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Moore JM, Garg K, Laskowski IA, Maldonado TS, Mateo RB, Babu S, Goyal A, Ventarola DJ, Chang H. Intraoperative Infusion of Dextran Confers No Additional Benefit after Carotid Endarterectomy but Is Associated with Increased Perioperative Major Adverse Cardiac Events. Ann Vasc Surg 2023; 97:8-17. [PMID: 37004920 DOI: 10.1016/j.avsg.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/25/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Intraoperative dextran infusion has been associated with reduction of an embolic risk in patients undergoing carotid endarterectomy (CEA). Nonetheless, dextran has been associated with adverse reactions, including anaphylaxis, hemorrhage, cardiac, and renal complications. Herein, we aimed to compare the perioperative outcomes of CEA stratified by the use of intraoperative dextran infusion using a large multiinstitutional dataset. METHODS Patients undergoing CEA between 2008 and 2022 from the Vascular Quality Initiative database were reviewed. Patients were categorized by use of intraoperative dextran infusion, and demographics, procedural data, and in-hospital outcomes were compared. Logistic regression analysis was utilized to adjust for differences in patients while assessing the association between postoperative outcomes and intraoperative infusion of dextran. RESULTS Of 140,893 patients undergoing CEA, 9,935 (7.1%) patients had intraoperative dextran infusion. Patients with intraoperative dextran infusion were older with lower rates of symptomatic stenosis (24.7% vs. 29.3%; P < 0.001) and preoperative use of antiplatelets, anticoagulants and statins. Additionally, they were more likely to have severe carotid stenosis (>80%; 49% vs. 45%; P < 0.001) and undergo CEA under general anesthesia (96.4% vs. 92.3%; P < 0.001), with a more frequent use of shunt (64.4% vs. 49.5%; P < 0.001). After adjustment, multivariable analysis showed that intraoperative dextran infusion was associated with higher odds of in-hospital major adverse cardiac events (MACE), including myocardial infarction [MI] (odds ratio [OR], 1.76, 95% confidence interval [CI]: 1.34-2.3, P < 0.001), congestive heart failure [CHF] (OR, 2.15, 95% CI: 1.67-2.77, P = 0.001), and hemodynamic instability requiring vasoactive agents (OR, 1.08, 95% CI: 1.03-1.13, P = 0.001). However, it was not associated with decreased odds of stroke (OR, 0.92, 95% CI: 0.74-1.16, P = 0.489) or death (OR, 0.88, 95% CI: 0.58-1.35, P = 0.554). These trends persisted even when stratified by symptomatic status and degree of stenosis. CONCLUSIONS Intraoperative infusion of dextran was associated with increased odds of MACE, including MI, CHF, and persistent hemodynamic instability, without decreasing the risk of stroke perioperatively. Given these results, judicious use of dextran in patients undergoing CEA is recommended. Furthermore, careful perioperative cardiac management is warranted in select patients receiving intraoperative dextran during CEA.
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Affiliation(s)
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Igor A Laskowski
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Medical Center, New York, NY
| | - Romeo B Mateo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Sateesh Babu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Arun Goyal
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Daniel J Ventarola
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Heepeel Chang
- New York Medical College, Valhalla, NY; Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY.
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Razumovsky AY, Jahangiri FR, Balzer J, Alexandrov AV. ASNM and ASN joint guidelines for transcranial Doppler ultrasonic monitoring: An update. J Neuroimaging 2022; 32:781-797. [PMID: 35589555 DOI: 10.1111/jon.13013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 11/26/2022] Open
Abstract
Today, it seems prudent to reconsider how ultrasound technology can be used for providing intraoperative neurophysiologic monitoring that will result in better patient outcomes and decreased length and cost of hospitalization. An extensive and rapidly growing literature suggests that the essential hemodynamic information provided by transcranial Doppler (TCD) ultrasonography neuromonitoring (TCDNM) would provide effective monitoring modality for improving outcomes after different types of vascular, neurosurgical, orthopedic, cardiovascular, and cardiothoracic surgeries and some endovascular interventional or diagnostic procedures, like cardiac catheterization or cerebral angiography. Understanding, avoiding, and preventing peri- or postoperative complications, including neurological deficits following abovementioned surgeries, endovascular intervention, or diagnostic procedures, represents an area of great public and economic benefit for society, especially considering the aging population. The American Society of Neurophysiologic Monitoring and American Society of Neuroimaging Guidelines Committees formed a joint task force and developed updated guidelines to assist in the use of TCDNM in the surgical and intensive care settings. Specifically, these guidelines define (1) the objectives of TCD monitoring; (2) the responsibilities and behaviors of the neurosonographer during monitoring; (3) instrumentation and acquisition parameters; (4) safety considerations; (5) contemporary rationale for TCDNM; (6) TCDNM perspectives; and (7) major recommendations.
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Affiliation(s)
| | | | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrei V Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Kussman BD, Imaduddin SM, Gharedaghi MH, Heldt T, LaRovere K. Cerebral Emboli Monitoring Using Transcranial Doppler Ultrasonography in Adults and Children: A Review of the Current Technology and Clinical Applications in the Perioperative and Intensive Care Setting. Anesth Analg 2021; 133:379-392. [PMID: 33764341 DOI: 10.1213/ane.0000000000005417] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcranial Doppler (TCD) ultrasonography is the only noninvasive bedside technology for the detection and monitoring of cerebral embolism. TCD may identify patients at risk of acute and chronic neurologic injury from gaseous or solid emboli. Importantly, a window of opportunity for intervention-to eliminate the source of the emboli and thereby prevent subsequent development of a clinical or subclinical stroke-may be identified using TCD. In this review, we discuss the application of TCD sonography in the perioperative and intensive care setting in adults and children known to be at increased risk of cerebral embolism. The major challenge for evaluation of emboli, especially in children, is the need to establish the ground truth and define true emboli identified by TCD. This requires the development and validation of a predictive TCD emboli monitoring technique so that appropriately designed clinical studies intended to identify specific modifiable factors and develop potential strategies to reduce pathologic cerebral embolic burden can be performed.
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Affiliation(s)
- Barry D Kussman
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Syed M Imaduddin
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Mohammad Hadi Gharedaghi
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Thomas Heldt
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Kerri LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.,Department of Neurology, Harvard Medical School, Boston, Massachusetts
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Kam P, Liou J, Yang K. In vitro evaluation of the effect of haemodilution with dextran 40 on coagulation profile as measured by thromboelastometry and multiple electrode aggregometry. Anaesth Intensive Care 2017; 45:562-568. [PMID: 28911285 DOI: 10.1177/0310057x1704500506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We evaluated the effects of haemodilution with either dextran 40 or 0.9% normal saline on coagulation in vitro using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany) and multiple electrode aggregometry (Multiplate® Platelet Function Analyser, Dynabyte, Munich, Germany). Venous blood samples obtained from 20 healthy volunteers were diluted in vitro with dextran 40 or normal saline by 5%, 10% and 15%. Fibrinogen concentration, ROTEM-EXTEM® (screening test for the extrinsic coagulation pathway), FIBTEM® (an EXTEM-based assay of the fibrin component of clot) parameters including coagulation time, clot formation time, alpha angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each level of haemodilution. Dextran 40 at 15% haemodilution significantly prolonged coagulation time, clot formation time and significantly decreased the alpha angle and maximal clot firmness (EXTEM amplitude at five minutes [A5] and ten minutes [A10]) compared with normal saline. The FIBTEM assay (maximal clot firmness and FIBTEM A5 and A10) showed a marked decrease in maximal clot firmness at all dilutions suggesting impaired fibrinogen activity and a risk of bleeding. Multiple electrode aggregometry did not demonstrate any platelet dysfunction. Haemodilution with dextran 40 causes significant impairment in clot formation and strength compared to saline haemodilution and undiluted blood. At the levels of in vitro haemodilution designed to reflect the clinical use of dextran infusions, no significant fibrinolysis or platelet inhibition was observed.
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Affiliation(s)
- Pca Kam
- Discipline of Anaesthetics , Sydney Medical School, University of Sydney
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Linzey JR, Griauzde J, Guan Z, Bentley N, Gemmete JJ, Chaudhary N, Thompson BG, Pandey AS. Stent-assisted coiling of cerebrovascular aneurysms: experience at a large tertiary care center with a focus on predictors of recurrence. J Neurointerv Surg 2016; 9:1081-1085. [DOI: 10.1136/neurintsurg-2016-012704] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/04/2022]
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Abstract
The purpose of this paper is to discuss the role and efficacy of dextran in vascular procedures using evidence-based data from the review of surgical literature. A MEDLINE search using “dextran,” “vascular surgery,” and “antiplatelet therapy” as keywords was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. Dextran is commonly used in carotid endarterectomy (CEA) patients where the embolic rate is reduced by 46%, resulting in fewer procedure-related strokes. As a prophylactic agent against thrombosis, multiple randomized studies have reported its benefit over other antithrombotic medications. Dextran is also particularly useful in “difficult” infragenicular lower extremity bypasses where artificial grafts (such as polytetrafluoroethylene [PTFE] or umbilical vein) are used in the setting of poor outflow vessels, or those with composite grafts and small-caliber venous conduits. Distal bypasses with adjunctive procedures (eg, arteriovenous fistula or anastomotic cuffs) also have a better outcome with the addition of dextran. Dextran has numerous important implications in vascular surgery, in particular with CEA patients or “difficult” infragenicular bypasses. Its effectiveness with endovascular stents remains unknown.
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Affiliation(s)
- Farshad Abir
- Yale University School of Medicine, Section of Vascular Surgery, New Haven, CT 06520-5062, USA
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Bourke V, Bourke B, Beiles C. Operative Factors Associated with the Development of New Brain Lesions During Awake Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2016; 51:167-73. [DOI: 10.1016/j.ejvs.2015.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 08/26/2015] [Indexed: 11/28/2022]
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Huibers A, Calvet D, Kennedy F, Czuriga-Kovács KR, Featherstone RL, Moll FL, Brown MM, Richards T, de Borst GJ. Mechanism of Procedural Stroke Following Carotid Endarterectomy or Carotid Artery Stenting Within the International Carotid Stenting Study (ICSS) Randomised Trial. Eur J Vasc Endovasc Surg 2015; 50:281-8. [PMID: 26160210 PMCID: PMC4580136 DOI: 10.1016/j.ejvs.2015.05.017] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/08/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To decrease the procedural risk of carotid revascularisation it is crucial to understand the mechanisms of procedural stroke. This study analysed the features of procedural strokes associated with carotid artery stenting (CAS) and carotid endarterectomy (CEA) within the International Carotid Stenting Study (ICSS) to identify the underlying pathophysiological mechanism. MATERIALS AND METHODS Patients with recently symptomatic carotid stenosis (1,713) were randomly allocated to CAS or CEA. Procedural strokes were classified by type (ischaemic or haemorrhagic), time of onset (intraprocedural or after the procedure), side (ipsilateral or contralateral), severity (disabling or non-disabling), and patency of the treated artery. Only patients in whom the allocated treatment was initiated were included. The most likely pathophysiological mechanism was determined using the following classification system: (1) carotid-embolic, (2) haemodynamic, (3) thrombosis or occlusion of the revascularised carotid artery, (4) hyperperfusion, (5) cardio-embolic, (6) multiple, and (7) undetermined. RESULTS Procedural stroke occurred within 30 days of revascularisation in 85 patients (CAS 58 out of 791 and CEA 27 out of 819). Strokes were predominately ischaemic (77; 56 CAS and 21 CEA), after the procedure (57; 37 CAS and 20 CEA), ipsilateral to the treated artery (77; 52 CAS and 25 CEA), and non-disabling (47; 36 CAS and 11 CEA). Mechanisms of stroke were carotid-embolic (14; 10 CAS and 4 CEA), haemodynamic (20; 15 CAS and 5 CEA), thrombosis or occlusion of the carotid artery (15; 11 CAS and 4 CEA), hyperperfusion (9; 3 CAS and 6 CEA), cardio-embolic (5; 2 CAS and 3 CEA) and multiple causes (3; 3 CAS). In 19 patients (14 CAS and 5 CEA) the cause of stroke remained undetermined. CONCLUSION Although the mechanism of procedural stroke in both CAS and CEA is diverse, haemodynamic disturbance is an important mechanism. Careful attention to blood pressure control could lower the incidence of procedural stroke.
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Affiliation(s)
- A Huibers
- Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK; Department of Vascular Surgery, University Medical Centre Utrecht, The Netherlands
| | - D Calvet
- Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK; Centre de Psychiatrie et Neurosciences, INSERM UMR 894, Paris Descartes University, Paris, France; Department of Neurology, Centre hospitalier Sainte-Anne, Paris, France
| | - F Kennedy
- Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK
| | - K R Czuriga-Kovács
- Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK; Department of Neurology, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - R L Featherstone
- Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK
| | - F L Moll
- Department of Vascular Surgery, University Medical Centre Utrecht, The Netherlands
| | - M M Brown
- Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK.
| | - T Richards
- Department of Surgical and Interventional Sciences, University College London, London, UK
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, The Netherlands
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Abstract
BACKGROUND Ischaemic stroke interrupts the flow of blood to part of the brain. Haemodilution is thought to improve the flow of blood to the affected areas of the brain and thus reduce infarct size. OBJECTIVES To assess the effects of haemodilution in acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (February 2014), the Cochrane Central Register of Controlled Trials (Issue 1, 2014), MEDLINE (January 2008 to October 2013) and EMBASE (January 2008 to October 2013). We also searched trials registers, scanned reference lists and contacted authors. For the previous version of the review, the authors contacted manufacturers and investigators in the field. SELECTION CRITERIA Randomised trials of haemodilution treatment in people with acute ischaemic stroke. We included only trials in which treatment was started within 72 hours of stroke onset. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and one review author extracted the data. MAIN RESULTS We included 21 trials involving 4174 participants. Nine trials used a combination of venesection and plasma volume expander. Twelve trials used plasma volume expander alone. The plasma volume expander was plasma alone in one trial, dextran 40 in 12 trials, hydroxyethyl starch (HES) in five trials and albumin in three trials. Two trials tested haemodilution in combination with another therapy. Evaluation was blinded in 14 trials. Five trials probably included some participants with intracerebral haemorrhage. Haemodilution did not significantly reduce deaths within the first four weeks (risk ratio (RR) 1.10; 95% confidence interval (CI) 0.90 to 1.34). Similarly, haemodilution did not influence deaths within three to six months (RR 1.05; 95% CI 0.93 to 1.20), or death and dependency or institutionalisation (RR 0.96; 95% CI 0.85 to 1.07). The results were similar in confounded and unconfounded trials, and in trials of isovolaemic and hypervolaemic haemodilution. No statistically significant benefits were documented for any particular type of haemodiluting agents, but the statistical power to detect effects of HES was weak. Six trials reported venous thromboembolic events. There was a tendency towards reduction in deep venous thrombosis or pulmonary embolism or both at three to six months' follow-up (RR 0.68; 95% CI 0.37 to 1.24). There was no statistically significant increased risk of serious cardiac events among haemodiluted participants. AUTHORS' CONCLUSIONS The overall results of this review showed no clear evidence of benefit of haemodilution therapy for acute ischaemic stroke.These results are compatible with no persuasive beneficial evidence of haemodilution therapy for acute ischaemic stroke. This therapy has not been proven to improve survival or functional outcome.
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Affiliation(s)
- Timothy S Chang
- University of WisconsinInstitute for Clinical and Translational ResearchFCB Room 72731685 Highland AveMadisonWIUSA53705
| | - Matthew B Jensen
- University of WisconsinDepartment of Neurology1685 Highland Ave, room 7273MadisonWIUSA53705
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Dual antiplatelet therapy plus postoperative heparin and dextran is safe and effective for reducing risk of embolic stroke during aneurysm coiling. Acta Neurochir (Wien) 2014; 156:855-9. [PMID: 24595538 DOI: 10.1007/s00701-014-2031-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 02/10/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Thromboembolic events represent a clinically significant cause of neurological morbidity during the endovascular management of cerebral aneurysms. We have implemented an anti-thromboembolic regimen consisting of pre- and postoperative dual antiplatelet therapy, as well as postoperative anticoagulation using heparin and dextran. The aims of our study were to examine the effect of this regimen on thromboembolic rates during elective aneurysm coiling, and to elucidate risk factors associated with the development of thromboembolic events in this setting. METHODS We conducted a retrospective review of patients who underwent elective intracranial aneurysm coiling between January 2005 and February 2012. The primary outcome of interest was the occurrence of a clinically significant peri-procedural thromboembolic event. Secondary outcomes included the occurrence of a central nervous system (CNS) or systemic hemorrhage. RESULTS During the study period, 312 patients underwent elective aneurysm coiling and six (2 %) thromboembolic events occurred; three (1 %) occurred in the group that received the anti-thromboembolic regimen (261 patients) and three (6 %) occurred in the group that did not receive the regimen (51 patients), resulting in a statistically significant difference (P = 0.024). Both the presence of a hypercoagulable state (P = 0.014) and the lack of the anti-thromboembolic regimen (P = 0.043) were significantly associated with the occurrence of a thromboembolic event. CONCLUSIONS This study provides evidence that the regimen described here is safe and reduces thromboembolic complications during elective aneurysm coiling. Ours is likely the most aggressive regimen in the published literature and significantly reduced the rate of thromboembolism without any significant increase hemorrhagic complications.
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Tan TW, Farber A. Reply: To PMID 23337295. J Vasc Surg 2013; 58:1167-8. [PMID: 24075116 DOI: 10.1016/j.jvs.2013.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 06/12/2013] [Accepted: 06/12/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Tze-Woei Tan
- Division of Vascular and Endovascular Surgery, Louisiana State University Health Science Center-Shreveport, Shreveport, La
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12
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Regarding "Intraoperative use of dextran is associated with cardiac complications after carotid endarterectomy". J Vasc Surg 2013; 58:1167. [PMID: 24075115 DOI: 10.1016/j.jvs.2013.05.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 05/15/2013] [Accepted: 05/17/2013] [Indexed: 11/20/2022]
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Farber A, Tan TW, Rybin D, Kalish JA, Hamburg NM, Doros G, Goodney PP, Cronenwett JL. Intraoperative use of dextran is associated with cardiac complications after carotid endarterectomy. J Vasc Surg 2013; 57:635-41. [PMID: 23337295 DOI: 10.1016/j.jvs.2012.09.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/17/2012] [Accepted: 09/18/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Although dextran has been theorized to diminish the risk of stroke associated with carotid endarterectomy (CEA), variation exists in its use. We evaluated outcomes of dextran use in patients undergoing CEA to clarify its utility. METHODS We studied all primary CEAs performed by 89 surgeons within the Vascular Study Group of New England database (2003-2010). Patients were stratified by intraoperative dextran use. Outcomes included perioperative death, stroke, myocardial infarction (MI), and congestive heart failure (CHF). Group and propensity score matching was performed for risk-adjusted comparisons, and multivariable logistic and gamma regressions were used to examine associations between dextran use and outcomes. RESULTS There were 6641 CEAs performed, with dextran used in 334 procedures (5%). Dextran-treated and untreated patients were similar in age (70 years) and symptomatic status (25%). Clinical differences between the cohorts were eliminated by statistical adjustment. In crude, group-matched, and propensity-matched analyses, the stroke/death rate was similar for the two cohorts (1.2%). Dextran-treated patients were more likely to suffer postoperative MI (crude: 2.4% vs 1.0%; P = .03; group-matched: 2.4% vs 0.6%; P = .01; propensity-matched: 2.4% vs 0.5%; P = .003) and CHF (2.1% vs 0.6%; P = .01; 2.1% vs 0.5%; P = .01; 2.1% vs 0.2%; P < .001). In multivariable analysis of the crude sample, dextran was associated with a higher risk of postoperative MI (odds ratio, 3.52; 95% confidence interval, 1.62-7.64) and CHF (odds ratio, 5.71; 95% confidence interval, 2.35-13.89). CONCLUSIONS Dextran use was not associated with lower perioperative stroke but was associated with higher rates of MI and CHF. Taken together, our findings suggest limited clinical utility for routine use of intraoperative dextran during CEA.
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Affiliation(s)
- Alik Farber
- Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, MA, USA.
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Registry Report on Kinetics of Rescue Antiplatelet Treatment to Abolish Cerebral Microemboli After Carotid Endarterectomy. Stroke 2013; 44:230-3. [DOI: 10.1161/strokeaha.112.676338] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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15
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Jaipersad TS, Saedon M, Tiivas C, Marshall C, Higman DJ, Imray CHE. Perioperative transorbital Doppler flow imaging offers an alternative to transcranial Doppler monitoring in those patients without a temporal bone acoustic window. ULTRASOUND IN MEDICINE & BIOLOGY 2011; 37:719-722. [PMID: 21458149 DOI: 10.1016/j.ultrasmedbio.2011.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 01/13/2011] [Accepted: 01/27/2011] [Indexed: 05/30/2023]
Abstract
Transcranial Doppler has been used to identify microembolic signals before, during and after carotid endarterectomy, but 10% to 15% of patients are reported not to have suitable temporal bone window. The aim of this study was to assess the feasibility of transorbital Doppler monitoring of patients with absent temporal bone acoustic window. Between 2005 and 2008, those patients with absent temporal bone acoustic window were assessed for a transorbital acoustic window. During the study period, 318 carotid endarterectomy were performed. In the 29 (9.1%) with absent temporal bone acoustic window, 25 (86%) had satisfactory transorbital acoustic windows, consequently only four (1.2%) of patients could not be monitored postoperatively. One patient required postoperative transorbital acoustic windows directed glycoprotein IIb/IIIa receptor antagonist infusion due to excessive carotid microembolisation to prevent stroke. This is the first description of the use of transorbital flow imaging to determine postoperative cerebral blood flow, microembolic load and to direct the use of intravenous antiplatelet agents.
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Affiliation(s)
- Tony S Jaipersad
- Coventry and Warwickshire County Vascular Unit, Warwick Medical School, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
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McMahon GS, Webster SE, Hayes PD, Jones CI, Goodall AH, Naylor AR. Low molecular weight heparin significantly reduces embolisation after carotid endarterectomy--a randomised controlled trial. Eur J Vasc Endovasc Surg 2009; 37:633-9. [PMID: 19328023 DOI: 10.1016/j.ejvs.2009.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2008] [Accepted: 02/22/2009] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The administration of unfractionated heparin (UFH) prior to carotid clamping during carotid endarterectomy (CEA) transiently increases the platelet aggregation response to arachidonic acid (AA) despite the use of aspirin. We hypothesized that this phenomenon might be reduced by using low molecular weight heparin (LMWH) resulting in fewer emboli in the early post-operative period. METHODS 183 aspirinated patients undergoing CEA were randomised to 5000 IU UFH (n=91) or 2500 IU LMWH (dalteparin, n=92) prior to carotid clamping. End-points were: transcranial Doppler (TCD) measurement of embolisation, effect on bleeding and platelet aggregation to AA and adenosine 5'-diphosphate (ADP). RESULTS Patients randomised to UFH had twice the odds of experiencing a higher number of emboli in the first 3h after CEA, than those randomised to LMWH (p=0.04). This was not associated with increased bleeding (mean time from flow restoration to operation end: 23 min (UFH) vs. 24 min (LMWH), p=0.18). Platelet aggregation to AA increased significantly following heparinisation, but was unaffected by heparin type (p=0.90). The platelets of patients randomised to LMWH exhibited significantly lower aggregation to ADP compared to UFH (p<0.0001). CONCLUSIONS Intravenous LMWH is associated with a significant reduction in post-operative embolisation without increased bleeding. The higher rate of embolisation seen with UFH may be mediated by increased platelet aggregation to ADP, rather than to AA.
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Affiliation(s)
- G S McMahon
- Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, Leicester, UK.
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Karkos CD, Hernandez-Lahoz I, Naylor AR. Urgent Carotid Surgery in Patients with Crescendo Transient Ischaemic Attacks and Stroke-in-Evolution: A Systematic Review. Eur J Vasc Endovasc Surg 2009; 37:279-88. [PMID: 19162516 DOI: 10.1016/j.ejvs.2008.12.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Accepted: 12/01/2008] [Indexed: 11/29/2022]
Affiliation(s)
- C D Karkos
- Department of Vascular and Endovascular Surgery, Leicester Royal Infirmary, Leicester, UK.
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Luengo-Fernandez R, Gray AM, Rothwell PM. Costs of stroke using patient-level data: a critical review of the literature. Stroke 2008; 40:e18-23. [PMID: 19109540 DOI: 10.1161/strokeaha.108.529776] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE With decision-analytic models becoming more popular to assess the cost-effectiveness of health care interventions, the need for robust estimates on the costs of cerebrovascular disease is paramount. This study reports the results from a literature review of the costs of cerebrovascular diseases, and assesses the quality of the published evidence against a set of defined criteria. METHODS A broad literature search was conducted. Those studies reporting mean/median costs of cerebrovascular diseases derived from patient-level data in a developed country setting were included. Data were abstracted using standardized reporting forms and assessed against 4 predefined criteria: use of adequate methodologies, use of a population-based study, inclusion of premorbid resource use, and reporting of costs by different patient subgroups. RESULTS A total of 120 cost studies were identified. The cost estimates of stroke were compared by taking into account the effects of inflation and price differentials between countries. Average costs of stroke ranged from $468 to $146 149. Differences in costs were also found within country, with estimates in the USA varying 20-fold. Although the costing methodologies used were generally appropriate, only 5 studies were based on population-based studies, which are the gold standard study design when comparing incidence, outcome, and costs. CONCLUSIONS This review showed large variations in the costs of stroke, mainly attributable to differences in the populations studied, methods, and cost categories included. The wide range of cost estimates could lead to selection bias in secondary health economic analyses, with authors including those costs that are more likely to produce the desired results.
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Affiliation(s)
- Ramon Luengo-Fernandez
- Department of Public Health, Health Economics Research Centre, University of Oxford, Oxford, USA.
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Jones CI, Payne DA, Hayes PD, Naylor AR, Bell PRF, Thompson MM, Goodall AH. The antithrombotic effect of dextran-40 in man is due to enhanced fibrinolysis in vivo. J Vasc Surg 2008; 48:715-22. [PMID: 18572351 DOI: 10.1016/j.jvs.2008.04.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Revised: 04/04/2008] [Accepted: 04/06/2008] [Indexed: 12/25/2022]
Abstract
BACKGROUND Dextran-40 is effective in reducing postoperative Doppler-detectable embolization in patients undergoing carotid endarterectomy (CEA). Dextrans are thought to have antithrombotic and antiplatelet effects. The mode of action is unclear. In rats, dextran blocks uptake of tissue plasminogen activator (tPA) by mannose-binding receptors. Because this would have the effect of enhancing endogenous fibrinolysis, we explored this effect of dextran-40 on fibrinolysis in man. METHODS Twenty patients undergoing endovascular stenting for abdominal aortic aneurysm were randomized to receive 100 mL of 10% dextran-40 or saline, over 1 hour, during their operation in addition to heparin. Blood samples were taken preoperatively, intraoperatively (immediately after operative procedure), and 24 hours postoperatively. Thrombi were formed in a Chandler loop and used to assess endogenous fibrinolysis over 24 hours, measured as the fall in thrombus weight, and the release of fluorescently labelled fibrinogen from the thrombus. Plasma samples were analyzed for markers of fibrinolysis; plasmin-antiplasmin (PAP), PAI-1, and t-PA, and for functional von Willebrand factor (vWF). Platelet response to thrombin and other agonists was measured by flow cytometry. RESULTS Thrombi formed ex vivo from the intraoperative blood samples from the dextran-treated patients exhibited significantly greater fibrinolysis vs preoperative samples, seen both as a significantly greater percentage reduction in thrombus weight (from 34.7% to 70.6% reduction) and as an 175% increase in the release of fluorescence (P < .05). Fibrinolysis returned to baseline levels the next day. No change was seen in the saline-treated group. Plasma levels of PAP and PAI-1 increased significantly postoperatively in the dextran-treated group vs the saline group (P < .05). The postoperative level of functional VWF was significantly lower in the dextran-treated group vs controls. A specific reduction occurred in the platelet response to thrombin, but not to other agonists, in the intraoperative samples from the dextran-treated group (11.1% vs 37.1%; P = .022), which was not seen in the controls. CONCLUSIONS These data are consistent with a rise in plasmin due to dextran blockade of tPA uptake in vivo, leading to enhanced fibrinolysis, cleavage of vWF and of the platelet protease-activated receptor-1 (PAR-1) thrombin receptor. This suggests that dextran exerts a combined therapeutic effect, enhancing endogenous fibrinolysis, whilst also reducing platelet adhesion to vWF and platelet activation by thrombin. The proven antithrombotic efficacy of low-dose dextran in carotid surgery may be applicable to wider therapeutic use.
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Affiliation(s)
- Chris I Jones
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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van Dellen D, Tiivas CAS, Jarvi K, Marshall C, Higman DJ, Imray CHE. Transcranial Doppler ultrasonography-directed intravenous glycoprotein IIb/IIIa receptor antagonist therapy to control transient cerebral microemboli before and after carotid endarterectomy. Br J Surg 2008; 95:709-13. [PMID: 18425794 DOI: 10.1002/bjs.6204] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with a transient focal neurological deficit, critical carotid stenosis and/or microemboli detected by transcranial Doppler ultrasonography (TCD) have a significant risk of stroke. The effect of tirofiban, a selective glycoprotein IIb/IIIa inhibitor, was assessed in patients with microembolic signals on TCD after transient ischaemic attacks or carotid endarterectomy (CEA). METHODS Thirty-three patients with microemboli on TCD (13 symptomatic preoperative, 19 postoperative, one both) were treated with tirofiban between 2002 and 2007. All patients had carotid stenosis greater than 70 per cent. TCD monitoring was used during and after tirofiban therapy. RESULTS The median (range) rate of microemboli decreased from 22 (4-260) per h before surgery and 81 (44-216) per h after surgery to 0 (0-9) per h in both groups (P < 0.001, Mann-Whitney U test). This occurred rapidly (preoperative median 30 min; postoperative median 45 min) and was well tolerated in all patients, with no serious adverse effects. CONCLUSION Cerebral microemboli were controlled by tirofiban both before and after CEA. Further study is required to compare the relative efficacy of tirofiban and dextran.
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Affiliation(s)
- D van Dellen
- Coventry and Warwickshire County Vascular Unit, University Hospitals Coventry and Warwickshire NHS Trust, Walsgrave Hospital, Coventry, UK
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21
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de Borst GJ, Hilgevoord AAJ, de Vries JPPM, van der Mee M, Moll FL, van de Pavoordt HDWM, Ackerstaff RGA. Influence of Antiplatelet Therapy on Cerebral Micro-Emboli after Carotid Endarterectomy using Postoperative Transcranial Doppler Monitoring. Eur J Vasc Endovasc Surg 2007; 34:135-42. [PMID: 17521930 DOI: 10.1016/j.ejvs.2007.03.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Accepted: 03/16/2007] [Indexed: 11/19/2022]
Abstract
AIM To study the effect of different antiplatelet regimens (APT) on the rate of postoperative TCD registered micro-embolic signals (MES) following carotid endarterectomy (CEA). DESIGN Prospective, randomised, double-blinded, pilot study. METHODS The study group of 102 CEA patients (76 men, mean age 66.8 years) was randomised to routine Asasantin (Dipyridamole 200mg/Aspirin 25mg) twice daily (group I; n=39), Asasantin plus 75 mg Clopidogrel once daily (group II; n=33), or Asasantin plus Rheomacrodex (Dextran 40) 100g/L iv; 500 ml (group III; n=30). TCD monitoring of the ipsilateral middle cerebral artery for the occurrence of MES was performed intra-operatively and during the second postoperative hour following CEA. Primary endpoints were the rate of postoperative emboli and the occurrence of cerebrovascular complications. Secondary endpoint was any adverse bleeding. RESULTS There were no deaths or major strokes. We observed 2 intraoperative TIA's (group II and III) and 1 postoperative minor stroke (group I). In comparison with placebo, Clopidogrel or Rheomacrodex in addition to Asasantin produced no significant reduction in the number of postoperative MES. There was no significant difference between the number of postoperative MES and different antiplatelet regimens. The incidence of bleeding complications was not significantly different between the 3 APT groups. CONCLUSION In the present study, we could not show a significant influence of different antiplatelet regimens on TCD detected postoperative embolization following CEA.
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Affiliation(s)
- G J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, The Netherlands.
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22
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Mayer RC, Bingley J, Westcott MJ, Deshpande A, Davies MJ, Lovelock ME, Vidovich J, Doyle J, Denton MJ, Gurry JF. INTRAOPERATIVE NEUROLOGICAL CHANGES IN 1665 REGIONAL ANAESTHETIC CAROTID ENDARTERECTOMIES PREDICTS POSTOPERATIVE STROKE. ANZ J Surg 2007; 77:49-53. [PMID: 17295821 DOI: 10.1111/j.1445-2197.2006.03976.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To maximize the benefit of carotid endarterectomy (CEA) in stroke prevention its complication rate must be minimized. The purpose of this study was to report the outcomes of a large series of CEA carried out under regional anaesthesia with selective shunting, with particular emphasis on identifying predictors for perioperative stroke and mortality. METHODS Between 1987 and 2003 the data for 1665 consecutive regional anaesthetic CEA carried out in 1495 patients were collected prospectively; awake neurological testing facilitated selective shunting. Preoperative data, intraoperative events and postoperative in-hospital complications were recorded and analysed. RESULTS There were 38 non-fatal strokes (2.3%) and 10 deaths (0.6%), giving a combined stroke and mortality rate of 2.9%. Only patients who needed shunting were found to have significantly higher rate of postoperative stroke and mortality (7.0 vs 1.9%, P < 0.001). Patient characteristics, comorbidities, indication for operation (P = 0.34) and the degree of stenosis of the contralateral carotid artery (P = 0.65) were not found to be predictive of perioperative stroke or mortality, although the latter two were found to be predictive of the need for shunting (P < 0.001 and P = 0.002). CONCLUSION Regional anaesthetic CEA is a safe and effective technique with excellent morbidity and mortality rates. The technique can be undertaken safely regardless of the indication for endarterectomy or the status of the contralateral carotid artery. Patients who developed intraoperative neurological changes requiring shunting are identified as high risk for perioperative stroke or mortality and should therefore be carefully monitored postoperatively.
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Affiliation(s)
- Raoul C Mayer
- Department of Vascular Surgery, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
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Sloan MA. Prevention of Ischemic Neurologic Injury With Intraoperative Monitoring of Selected Cardiovascular and Cerebrovascular Procedures: Roles of Electroencephalography, Somatosensory Evoked Potentials, Transcranial Doppler, and Near-Infrared Spectroscopy. Neurol Clin 2006; 24:631-45. [PMID: 16935192 DOI: 10.1016/j.ncl.2006.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
All neuromonitoring techniques, although imperfect, provide useful information for monitoring cardiothoracic and carotid vascular operations. They may be viewed as providing complementary information, which may help surgical technique and, as a result, possibly improve clinical outcomes. As of this writing, the efficacy of TCD and NIRS monitoring during cardiothoracic and vascular surgery cannot be considered established. Well designed, prospective, adequately powered, double-blind, and randomized outcome studies are needed to determine the optimal neurologic monitoring modality (or modalities), in specific surgical settings.
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Affiliation(s)
- Michael A Sloan
- Division of Neurology, Neuroscience and Spine Institute, Carolinas Medical Center, Charlotte, NC 28207, USA.
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Gortler D, Maloney S, Rutland R, Westvik T, Muto A, Kudo FA, Dardik A. Adjunctive pharmacologic use in carotid endarterectomy: a review. Vascular 2006; 14:93-102. [PMID: 16956478 DOI: 10.2310/6670.2006.00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although carotid endarterectomy (CEA) is now widely accepted as the surgical therapy for carotid stenosis, the role of and indications and evidence for many pharmacologic agents that are used adjunctively in the perioperative setting have not been conclusively established. Aspirin (acetylsalicylic acid) is the pharmaceutical agent that has been studied most extensively in conjunction with CEA; other than aspirin and dextran, the use of many agents before, during, and after CEA has not been standardized. Prospective randomized trials are still needed to demonstrate efficacy, predict outcome, and determine the optimal use of these medications in their adjunctive use during CEA to improve patient care and obtain optimal surgical outcomes.
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Affiliation(s)
- David Gortler
- VA Connecticut Healthcare System, West Haven, CT, USA
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Ljungström KG. Invited commentary: Pretreatment with dextran 1 makes dextran 40 therapy safer. J Vasc Surg 2006; 43:1070-2. [PMID: 16678710 DOI: 10.1016/j.jvs.2005.11.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2005] [Accepted: 11/23/2005] [Indexed: 11/21/2022]
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Horn J, Naylor AR, Laman DM, Chambers BR, Stork JL, Schroeder TV, Nielsen MY, Dunne VG, Ackerstaff RGA. Identification of Patients at Risk for Ischaemic Cerebral Complications After Carotid Endarterectomy with TCD Monitoring. Eur J Vasc Endovasc Surg 2005; 30:270-4. [PMID: 15963744 DOI: 10.1016/j.ejvs.2005.04.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Accepted: 04/05/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Transcranial Doppler (TCD) monitoring for micro embolic signals (MES), directly after carotid endarterectomy (CEA) may identify patients at risk of developing ischaemic complications. In this retrospective multicentre study, this hypothesis was investigated. METHODS Centres that monitored for MES after CEA were identified by searching Medline. Individual patient data were obtained from centres willing to collaborate. The number of emboli in 1h was computed. Uni- and multivariate logistic regression analyses were performed for the variables gender, age and number of MES. Discriminative ability of MES monitoring was investigated in a ROC curve. RESULTS Nine hundred and ninety-one patients were monitored in the first 3h after CEA. Two percent developed ischaemic cerebral complications. Univariate analysis revealed statistically significant associations between ischaemic cerebral complications and both gender and MES, but not age. In a multivariate analysis, > or =8 MES/h showed a statistically significant relationship with cerebral complications (OR 8.1, 95% CI 1.8-36), in contrast to gender (OR 2.2, 95% CI 0.9-5.5). The ROC curve yielded an AUC of 0.83 for monitoring of MES. CONCLUSIONS These results support the use of TCD monitoring for MES shortly after CEA in order to identify patients at risk of developing ischaemic cerebral complications.
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Affiliation(s)
- J Horn
- Department of Clinical Neurophysiology, Antonius Hospital, P.O. Box 2500, 3430 EM Nieuwegein, The Netherlands
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Imray CHE, Tiivas CAS. Are some strokes preventable? The potential role of transcranial doppler in transient ischaemic attacks of carotid origin. Lancet Neurol 2005; 4:580-6. [PMID: 16109365 DOI: 10.1016/s1474-4422(05)70169-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transient ischaemic attacks (TIA) are more than just ministrokes. The high frequency of early stroke following TIA has resulted in the recent publication of guidelines in the UK. The guidelines recommend that patients attend a neurovascular clinic within 7 days of the index event to expedite investigation and treatment and so reduce the risk of a subsequent (potentially more serious) neurological event. After a TIA or stroke caused by carotid-artery disease, there is an increase in cerebral microemboli detectable by transcranial doppler (TCD). High microembolic loads appear to be surrogate markers for future neurological events, and the pharmacological efficacy of therapeutic interventions can now be rapidly and non-invasively assessed in the clinic or at the bedside. Medical treatments can now be optimised, avoiding the need for urgent or emergency carotid surgery and therefore allowing patients to undergo safer elective surgery when appropriate.
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Affiliation(s)
- Christopher H E Imray
- Coventry and Warwickshire County Vascular Unit, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK.
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Leseche G, Castier Y, Francis F, Besnard M. [Optimization of carotid endarteriectomy results]. JOURNAL DES MALADIES VASCULAIRES 2005; 30:88-93. [PMID: 16107091 DOI: 10.1016/s0398-0499(05)83813-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- G Leseche
- Service de Chirurgie Vasculaire et Thoracique, Hôpital Beaujon, Assistance Publique, Hôpitaux de Paris, 100, Bd du Général Leclerc, 92110 Clichy.
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Russell DA, Gough MJ. Intracerebral Haemorrhage Following Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2004; 28:115-23. [PMID: 15234690 DOI: 10.1016/j.ejvs.2004.03.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2004] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine risk factors for the development of hyperperfusion and intra-cerebral haemorrhage following carotid endarterectomy and formulate potential protocols for prevention. METHODS MEDLINE database search of the English language literature (1966-2002) was performed using the words 'cerebral haemorrhage', 'intracranial haemorrhage' and 'carotid endarterectomy'. Other articles were cross-referenced by hand. RESULTS There are no data from randomised trials confirming the significance of any single risk factor. The evidence suggests that the following may have a role: pre-operative hypertension, recent ipsilateral non-haemorrhagic stroke, previous ischaemic cerebral infarction, surgery for a > 90% ipsilateral internal carotid artery (ICA) stenosis, impaired cerebrovascular reserve, intra-operative haemodynamic or embolic ischaemia, post-operative hypertension, an ipsilateral increase of > or =175% in peak middle cerebral artery velocity (MCAV) and/or a > or =100% increase in pulsatility index. CONCLUSIONS A critical ICA stenosis with impaired cerebrovascular reserve resulting in maximal intracerebral vasodilatation and post-operative hyperperfusion (impaired autoregulation) appear to be central to the development of ICH. Appropriate pre-operative screening and post-operative monitoring in high risk patients might identify those who would benefit from manipulation of the haemodynamic events that appear to promote ICH.
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Affiliation(s)
- D A Russell
- Vascular Surgical Unit, The General Infirmary at Leeds, Leeds, UK
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Lennard NS, Vijayasekar C, Tiivas C, Chan CWM, Higman DJ, Imray CHE. Control of emboli in patients with recurrent or crescendo transient ischaemic attacks using preoperative transcranial Doppler-directed Dextran therapy. Br J Surg 2003; 90:166-70. [PMID: 12555291 DOI: 10.1002/bjs.4030] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Transcranial Doppler (TCD)-directed Dextran 40 treatment after carotid endarterectomy reduces the rate of early postoperative thrombosis. This study assessed the efficacy of intravenous Dextran 40 at controlling symptoms and emboli before elective carotid endarterectomy in patients with recurrent or crescendo transient ischaemic attacks (TIAs). METHODS In a prospective study, patients with more than 70 per cent internal carotid artery stenosis who had two or more symptomatic episodes within 30 days and TCD-detected microemboli were studied. Dextran 40 was commenced at 20 ml/h and TCD was repeated to reassess the rate of embolization. The infusion was increased in 20-ml/h increments until symptoms and emboli were controlled. The patient then had carotid surgery on the next elective list. RESULTS Nineteen patients with internal carotid stenosis greater than 70 per cent, recurrent symptoms and TCD-detected emboli were studied. All patients had symptoms and emboli controlled with Dextran 40. One patient with both unstable angina (awaiting urgent operation) and crescendo TIAs died from a myocardial infarct before undergoing operation. Of the 18 patients who had an operation, one suffered a non-disabling stroke on the third postoperative day. CONCLUSION TCD-directed Dextran 40 offers a safe approach to high-risk patients before elective carotid endarterectomy, and warrants further study.
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Affiliation(s)
- N S Lennard
- Coventry and Warwickshire County Vascular Unit, Coventry University Hospital, Clifford Bridge Road, Walsgrave, Coventry CV2 2DX, UK
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de Borst GJ, Moll FL, van de Pavoordt HD, Mauser HW, Kelder JC, Ackerstaf RG. Stroke from carotid endarterectomy: when and how to reduce perioperative stroke rate? Eur J Vasc Endovasc Surg 2001; 21:484-9. [PMID: 11397020 DOI: 10.1053/ejvs.2001.1360] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To analyse four years of CEA with respect to the underlying mechanisms of perioperative stroke and the role of intraoperative monitoring in the prevention of stroke. PATIENTS AND METHODS From January 1996 through December 1999, 599 CEAs were performed in 404 men and 195 women (mean age: 65 years, range: 39-88). All operations were performed under general anaesthesia using computerised electroencephalography (EEG) and transcranial Doppler (TCD). Any new or any extension of an existing focal cerebral deficit, as well as stroke-related death were registered. Perioperative strokes were classified by time of onset (intraoperative or postoperative), outcome (minor or major stroke), and side (ipsilateral or contralateral). Stroke aetiology was assessed intraoperatively by means of EEG, TCD, completion arteriography or immediate re-exploration, and postoperatively by duplex sonography, computerised tomography (CT) or magnetic resonance imaging (MRI) of the head. RESULTS Perioperative stroke or death occurred in 20 (3.3%) patients. In four operations stroke was apparent immediately after surgery. Mechanisms of these strokes were ipsilateral carotid artery occlusion (1) and embolisation (3). In 16 patients stroke developed after a symptom-free interval (2-72 h, mean 18 h) due to occlusion of the internal carotid artery on the side of surgery (9). Other mechanisms were: contralateral occlusion of the internal carotid artery (1), postoperative hyperperfusion syndrome (1), intracerebral haemorrhage (1), and contralateral ischaemia due to prolonged clamping (1). In three procedures the cause was unknown. CONCLUSIONS In our experience most strokes from CEA developed after a symptom-free interval and mainly due to thromboembolism of the operated artery. We suggest the introduction of additional TCD monitoring during the immediate postoperative phase.
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Affiliation(s)
- G J de Borst
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Abstract
BACKGROUND Ischaemic stroke interrupts the flow of blood to part of the brain. Haemodilution is thought to improve the flow of blood to the affected areas of the brain. OBJECTIVES The objective of this review was to assess the effects of haemodilution in acute ischaemic stroke. SEARCH STRATEGY We searched the Cochrane Stroke Group trials register, Medline and conference abstracts. We contacted manufactures and investigators in the field. SELECTION CRITERIA Randomised trials of haemodilution treatment in people with acute ischaemic stroke. Only trials where treatment was started within 72 hours of stroke onset were included. DATA COLLECTION AND ANALYSIS Two reviewers assessed trial quality and independently extracted the data. MAIN RESULTS Sixteen trials were included. A combination of venesection and plasma volume expander was used in eight trials. Eight trials used plasma volume expander alone. The plasma volume expander was dextran 40 in 11 trials, hydroxyethyl starch in four trials and albumin in one trial. Two trials tested haemodilution in combination with another therapy. Evaluation was blinded in 11 trials. Five trials probably included some patients with intracerebral haemorrhage. Haemodilution did not significantly reduce deaths within seven to 28 days (odds ratio 1.12, 95% confidence interval 0.88 to 1.43). Similarly, haemodilution did not influence deaths within three to six months (odds ratio 1.02, 95% confidence interval 0.85 to 1.23), or death and dependency or institutionalisation (odds ratio 1.01, 95% confidence interval 0.86 to 1.19). The results were similar in confounded and unconfounded trials, in trials of isovolaemic and hypervolaemic haemodilution, and in trials using different types of hemodiluting agents. Six trials reported venous thromboembolic events. There was a tendency towards reduction in deep venous thrombosis and/or pulmonary embolism at three to six months follow-up (odds ratio 0.59, 95% confidence interval 0.33 to 1.06). REVIEWER'S CONCLUSIONS The overall results of this review are compatible both with a modest benefit and a moderate harm of haemodilution therapy for acute ischaemic stroke. As used in the randomised trials, this therapy has not been proven to improve survival or functional outcome.
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Affiliation(s)
- K Asplund
- Department of Medicine, University Hospital, Umeå, Sweden, Umeå, Sweden, SE-901 85.
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