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Elsayed N, Locham S, Janssen C, Patel R, Gaffey A, Kashyap VS, Stoner M, Malas MB. Impact of Routine Intracerebral Completion Angiography on Outcomes After TransCarotid Artery Revascularization. J Vasc Surg 2022; 75:1958-1965. [PMID: 35063610 DOI: 10.1016/j.jvs.2021.12.074] [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: 09/26/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Completion intracerebral angiography (CIA) following transcarotid artery revascularization (TCAR) aims to identify distal embolization after stenting and serve as a measure of intraoperative quality control. Nevertheless, there is no general evidence regarding the benefit of performing routine CIA. The aim of this study was to evaluate the potential risk and benefit of routine CIA. METHODS We retrospectively reviewed the Vascular Quality Initiative (VQI) database for transcarotid artery revascularization between 2016-2021. Patients were divided into two groups: patients with no CIA performed and those with completion angiography performed. The primary outcome was in-hospital stroke or death. Secondary outcomes included stroke, death, myocardial infarction (MI) and return to the operating room (RTOR). Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier. RESULTS A total of 18,155 patients who underwent TCAR were identified, 63.7% of them had routine CIA performed. Patients who had routine CIA were more likely to have contralateral carotid occlusion and general anesthesia. After adjusting for potential confounders, we found no difference in the risk of stroke or death (aOR): 1.03, 95%CI (0.8-1.3), P=.820), stroke/TIA (aOR, 1, 95%CI (0.8-1.3), P=.998), stroke (aOR: 1.1, 95%CI (0.8-1.4), P=.452), death (aOR: 0.98, 95%CI (0.6-1.6), P=.953), MI (aOR: 0.78, 95%CI (0.5-1.2), P=.240), or RTOR (aOR: 1.5, 95%CI (0.6-3.8), P=.412) between patients who had CIA compared to those who did not. A sub-analysis of patients who had new occlusion detected on CIA (69 patients, 0.6%; 19 not treated and 50 treated) indicated higher risk of stroke or death in patients with treated new occlusions (OR: 7.1, 95%CI (2.9-17.3), P<.001) and stroke/TIA (aOR, 5.8, 95%CI (2.3-14.7), P<.001) compared to patients who had no CIA. However, no difference in stroke/death (OR: 3.3, 95%CI (0.37-29.5), P=.283) or stroke/TIA (aOR, 3.1, 95%CI (0.3-29.4), P=.327) was found in patients with non-treated new occlusions compared to patients who had no CIA. CONCLUSIONS In this retrospective study, routine performance of completion cerebral angiography was not beneficial with no significant differences in in-hospital stroke or death detected. Detection of new lesions on completion cerebral angiography was rare. Moreover, identifying new occlusions following intracranial angiography was associated with higher odds of stroke or death when these new lesions are treated. Further studies are needed to define the etiology of worse outcomes in patients undergoing intervention for lesions discovered on completion cerebral angiogram and delineate optimal timing for further imaging and intervention.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California
| | - Satinderjit Locham
- Division of Vascular and Endovascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Claire Janssen
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California
| | - Rohini Patel
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California
| | - Ann Gaffey
- University of Pennsylvania Health System, Division of Vascular Surgery and Endovascular Therapy, Philadelphia, PA
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Michael Stoner
- Division of Vascular and Endovascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California.
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Dillner J, Meyer F, Halloul Z, Görtler M. [Intraoperative angiography in carotid artery reconstruction-Pathological findings, reliability and importance of the procedure]. Chirurg 2021; 92:1123-1131. [PMID: 33852016 PMCID: PMC8629857 DOI: 10.1007/s00104-021-01403-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 02/27/2021] [Indexed: 11/05/2022]
Abstract
Ziel Der Wert der intraoperativen Angiographie und deren Ad-hoc-Beurteilung im Hinblick auf operationstechnische Unzulänglichkeiten soll geprüft werden. Methode Insgesamt 523 konsekutive A.-cartotis-Thrombendarteriektomie(TEA)-Patienten mit intraoperativer Kontrollangiographie, postoperativer Duplexsonographie und retrospektiver Zweitbeurteilung der Angiographie wurden in die Auswertung einbezogen. Ergebnisse In der retrospektiven Zweitbeurteilung der Angiographie wurden 23 (4,4%) Verschlüsse oder hochgradige Stenosen der Arteria carotis communis (ACC) oder Arteria carotis interna (ACI) im Operationsbereich (12/2,3%) bzw. in der Abstrombahn (distale extrakranielle und intrakranielle ACI, A. cerebri media [ACM]) detektiert (11/2,1%), wohingegen bei der intraoperativen Ad-hoc-Beurteilung nur 13 (2,5%) derartige Pathologien beschrieben worden waren (7/1,3% im Operationsbereich, 6/1,1% in der Abstrombahn; p=0,002). Duplexsonographisch wurden postoperativ bei 50 von 505 untersuchten Patienten (10,1%) operationstechnische Unzulänglichkeiten lokal detektiert, was signifikant mehr war als in der Angiographie (p<0,001). In den meisten Fällen handelte es sich um nicht okkludierende/nicht hochgradig stenosierende Intima-Media-Ablösungen (19), Nahteinziehungen (13) und Kinkings/Kalibersprünge am distalen Patchende (14). Nahteinziehungen und Kinkings/Kalibersprünge waren mit einer linksseitigen TEA (adjustierte OR: 2,4; 95%-KI: 1,1‑5,1), einer Operation ohne Patch (adjustierte OR: 16,6; 95%-KI: 1,3–215,0) und der Verwendung eines Dacron- vs. Polytetrafluorethylen-Patch (adjustierte OR: 3,0; 95%-KI: 1,4–6,6) assoziiert. Schlussfolgerung Bei der Ad-hoc-Beurteilung der intraoperativen Kontrollangiographie kann eine nicht unerhebliche Zahl auch okkludierender und hochgradig stenosierender Pathologien übersehen werden (zur Detektion nicht okkludierender und nicht hochgradig stenosierender operativer Unzulänglichkeiten methodisch nicht geeignet – Ausweich: postoperative Duplexsonographie).
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Affiliation(s)
- Jasmin Dillner
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A.ö.R., Leipziger Straße 44, 39120, Magdeburg, Deutschland
| | - Frank Meyer
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A.ö.R., Leipziger Straße 44, 39120, Magdeburg, Deutschland.
| | - Zuhir Halloul
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A.ö.R., Leipziger Straße 44, 39120, Magdeburg, Deutschland
| | - Michael Görtler
- Klinik für Neurologie, Universitätsklinikum Magdeburg A.ö.R., Leipziger Straße 44, 39120, Magdeburg, Deutschland
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Knappich C, Schmid S, Tsantilas P, Kallmayer M, Salvermoser M, Zimmermann A, Eckstein HH. Prospective Comparison of Duplex Ultrasound and Angiography for Intra-operative Completion Studies after Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2020; 59:881-889. [PMID: 32197998 DOI: 10.1016/j.ejvs.2020.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 02/02/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The application of intra-operative completion studies may have contributed to the ongoing improvement of peri-operative outcomes in carotid surgery. METHODS This prospective study aimed to compare angiography and duplex ultrasound (IDUS) as intra-operative completion studies after carotid endarterectomy (CEA) with respect to differences in the rating of vessel wall defects and interobserver reliability. Patients undergoing CEA for symptomatic or asymptomatic carotid stenosis were included. After CEA, angiography and IDUS were performed. Intra-operatively obtained video footage was evaluated at a later date by three independent and blinded raters with different levels of clinical experience. Rating was done according to a four step rating scale, with higher grades representing more severe defects. Standard statistical methods (Pearson's chi square test; permutation test; Wilcoxon signed rank test; Kendall's coefficient of concordance, Wt) were applied. RESULTS In total, 150 patients (mean ± standard deviation age 72 ± 7 years, 68.7% male, 33.3% symptomatic) were enrolled between March 2016 and September 2017. Significantly more defects requiring intra-operative revision (grades 3 and 4 on rating scale) were detected by IDUS, which, in part, remained undetected by angiography: 22 (14.7%) vs. 10 (6.7%) (p = .040). Defects were also judged to be more severe with IDUS than with angiography: median rating grade 1: 74 (49.3%) vs. 102 (68.0%); grade 2: 54 (36.0%) vs. 38 (25.3%); grade 3: 21 (14.0%) vs. 9 (6.0%); grade 4: 1 (0.7%) vs.1 (0.7%) (p < .001). Furthermore, Wt was significantly higher for IDUS compared with angiography (0.70 vs. 0.57; p = .003). CONCLUSION IDUS revealed more defects after CEA than angiography. Despite both techniques only showing moderate interobserver reliability, IDUS is less dependent on the surgeon's subjectivity than angiography. Taking into account the absence of procedure associated risks (i.e., adverse effects of iodinated contrast media and Xray), IDUS could be considered as an alternative intra-operative morphological assessment tool in carotid surgery.
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Affiliation(s)
- Christoph Knappich
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sofie Schmid
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Pavlos Tsantilas
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Salvermoser
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Zimmermann
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Sen AN, Fridley J, Sebastian S, Duckworth EAM. Intraoperative Computed Tomography Angiography: A Novel Completion Imaging Modality for Carotid Endarterectomy. Oper Neurosurg (Hagerstown) 2017; 13:739-745. [DOI: 10.1093/ons/opw036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 03/30/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Intraoperative computed tomography angiography (ICTA) is a novel completion imaging modality for carotid endarterectomy (CEA). No studies exist in the literature describing ICTA use in CEA.
OBJECTIVE
To evaluate the feasibility and efficacy of ICTA as a method of immediately evaluating the technical results of CEA.
METHODS
Twenty-three consecutive CEAs were performed by a single neurosurgeon over an 8-month period. Of this series, 12 utilized ICTA for completion imaging, 10 utilized duplex ultrasonography (US), and 1 utilized no intraoperative completion imaging. Electronic medical records were reviewed to assess demographics, CTA results, US results, and need for revisions.
RESULTS
Patients included 13 men (62%) and 8 women (38%). All patients had symptomatic internal carotid artery stenosis. Polytetrafluoroethylene (PTFE) patch angioplasty was used in 16 cases (70%). Average operative times were comparable between cases that utilized CTA and US, 180 and 175 min, respectively. Major technical defects were identified in one of the 12 cases utilizing ICTA and none of the 10 cases utilizing intraoperative US. The technical defect was revised without subsequent neurological complication. One patient had a postoperative intracerebral hemorrhage requiring surgical evacuation. Fifteen patients were followed for up to 3 months with no postoperative stroke or transient ischemic attacks.
CONCLUSION
ICTA is a potentially safe and effective completion imaging modality compared to traditional alternatives, enabling the identification of technical deficits intraoperatively. While no statistically significant difference in operative times were noted between intraoperative CTA and US use, numerous steps must be taken to maximize the efficiency of ICTA.
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Affiliation(s)
- Anish N Sen
- Department of Neurosurgery, Baylor Col-lege of Medicine, Houston, Texas
| | - Jared Fridley
- Department of Neurosurgery, Baylor Col-lege of Medicine, Houston, Texas
| | - Sherly Sebastian
- Department of Neurosurgery, Baylor Col-lege of Medicine, Houston, Texas
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Rockman CB, Halm EA. Intraoperative Imaging: Does it Really Improve Perioperative Outcomes of Carotid Endarterectomy? Semin Vasc Surg 2007; 20:236-43. [DOI: 10.1053/j.semvascsurg.2007.10.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pratesi C, Dorigo W, Troisi N, Fargion A, Innocenti AA, Pratesi G, Barbanti E, Pulli R. Routine Completion Angiography during Carotid Endarterectomy is not Mandatory. Eur J Vasc Endovasc Surg 2006; 32:369-73; discussion 374. [PMID: 16777443 DOI: 10.1016/j.ejvs.2006.04.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 04/15/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Intraoperative quality control after carotid endarterectomy (CEA) has been advocated to improve the results of surgical treatment of extracranial carotid artery disease. The aim of this study was to evaluate the usefulness of completion angiography (CA) in prevention of stroke and restenosis after CEA in a single center experience. MATERIALS AND METHODS Data concerning 914 consecutive CEAs performed in 3 years (2000-2002) were prospectively collected in a dedicated database. Patients were divided into two groups: in the first group (mandatory-CA group; 430 cases) CA was routinely carried out, except in presence of contraindications to iodinate contrast agents; in the second group (selective-CA group, 484 cases) CA was performed only in selected cases, at surgeon's discretion. RESULTS There were no significant differences between the two groups in terms of neurological complications at awakening (0.5% in mandatory-CA group and 0.4% in selective-CA group; p=n.s.) and in 30-day stroke and death rate (1.9% and 1.4%, respectively; p=n.s.). A surgical revision on the basis of CA findings was performed in 5 cases in mandatory-CA group and in 2 cases in selective-CA group (1.2% and 0.4%, respectively; p=n.s.). In the second group, the conditions significantly associated with the need for CA examination were internal carotid near-occlusion, preoperative symptoms, shunt insertion, kind of surgical reconstruction, redo surgery. Estimated absence of ipsilateral stroke and absence of restenosis at 18 months was 98.9% and 89.7% in mandatory-CA group and 99.3% and 93.4% in selective-CA group (p=n.s.) respectively. CONCLUSIONS Based on our experience, routine CA following CEA is not suggested. A policy of selected CA at the surgeon's discretion seems to make the intervention safe and durable as well.
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Affiliation(s)
- C Pratesi
- Department of Vascular Surgery, University of Florence, Italy
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Lozano F, Vaquero-Puerta C, Fonseca-Legrand J, Vaquero-Morillo F. Medicina basada en la evidencia y endarterectomía carotídea. Variabilidad de la práctica clínica en la Comunidad Autónoma de Castilla y León. ANGIOLOGIA 2004. [DOI: 10.1016/s0003-3170(04)74908-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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