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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.
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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
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Kotsis T, Christoforou P, Tsekoura D, Nastos K. Eversion Carotid Endarterectomy: Cardiac Troponin Assessment. Int J Angiol 2022; 32:100-105. [DOI: 10.1055/s-0042-1743254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractMyocardial infarction (MI) is an eversion carotid endarterectomy (eCEA) complication, but most events are unknown, and true incidence and correlation remain controversial. Routine cardiac troponin measurement is a commonly used method for assessing early identification and treatment of MI and stratifying high-risk patients. The aim of the present study is to evaluate the effect of troponin elevation levels following eCEA and to investigate a possible correlation between adverse cardiovascular events and the incidence of postoperative myocardial infarction following emergent vascular surgery. The study included 54 patients who underwent eCEA. High-sensitive troponin I (hsTnI) levels were routinely monitored pre- and postoperatively, with an upper reference range of 34.5 pg/mL for men and 15.6 pg/mL for women. Increases were correlated with demographic and clinical risk factors, as well as clinical or subclinical cardiovascular events. hsTnI was increased in percentage (13%) postoperatively, and non-ST segment elevation MI was diagnosed in eight patients. No patient had clinical symptoms of MI and only two of them presented with simultaneous electrocardiographic changes. Increased levels did not correlate with comorbidities or other surgical risk factors. hsTnI elevation may occur in patients after eCEA and mostly correlates with silent non-ST segment elevation MI that occurred in the early postoperative phase, indicating a possible value as a tool for cardiovascular event diagnosis during the patient's hospitalization.
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Affiliation(s)
- Thomas Kotsis
- Surgery Department, 2nd Clinic of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Attica, Greece
| | - Panagitsa Christoforou
- Surgery Department, 2nd Clinic of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Attica, Greece
| | - Dorothea Tsekoura
- Cardiological Department, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Attica, Greece
| | - Konstantinos Nastos
- 2nd Clinic of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Attica, Greece
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Meyer A, Gall C, Verdenhalven J, Lang W, Almasi-Sperling V, Behrendt CA, Guenther J, Rother U. Influence of Eversion Endarterectomy and Patch Reconstruction on Postoperative Blood Pressure After Carotid Surgery. Ann Vasc Surg 2021; 78:61-69. [PMID: 34464726 DOI: 10.1016/j.avsg.2021.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/17/2021] [Accepted: 06/12/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Post carotid blood pressure fluctuation and hypertension (PEH) are associated with increased risk for adverse outcome; there is limited evidence on the impact of eversion endarterectomy (E-CEA) versus conventional endarterectomy with patch closure (C-CEA) on postoperative blood pressure course. PATIENTS AND METHODS In this retrospective observational study, 859 consecutive carotid endarterectomy procedures between 2004 and 2014 (C-CEA n = 585 vs. E-CEA n = 274), were evaluated. Pre- and postoperative blood pressure values were recorded from recovery room until third postoperative day and compared between both techniques; influences on the dichotomous target variable "at least one postoperative blood pressure peak", that is need for postoperative vasodilators, were analyzed by a logistic regression model. Influences on postoperative systolic blood pressure were evaluated by a linear mixed effects regression model. RESULTS Preoperative baseline blood pressure was not different between both comparison groups. During postoperative course, significantly increased mean systolic blood pressure values in the E-CEA group from recovery room to second postoperative day (recovery room C-CEA: 129.2 mm Hg vs. E-CEA: 136.5 mm Hg; P < 0.001; first postoperative day C-CEA: 132.4 mm Hg vs. E-CEA: 139.3 mm Hg; P = 0.0002; second postoperative day C-CEA: 138.6 mm Hg vs. E-CEA: 143.1 mm Hg; P = 0.023) were observed. No hyperperfusion syndrome was detected as wells as no difference in postoperative complication rate. Frequency of antihypertensive interventions was also elevated in E-CEA group (C-CEA 22.1 % vs. E-CEA 31.8 %; P = 0.003). E-CEA (OR 1.591, 95% CI [1.146; 2.202]; P = 0.005) and presence of preoperatively elevated systolic readings (OR 1.015, 95%CI [1.006;1.024]; P < 0.001) was also associated with increased need for antihypertensive interventions. CONCLUSION E-CEA was associated with significantly elevated postoperative blood pressure, compared to C-CEA. C-CEA was associated with postoperative blood pressure decrease; however, no difference as to neurologic and surgical complications was detected between both surgical techniques in clinical practice.
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Affiliation(s)
- Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany.
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Julia Verdenhalven
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | | | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Josefine Guenther
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
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