and death rate in female patients. At multivariate analysis, only diabetes (odds ratio [OR] 3.6, 95% confidence interval [CI] 0.1-0.9; P = .05) and contralateral occlusion (OR 7.4, 95% CI 0.03-0.6; P = .006) were independently associated with an increased perioperative risk of stroke and death. Median duration of follow-up was 27 months (range, 1-144 months). There were no overall differences between the two groups in terms of survival, freedom from ipsilateral stroke, freedom from any neurological symptom, and incidence of severe (>70%) restenosis. In contrast to male patients, univariate and multivariate analysis demonstrated that female patients with diabetes or contralateral occlusion had an increased risk of developing ipsilateral neurological events during follow-up. CONCLUSIONS Female sex per se does not represent an adjunctive risk factor during CEA, with early and long term results comparable to those obtained in male patients. However, in our study we found subgroups of female patients at higher surgical risk, requiring careful intra- and postoperative management.
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Affiliation(s)
- Walter Dorigo
- Department of Vascular Surgery, University of Florence, Florence, Italy.
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Iyem H, Buket S. Early results of combined and staged coronary bypass and carotid endarterectomy in advanced age patients in single centre. Open Cardiovasc Med J 2009; 3:8-14. [PMID: 19430573 PMCID: PMC2678823 DOI: 10.2174/1874192400903010008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 02/27/2009] [Accepted: 03/04/2009] [Indexed: 11/24/2022] Open
Abstract
Aim: In present study, we aimed to compare the staged and combined surgery in patients with severe carotid stenosis and coronary atherosclerosis and detect the factors affecting mortality and morbidity. Material and method: Between 2004 and 2008, 120 patients with predominant ischemic heart disease were enrolled to study. Patients were divided into three groups on basis surgery procedure. Group 1 (n=40) includeed patients had coronary artery disease without carotid disease underwent coronary artery by-pass graft (CABG) operation. Group 2 (n=40): included patients underwent combined surgery procedure including CABG and carotid endarterectomy (CEA). Patients underwent staged CABG and CEA were enrolled to Group 3 (n=40). All patients were in advanced aged and were had the same risk factors atributable atherosclerosis Results: Mean age of the patients in all groups were 68±6, 69±3, 71±2 respectively, and 83% were male. Eight patients died in all groups at follow-up(seven in group 2 and 3, and one in group 1) and the difference between both groups was statistically significant (p<0.001). The follow-up period in the intensive care unit, and hospitalization period were not statistically different between CABG group and combined CEA plus CABG group. Conclusion: We think that the results of staged or combined CABG plus CEA surgery are satisfactory in patients with severe carotid disease and advanced coronary artery disease. However, the mortality and morbidity in both procedures are higher than those of alone.
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Affiliation(s)
- Hikmet Iyem
- Dicle University, Department of Cardiovascular Surgery, Diyarbakir, Turkey.
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Halm EA, Tuhrim S, Wang JJ, Rockman C, Riles TS, Chassin MR. Risk factors for perioperative death and stroke after carotid endarterectomy: results of the new york carotid artery surgery study. Stroke 2008; 40:221-9. [PMID: 18948605 DOI: 10.1161/strokeaha.108.524785] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefit of carotid endarterectomy is heavily influenced by the risk of perioperative death or stroke. This study developed a multivariable model predicting the risk of death or stroke within 30 days of carotid endarterectomy. METHODS The New York Carotid Artery Surgery (NYCAS) Study is a population-based cohort of 9308 carotid endarterectomies performed on Medicare patients from January 1998 through June 1999 in New York State. Detailed clinical data were abstracted from medical charts to assess sociodemographic, neurological, and comorbidity risk factors. Deaths and strokes within 30 days of surgery were confirmed by physician overreading. Multivariable logistic regression was used to identify independent patient risk factors. RESULTS The 30-day rate of death or stroke was 2.71% among asymptomatic patients with no history of stroke/transient ischemic attack (TIA), 4.06% among asymptomatic ones with a distant history of stroke/TIA, 5.62% among those operated on for carotid TIA, 7.89% of those with stroke, and 13.33% in those with crescendo TIA/stroke-in-evolution. Significant multivariable predictors of death or stroke included: age >/=80 years (OR, 1.30; 95% CI, 1.03 to 1.64), nonwhite (OR, 1.83; 1.23 to 2.72), admission from the emergency department (OR, 1.95; 1.50 to 2.54), asymptomatic but distant history of stroke/TIA (OR, 1.40; 1.02 to 1.94), TIA as an indication for surgery (OR, 1.81; 1.39 to 2.36), stroke as the indication (OR, 2.40; 1.74 to 3.31), crescendo TIA/stroke-in-evolution (OR, 3.61; 1.15 to 11.28), contralateral carotid stenosis >/=50% (OR, 1.44; 1.15 to 1.79), severe disability (OR, 2.94; 1.91 to 4.50), coronary artery disease (OR, 1.51; 1.20 to 1.91), and diabetes on insulin (OR, 1.55; 1.10 to 2.18). Presence of a deep carotid ulcer was of borderline significance (OR, 2.08; 0.93 to 4.68). CONCLUSIONS Several sociodemographic, neurological, and comorbidity risk factors predicted perioperative death or stroke after carotid endarterectomy. This information may help inform decisions about appropriate patient selection, assessments about the impact of different surgical processes of care on outcomes, and facilitate comparisons of risk-adjusted outcomes among providers.
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Affiliation(s)
- Ethan A Halm
- Department of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8889, USA.
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Makihara N, Toyoda K, Uda K, Inoue T, Gotoh S, Fujimoto S, Yasumori K, Ibayashi S, Iida M, Okada Y. Characteristic sonographic findings of early restenosis after carotid endarterectomy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:1345-1352. [PMID: 18716144 DOI: 10.7863/jum.2008.27.9.1345] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Restenosis of the carotid artery after carotid endarterectomy (CEA) is a major complication. The frequency, time of occurrence, and tissue characteristics of carotid restenosis were assessed with sonography. METHODS Two hundred sixteen patients who had CEA for carotid stenosis were studied; follow-up sonography and magnetic resonance angiography were done 2 weeks, 3 months, and then every year after CEA. On sonography, restenosis was defined as an internal carotid artery (ICA) with a peak systolic velocity of 170 cm/s or greater or a maximum area of stenosis of 90% or greater. RESULTS During 605 artery-years of follow-up, 18 patients (7.5%) were found to have restenosis on sonography: 4 at 3 months, 11 at 1 year, and 3 at 2 years after CEA. At the time that restenosis was detected, in all 18 ICAs the peak systolic velocity exceeded 200 cm/s and had more than doubled since the last measurement (mean +/- SD, 103 +/- 27 to 321 +/-107 cm/s), whereas the area of stenosis exceeded 90% in 6 patients, and magnetic resonance angiography revealed stenosis of 60% or greater in 8 patients. On sonography, all of the restenotic plaques were isoechoic and concentric. The restenosis was asymptomatic in 17 patients. Vascular risk factors or the severity of initial carotid stenosis before CEA were not associated with development of restenosis. Eleven patients had successful endovascular therapy, and the others received medical treatment. CONCLUSIONS A marked increase in the flow velocity through an operated ICA is a good indication of restenosis. The isoechogenicity and concentricity of the restenotic plaques suggest that the restenosis is primarily the result of intimal hyperplasia.
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Affiliation(s)
- Noriko Makihara
- Department of Cerebrovascular Disease, Cerebrovascular Center and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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Friedell ML, Clark JM, Graham DA, Isley MR, Zhang XF. Cerebral oximetry does not correlate with electroencephalography and somatosensory evoked potentials in determining the need for shunting during carotid endarterectomy. J Vasc Surg 2008; 48:601-6. [PMID: 18639412 DOI: 10.1016/j.jvs.2008.04.065] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 04/27/2008] [Accepted: 04/29/2008] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Several reports in the literature have described the value of regional cerebral oximetry (rSO(2)) as a neuromonitoring device during carotid endarterectomy (CEA). The use of rSO(2) is enticing because it is simpler and less expensive than other neuromonitoring modalities. This study was performed to compare the efficacy of rSO(2) with electroencephalography (EEG) and median nerve somatosensory evoked potentials (SSEP) in determining when to place a shunt during CEA. METHODS From October 2000 to June 2006, 323 CEAs were performed under general anesthesia by six surgeons. Shunting was done selectively on the basis of EEG and SSEP monitoring under the auspices of an intraoperative neurophysiologist. All patients were retrospectively reviewed to see if significant discrepancies existed between EEG/SSEP and rSO(2). RESULTS Twenty-four patients (7.4%) showed significant discrepancies. Sixteen patients showed no significant EEG/SSEP changes, but profound changes occurred in rSO(2), and no shunt was placed. In seven patients there was no change in rSO(2) but a profound change occurred in EEG/SSEP, and shunts were placed. In one patient early in the series, the EEG and SSEP were unchanged but the rSO(2) dropped precipitously, and a shunt was placed. In the 299 patients who showed no discrepancies, 285 were not shunted and 14 required a shunt. Two strokes occurred in the entire series (0.6%), none intraoperatively. Shunts were placed in 23 patients (7%). The sensitivity of rSO(2) compared with EEG/SSEP was 68%, and the specificity was 94%. This gave a positive-predictive value of 47% and a negative-predictive value of 98%. CONCLUSIONS Relying on rSO(2) alone for selective shunting is potentially dangerous and might have led to intraoperative ischemic strokes in seven patients and the unnecessary use of shunts in at least 16 patients in this series. The use of rSO(2) adds nothing to the information already provided by EEG and SSEP in determining when to place a shunt during CEA.
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Affiliation(s)
- Mark L Friedell
- Department of Surgical Education, Orlando Regional Healthcare, Orlando, Florida, USA.
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