1
|
Sultan S, Acharya Y, Dulai M, Tawfick W, Hynes N, Wijns W, Soliman O. Redefining postoperative hypertension management in carotid surgery: a comprehensive analysis of blood pressure homeostasis and hyperperfusion syndrome in unilateral vs. bilateral carotid surgeries and implications for clinical practice. Front Surg 2024; 11:1361963. [PMID: 38638141 PMCID: PMC11025470 DOI: 10.3389/fsurg.2024.1361963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
Background This study evaluates the implications of blood pressure homeostasis in bilateral vs. unilateral carotid surgeries, focusing on the incidence of postoperative hypertension, hyperperfusion syndrome, and stroke as primary outcomes. It further delves into the secondary outcomes encompassing major adverse cardiovascular events and all-cause mortality. Methods Spanning two decades (2002-2023), this comprehensive retrospective research encompasses 15,369 carotid referrals, out of which 1,230 underwent carotid interventions. A subset of 690 patients received open carotid procedures, with a 10-year follow-up, comprising 599 unilateral and 91 bilateral surgeries. The Society for Vascular Surgery Carotid Reporting Standards underpin our methodological approach for data collection. Both univariate and multivariate analyses were utilized to identify factors associated with postoperative hypertension using the Statistical Package for the Social Sciences (SPSS) Version 22 (SPSS®, IBM® Corp., Armonk, N.Y., USA). Results A marked acute elevation in blood pressure was observed in patients undergoing both unilateral and bilateral carotid surgeries (p < 0.001). Smoking (OR: 1.183, p = 0.007), hyperfibrinogenemia (OR: 0.834, p = 0.004), emergency admission (OR: 1.192, p = 0.005), severe ipsilateral carotid stenosis (OR: 1.501, p = 0.022), and prior ipsilateral interventions (OR: 1.722, p = 0.003) emerged as significant factors that correlates with postoperative hypertension in unilateral surgeries. Conversely, in bilateral procedures, gender, emergency admissions (p = 0.012), and plaque morphology (p = 0.035) significantly influenced postoperative hypertension. Notably, 2.2% of bilateral surgery patients developed hyperperfusion syndrome, culminating in hemorrhagic stroke within 30 days. Intriguingly, postoperative stage II hypertension was identified as an independent predictor of neurological deficits post-secondary procedure in bilateral CEA cases (p = 0.004), attributable to hyperperfusion syndrome. However, it did not independently predict myocardial infarction or mortality outcomes. The overall 30-day stroke rate stood at 0.90%. Lowest incidence of post operative hypertension or any complications were observed in eversion carotid endartrertomy. Conclusion The study identifies postoperative hypertension as a crucial independent predictor of perioperative stroke following bilateral carotid surgery. Moreover, the study elucidates the significant impact of bilateral CEA on the development of post-operative hyperperfusion syndrome or stroke, as compared to unilateral CEA. Currently almost 90% of our carotid practice is eversion carotid endartrerectomy.
Collapse
Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
| | - Yogesh Acharya
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Makinder Dulai
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - William Wijns
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
| |
Collapse
|
2
|
Penton A, Kelly R, Le L, Blecha M. Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy. Vasc Endovascular Surg 2023; 57:869-877. [PMID: 37303024 DOI: 10.1177/15385744231183750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up. METHODS There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing. RESULTS There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics (P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking. CONCLUSIONS Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.
Collapse
Affiliation(s)
- Ashley Penton
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Robert Kelly
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Linda Le
- Department of Cardiovascular Surgery, Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| |
Collapse
|
3
|
Perioperative Medical Management for Symptomatic Carotid Artery Interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
4
|
Bevilacqua S, Ticozzelli G, Orso M, Alba G, Capoccia L, Cappelli A, Cernetti C, Diomedi M, Dorigo W, Faggioli G, Giannace G, Giannandrea D, Giannetta M, Lessiani G, Marone EM, Mazzaccaro D, Migliacci R, Nano G, Pagliariccio G, Petruzzellis M, Plutino A, Pomatto S, Pulli R, Sirignano P, Vacirca A, Visco E, Moghadam SP, Lanza G, Lanza J. Anesthetic management of carotid endarterectomy: an update from Italian guidelines. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:24. [PMID: 37386522 PMCID: PMC10245611 DOI: 10.1186/s44158-022-00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/12/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND AIMS In order to systematically review the latest evidence on anesthesia, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure management for carotid endarterectomy. The present review is based on a single chapter of the Italian Health Institute Guidelines for diagnosis and treatment of extracranial carotid stenosis and stroke prevention. METHODS AND RESULTS A systematic article review focused on the previously cited topics published between January 2016 and October 2020 has been performed; we looked for both primary and secondary studies in the extensive archive of Medline/PubMed and Cochrane library databases. We selected 14 systematic reviews and meta-analyses, 13 randomized controlled trials, 8 observational studies, and 1 narrative review. Based on this analysis, syntheses of the available evidence were shared and recommendations were indicated complying with the GRADE-SIGN version methodology. CONCLUSIONS From this up-to-date analysis, it has emerged that any type of anesthesia and neurological monitoring method is related to a better outcome after carotid endarterectomy. In addition, insufficient evidence was found to justify reversal or no-reversal of heparin at the end of surgery. Furthermore, despite a low evidence level, a suggestion for blood pressure monitoring in the postoperative period was formulated.
Collapse
Affiliation(s)
- Sergio Bevilacqua
- Department of Anesthesia, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | - Giulia Ticozzelli
- Anesthesiology and Intensive Care Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
| | - Massimiliano Orso
- Società Italiana di Chirurgia Vascolare ed Endovascolare (SICVE), Roma, Italy
| | - Giuseppe Alba
- Department of Vascular Surgery, University of Siena, Siena, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Division, Policlinico Umberto I La Sapienza University of Rome, Rome, Italy
| | - Alessandro Cappelli
- Vascular Surgery Unit, Policlinico Le Scotte Hospital University of Siena, Siena, Italy
| | - Carlo Cernetti
- Division of Cardiology and and Interventional Hemodynamics, Ca' Foncello Hospital, Azienda USLL2 Marca Trevigiana, Treviso, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, Tor Vergata University Hospital, Rome, Italy
| | - Walter Dorigo
- Vascular Surgery Unit, University of Florence, Florence, Italy
| | - Gianluca Faggioli
- Vascular Surgery Unit, Policlinico Sant'Orsola, Alma Mater Studiorum University, Bologna, Italy
| | - Giovanni Giannace
- Vascular Surgery Unit, Arcispedale Snata Maria Nuova, Reggio Emilia, Italy
| | - David Giannandrea
- Stroke Unit, Neurology Department, USL Umbria 1, Cittá di Castello, Perugia, Italy
| | - Matteo Giannetta
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | | | - Enrico Maria Marone
- Vascular Surgery Unit, Department of Policlinico Monaza, Monza, Italy
- Pavia University, Pavia, Italy
| | - Daniela Mazzaccaro
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | - Rino Migliacci
- Angiology and Internal Medicine, Valdichiana S.Margherita Hospital, Cortona, Italy
| | - Giovanni Nano
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | | | | | | | - Sara Pomatto
- Vascular Surgery Unit, Policlinico Sant'Orsola, Alma Mater Studiorum University, Bologna, Italy
| | - Raffaele Pulli
- Vascular Surgery Unit, Policlinico Careggi Hospital University, Florence, Italy
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Sant'andrea Hospital , "La sapienza" University of Rome, Rome, Italy
| | - Andrea Vacirca
- Vascular Surgery Unit, Policlinico San'Orsola-Alma Mater Studiorum University, Bologna, Italy
| | - Emanuele Visco
- Division of Cardiology and Interventional Hemodynamic, San Giacomo Apostolo Hospital, Azienda ULSS2 Marca Trevigiana, Castelfranco Veneto, Italy
| | | | - Gaetano Lanza
- Vascular Surgery Department, Multimedica Hospital-IRCCS, Castellanza, Italy
| | - Jessica Lanza
- Vascular Surgery Department, IRCSS Ospedale Policlinico, San Martino Genova, Italy
| |
Collapse
|
5
|
Schultz-Lebahn A, Nissen PH, Pedersen TF, Tang M, Hvas AM. Platelet function assessed by ROTEM ® platelet in patients receiving antiplatelet therapy during cardiac and vascular surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 82:18-27. [PMID: 34890293 DOI: 10.1080/00365513.2021.2012820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients undergoing coronary artery bypass graft (CABG) surgery or carotid endarterectomy (CEA) continue antiplatelet therapy perioperatively, which may increase bleeding risk. We aimed to investigate whether Rotational thromboelastometry (ROTEM®) platelet, a newly marketed platelet function analysis, would detect antiplatelet therapy in CABG and CEA patients; whether detection of reduced platelet function was associated with increased bleeding; and whether ex vivo desmopressin increased platelet function. We included 20 CABG patients continuing aspirin and 20 CEA patients continuing clopidogrel (n = 1) or clopidogrel and aspirin (n = 19). Platelet function was analyzed with ROTEM® platelet and light transmission aggregometry (LTA). According to the lower reference limit, ROTEM® platelet managed to detect aspirin, but clopidogrel detection was inadequate compared to LTA. Using a previously published cut-off for bleeding risk, 6 (30%) patients receiving aspirin and 4 (21%) patients receiving both clopidogrel and aspirin demonstrated platelet function below this cut-off. One of the four CEA patients below the cut-off died from intracerebral hemorrhage postoperatively. CABG patients below (n = 6) and above (n = 14) the cut-off did not differ in chest tube output (median [range]: 373 ml [250-900] vs. 368 ml [195-820]). Ex vivo addition of desmopressin did not increase platelet function. In conclusion, ROTEM® platelet does reveal aspirin treatment whereas clopidogrel treatment is most often overlooked. Due to low bleeding in the study population, it was not possible to conclude on the association with bleeding risk.
Collapse
Affiliation(s)
- Anna Schultz-Lebahn
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Peter H Nissen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels Fogh Pedersen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mariann Tang
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
6
|
Schaafsma M, Glade GJ, Keller PJ, Schaafsma A. Age corrected changes in intracranial hemodynamics after carotid endarterectomy. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:354-363. [PMID: 33829743 DOI: 10.23736/s0021-9509.21.11705-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Transcranial Doppler ultrasound (TCD) is a frequently used method to monitor brain perfusion during and following carotid endarterectomy (CEA). Our aim was to define the normally occurring changes of intracranial hemodynamics in patients undergoing CEA measuring recently developed TCD parameters. METHODS A retrospective, single-center cohort study was performed. Patients undergoing CEA were evaluated pre- and postoperatively from day 0 to day 3 measuring middle cerebral artery flow velocity (MCAFV). The following parameters were analyzed: the first systolic peak (Sys1), the second systolic peak (Sys2) and diastolic flow velocity at a fixed time after heartbeat onset (Dias@560). These parameters linearly decrease with age and were, therefore, transformed to Z-scores. RESULTS Three hundred eighteen patients were included with a mean age of 70.8 years. Most patients were male (71%). Compared to preoperatively, the Z-scores of Sys1 and Sys2 were larger on postoperative day 3: +1.12 standard deviation (SD) or 16.0 cm/s (CI: 0.93 to 1.32; P<0.001) and +0.55 SD or 7.8 cm/s (CI: 0.35 to 0.74; P<0.001), respectively. The Z-score for Dias@560 was smaller than preoperatively: -0.23 SD or -1.9 cm/s (CI: -0.41 to -0.05, P=0.015). CONCLUSIONS Under normal circumstances Sys1 profits more from CEA than Sys2, whilst diastolic flow velocity decreases. This indicates a return to normal arteriolar vascular resistance. Carefully describing normal changes in MCAFV, may in future enable discrimination of abnormalities, such as hyperperfusion syndrome.
Collapse
Affiliation(s)
- Mirte Schaafsma
- Amsterdam University Medical Center, Amsterdam, the Netherlands -
| | - Gerard J Glade
- Department of Vascular Surgery and Clinical Neurophysiology, Martini Ziekenhuis Groningen, Groningen, the Netherlands
| | - Paul J Keller
- Department of Vascular Surgery and Clinical Neurophysiology, Martini Ziekenhuis Groningen, Groningen, the Netherlands
| | - Arjen Schaafsma
- Department of Vascular Surgery and Clinical Neurophysiology, Martini Ziekenhuis Groningen, Groningen, the Netherlands
| |
Collapse
|
7
|
Braet DJ, Smith JB, Bath J, Kruse RL, Vogel TR. Risk factors associated with 30-day hospital readmission after carotid endarterectomy. Vascular 2021; 29:61-68. [PMID: 32628069 PMCID: PMC7782206 DOI: 10.1177/1708538120937955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The current study evaluated all-cause 30-day readmissions after carotid endarterectomy. METHODS Patients undergoing carotid endarterectomy were selected from the Cerner Health Facts® database using ICD-9-CM procedure codes from their index admission. Readmission within 30 days of discharge was determined. Chi-square analysis determined characteristics of the index admission (demographics, diagnoses, postoperative medications, and laboratory results) associated with readmission. Multivariate logistic regression models were used to identify characteristics independently associated with readmission. RESULTS In total, 5257 patients undergoing elective carotid endarterectomy were identified. Readmission within 30 days was 3.1%. After multivariable adjustment, readmission was associated with end-stage renal disease (OR: 3.21, 95% CI: 1.01-10.2), hemorrhage or hematoma (OR: 2.34, 95% CI: 1.15-4.77), procedural complications (OR: 3.07, 95% CI: 1.24-7.57), use of bronchodilators (OR: 1.48, 95% CI: 1.03-2.11), increased Charlson index scores (OR: 1.22, 95% CI: 1.08-1.38), and electrolyte abnormalities (hyponatremia < 135 mEq/L (OR: 1.69, 95% CI: 1.07-2.67) and hypokalemia less than 3.7 mEq/L (OR: 2.26, 95% CI: 1.03-4.98)). CONCLUSIONS Factors associated with readmission following carotid endarterectomy included younger age, increased comorbidity burden, end-stage renal disease, electrolyte disorders, the use of bronchodilators, and complications including bleeding (hemorrhage or hematoma). Of note, in this real-world study, only 40% of the patients received protamine, despite evidence-based literature demonstrating the reduced risk of bleeding complications. As healthcare moves towards quality of care-driven reimbursement, physician modifiable targets such as protamine utilization to reduce bleeding are greatly needed to reduce readmission, and failure to reduce preventable physician-driven complications after carotid interventions may be associated with decreased reimbursement.
Collapse
Affiliation(s)
- Drew J. Braet
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - Jamie B. Smith
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Missouri
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| | - Robin L. Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Missouri
| | - Todd R. Vogel
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri
| |
Collapse
|
8
|
Lee S, Conway AM, Nguyen Tranh N, Anand G, Leung TM, Fatakhova O, Giangola G, Carroccio A. Risk Factors for Postoperative Hypotension and Hypertension following Carotid Endarterectomy. Ann Vasc Surg 2020; 69:182-189. [PMID: 32502683 DOI: 10.1016/j.avsg.2020.05.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/06/2020] [Accepted: 05/20/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients undergoing carotid endarterectomy (CEA) often experience postoperative hemodynamic changes that require intravenous medications for hypo- and hypertension. Prior studies have found these changes to be associated with increased risks of 30-day mortality, stroke, myocardial infarction (MI), and length of stay (LOS). Our aim is to investigate preoperative risk factors associated with the need for postoperative intravenous medications for blood pressure control. METHODS A retrospective review of an internally maintained prospective database of patients undergoing carotid interventions between January 2014 and March 2019 was performed. Demographic data, clinical history, and perioperative data were recorded. Carotid artery stents and reinterventions were excluded. Our primary end points were the need to intervene with intravenous medication for either postoperative hypotension [systolic blood pressure (SBP) <100 mm Hg] or postoperative hypertension (SBP >160 mm Hg). RESULTS A total of 221 patients were included in the study after excluding those with a prior ipsilateral CEA or carotid artery stent. The mean age was 72.3 (±8.9) years, 157 (71%) patients were male, and 78 (35.3%) were Caucasian. Following CEA, 151 (68.3%) patients were normotensive, while 33 (14.9%) and 37 (16.7%) required medication for hypotension and hypertension, respectively. A univariate logistic regression identified 5 variables as being associated with postoperative blood pressure including race, history of MI, prior percutaneous transluminal coronary angioplasty (PTCA), statin use, and angiotensin-converting enzyme-inhibitor/angiotensin-receptor blocker (ARB) use. A stepwise regression selection found race, prior MI, and statin use to be associated with our primary end points. The hypertensive group was more likely to have a history of MI compared to the hypotensive and normotensive groups (40.5% vs. 27.3% vs. 18.5%, P = 0.02), PTCA (43.2% vs. 39.4% vs. 23.8%, P = 0.03), and statin use (94.6% vs. 93.9% vs. 78.8%, P = 0.01). Mean LOS was also the highest for the hypertensive group, followed by hypotensive and normotensive patients [2.0 (±1.6) vs. 1.8 (±2.4) vs. 1.3 (±0.8), P = 0.002]. Multivariable logistic regression demonstrated that non-Caucasian patients [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.26-5.86, P = 0.01] and those with a history of MI (OR 2.98, 95% CI 1.33-6.67) were more likely to have postoperative hypertension compared to patients who were Caucasian or had no history of MI. CONCLUSIONS Postoperative hypertension is associated with non-Caucasian race and a history of MI. Given the potential implications for adverse perioperative outcomes including MI, mortality, and LOS, it is important to continue to elucidate potential risk factors in order to further tailor the perioperative management of patients undergoing CEA.
Collapse
Affiliation(s)
- Samuel Lee
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
| | - Allan M Conway
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Nhan Nguyen Tranh
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Gautam Anand
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Tung Ming Leung
- Department of Biostatistics, Feinstein Institute for Medical Research, Manhasset, NY
| | - Olga Fatakhova
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Gary Giangola
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alfio Carroccio
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| |
Collapse
|
9
|
Perioperative Assessment of High-Risk Abdominal Surgery: A Case Study. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2020; 8:374-382. [PMID: 32775620 PMCID: PMC7413206 DOI: 10.12691/ajmcr-8-10-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objectives • To outline the key components of a pre-operative cardiac risk assessment. • To review the major guidelines utilized to assess patients' surgical risks. • To discuss the perioperative management of surgical patients to prevent cardiac and pulmonary complications. • To review the utility of biomarkers in the pre- and post-operative period.
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW The effects of statin loading before, during or after vascular interventions on cardiovascular and renal outcomes are discussed. Furthermore, the selection of optimal statin type and dose, according to current evidence or guidelines, is considered. The importance of treating statin intolerance and avoiding statin discontinuation is also discussed. RECENT FINDINGS Statin loading has been shown to beneficially affect cardiovascular outcomes, total mortality and/or contrast-induced acute kidney injury, in patients undergoing vascular procedures such as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), carotid artery stenting, endovascular aneurysm repair, open abdominal aortic aneurysms (AAA) repair and lower extremities vascular interventions. High-dose statin pretreatment is recommended for PCI and CABG according to current guidelines. Statin discontinuation should be avoided during acute cardiovascular events and vascular interventions; adequate measures should be implemented to overcome statin intolerance. SUMMARY Statin loading is an important clinical issue in patients with cardiac and noncardiac vascular diseases, including carotid artery disease, peripheral artery disease and AAA, undergoing vascular interventions. Cardiologists and vascular surgeons should be aware of current evidence and implement guidelines in relation to statin loading, discontinuation and intolerance.
Collapse
|
11
|
Song GF, Wu CJ, Dong SX, Yu CH, Li X. Rehabilitation training combined acupuncture for limb hemiplegia caused by cerebral hemorrhage: A protocol for a systematic review of randomized controlled trial. Medicine (Baltimore) 2019; 98:e14726. [PMID: 30817621 PMCID: PMC6831227 DOI: 10.1097/md.0000000000014726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Previous studies have reported that rehabilitation training combined acupuncture (RTA) can be used for the treatment of limb hemiplegia (LH) caused by cerebral hemorrhage (CH). However, its effectiveness is still unclear. In this systematic review study, we aim to evaluate the effectiveness and safety of RTA for LH following CH. METHODS We will retrieve the databases of CENTRAL, EMBASE, MEDILINE, CINAHL, AMED, CBM, and CNKI from inception to March 1, 2019 with no language restrictions. The randomized controlled trials of RTA for evaluating effectiveness and safety in patients with LH following CH will be included. Cochrane risk of bias tool will be used to measure the methodological quality for all included studies. Two authors will independently select the studies, extract the data, and assess the methodological quality of included studies. A third author will be invited to discuss if any disagreements exist between 2 authors. If more than 2 eligible studies will be included, the outcome data will be pooled, and meta-analysis will be conducted if it is possible. RESULTS This systematic review will assess the effectiveness and safety of RTA for LH caused by CH. The primary outcome includes limbs function. The secondary outcomes consist of muscle strength, muscle tone, quality of life, and any adverse events. CONCLUSION The findings of this study will summarize the current evidence of RTA for LH caused by CH, and may provide helpful evidence for the clinical treatment. DISSEMINATION AND ETHICS The results of this study will be published in peer-reviewed journals or will be presented on conference meeting. This work does not require ethic approval, because it will be conducted based on the published studies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019120034.
Collapse
Affiliation(s)
| | | | | | | | - Xin Li
- Department of Neurology, First Affiliated Hospital of Jiamusi University, Jiamusi, China
| |
Collapse
|
12
|
Katsiki N, Mikhailidis DP. Lipids: a personal view of the past decade. Hormones (Athens) 2018; 17:461-478. [PMID: 30229482 DOI: 10.1007/s42000-018-0058-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/31/2018] [Indexed: 12/27/2022]
Abstract
The past decade has witnessed considerable progress in the field of lipids. New drugs have been "rapidly" developed and some of these drugs have already been evaluated in event-based large trials. This evidence has led to the guidelines recommending new, more aggressive treatment goals for low-density lipoprotein cholesterol (LDL-C) levels. Although LDL-C remains the principal goal for cardiovascular disease (CVD) risk reduction, there has also been considerable interest in other lipid variables, such as high-density lipoprotein cholesterol, triglycerides, and lipoprotein(a). Statin intolerance is now considered a very important topic in daily clinical practice. This has resulted in more attention focusing on non-statin drugs [e.g., ezetimibe and proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors] and statin-related side effects. The latter mainly involve muscles, but there is also a need to consider other adverse effects associated with statin use (e.g., new onset diabetes). New specific areas of statin use have attracted interest. For example, statin-loading before procedures (e.g., coronary stenting), the prevention of stroke, and the treatment of non-alcoholic fatty liver disease (NAFLD). Statins will remain the most widely used drugs to treat dyslipidaemia and decrease CVD risk. However, we also need to briefly consider some other lipid-lowering drugs, including those that may become available in the future.
Collapse
Affiliation(s)
- Niki Katsiki
- Second Department of Propaedeutic Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), Pond Street, London, NW3 2QG, UK.
| |
Collapse
|