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BIANCOFIORE B, DE BLASIS S, FALSO R, DOLFI L, PANELLA M, DI DOMENICO R, DORIGO W, PULLI R, PRATESI C. How to improve results in carotid surgery. Analysis of a 20-year case history of more than 7000 operations. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2023. [DOI: 10.23736/s1824-4777.22.01562-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Djedovic M, Hadzimehmedagic A, Granov N, Haxhibeqiri-Karabdic I, Štraus S, Banjanovic B, Kabil E, Selimovic T. The Effect of Severe Contralateral Carotid Stenosis or Occlusion on Early Outcomes after Carotid Endarterectomy. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Stenosis of the carotid arteries, as a consequence of atherosclerosis is the most common cause of cerebrovascular insult (CVI). Severe (>70%) contralateral stenosis or occlusion (SCSO) of the carotid artery may represent an additional pre-operative risk factor for neurologic incidents.
AIM: The aim of this study was to confirm and compare early perioperative results (0-30 days) of carotid endarterectomy (CEA) in patients with and without SCSO.
PATIENT AND METHODS: In our retrospective-prospective study, we analysed the results of 273 CEA, divided into two groups based on the presence of significant contralateral stenosis or occlusion (non-SCSO and SCSO groups)
RESULTS: 273 CEA’s were performed, divided into two groups: SCSO groups 40 (14.7%) and non-SCSO group 233 (85.3%). Between the two groups, a statistically significant difference between patients was found (54.1% compared to 87.5%; p<0.0005), CEA with patch angioplasty (25.3% compared to 52.5%; p=0.001), and CEA with the use of a shunt (3.9% compared to 35%; p<0.0005) in favour of the SCSO group. There was no statistically significant difference (SCSO was not identified as a risk factor) for any type of stroke or mortality. Logistically regression confirmed SCSO to be an independent predictor of 30-day mortality (OR 21.58; 95% CI 1.27-36.3; p= 0.033) and any type of stroke or mortality (OR 9.27; 95% CI 1.61-53.22; p= 0.012). SCSO was not a predictor of any type of stroke within 30 days. Predictors of any type of stroke was dyslipidemia (OR 0.12, 95% CI 0.02-0.76; p= 0.024).
CONCLUSIONS: There was no statistically significant difference in the incidence of early (30 day) perioperative complications between the analysed groups. The percentage of perioperative complications remains within the accepted parameters, and thus, SCSO should not be qualified as a significant risk factor for CEA. We are of the opinion that CEA remains a safe and acceptable options for patients with SCSO, and SCSO should not be a reason for preferential use of carotid stenting.
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Xu N, Li LX, Wang TL, Jiao LQ, Hua Y, Yao DX, Wu J, Ma YH, Tian T, Sun XL. Processed Multiparameter Electroencephalogram-Guided General Anesthesia Management Can Reduce Postoperative Delirium Following Carotid Endarterectomy: A Randomized Clinical Trial. Front Neurol 2021; 12:666814. [PMID: 34322079 PMCID: PMC8311024 DOI: 10.3389/fneur.2021.666814] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/09/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Patients undergoing carotid endarterectomy (CEA) for severe carotid stenosis are vulnerable to postoperative delirium, a complication frequently associated with poor outcome. This study investigated the impact of processed electroencephalogram (EEG)-guided anesthesia management on the incidence of postoperative delirium in patients undergoing CEA. Methods: This single-center, prospective, randomized clinical trial on 255 patients receiving CEA under general anesthesia compared the outcomes of patient state index (PSI) monitoring [SEDLine Brain Function Monitor (Masimo, Inc, Irvine, CA)] (standard group, n = 128) with PSI combined with density spectral array(DSA) -guided monitoring (intervention group, n = 127) to reduce the risk of intraoperative EEG burst suppression. All patients were monitored by continuous transcranial Doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) to avoid perioperative cerebral hypoperfusion or hyperperfusion. According to the surgical process, EEG suppression time was calculated separately for three stages: S1 (from anesthesia induction to carotid artery clamping), S2 (from clamping to declamping), and S3 (from declamping to the end of surgery). The primary outcome was incidence of postoperative delirium according to the Confusion Assessment Method algorithm during the first 3 days post-surgery, and secondary outcomes were other neurologic complications and length of hospital stay. Results: There were no episodes of cerebral hypoperfusion or hyperperfusion according to TCD and NIRS monitoring in either group during surgery. The incidence of postoperative delirium within 3 days post-surgery was significantly lower in the intervention group than the standard group (7.87 vs. 28.91%, P < 0.01). In the intervention group, the total EEG suppression time and the EEG suppression time during S2 and S3 were shorter (Total, 0 "0" vs. 0 "1.17" min, P = 0.04; S2, 0 "0" vs. 0 "0.1" min, P < 0.01; S3, 0 "0" vs. 0 "0" min, P = 0.02). There were no group differences in incidence of neurologic complications and length of postoperative hospital stay. Conclusion: Processed electroencephalogram-guided general anesthesia management, consisting of PSI combined with DSA monitoring, can significantly reduce the risk of postoperative delirium in patients undergoing CEA. Patients, especially those exhibiting hemodynamic fluctuations or receiving surgical procedures that disrupt cerebral perfusion, may benefit from the monitoring of multiple EEG parameters during surgery. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03622515.
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Affiliation(s)
- Na Xu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li-Xia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tian-Long Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li-Qun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasound, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dong-Xu Yao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Wu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan-Hui Ma
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tian Tian
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue-Li Sun
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Zhao W, Gao F, Wu C, Peng D, Jin X, Lou L, Sun W. Severe contralateral carotid stenosis or occlusion drive 30-day risk after carotid endarterectomy. Vascular 2021; 30:3-13. [PMID: 33596788 DOI: 10.1177/1708538121993619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The significant effects on the treatment of severe carotid stenosis by carotid endarterectomy have been widely recognized. However, it is controversial whether patients with severe contralateral carotid stenosis or occlusion (SCSO) can benefit from carotid endarterectomy surgery. This study aimed to estimate the SCSO effects on early outcomes after carotid endarterectomy with selective shunting. METHODS Between August 2011 and October 2019, a total of 617 patients who underwent carotid endarterectomy with selective shunting were analyzed. SCSO was defined as >70% luminal narrowing of the contralateral extracranial carotid stenosis or occlusion. Of these patients, 116 were categorized into an SCSO group while the rest were assigned to the non-SCSO group. Primary study outcomes were the occurrence of major adverse events, defined as stroke, all-cause mortality, and myocardial infarction during the perioperative period after carotid endarterectomy. Traditional multivariable logistic regression model and logistic regression model adjusted for propensity scores were used to estimate the SCSO effects on primary outcomes. Interaction and stratified analyses were conducted according to age, sex, comorbidities (hypertension, diabetes), preoperative neurological deficit, preoperative symptoms, and shunt use. RESULTS Mean age was 68.5 ± 9.2 years (86.1% men). Overall major adverse events rate within 30 days was 2.5%. Major adverse events rates in SCSO and non-SCSO groups were 9.5% and 1.6%, respectively. This difference was statistically significant (p < 0.001). In multivariable regression analysis, patients with SCSO had a higher risk of major adverse events (non-SCSO vs. SCSO: aOR 5.05 [95% CI, 1.78-14.55]). In 342 propensity score matched patients, results were consistent (propensity score: aOR, 3.78 [95% CI, 1.13-12.64]). CONCLUSIONS SCSO is an independent predictor of 30-day major adverse events. Whether these patients with SCSO are suitable for carotid endarterectomy should be carefully considered.
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Affiliation(s)
- Wenyan Zhao
- General Practice Department, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Faliang Gao
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Cheng Wu
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Deqing Peng
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xiao Jin
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Lin Lou
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Weijun Sun
- Department of Neurosurgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
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Schneider JR, Wilkinson JB, Rogers TJ, Verta MJ, Jackson CR, Hoel AW. Results of carotid endarterectomy in patients with contralateral internal carotid artery occlusion from the Mid-America Vascular Study Group and the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2020; 71:832-841. [DOI: 10.1016/j.jvs.2019.05.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 05/04/2019] [Indexed: 11/17/2022]
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Kokkinidis DG, Chaitidis N, Giannopoulos S, Texakalidis P, Haider MN, Aronow HD, Giri JS, Armstrong EJ. Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients. J Endovasc Ther 2020; 27:334-344. [PMID: 32066317 DOI: 10.1177/1526602820904163] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I2 test. I2>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I2=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I2=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I2=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I2=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I2=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I2=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I2=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I2=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I2=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I2=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA.,Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nikos Chaitidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Pavlos Texakalidis
- Division of Neurological Surgery, Emory University Hospital, Atlanta, GA, USA
| | - Moosa N Haider
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, USA
| | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Jay S Giri
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Carotid stenting and endarterectomy and contralateral carotid occlusion. J Vasc Surg 2019; 70:824-831. [DOI: 10.1016/j.jvs.2018.12.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 12/12/2018] [Indexed: 11/21/2022]
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Influence of Contralateral Carotid Occlusion on Outcomes After Carotid Endarterectomy: A Meta-Analysis. J Stroke Cerebrovasc Dis 2018; 27:2587-2595. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/09/2018] [Accepted: 05/19/2018] [Indexed: 11/23/2022] Open
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Reddy RP, Brahme IS, Karnati T, Balzer JR, Crammond DJ, Anetakis KM, Thirumala PD. Diagnostic value of somatosensory evoked potential changes during carotid endarterectomy for 30-day perioperative stroke. Clin Neurophysiol 2018; 129:1819-1831. [DOI: 10.1016/j.clinph.2018.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/25/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
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10
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Severe contralateral carotid stenosis or occlusion does not have an impact on risk of ipsilateral stroke after carotid endarterectomy. J Vasc Surg 2018; 67:1744-1751. [DOI: 10.1016/j.jvs.2017.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 09/22/2017] [Indexed: 11/21/2022]
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Djedović M, Imširović B, Djedović S, Hadžimehmedagić A, Vukas H, Rovčanin B, Kamenjašević I. Carotid Endarterectomy in Women versus Man: Patient Characteristics and Perioperative Complication (<30 Day). Open Access Maced J Med Sci 2018; 6:463-466. [PMID: 29610601 PMCID: PMC5874366 DOI: 10.3889/oamjms.2018.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/02/2018] [Accepted: 02/07/2018] [Indexed: 11/05/2022] Open
Abstract
AIM Compare the basic characteristics of patients and to examine the existence of higher rates of perioperative complications (0 - 30 days) in women versus men after carotid endarterectomy (CEA). METHODS This is a retrospective-prospective study included 270 patients with significant stenosis of carotid in whom CEA was performed, during the period from 2012 to 2017. Patients they were divided: group 1 - 100 female patients, group 2 - 170 male patients. RESULTS No statistically significant age difference was observed between the two groups, group 1 - 66.01 years (SD 8.42, 46 to 86 years), group 2 - 66.46 years (SD 8.03, 47 to 85 years) (p = 0.659). Risk factors represent a greater prevalence in group 2, but the observed difference is not statistically significant. The average duration of surgery and the time of carotid artery clamping time were longer in group 1: (p = 0.002; p = 0.005). The number of classic endarterectomy with the patch was higher in women (41 (41%) versus 31 (18. 2%), p = 0.005), while the number of bilateral CEAs was not statistically significant. CONCLUSION The results of this study of this study did not indicate a greater presence of perioperative complications (< 30 days) in women versus male patients after CEA.
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Affiliation(s)
- Muhamed Djedović
- University Clinical Centre of Sarajevo - Clinic of Cardiovascular Surgery, Sarajevo, Bosnia and Herzegovina
| | - Bilal Imširović
- General Hospital „Prim. Dr. Abdulah Nakaš” - Radiology, Sarajevo, Bosnia and Herzegovina
| | | | - Amel Hadžimehmedagić
- University Clinical Centre of Sarajevo - Clinic for Cardiovascular Surgery, Sarajevo, Bosnia and Herzegovina
| | - Haris Vukas
- University Clinical Centre of Sarajevo - Clinic for Cardiovascular Surgery, Sarajevo, Bosnia and Herzegovina
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Piffaretti G, Tarallo A, Franchin M, Bacuzzi A, Rivolta N, Ferrario M, Ferraro S, Bossi M, Castelli P, Tozzi M. Outcome Analysis of Carotid Cross-Clamp Intolerance during Carotid Endarterectomy under Locoregional Anesthesia. Ann Vasc Surg 2017; 43:249-257. [DOI: 10.1016/j.avsg.2016.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/12/2016] [Accepted: 11/28/2016] [Indexed: 10/19/2022]
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Braca JA, Bookland MJ, Heiferman DM, Loftus CM. Indications for Carotid Endarterectomy in Patients with Asymptomatic and Symptomatic Carotid Stenosis. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00074-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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14
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Papapetrou A, Moris D, Patelis N, Kouvelos GN, Bakogiannis C, Klonaris C, Georgopoulos S. Oxidative Stress and Total Antioxidant Status During Internal Carotid Artery Clamping with or without Shunting: An Experimental Pilot Study. Med Sci Monit Basic Res 2015; 21:200-5. [PMID: 26391530 PMCID: PMC4596353 DOI: 10.12659/msmbr.894756] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background The exact role of shunting during carotid endarterectomy remains controversial and unclear. The aim of this experimental study was to investigate to what degree carotid clamping may induce changes in the cerebral oxidative status and to focus on the relation of these changes with shunt insertion. Material/Methods Forty New-Zealand rabbits were randomized into 4 groups: group 1 classifying animals with carotid shunt and patent contralateral carotid artery; group 2 shunt and occlusion of the contralateral carotid artery; group 3 no-shunt and patent contralateral carotid artery; and group 4 no-shunt and occlusion of the contralateral carotid artery. Blood samples were collected from the ipsilateral internal jugular vein, immediately after carotid clamping (time 0), and then at 5, 10, 15, 30, and 60 minutes afterwards. Evaluation of oxidative stress was accomplished by measuring the lag-time, representing the initial phase of oxidation, rate of accumulation (RA), showing concentration of free oxygen radical and total antioxidant status (TAS) representing antioxidant composition of serum. Results Lag-time was significantly different in time points 0, 30 and 60 minutes within each different group. TAS was significantly different in time points 0, 15 and 60 min and RA in time points 0, 5, 10 and 60 min within each different group. 60 minutes after carotid clamping, the rate of accumulation as well as lag-time and TAS were increased in all groups, independently of using or not shunting or the presence of contralateral occlusion. After comparing groups 1, 2 and 3 regarding lag-time, TAS and RA, we did not find statistical difference among the groups at any time point. On the contrary, groups 1, 2 and 3 did show significantly different values comparing to group 4 after 60 min of occlusion. Conclusions Our experimental work based on cerebral metabolism found a significantly higher oxidative stress in models with contralateral carotid occlusion. The use of shunt in all other models did not have any influence on oxidative response. Future human studies should focus on the relation of oxidative status and shunt insertion to determine the benefit of selective or routine shunting during CEA.
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Affiliation(s)
- Anastasios Papapetrou
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Demetrios Moris
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Patelis
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - George N Kouvelos
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Chris Bakogiannis
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Chris Klonaris
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
| | - Sotiris Georgopoulos
- 1st Department of Surgical, Vascular Division, Laikon General Hospital, National Kapodistrian University of Athens, Athens, Greece
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Kretz B, Abello N, Bouchot O, Kazandjian C, Beaumont M, Terriat B, Bernard A, Brenot R, Steinmetz E. Risk Index for Predicting Shunt in Carotid Endarterectomy. Ann Vasc Surg 2014; 28:1204-12. [DOI: 10.1016/j.avsg.2013.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/02/2013] [Accepted: 09/16/2013] [Indexed: 10/25/2022]
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16
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Yang SS, Kim YW, Kim DI, Kim KH, Jeon P, Kim GM, Chung CS, Lee KH. Impact of contralateral carotid or vertebral artery occlusion in patients undergoing carotid endarterectomy or carotid artery stenting. J Vasc Surg 2013; 59:749-55. [PMID: 24360588 DOI: 10.1016/j.jvs.2013.10.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 09/05/2013] [Accepted: 10/06/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the impact of contralateral carotid occlusion (CCO) and/or vertebral artery occlusion (VAO) on the development of early postoperative neurologic complications after carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS A retrospective analysis was conducted using a database of patients who underwent CEA (n = 698) or CAS (n = 455) at a single institution. Excluded were 44 CEAs synchronously performed with coronary artery bypass grafting and 76 CASs performed without an embolic protective device (n = 69) or that resulted in technical failures (n = 7). All CEAs were the conventional type and performed under general anesthesia, and carotid shunts were routinely used. Patients were categorized into three groups according to patency of the contralateral carotid and vertebral arteries: Group I (no CCO or VAO); Group II (CCO with or without VAO); Group III (with VAO but no CCO). CCO or VAO were diagnosed with two or more carotid imaging studies including duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, or conventional carotid angiography. Patient groups were compared with demographics, preoperative symptomatic status, and frequencies of early (<30 days) symptomatic neurologic complications (ESNCs) including transient ischemic attack and stroke. Postprocedural stroke alone was separately compared. Univariate (χ(2) or Fisher's exact test) and multivariate analysis (multiple logistic regression) were conducted to determine predictors of ESNC or postprocedural stroke. RESULTS ESNCs and postprocedural stroke developed significantly more often with CAS compared with CEA (ESNC, 2.6% vs 8.1%; P < .001; stroke, 1.3% vs 6.8%; P < .001). In group II, the frequency of ESNCs was higher (6.8% vs 1.8%; P = .044), but the frequency of postprocedural stroke was not significantly higher (2.3% vs 0.9%; P = .405) in the CEA group. By multivariate analysis, the presenting symptom of stroke (odds ratio, 3.612; 95% confidence interval, 1.288-10.130; P = .015) and group II (odds ratio, 7.242; 95% confidence interval, 1.727-30.374; P = .007) were independent risk factors of ESNC following CEA but not CAS. When we analyzed the risk factor for postprocedural stroke alone, the presenting symptom of stroke was the only risk factor, while presence of CCO or VAO was not. CONCLUSIONS CAS was followed by a significantly higher frequency of ESNC and postprocedural stroke compared with CEA. By subgroup analysis, CCO was a risk factor for ESNC but not for postprocedural stroke alone in patients undergoing CEA. Unilateral or bilateral VAO was not associated with a higher rate of ESNC or stroke in CEA or CAS.
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Affiliation(s)
- Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Keon-ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chin-Sang Chung
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kwang-Ho Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Faggioli G, Pini R, Mauro R, Freyrie A, Gargiulo M, Stella A. Contralateral carotid occlusion in endovascular and surgical carotid revascularization: a single centre experience with literature review and meta-analysis. Eur J Vasc Endovasc Surg 2013; 46:10-20. [PMID: 23639235 DOI: 10.1016/j.ejvs.2013.03.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 03/21/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE/BACKGROUND The influence of contralateral carotid occlusion (CCO) on the outcome of carotid endarterectomy (CEA) and stenting (CAS) is debated. This study aims to evaluate CEA and CAS results in patients with CCO. METHODS All carotid revascularizations from 2005 to 2011 were analyzed, focusing on the role of CCO on 30-day cerebral events and death (CED). A meta-analysis was performed to evaluate the results of the literature by random effect. RESULTS Of the 1,218 carotid revascularizations performed in our institution, 706 (57.9%) were CEA and 512 (42.1%) were CAS. CED occurred in 3.6% of the CEAs and 8.2% of the CASs (p = .001). CCO was present in 37 (5.2%) CEAs and 38 (7.4%) CASs. In CEA, CCO patients had a higher CED compared with the non-CCO patients (16.2% vs. 2.9%, p = .001), as confirmed by multiple regression analysis (OR [odds ratio]: 5.1[1.7-14.5]). In CAS, CED was not significantly different in the CCO and non-CCO patients (2.6% vs. 8.7%, p = 0.23). The comparative analysis of the CCO patients showed a higher CED in CEA compared with that in CAS (16.2% vs. 2.6%, p = 0.04). Meta-analysis of 33 papers (27 on CEA and 6 on CAS) revealed that CCO was associated with a higher CED in CEA, but not in CAS (OR: 1.82 [1.57-2.11]; OR: 1.22 [0.60-2.49], respectively). CONCLUSION CCO can be considered as a risk factor for CED in CEA, but not in CAS. CAS appears to be associated with lower CED than CEA in CCO patients.
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Affiliation(s)
- G Faggioli
- Vascular Surgery, University of Bologna, Bologna, Italy
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Antoniou GA, Kuhan G, Sfyroeras GS, Georgiadis GS, Antoniou SA, Murray D, Serracino-Inglott F. Contralateral occlusion of the internal carotid artery increases the risk of patients undergoing carotid endarterectomy. J Vasc Surg 2013; 57:1134-45. [DOI: 10.1016/j.jvs.2012.12.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 11/28/2012] [Accepted: 12/01/2012] [Indexed: 01/22/2023]
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Kretz B, Abello N, Astruc K, Terriat B, Favier C, Bouchot O, Brenot R, Steinmetz E. Influence of the Contralateral Carotid Artery on Carotid Surgery Outcome. Ann Vasc Surg 2012; 26:766-74. [DOI: 10.1016/j.avsg.2011.12.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 11/25/2011] [Accepted: 12/03/2011] [Indexed: 11/30/2022]
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Impact of practice patterns in shunt use during carotid endarterectomy with contralateral carotid occlusion. J Vasc Surg 2011; 55:61-71.e1. [PMID: 22051863 DOI: 10.1016/j.jvs.2011.07.046] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 06/30/2011] [Accepted: 07/01/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE This study investigated the association between surgeon practice pattern in shunt placement and 30-day stroke/death in patients undergoing carotid endarterectomy (CEA) with contralateral carotid occlusion (CCO). METHODS Among 6379 CEAs performed in the Vascular Study Group of New England (VSGNE) between 2002 and 2009, we identified 353 patients who underwent CEA with CCO and compared the 30-day stroke/death rate with 5279 patients who underwent primary, isolated CEA with a patent contralateral carotid artery. Within patients with CCO, we examined the 30-day stroke/death rate across the reason for shunt placement and two distinct surgeon practice patterns in shunt placement: surgeons who selectively used a shunt (≤95% of CEAs) or routinely used a shunt (>95% of CEAs). We used observed/expected (O/E) ratios to provide risk-adjusted comparisons across groups. RESULTS Of 353 patients with CCO, 118 (33%) underwent CEA without a shunt, 173 (49%) underwent CEA using a shunt placed routinely, and 62 (18%) had a shunt placed for a neurologic indication. Rates of 30-day stroke/death across categories of reason for shunt use were no shunt, 3.4%; routine shunt, 4.0%; and shunt for indication, 4.8% (P = .891). The risk of 30-day stroke/death was higher for surgeons who selectively placed shunts (5.6%) in all their CEAs and lower for surgeons who routinely placed shunts (1.5%, P = .05). The risk of 30-day stroke/death was >1 in patients undergoing selective shunting (O/E ratio, 1.4; 95% confidence interval [CI], 1.1-1.7) and <1 for surgeons who placed shunts routinely (O/E ratio, 0.4; 95% CI, 0.2-0.9). Stroke/death rates were lowest when individual surgeons' intraoperative decisions reflected their usual pattern of practice: 1.5% stroke/death rate when "routine" surgeons placed a shunt, 3.4% when "selective" surgeons did not place a shunt, and 7.6% stroke/death rate for "selective" surgeons who placed a shunt (P = .05 for trend). CONCLUSIONS The risk of 30-day stroke/death is higher in CEA in patients with CCO than with a patent contralateral carotid artery. Surgeons who place shunts selectively during CEA have higher rates of stroke/death in patients with CCO. This suggests that shunt use for CCO during CEA is associated with fewer complications, but only if the surgeon uses a shunt as part of his or her routine practice in CEA. Surgeons should preoperatively consider their own practice pattern in shunt use when faced with a patient who may require shunt placement.
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Does a contralateral carotid occlusion adversely impact carotid artery stenting outcomes? Ann Vasc Surg 2011; 26:40-5. [PMID: 21963325 DOI: 10.1016/j.avsg.2011.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 06/23/2011] [Accepted: 07/06/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) has grown as a possible alternative for the treatment of extracranial cerebrovascular disease in the past decade. A preexisting contralateral carotid artery occlusion has been described as a risk factor for inferior outcomes after carotid endarterectomy, but its impact on CAS outcomes is less understood. METHODS A retrospective review of 417 CAS procedures performed between May 2001 and July 2010 at a single center using self-expanding nitinol stents and mechanical embolic protection devices was conducted. Patients were divided into two groups, those with a preexisting contralateral carotid occlusion (group A, n = 39) versus those without a contralateral occlusion (group B, n = 378). Patient demographics and comorbidities as well as 30-day and late death, stroke, and myocardial infarction (MI) rates were analyzed. Mean follow-up was 4 years (range: 0-9.4 years). RESULTS Overall, mean age of the 314 men and 103 women was 70.5 years. In group A, there were two (5.1%) octogenarians and nine patients (23.1%) with symptomatic disease as compared with group B with 53 (14%) octogenarians and 121 (32%) patients with symptomatic disease. The overall 30-day death, stroke, and MI rates were 0.5%, 1.9%, and 0.7%, respectively. When comparing group A with group B, these results were not significantly different: death (0% vs. 0.5%), stroke (2.6% vs. 1.9%), and MI (0% vs. 0.8%). Long-term outcomes for groups A and B were also not significantly different: death (25.6% vs. 22.2%), stroke (5.3% vs. 3.4%), and MI (15.4% vs. 14%) (p = nonsignificant). CONCLUSION A preexisting contralateral carotid artery occlusion does not seem to adversely impact CAS outcomes.
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22
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Early and long-term results of carotid endarterectomy in diabetic patients. J Vasc Surg 2011; 53:44-52. [DOI: 10.1016/j.jvs.2010.08.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Revised: 08/10/2010] [Accepted: 08/12/2010] [Indexed: 11/19/2022]
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Surgical Management of Asymptomatic Carotid Stenosis. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chiriano J, Abou-Zamzam AM, Nguyen K, Molkara AM, Zhang WW, Bianchi C, Teruya TH. Preoperative Carotid Duplex Findings Predict Carotid Stump Pressures During Endarterectomy in Symptomatic But Not Asymptomatic Patients. Ann Vasc Surg 2010; 24:1038-44. [DOI: 10.1016/j.avsg.2010.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 05/05/2010] [Accepted: 05/21/2010] [Indexed: 11/30/2022]
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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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26
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Mehta RH, Zahn R, Hochadel M, Mudra H, Ischinger T, Hauptmann KE, Jung J, Seggewiss H, Zeymer U, Senges J. Effectiveness and safety of carotid artery stenting for significant carotid stenosis in patients with contralateral occlusion (from the German ALKK-CAS Registry experience). Am J Cardiol 2009; 104:725-31. [PMID: 19699352 DOI: 10.1016/j.amjcard.2009.04.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 04/27/2009] [Accepted: 04/27/2009] [Indexed: 11/30/2022]
Abstract
Data on the safety of carotid artery stenting (CAS) in a large number of unselected patients with contralateral occlusion and significant ipsilateral stenosis are less known. Accordingly, we evaluated 3,137 patients undergoing CAS who were enrolled in a German Registry from 2000 to 2008 and compared the clinical features and in-hospital outcomes of those with and without contralateral carotid occlusion. Contralateral carotid occlusion was present in 191 patients (6.1%) undergoing CAS. Despite the similar age of the patients with and without contralateral carotid occlusion, those with contralateral occlusion had a greater prevalence of co-morbidities, complex carotid stenosis, and greater number of focal neurologic lesions on the contralateral side. The incidence of in-hospital events, including death (1.0% vs 0.5%), ipsilateral major stroke (1.1% vs 1.1%), death or major ipsilateral stroke (1.6% vs 1.4%), ipsilateral transient ischemic attack (2.7% vs 2.5%), myocardial infarction (0.0% vs 0.1%), and reintervention (0.5% vs 1.1%), was low and was not significantly different between those with and without contralateral occlusion (p >0.05 for all comparisons). Among patients with carotid occlusion, major ipsilateral stroke (2.2%), death (2.2%), and a combination of these 2 events (3.3%) were observed exclusively in symptomatic patients with no event in asymptomatic patients. In conclusion, our data from a large number of patients undergoing CAS in a recent contemporary community-based practice attests to the low risk of periprocedural events among patients with contralateral carotid occlusion supporting CAS as an attractive option for the treatment of these patients.
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Affiliation(s)
- Rajendra H Mehta
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA.
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Bonamigo TP, Lucas ML. Análise crítica das indicações e resultados do tratamento cirúrgico da doença carotídea. J Vasc Bras 2007. [DOI: 10.1590/s1677-54492007000400011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
O tratamento da doença carotídea tem ganhado enfoque nos últimos anos, principalmente com o advento da técnica endovascular, que defende o emprego da angioplastia e stent de carótida (CAS), principalmente em pacientes considerados de "alto risco" para a endarterectomia carotídea (ECA). Através da revisão bibliográfica, analisamos os resultados do tratamento da lesão carotídea em ambas as técnicas, realizando comentários embasados na experiência pessoal e nos dados da literatura, sobretudo nos pacientes de alto risco. Até o presente momento, não há evidência e justificativa para o emprego da CAS em larga escala nos pacientes com doença carotídea, inclusive nas situações de alto risco, tais como nos octogenários. No entanto, acreditamos que a CAS possa ser um coadjuvante no tratamento de pequeno número de pacientes com lesão carotídea (até 4% dos casos), como na presença de pescoço hostil, radioterapia prévia e alguns casos de estenose carotídea alta. Quando realizada com os cuidados técnicos necessários, a ECA ainda continua a melhor opção terapêutica aos doentes com lesão carotídea.
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Affiliation(s)
- Telmo P. Bonamigo
- Fundação Faculdade Federal de Ciências Médicas de Porto Alegre; Santa Casa de Porto Alegre
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Baton O, Szym P, Hoffmann JJ, Borne M, Diraison Y, Baranger B. Cerebral Monitoring of Somatosensory Evoked Potentials during Carotid Surgery: A Review of 100 Cases. Ann Vasc Surg 2007; 21:30-3. [PMID: 17349332 DOI: 10.1016/j.avsg.2006.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The purpose of this study was to evaluate immediate and middle-term results of surgical carotid artery revascularization (CAR) with cerebral monitoring of intraoperative somatosensory evoked potentials (SEPs). Between 1998 and 2004, a total of 100 CARs in 86 patients were performed under general anesthesia with SEP monitoring. A shunt was inserted if SEP amplitude decreased by 50% or latency time increased by 10%. Immediate and middle-term results were analyzed retrospectively. The shunt insertion rate was 5%. Two transient ischemic attacks were observed, and one patient died postoperatively due to myocardial infarction. The cumulative stroke and death rate was 1% at 30 days. Intraoperative SEP monitoring with selective shunt placement can be used safely for carotid surgery. Randomized studies will be necessary to determine the respective indications for various cerebral monitoring techniques.
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Affiliation(s)
- Olivier Baton
- Department of Visceral and Vascular Surgery, Val de Grace Military Teaching Hospital, Paris, France
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29
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Rijbroek A, Wisselink W, Vriens EM, Barkhof F, Lammertsma AA, Rauwerda JA. Asymptomatic Carotid Artery Stenosis: Past, Present and Future. Eur Neurol 2006; 56:139-54. [PMID: 17035702 DOI: 10.1159/000096178] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 07/17/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND The role of carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis (aCAS) remains a matter of debate. It seems that not only the degree of stenosis, but also other factors have to be taken in account to improve patient selection and increase the benefit of CEA for aCAS. METHODS AND RESULTS The literature pertaining aCAS was reviewed in order to describe the natural history, risk of stroke and benefit of CEA for patients with aCAS in regard to several factors. CONCLUSION The benefit of CEA for aCAS is low. Current factors influencing the indication for CEA are severity of stenosis, age, contralateral disease, stenosis progression to >80%, gender, concomitant operations and life expectancy. To improve patient selection investigations will concentrate on plaque characteristics and instability and cerebral hemodynamics and metabolism.
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Affiliation(s)
- A Rijbroek
- Department of General Surgery, Kennemer Gasthuis, NK-2000 AK Haarlem, The Netherlands.
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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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Grego F, Antonello M, Lepidi S, Zaramella M, Galzignan E, Menegolo M, Deriu GP. Is contralateral carotid artery occlusion a risk factor for carotid endarterectomy? Ann Vasc Surg 2006; 19:882-9. [PMID: 16200472 DOI: 10.1007/s10016-005-7719-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Occlusion of the contralateral internal carotid artery (ICA) is considered to have a significant impact on the outcome of carotid endarterectomy (CEA). The purpose of this study was to review one center's experience concerning CEA opposite an occluded ICA, to see whether results differed from those obtained in patients with patent contralateral ICA in terms of relevant neurologic complication rate (RNCR, fatal + disabling stroke), stroke-free rate, and survival rate. From January 1997 to December 2002, 1,381 patients underwent a total of 1,445 CEAs at the Department of Vascular Surgery of Padua University. Patients were divided into two groups: group A included 144 patients with occlusion of the contralateral ICA and group B consisted of 1,237 patients with a patent contralateral ICA. There was no postoperative mortality in patients of group A, while in group B, two patients died as a result of myocardial infarction and cardiac failure and one died as a direct result of perioperative stroke. Postoperative disabling strokes occurred in one (0.7%) patient in group A and 10 (0.8%) patients in group B (p > 0.5). At 72 months, there were no statistical differences between the two groups in terms of RNCR, stroke-free rate, and late death. Our results show that contralateral carotid occlusion does not reduce the safety of CEA. The efficacy in terms of RNCR, stroke-free rate, and late survival is no different in patients with contralateral carotid occlusion.
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Affiliation(s)
- Franco Grego
- Division of Vascular Surgery, Department of Medical and Surgical Sciences, University of Padua, Via Giustiniani 2, 35100 Padua, Italy.
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Martínez-Aguilar E, Bueno-Bertomeu A, de Benito-Fernández L, March-García J, Acín F. ¿Es la oclusión contralateral un factor de riesgo para la endarterectomía carotídea? ANGIOLOGIA 2006. [DOI: 10.1016/s0003-3170(06)74957-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Pulli R, Dorigo W, Barbanti E, Azas L, Pratesi G, Innocenti AA, Pratesi C. Does the high-risk patient for carotid endarterectomy really exist? Am J Surg 2005; 189:714-9. [PMID: 15910725 DOI: 10.1016/j.amjsurg.2005.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2004] [Revised: 10/05/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND High surgical risk is advocated as a major criterion for carotid artery stenting. To date, definitely accepted criteria to identify "high-risk" patients for carotid endarterectomy (CEA) do not exist. The aim of this study was to analyze the statistical weight of each single previously described risk factor on early and late results after carotid surgery in our experience. METHODS A retrospective review of 1,883 CEAs performed during a 6-year period in a single institution was performed. Early and late results in terms of mortality and neurologic events were recorded. Univariate and multivariate analysis for early and late risk of stroke and death were performed, considering the influence of age, sex, comorbidities, clinical symptoms, and anatomic features. RESULTS The cumulative 30-day stroke and death rate was 1.3%. Univariate analysis and logistic regression did not show statistical significance for 30-day results in any of the considered variables. The three-year stroke-free survival was 94.5%, and it was significantly affected by chronic renal failure, respiratory insufficiency, and older age. CONCLUSIONS Carotid endarterectomy is a safe procedure also in so-called high-risk subsets of patients. Severe comorbidities seem to affect only long-term survival.
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Affiliation(s)
- Raffaele Pulli
- Department of Vascular Surgery, University of Florence, Chirurgia Vascolare-Università di Firenze, Viale Morgagni 85, 50134 Firenze, Italy.
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Sabeti S, Schillinger M, Mlekusch W, Nachtmann T, Lang W, Ahmadi R, Minar E. Contralateral High-Grade Carotid Artery Stenosis or Occlusion Is Not Associated with Increased Risk for Poor Neurologic Outcome after Elective Carotid Stent Placement. Radiology 2004; 230:70-6. [PMID: 14695388 DOI: 10.1148/radiol.2301021371] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To compare neurologic outcome after elective internal carotid artery (ICA) stents have been placed in patients with and in patients without contralateral ICA obstructions. MATERIALS AND METHODS This study included 471 consecutive patients from a registry database who underwent elective ICA stent placement without cerebral protection for high-grade (greater than 70% stenosis of the ICA, according to the North American Symptomatic Carotid Endarterectomy Trial) symptomatic (n = 147) or asymptomatic (n = 324) ICA stenosis. Contralateral carotid arteries were investigated with angiography. Patients with and patients without contralateral high-grade stenosis (70%-99% stenosis, according to the North American Symptomatic Carotid Endarterectomy Trial) or occlusion were compared with respect to 30-day neurologic outcome by using the chi2 test and multivariate logistic regression analysis. RESULTS Neurologic events were observed in 33 patients (7%) with 15 transient ischemic attacks, eight minor strokes, and 10 major strokes that led to death in two patients (combined stroke and death rate, 4%). Eighty-eight patients (19%) with contralateral high-grade ICA stenosis and 43 patients (9%) with contralateral ICA occlusion exhibited a similar rate of postintervention combined neurologic events (n = 9, 7%) compared with patients without contralateral high-grade ICA stenosis or occlusion (n = 24, 7%) (P =.94). No differences were observed between symptomatic and asymptomatic patients. Combined stroke and death rates were also comparable between symptomatic (four of 131, 3%) and asymptomatic (14 of 340, 4%) patients (P =.59). Of all variables tested, multivariate analysis did not detect any predictor for peri- or postinterventional neurologic events. CONCLUSION Contralateral high-grade ICA stenosis or occlusion was not associated with an increased risk for neurologic events after elective ICA stent placement.
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Affiliation(s)
- Schila Sabeti
- Departments of Angiology and Clinical Neurology, University of Vienna Medical School, Austria.
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