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Orrapin S, Benyakorn T, Siribumrungwong B, Rerkasem K. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev 2022; 8:CD000160. [PMID: 35920689 PMCID: PMC9347312 DOI: 10.1002/14651858.cd000160.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Carotid patch angioplasty may reduce the risk of acute occlusion or long-term restenosis of the carotid artery and subsequent ischaemic stroke in people undergoing carotid endarterectomy (CEA). This is an update of a Cochrane Review originally published in 1995 and updated in 2008. OBJECTIVES To assess the safety and efficacy of routine or selective carotid patch angioplasty with either a venous patch or a synthetic patch compared with primary closure in people undergoing CEA. We wished to test the primary hypothesis that carotid patch angioplasty results in a lower rate of severe arterial restenosis and therefore fewer recurrent strokes and stroke-related deaths, without a considerable increase in perioperative complications. SEARCH METHODS We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and two trial registries in September 2021. SELECTION CRITERIA Randomised controlled trials and quasi-randomised trials comparing carotid patch angioplasty with primary closure in people undergoing CEA. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and risk of bias; extracted data; and determined the certainty of evidence using the GRADE approach. Outcomes of interest included stroke, death, significant complications related to surgery, and artery restenosis or occlusion during the perioperative period (within 30 days of the operation) or during long-term follow-up. MAIN RESULTS We included 11 trials involving 2100 participants undergoing 2304 CEA operations. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Compared with primary closure, carotid patch angioplasty may make little or no difference to reduction in risk of any stroke during the perioperative period (odds ratio (OR) 0.57, 95% confidence interval (CI) 0.31 to 1.03; P = 0.063; 8 studies, 1769 participants; very low-certainty evidence), but may lower the risk of any stroke during long-term follow-up (OR 0.49, 95% CI 0.27 to 0.90; P = 0.022; 7 studies, 1332 participants; very low-certainty evidence). In the included studies, carotid patch angioplasty resulted in a lower risk of ipsilateral stroke during the perioperative period (OR 0.31, 95% CI 0.15 to 0.63; P = 0.001; 7 studies, 1201 participants; very low-certainty evidence), and during long-term follow-up (OR 0.32, 95% CI 0.16 to 0.63; P = 0.001; 6 studies, 1141 participants; very low-certainty evidence). The intervention was associated with a reduction in the risk of any stroke or death during long-term follow-up (OR 0.59, 95% CI 0.42 to 0.84; P = 0.003; 6 studies, 1019 participants; very low-certainty evidence). In addition, the included studies suggest that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08 to 0.41; P < 0.0001; 7 studies, 1435 participants; low-certainty evidence), and may reduce the risk of restenosis during long-term follow-up (OR 0.24, 95% CI 0.17 to 0.34; P < 0.00001; 8 studies, 1719 participants; low-certainty evidence). The studies recorded very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation, with either patch or primary closure. We found no correlation between the use of patch angioplasty and the risk of either perioperative or long-term stroke-related death or all-cause death rates. AUTHORS' CONCLUSIONS Compared with primary closure, carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and long-term restenosis of the operated artery. It would appear to reduce the risk of ipsilateral stroke during the perioperative and long-term period and reduce the risk of any stroke in the long-term when compared with primary closure. However, the evidence is uncertain due to the limited quality of included trials.
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Affiliation(s)
- Saritphat Orrapin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Thoetphum Benyakorn
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Boonying Siribumrungwong
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Kittipan Rerkasem
- Environmental - Occupational Health Sciences and Non-Communicable Diseases Research Group, Research Institute of Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Zagzoog N, Elgheriani A, Attar A, Takroni R, Aljoghaiman M, Klotz L, Vandervelde C, Darling C, Farrokhyar F, Martyniuk A, Algird A. Comprehensive comparison of carotid endarterectomy primary closure and patch angioplasty: A single-institution experience. Surg Neurol Int 2022; 13:1. [PMID: 35127201 PMCID: PMC8813614 DOI: 10.25259/sni_1013_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA. Methods: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients’ baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured. Results: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82–1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort. Conclusion: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.
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Affiliation(s)
- Nirmeen Zagzoog
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Ali Elgheriani
- Department of Internal Medicine, University of Manitoba, Manitoba, Canada
| | - Ahmed Attar
- Department of Neurology, McMaster University, Hamilton, Canada,
- King Abdullah International Medical Research Center, Jeddeah, Saudi Arabia,
| | - Radwan Takroni
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Majid Aljoghaiman
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Klotz
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | - Chloe Darling
- Fleming School of Nursing, Trent University, Peterborough, Ontario, Canada
| | - Forrough Farrokhyar
- Department of Health, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Martyniuk
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Almunder Algird
- Department of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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3
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Oldenburg WA, Almerey T, Selim M, Farres H, Hakaim AG. Durability of Carotid Endarterectomy with Bovine Pericardial Patch. Ann Vasc Surg 2018; 50:218-224. [PMID: 29481939 DOI: 10.1016/j.avsg.2017.11.062] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/10/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Multiple studies have shown that patch angioplasty after carotid endarterectomy (CEA) reduces the risk of stroke and restenosis when compared with primary closure. Biological, synthetic, or vein patches have been traditionally used in CEA. This article reports the early and long-term outcomes of bovine pericardium (BP) for patch angioplasty in CEA. METHODS A retrospective, consecutive analysis of 874 patients who underwent CEA during the past 17 years at Mayo Clinic, Florida, was performed. BP patch (BPP) was used in 680 patients. Other CEA techniques were used in 194 patients (standard without patch, 78; standard with Dacron, 74; standard with vein patch, 16; and other techniques: bypasses, 26). We defined group 1 as those who underwent BPP angioplasty and group 2 as those who underwent all other techniques. Early and late clinical outcomes and patch-related complications (restenosis, infection, and hematoma) were recorded and analyzed. RESULTS Median follow-up for the entire series was 39.6 months. There were no statistically significant differences in 30-day mortality and morbidity between the 2 groups, except that BP group has less 30-day stroke (0.1%, 1 of 680) versus other techniques (1.5%, 3 of 194, P = 0.03). Thirty-day postoperative mortality rate was 0.1% (1 of 680) in BPP group and 1.0% (2 of 194) in other technique group (P = 0.13). No statistically significant difference was noted in 30-day postoperative major complications (transient ischemic attack [TIA], wound infection, hematoma requiring surgical evacuation, and nerve injury) between the 2 groups. Ten-year freedom from stroke/TIA were 97.8% in the BP group compared with 98.5% in the other group (P = 0.86). Ten-year freedom from restenosis was also similar between groups (89.0% BP vs. 90.4% others, P = 0.69). Ten-year survival rate was 38.4% in BP group and 45.0% in other technique group, and this was statistically significant on univariate analysis only. CONCLUSIONS CEA with BP angioplasty has excellent early and late outcomes with minor morbidity and mortality.
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Affiliation(s)
| | - Tariq Almerey
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Mahmoud Selim
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Houssam Farres
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL
| | - Albert G Hakaim
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL
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Cheng I, Vyas KS, Velaga S, Davenport DL, Saha SP. Outcomes of Carotid Endarterectomy with Primary Closure. Int J Angiol 2017; 26:83-88. [PMID: 28566933 DOI: 10.1055/s-0037-1601053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid artery stenosis, although the optimal surgical technique is debated. The literature suggests that patch angioplasty reduces complication risk, although primary closure shortens cross-clamp time and eliminates complications associated with grafts. The objective of this study was to assess the complication rate after CEA with primary closure. Retrospective review of 240 consecutive patients between 2002 and 2010. Of these patients, 70% returned for follow-up visits for at least 2 or more years. Primary closure was used in all patients. The average cross-clamp time was 18 minutes. Complications in the immediate postoperative period within 30 days were as follows: stroke (n = 3; 1.1%), transient ischemic attack (TIA; n = 4; 1.5%), myocardial infarction (MI; n = 3; 1.1%), and death (n = 1; 0.4%). Short-term follow-up revealed eight patients who were found to have significant restenosis (>80%) by carotid duplex imaging. Two to ten year postoperative complication rates were as follows: stroke (n = 7; 4.2%), TIA (n = 7; 4.2%), amaurosis fugax (n = 1; 0.6%), MI (n = 8; 4.8%), and death (n = 28; 17%). Mortality was due to stroke or heart attack (n = 2; 1.2%), cancer (n = 7; 4.2%), and unknown causes (n = 19; 11%). This study presents our experience with complications after primary closure after CEA. In our experience, CEA is a safe and effective surgical means of preventing stroke in the short term. Well-designed prospective studies are needed to confirm specific patient characteristics in which primary closure and patch angioplasty are indicated.
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Affiliation(s)
- Ivy Cheng
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Santhosh Velaga
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Daniel L Davenport
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Sibu P Saha
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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Chou D, Tulloch A, Cossman DV, Cohen JL, Rao R, Barmparas G, Mirocha J, Wagner W. The Influence of Collagen Impregnation of a Knitted Dacron Patch Used in Carotid Endarterectomy. Ann Vasc Surg 2016; 39:209-215. [PMID: 27666808 DOI: 10.1016/j.avsg.2016.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In selected populations, carotid endarterectomy (CEA) reduces long-term stroke risk. Studies have shown increased risk of restenosis with use of a collagen-impregnated Dacron patch compared to a polytetrafluorethylene patch. There is concern that collagen impregnation may initiate thrombosis or promote restenosis due to platelet activation. We performed a retrospective analysis of our CEA experience with routine patching using knitted Dacron patches with (Hemashield) and without (Sauvage) collagen impregnation. METHODS Our database was queried for all CEAs between January 2006 and December 2010. Seven surgeons performed 655 CEAs. Patients were excluded if no patch was used (n = 1), a primary CEA was performed before study period or by other surgeons (n = 11), or the patch type was indeterminable (n = 38). Demographics, clinical data, and outcomes were compared between the collagen-impregnated (C, Hemashield) group and non-collagen-impregnated (NC, Sauvage) group. RESULTS A total of 605 CEAs were analyzed (395 C and 210 NC). Demographics were similar except for coronary artery disease (C 54.3% vs. NC 41.6%, P = 0.003). There was no statistically significant difference in 30-day (C 99.7% vs. NC 99.5%, P > 0.99) or 5-year survival (C 80.0% vs. NC 83.7%, P = 0.26) or 30-day stroke rate (C 0.3% vs. NC 1.0%, P = 0.28). No late ipsilateral strokes occurred during 5-year follow-up. The 5-year freedom from restenosis >30% (C 85.3% vs. NC 86.4%, P = 0.33), restenosis >50% (C 94.5% vs. NC 95.5%, P = 0.44), and restenosis >70% (C 98.6% vs. NC 98.9%, P = 0.73) were similar. Two patients underwent carotid stenting for restenosis >70%. Two patients (both in the C group) developed occlusion of the carotid artery. CONCLUSIONS The thrombosis and restenosis rates in the 2 groups were similar. This suggests that collagen-impregnated patches do not initiate thrombosis or increase restenosis rates after CEA.
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Affiliation(s)
- Daisy Chou
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Allan Tulloch
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David V Cossman
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - J Louis Cohen
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Rajeev Rao
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Galinos Barmparas
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - James Mirocha
- Biostatistics Core, Research Institute and Clinical and Translational Science Institute (CTSI), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Willis Wagner
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
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Nass CM, Allen JK, Jermyn RM, Fleisher LA. Secondary prevention of coronary artery disease in patients undergoing elective surgery for peripheral arterial disease. Vasc Med 2016; 6:35-41. [PMID: 11358159 DOI: 10.1177/1358836x0100600107] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of the study was to assess the implementation of secondary prevention guidelines of coronary artery disease (CAD) in patients undergoing peripheral revascularization surgery. The design was a descriptive study of the prevalence of cardiac risk factors and preventive pharmacological therapy in vascular surgical patients set in an academic medical center between July 1996 and February 1999. A total of 237 patients were recruited, 82 (35%) having carotid surgery and 155 (65%) having lower extremity bypass. Data were collected from an existing database of a study examining perioperative cardiac events in vascular surgery patients. The majority of patients were hypertensive and 58% of patients had a blood pressure.140/90 mmHg. Most patients (81%) reported a history of tobacco use and 23% were active smokers. Of the 41% of patients who were diabetic, 46% had a random glucose .140 mg/dl. Half of the patients took aspirin, 35% a lipid-lowering medication, 30% a beta-blocker. Patients with lower extremity disease were less likely than patients with carotid disease to be on aspirin (45% vs. 62%), a lipid-lowering agent (30% vs. 45%), or a beta-blocker (26% vs. 39%) (all p,0.05). Of patients with heart disease, more men than women were on aspirin (62% vs. 45%) (p,0.05). In conclusion, our findings suggest that patients presenting for vascular surgery have a high prevalence of modifiable CAD risk factors that are not being adequately managed. Preoperative examination of vascular patients is an important opportunity to assess and implement neglected secondary prevention measures.
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Affiliation(s)
- C M Nass
- School of Medicine, John Hopkins University, Baltimore, MD, USA.
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Calaitges J, Kashyap A, Annest S. Eversion Carotid Endarterectomy: A Safe, Advantageous Alternative to Conventional Carotid Endarterectomy. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449603000506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To compare the results and time and cost efficacy of eversion carotid endarterectomy (ECEA) with standard carotid endarterectomy (SCEA). Methods: A retrospective analysis of 88 carotid endarterectomies performed by the residents under the guidance of the senior author between January 1, 1991, and December 31, 1993, was done. Fifty-five patients underwent SCEA (44 vein patch, 11 primary closure) and 33 had ECEA. The two groups were compared for operative time, intraoperative evaluation, cost, immediate and delayed morbidity, and restenosis (≥ 50%). Results: The two groups were found to be similar for age, sex ratio, and associated diseases. The indications for surgery were transient ischemic attack (TIA) (57% ECEA, 64% SCEA), previous stroke with minimal residual deficit (9% ECEA, 17% SCEA), and asymptomatic high-grade stenosis (34% ECEA, 19% SCEA). The average operative time for ECEA was significantly less (99.2 vs 135.2 minutes, P < 0.02). The mean blood loss was also less for ECEA (86 vs 181 cc). Two SCEA patients had immediate postoperative thrombosis resulting in 1 cerebrovascular accident (CVA) (1.8%), and 3 SCEA patients had cranial nerve injuries. In follow-up, 1 patient with SCEA had restenosis and 1 had a CVA unrelated to carotid disease. Morbidity associated with ECEA included 1 unsuccessful ECEA requiring interposition vein grafting and 1 intraoperative repair of an intimal flap. There was no associated residual morbidity. There was no significant difference in stroke rate between the two groups. The operative cost (excluding surgeon fee) was 28% higher for SCEA patients. Conclusion: Eversion carotid endarterectomy is a safe procedure and can be an important addition to a surgeon's armamentarium in efforts to cut costs while maintaining quality.
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Affiliation(s)
| | | | - Stephen Annest
- Department of Surgery, Guthrie Clinic, Sayre, Pennsylvania
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AbuRahma AF, Robinson PA, Richmond BK. Reanalysis of Factors Predicting Recurrent Stenosis in a Prospective Randomized Trial of Carotid Endarterectomy Comparing Primary Closure and Patch Closure. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857440003400406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Several factors have been implicated in the pathogenesis of recurrent carotid stenosis after carotid endarterectomy. This study examines the factors that predict recurrent stenosis in a prospective randomized trial of carotid endarterectomy comparing primary closure and patch closure. Patients undergoing 399 carotid endarterectomies were randomized into primary closures (n=135), polytetrafluoroethylene (PTFE) patch closures (n=134), and vein patch closures (n=130). Postoperative duplex ultrasounds were done at 1, 6, and 12 months, and then yearly. The mean follow-up was 41 months. Univariate analyses of potential risk factors were examined for possible association with ≥50% recurrent stenosis, and factors most associated with recurrent stenosis were examined by multivariate analyses using multiple linear regression. Primary closure had a higher incidence of recurrent stenosis (37%) than vein patch closure (13%) and PTFE patch closure (3%, p<0.001). Women with primary closure had a higher incidence of recurrent stenosis than men (49% versus 26%, p=0.008). With use of multiple linear regression models, the occurrence of ≥50% stenosis and increasing degrees of stenosis were associated most strongly with primary closure (p<0.001) and female gender (p=0.007). Carotid artery diameter, patch closure, age, coronary artery disease, or atherosclerosis risk factors (smoking, hyperlipidemia, hypertension, and diabetes mellitus) were not significantly associated with recurrent stenosis. Female gender and primary closure after carotid endarterectomy were the two factors most strongly associated with recurrence.
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Affiliation(s)
- Ali F. AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center of West Virginia University, Charleston, West Virginia
| | | | - Bryan K. Richmond
- Department of Surgery, Robert C. Byrd Health Sciences Center of West Virginia University, Charleston, West Virginia
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Faries PL, Chaer RA, Patel S, Lin SC, DeRubertis B, Kent KC. Current Management of Extracranial Carotid Artery Disease. Vasc Endovascular Surg 2016; 40:165-75. [PMID: 16703204 DOI: 10.1177/153857440604000301] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year; 80% are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter, randomized, controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis and compare these data to a critical analysis of the recent results of CAS.
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Affiliation(s)
- Peter L Faries
- Division of Vascular Surgery, New York Presbyterian Hospital, Cornell University, New York, NY 10021, USA.
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Reid JA, Lau LL, Hannon RJ, Lee B, Young IS, Soong CV. Decreased Antioxidant Vitamin Concentration May Be a Risk Factor for Recurrent Carotid Stenosis. Vasc Endovascular Surg 2016; 41:330-4. [PMID: 17704336 DOI: 10.1177/1538574407302750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Carotid endarterectomy has been found to be associated with a transient increase in systemic oxidative stress, and this has been shown to be a predictor of restenosis. The aim of this study was to determine the incidence of early recurrent stenosis and investigate a possible role of oxidative stress in its development by measuring the concentration of antioxidant vitamins. Patients undergoing carotid endarterectomy between August 2001 and February 2003 were included in the study. A preoperative blood sample was analyzed for antioxidant vitamin concentrations. All patients were followed up by duplex scans 3 and 12 months postoperatively. Ninety-three patients (101 carotid endarterectomies) were recruited. Nine arteries had developed restenosis by 12 months. Those patients who developed recurrent stenosis had significantly lower vitamin C concentrations (19.10 ± 3.69 vs 30.11 ± 19.10, P = .02) than those who did not. This study suggests that low antioxidant vitamin levels may predispose to early restenosis after carotid endarterectomy.
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Affiliation(s)
- Julie A Reid
- Regional Vascular and Endovascular Unit, Belfast City Hospital, Belfast, Northern Ireland.
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Hines GL, Vatsia S. Isolated Endarterectomy and Patch Angioplasty for Common Femoral Artery Occlusive Lesions. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449402800807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Eleven patients underwent isolated common femoral artery endarterectomy and vein patch angioplasty over a five-year period. All patients had claudication. In addition 7 had rest pain and 2 had ischemic ulcerations. Mean age was 67.8 ± 11.2 years. The mean preoperative ankle/arm (a/a) index was 0.48 ±0.14. The operations were performed under local or regional anesthesia. There was no perioperative mortality or morbidity. The mean postoperative a/a index increased to 0.76 ±0.19 at 30.75 months. One reconstruction thrombosed at sixteen months. Two patients died of unrelated causes with patent grafts at six months. The increase in a/a index was the same irre spective of whether the presenting symptoms were claudication alone (0.29), rest pain (0.21), or ischemic ulceration (0.35). This study indicates that femoral endarterec tomy and patch angioplasty is a safe and durable procedure for focal common femoral artery stenosis or occlusion.
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Affiliation(s)
- George L. Hines
- Department of Thoracic and Cardiovascular Surgery, Winthrop-University Hospital, Mineola, Department of Surgery, State University of New York at Stony Brook, New York
| | - Sheel Vatsia
- Department of Thoracic and Cardiovascular Surgery, Winthrop-University Hospital, Mineola, Department of Surgery, State University of New York at Stony Brook, New York
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Abstract
The purpose of this study was to determine whether repeat carotid endarterectomy (CEA) poses a greater risk than first-time CEA. The authors analyzed data from 893 consecutive CEA cases (1981-1993). Thirty-three patients (3.7%) had repeat CEA, and 860 (96.3%) had first-time CEA. There were statistically significantly higher incidences of hypertension (60.6% vs 44.6%), smoking (84.8% vs 55%), hypertriglyceridemia (33.3% vs 16.2%), and coronary artery disease (66.6% vs 36%) in the repeat CEA group than in the first-time CEA group. Symptomatic disease was present in 25 (75.8%) patients in the repeat group and in 576 (67%) patients in the first-time group (P>0.05). The cause of recurrence was atherosclerosis in 25 patients (76%), myointimal hyperplasia in seven patients (21.2%), and intraluminal thrombus without an underlying lesion in one patient (3%). Redo CEA with vein patch angioplasty was performed in 27 patients (82%), vein patch angioplasty alone in five patients (15%), and interposition vein graft in one patient (3%). The hospital operative mortality was 0% (n=0) in the repeat CEA group and 0.6% (n=5) in the first-time CEA group (P>0.05). The incidence of postoperative stroke was 0% (n=0) in the repeat group and 1.2% (n= 10) in the first-time group (P>0.05). There was one case (3%) of transient ischemic attack (TIA) in the repeat group, and two cases (0.2%) of TIA in the first-time group. There was no difference in the incidence of cranial nerve dysfunction between the repeat group (n=2, 6%) and the first-time group (n=41, 4.8%; P>0.05). Late follow-up data were obtained for 30 patients (mean: 61.4 months, range: 5-158 months) in the repeat CEA group and 501 patients (mean: 55.8 months, range: 17-168 months) in the first-time CEA group. The incidence of late failure (ipsilateral stroke or TIA) was 3.3% (n= 1) in the repeat group and 3.2% (n= 16) in the firsttime CEA group; P>0.05. The overall late mortality was 20% (n=6) in the repeat CEA group and 14.6% (n=73) in the primary CEA group; P>0.05. Repeat CEA can be performed safely in individuals with severe recurrent carotid stenosis, and perioperative and long-term mortality and neurologic morbidity rates are similar to those for patients undergoing first-time carotid endarterectomy.
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Affiliation(s)
| | | | | | - Jimmy F. Howell
- Department of Vascular Surgery, Baylor College of Medicine, Houston, Texas
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Pratesi C, Credi G, Pulli R, Michelangnoli S, Bertini D. The Role of Endovascular Surgery in Carotid Restenosis. J Endovasc Ther 2016. [DOI: 10.1177/152660289500200106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To report the immediate and long-term outcome of intraoperative balloon angioplasty for the treatment of recurrent disease in the internal carotid arteries (ICAs). Methods: Three patients (2 males, 1 female; ages 53 to 70 years) presented with > 80% restenotic lesions (bilateral in one patient) at the distal aspect of a previous carotid endarterectomy. Two patients exhibited hemianopia, while the third was asymptomatic but had a contralateral ICA occlusion. All four lesions appeared smooth and fibrous on ultrasonography and were located high in the ICA. The location and morphology of the lesions made balloon angioplasty a more potentially successful treatment option. Results: Through open access to the common carotid artery, the lesions were approached and dilated under fluoroscopic guidance with monitoring of evoked potentials. The lesions were successfully dilated as determined by control arteriography, and no complications were encountered. Over a follow-up period extending to 18 months in one patient and 24 months in the other two, ultrasound imaging and arteriography have shown no restenosis at any treatment site. Conclusions: Although caution is prudent when dealing with lesions in the cervical arteries, balloon angioplasty may have a role in treating surgically in accessible restenotic carotid lesions that demonstrate a low potential for embolic complications. More experience with this technique will be required before widespread application of balloon angioplasty in the cervical vessels can occur.
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Affiliation(s)
- Carlo Pratesi
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Giovanni Credi
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Raffaele Pulli
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | | | - Domenico Bertini
- Department of Vascular Surgery, University of Florence, Florence, Italy
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Maertens V, Maertens H, Kint M, Coucke C, Blomme Y. Complication Rate after Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure. Ann Vasc Surg 2016; 30:248-52. [DOI: 10.1016/j.avsg.2015.07.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/18/2015] [Accepted: 07/26/2015] [Indexed: 10/22/2022]
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Abstract
Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.
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Affiliation(s)
- Yinn Cher Ooi
- Department of Neurosurgery, University of California, Los Angeles
| | - Nestor R. Gonzalez
- Department of Neurosurgery and Radiology, University of California, Los Angeles, 100 UCLA Med Plaza Suite# 219, Los Angeles, CA 90095, +1(310)825-5154
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Prospective randomized trial of ACUSEAL versus Vascu-Guard patching in carotid endarterectomy. Ann Vasc Surg 2014; 28:1530-8. [PMID: 24561207 DOI: 10.1016/j.avsg.2014.02.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 02/06/2014] [Accepted: 02/08/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Multiple studies have been conducted that demonstrate the superiority of patch angioplasty over primary closure for carotid endarterectomy (CEA). Patch angioplasty with polytetrafluorethylene patches (ACUSEAL) have shown results comparable to patch angioplasty with saphenous vein and polyester patches. This is a prospective randomized study to compare the clinical outcomes of CEA using ACUSEAL versus bovine pericardium patching (Vascu-Guard). METHODS Two hundred patients were randomized (1:1) to either ACUSEAL or Vascu-Guard patching. Demographic data/clinical characteristics were collected. Intraoperative hemostasis times and the frequency of reexploration for neck hematoma were recorded. All patients received immediate and 1-month postoperative duplex ultrasound studies, which were repeated at 6-month intervals. A Kaplan-Meier analysis was used to estimate the risk of restenosis and the stroke-free survival rates. RESULTS The demographics were similar in both groups, except for a higher incidence of current smokers in the ACUSEAL group and more patients with congestive heart failure in the Vascu-Guard group (P = 0.02 and 0.03, respectively). The mean operative internal carotid artery diameter and the mean arteriotomy length were similar in both groups. The mean hemostasis time was 4.90 min for ACUSEAL patching vs. 3.09 min for Vascu-Guard (P = 0.027); however, the mean operative times were similar for both groups (ACUSEAL 2.09 hr vs. Vascu-Guard 2.16 hr, P = 0.669). The incidence of reexploration for neck hematoma was higher in the Vascu-Guard group; 6.12% vs. 1.03% (P = 0.1183). The incidence of perioperative ipsilateral neurologic events was 3.09% for ACUSEAL patching vs. 1.02% for Vascu-Guard patching (P = 0.368). The mean follow-up period was 15 months. The respective freedom from ≥70% carotid restenosis at 1, 2, and 3 years were 100%, 100%, and 100% for ACUSEAL patching vs. 100%, 98%, and 98% for Vascu-Guard patching (P = 0.2478). The ipsilateral stroke-free rates at 1, 2, and 3 years were 96% for ACUSEAL and 99% for Vascu-Guard patching. CONCLUSIONS Although CEA patching with ACUSEAL versus Vascu-Guard differed in hemostasis time, the frequency of reexploration for neck hematomas was more frequent in the pericardial patch group; however, only 1 patient had documented suture line bleeding and the surgical reexploration rate is not likely to be patch related. There were not any significant differences in perioperative/late neurologic events and late restenosis in the 2 groups.
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Patching plus extended exposure and tacking of the common carotid cuff may reduce the late incidence of recurrent stenosis after carotid endarterectomy. J Vasc Surg 2013; 58:926-34.e1-2. [DOI: 10.1016/j.jvs.2013.04.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 04/10/2013] [Accepted: 04/10/2013] [Indexed: 11/20/2022]
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Kim JH, Cho YP, Kwon TW, Kim H, Kim GE. Ten-year comparative analysis of bovine pericardium and autogenous vein for patch angioplasty in patients undergoing carotid endarterectomy. Ann Vasc Surg 2012; 26:353-8. [PMID: 22321487 DOI: 10.1016/j.avsg.2011.10.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 09/25/2011] [Accepted: 10/23/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND To evaluate early and late clinical outcomes of carotid endarterectomy (CEA) with bovine pericardium patch in comparison with autogenous vein. METHODS During a 10-year period, 456 CEAs were performed using patch closure of the arteriotomy with bovine pericardium (252 cases) and autogenous vein (204 cases). Retrospectively, surgical outcomes were evaluated and compared regarding CEA-related parameters, early and late mortality and morbidity rates, and the incidence of restenosis and aneurysmal dilatation between patients with bovine pericardium patch closure and those with autogenous vein closure. RESULTS The two groups were comparable regarding basic demographics, clinical data, and anatomic data, except the incidence of coronary or peripheral arterial diseases. In patients with bovine pericardium patch closure, the total operating time and carotid clamping duration were statistically significantly shorter than in those with autogenous vein closure (P < 0.01). During the early postoperative period, 10 major (stroke and death) complications (2.2%) occurred without statistically significant difference between the two groups. The incidence of early minor postoperative complications was less with bovine pericardium patch closure (5.6% vs. 10.8%; P < 0.05). With a mean follow-up of 62 months for bovine pericardium patch closure and 67 months for autogenous vein closure, the incidence of restenosis was similar, but aneurysmal dilatation was higher in patients with autogenous vein closure with a statistically significant difference (0% vs. 2.0%; P < 0.05). CONCLUSION CEA with bovine pericardium patch angioplasty showed excellent early and late clinical outcomes. Our results demonstrated bovine pericardium to be a suitable patch material for routine use in CEA.
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Affiliation(s)
- Ji-Hoon Kim
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Louagie Y, Buche M, Eucher P, Goffinet JM, Laloux P, Jamart J. Case-matched comparison of early and long-term outcomes of everted cervical vein and saphenous vein carotid patch angioplasty. Eur J Vasc Endovasc Surg 2011; 42:766-74. [PMID: 21945512 DOI: 10.1016/j.ejvs.2011.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 08/22/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To compare outcomes after carotid endarterectomy (CEA) with saphenous vein patch closure (SV), with cervical vein (external jugular and common facial) patch closure (CV). DESIGN A total of 322 cases of CEA was achieved consecutively by using venous patch angioplasty. Propensity scores were calculated followed by a one-to-one basis case-matching. MATERIALS This resulted into 90 SV and 90 CV matched cases. METHODS The primary endpoint was the incidence of ipsilateral stroke and transient ischaemic attack at any time during follow-up. RESULTS Ten-year freedom from stroke was 94.1% ± 3.5% for the SV group and 90.5% ± 4.2% for the CV group (log rank P = 0.230). Ten-year freedom from ipsilateral neurological events (stroke and transient ischaemic attack) was 93.5% ± 3.3% for SV group and 92.4% ± 3.0% for the CV group (log rank P = 0.403). Ten-year freedom from ≥75% stenosis/occlusion was 93.1 ± 4.8% for the SV group and 89.9 ± 6.0% for the CV group (log rank P = 0.481). CONCLUSIONS CV is a good alternative to SV patching, particularly when the SV needs to be preserved for further use or is unsuitable.
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Affiliation(s)
- Y Louagie
- Cardio-vascular Surgery, CHU Mont Godinne, Belgium.
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. Stroke 2011; 42:e420-63. [DOI: 10.1161/str.0b013e3182112d08] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
| | - Thomas G. Brott
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Jonathan L. Halperin
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Suhny Abbara
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - J. Michael Bacharach
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - John D. Barr
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - Christopher U. Cates
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Mark A. Creager
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Susan B. Fowler
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Gary Friday
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - E. Bruce McIff
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - Peter D. Panagos
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Thomas S. Riles
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Robert H. Rosenwasser
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Allen J. Taylor
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. Circulation 2011; 124:489-532. [DOI: 10.1161/cir.0b013e31820d8d78] [Citation(s) in RCA: 406] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas G. Brott
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Jonathan L. Halperin
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Suhny Abbara
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - J. Michael Bacharach
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - John D. Barr
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - Christopher U. Cates
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Mark A. Creager
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Susan B. Fowler
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Gary Friday
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - E. Bruce McIff
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | | | - Peter D. Panagos
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Thomas S. Riles
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Robert H. Rosenwasser
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
| | - Allen J. Taylor
- ASA Representative. ACCF/AHA Representative and ACCF/AHA Task Force on Performance Measures Liaison. SCCT Representative. SVM Representative. ACR, ASNR, and SNIS Representative. SCAI Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. AANN Representative. AAN Representative. SIR Representative. ACEP Representative. SVS Representative. AANS and CNS Representative. SAIP Representative. Former Task Force member during this writing effort
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/ SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. Vasc Med 2011; 16:35-77. [DOI: 10.1177/1358863x11399328] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ, Jacobs AK, Smith SC, Anderson JL, Adams CD, Albert N, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ohman EM, Page RL, Riegel B, Stevenson WG, Tarkington LG, Yancy CW. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary. Catheter Cardiovasc Interv 2011; 81:E76-123. [DOI: 10.1002/ccd.22983] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary. J Am Coll Cardiol 2011; 57:1002-44. [DOI: 10.1016/j.jacc.2010.11.005] [Citation(s) in RCA: 262] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. J Am Coll Cardiol 2011; 57:e16-94. [PMID: 21288679 DOI: 10.1016/j.jacc.2010.11.006] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42:e464-540. [PMID: 21282493 DOI: 10.1161/str.0b013e3182112cc2] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011; 124:e54-130. [PMID: 21282504 DOI: 10.1161/cir.0b013e31820d8c98] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
Severe asymptomatic carotid stenosis is associated with a stroke risk of approximately 2% per annum. Aggressive management of risk factors is recommended, including cessation of smoking, and treatment of hypertension, diabetes, and hypercholesterolemia. Patients should be treated with antiplatelet agents. Carotid endarterectomy (CEA) in patients with greater than or equal to 60% stenosis reduces the risk of stroke by approximately 1% per annum overall. The benefit is greatest for men and younger patients. There may be no benefit for women or for older patients. Carotid angioplasty and stenting is not recommended as an alternative to CEA until there is clinical trial evidence of efficacy in asymptomatic stenosis, except in some patients with technical contraindications to CEA. There is no evidence that patients with asymptomatic severe carotid stenosis should undergo carotid revascularization prior to other surgical procedures, including coronary bypass surgery.
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Affiliation(s)
- Brian R Chambers
- National Stroke Research Institute, Department of Medicine, University of Melbourne, Austin Health, 300 Waterdale Road, Heidelberg Heights, 3081, Victoria, Australia.
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Abstract
BACKGROUND Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke. This is an update of a Cochrane Review originally published in 1995 and previously updated in 2004. OBJECTIVES To assess the safety and efficacy of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched 5 May 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2009), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008) and Index to Scientific and Technical Proceedings (1980 to November 2008). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field. SELECTION CRITERIA Randomised and quasi-randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility, trial quality and extracted data. MAIN RESULTS We included 10 trials involving 1967 patients undergoing 2157 operations. The quality of trials was generally poor. Follow up varied from hospital discharge to five years. Carotid patch angioplasty was associated with a reduction in the risk of ipsilateral stroke during the perioperative period (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.15 to 0.63, P = 0.001) and long-term follow up (OR 0.32, 95%CI 0.16 to 0.63, P = 0.001). It was also associated with a reduced risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08 to 0.41, P < 0.0001), and decreased restenosis during long-term follow up in eight trials (OR 0.24, 95% CI 0.17 to 0.34, P < 0.00001). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow up. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long-term all-cause death rates. AUTHORS' CONCLUSIONS Limited evidence suggests that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and restenosis. It would appear to reduce the risk of ipsilateral stroke and there is a non significant trend towards a reduction in perioperative any stroke rate and all-cause case fatality.
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Affiliation(s)
- Kittipan Rerkasem
- Chiang Mai UniversityDepartment of Surgery, Faculty of MedicineChiang MaiThailand50200
| | - Peter M Rothwell
- University of OxfordStroke Prevention Research Unit, Department of Clinical NeurologyLevel 6, West Wing, John Radcliffe HospitalHeadingtonOxfordUKOX3 9DU
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Patches for carotid artery endarterectomy: current materials and prospects. J Vasc Surg 2009; 50:206-13. [PMID: 19563972 DOI: 10.1016/j.jvs.2009.01.062] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 01/25/2009] [Accepted: 01/25/2009] [Indexed: 11/20/2022]
Abstract
Patch angioplasty is commonly performed after carotid endarterectomy. Randomized prospective trials and meta-analyses have documented improved rates of perioperative and long-term stroke prevention as well as reduced rates of restenosis for patches compared with primary closure of the arteriotomy. Although use of vein patches is considered to be the gold standard for patch closure, newer generations of synthetic and biologic materials rival outcomes associated with vein patches. Future bioengineered patches are likely to optimize patch performance, both by achieving minimal stroke risk and long-term rates of restenosis as well as by minimizing the risk of unusual complications of prosthetic patches such as infection and pseudoaneurysm formation. In addition, lessons from bioengineered patches will likely enable construction of bioengineered and tissue-engineered bypass grafts.
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Miyamotto M, Del Valle CE, Moreira RCR, Timi JRR. Resistência tensional do pericárdio bovino fixado em glutaraldeído comparada com a da veia safena magna. J Vasc Bras 2009. [DOI: 10.1590/s1677-54492009000200003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
CONTEXTO: O uso do pericárdio bovino como remendo na endarterectomia de carótida é uma alternativa à veia safena magna. As vantagens do pericárdio incluem facilidade de obtenção, menor tempo operatório e principalmente menor índice de ruptura. OBJETIVO: Avaliar a resistência tensional do pericárdio bovino tratado com glutaraldeído e compará-la com a da veia safena magna. MÉTODOS: Os remendos de pericárdio bovino (grupo I, n = 20) e de veia safena magna (grupo II, n = 20) foram recortados em dimensões iguais (50 x 5 mm) e preparados de modo habitual a sua utilização. Os grupos foram submetidos a ensaio de tração e comparados em relação a força de ruptura, força máxima e tensão de ruptura utilizando-se o teste t de Student. A correlação da espessura do remendo com a força de ruptura também foi analisada utilizando-se o coeficiente de correlação linear de Pearson. RESULTADOS: Os parâmetros força de ruptura e força máxima foram significativamente maiores no grupo dos remendos de pericárdio bovino: 1,97 versus 1,36 kgf (p = 0,001230) e 2,27 versus 1,51 kgf (p = 0,0001087), respectivamente. A tensão de ruptura média para o material pericárdio bovino também foi maior (193,99±43,05 versus 49,19±22,96 kgf/cm², p = 7,603e-16) do que na veia safena. A correlação entre a espessura e a força de ruptura foi considerada moderada (r = 0,5032993) para o pericárdio bovino e baixa (r = 0,3062166) para o grupo da veia safena. CONCLUSÃO: Os autores concluem que a resistência do pericárdio bovino à ruptura foi considerada adequada neste estudo, e é significativamente maior que a da veia safena magna, retirada da região da coxa. Além disso, a espessura do remendo em ambos os grupos não apresenta boa correlação com sua resistência a ruptura.
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Affiliation(s)
- Marcio Miyamotto
- Hospital Nossa Senhora das Graças; Pontifícia Universidade Católica do Paraná
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Prosthetic carotid bypass grafts for atherosclerotic lesions: a prospective study of 198 consecutive cases. Eur J Vasc Endovasc Surg 2008; 37:272-8. [PMID: 19111479 DOI: 10.1016/j.ejvs.2008.11.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 11/16/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Carotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. The goal of this study was to determine the outcome and durability of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to CEA. METHODS This is a prospective series of 198 consecutive patients with PCB, representing 12.4% of 1595 patients with a carotid reconstruction procedure performed in our department between September 1986 and December 2006. Qualifying event was stroke in 67 patients (34%) and transient ischaemic attack (TIA) in 45 (23%), and 86 patients (43%) were asymptomatic. Primary indications for PCB were extensive atherosclerotic lesions (n=71; 36%), carotid stenosis associated with kinking (n=49; 25%), recurrent stenosis (n=47; 23%), stenosis after radiation therapy (n=18; 9%) and technical failure of CEA (n=13; 7%), with excessive arterial wall thinning and perforation after endarterectomy (n=10) or intimal flap on completion digital angiography (n=3). RESULTS The combined stroke and death rate at 30 days were 0.5% (one stroke). Median follow-up was 9.5 years (interquartile range (IQR): 6.2-18.3 years). At 10 years, primary patency was 97.9+/-3.4%. Six PCBs (3.0%) became occluded during follow-up; one patient had a restenosis greater than 50% and 18 patients (9.1%) had a restenosis of less than 50%. Five patients had an ipsilateral stroke (one postoperative stroke, one at 103 days with a patent PCB and three related to occlusion of the PCB at 4, 13 and 15 years after the procedure). At 10 years, cumulative stroke-free survival was 98.4+/-3.2%, and cumulative survival was 78.8+/-7.0%. CONCLUSIONS PCB is a safe surgical alternative and is durable, with a low incidence of graft restenosis, when CEA seems hazardous.
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Her K, Choi C, Park Y, Shin H, Won Y. Concomitant peripheral artery disease and asymptomatic coronary artery disease: a management strategy. Ann Vasc Surg 2008; 22:649-56. [PMID: 18504099 DOI: 10.1016/j.avsg.2008.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Accepted: 01/14/2008] [Indexed: 11/28/2022]
Abstract
The present study examines the use of routine coronary angiography (CAG) before elective peripheral artery disease (PAD) surgery and the early outcome and technical features of simultaneous coronary revascularization and PAD surgery in PAD patients with asymptomatic coronary artery disease (CAD). We performed preoperative CAG in 82 patients who were undergoing elective peripheral arterial bypass surgery and who had no diagnosis or symptoms of ischemic heart disease. The 82 patients were grouped according to the criteria of <70% stenosis, >70% stenosis, and no coronary stenosis. In patients with >70% coronary artery stenosis, we performed simultaneous peripheral artery bypass surgery and coronary artery bypass grafting (CABG), while the other patients underwent peripheral artery bypass only. Preoperative coronary angiography revealed CAD in 69.5% (n = 57) of patients. Patients with CAD were more likely to be older, hypertensive, and diabetic than patients without CAD (all p < 0.05). Preoperative electrocardiography showed that only 3/57 (5.3%) patients with CAD had ischemic heart disease. Of the 61 patients who underwent peripheral artery bypass, 27 (47.4%) underwent simultaneous CABG. Of the patients with CAD, 78.9% (45/57) required peripheral artery bypass, whereas 64.0% (16/25) of patients without CAD required peripheral artery bypass (p = 0.11). Comparing simultaneous CABG and peripheral artery bypass in PAD patients with CAD and isolated peripheral artery bypass in PAD patients regardless of CAD, the only significant difference was in operating time (362.00 +/- 79.18 vs. 246.55 +/- 79.15 min, p = 0.00). When compared with PAD patients with CAD who underwent isolated peripheral artery bypass, the results were similar. Two patients who had CAD and underwent isolated peripheral artery bypass died (p = 0.16). Patients with peripheral arterial obstructive disease should be examined for CAD using CAG, regardless of whether they have symptomatic ischemic heart disease, and simultaneous CABG and peripheral artery bypass is safe and feasible.
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Affiliation(s)
- Keun Her
- Department of Thoracic and Cardiovascular Surgery, Armed Force Capital Hospital, Gyeonggi-do, Republic of Korea
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Abeysekara AMS, Siriwardana HPP, Prabaharan B, Tiwari A, Madipolagedara N, Jacob S. COMMON FACIAL VEIN: AN ALTERNATIVE PATCH MATERIAL IN CAROTID ANGIOPLASTY. ANZ J Surg 2008; 78:185-8. [PMID: 18269485 DOI: 10.1111/j.1445-2197.2007.04399.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cerebrovascular Disease. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Eskandari MK. Carotid endarterectomy for stroke prevention revisited. Expert Rev Neurother 2007; 7:935-8. [PMID: 17678487 DOI: 10.1586/14737175.7.8.935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since its original description, more than 50 years ago, carotid endarterectomy (CEA) has been challenged in its success in achieving adequate stroke prevention among both symptomatic and asymptomatic patients with cervical carotid stenosis. CEA remains the most common vascular surgical operation performed today, however, its future has been called into question with the introduction of percutaneous carotid angioplasty and stenting, more effective antiplatelet agents (i.e., clopidogrel), cholesterol-lowering agents (i.e., statins) and angiotensin-converting enzyme inhibitors. The focus of this article is to review the notable trials substantiating the efficacy of CEA, indications for surgery and technical components that have refined expected favorable outcomes.
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Affiliation(s)
- Mark K Eskandari
- Northwestern Memorial Hospital, Division of Vascular Surgery, Galter Pavilion, Chicago, IL 60613, USA.
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Kim DI, Moon JY, Lee CH, Kim DY, Jang YS, Kim GM, Chung CS, Lee KH, Kim SW. Primary Closure After a Carotid Endarterectomy. Surg Today 2007; 37:187-91. [PMID: 17342354 DOI: 10.1007/s00595-006-3385-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 08/17/2006] [Indexed: 10/23/2022]
Abstract
PURPOSE The prevalences of restenosis and stroke after a carotid endarterectomy (CEA) tend to differ substantially according to the surgeon. Primary closure after a CEA was the routine procedure in our institute. The primary objectives of this study were to compare the results of patients of a primary arteriotomy closure in CEA between our own and others' results based on the findings in the literature. METHODS One hundred and sixty-six patients who underwent a primary closure were analyzed. Perioperative neurologic deficits were determined by the neurologist. Restenosis was defined as >50% stenosis on duplex scan. The range of follow-up was 7-112 months. RESULTS Stroke including transient ischemic attack occurred within 30 postoperative days in 3 patients and after 30 postoperative days in 1 of the 166 patients. Five patients showed >50% asymptomatic restenosis. Two patients were treated with stent insertion and one underwent reoperation. One patient showed total occlusion during the follow-up period without any neurological deficits. One patient showed 50%-70% stenosis, and no intervention was done. CONCLUSIONS The rates of recurrent stenosis and postoperative stroke were found to be sufficiently low following a primary closure to justify the continued use of this technique.
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Affiliation(s)
- Dong-Ik Kim
- Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwondong, Kangnamku, Seoul 135-710, South Korea
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Hertzer NR, Mascha EJ. A personal experience with coronary artery bypass grafting, carotid patching, and other factors influencing the outcome of carotid endarterectomy. J Vasc Surg 2006; 43:959-968. [PMID: 16678690 DOI: 10.1016/j.jvs.2005.12.060] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Accepted: 12/22/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study was conducted to investigate the influence of coronary artery bypass grafting (CABG), carotid patching, and other factors on the outcome of all carotid endarterectomies (CEAs) performed by a single surgeon at a tertiary referral center. METHODS The series includes 2262 CEAs (335 bilateral) in 1521 men and 741 women (33%) with median ages of 66 and 68 years, respectively. Surgical indications were asymptomatic stenosis for 1503 procedures (66%), retinal ischemia or cerebral transient ischemic attacks each for 271 (12%), and prior stroke for 217 (9.6%). CEA was done as an isolated operation in 1959 patients and was performed in conjunction with simultaneous CABG in 303 (13%). Primary arteriotomy closure was used for 783 CEAs (35%), vein patching for 1232 (54%), and synthetic patching for 247 (11%). Outcome event rates were assessed by logistic regression analysis, proportional hazards models, and Kaplan-Meier estimations. RESULTS Postoperative mortality (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.7 to 7.5; P = .001), stroke (OR, 3.2; 95% CI, 1.6 to 6.4; P = .001), and combined stroke and mortality rates (OR, 3.4; 95% CI, 2.0 to 5.8; P < .001) were significantly higher for simultaneous CEA/CABG than for isolated CEA. Ipsilateral postoperative stroke rates were similar (2.6% vs 1.7%, P = .41) in both settings. Vein patching had a lower risk for ipsilateral stroke (OR, 0.42; 95% CI, 0.21 to 0.86; P = .015) than primary closure, but was not significantly different from synthetic patching (P = .10). The documented incidence of postoperative carotid thrombosis was 1.5% with primary closure, 0.6% with vein patching, and 2.0% with synthetic patching (P = .088). Overall Kaplan-Meier survival was 92% at 1 year, 71% at 5 years, 41% at 10 years, and 20% at 15 years, but long-term mortality rates were higher after simultaneous CEA/CABG (hazard ratio, 1.3; 95% CI, 1.1 to 1.5; P = .002) than after CEA alone. Late strokes or retinal infarctions have been reported after 97 (5.0%) of the 1923 operations for which follow-up was available, 51 (2.3%) of which were ipsilateral to CEA. The incidence of > or = 60% recurrent stenosis was independently influenced by carotid patching (OR, 0.61; 95% CI, 0.40 to 0.92; P = .019) but not by the choice of patch material (P = .11). CONCLUSIONS These results substantiate the common observation that patients who require simultaneous CEA/CABG have a higher risk for adverse outcomes than patients who undergo isolated CEA. Carotid patching provided significant benefit with respect to the risks for ipsilateral postoperative stroke and > or = 60% recurrent stenosis.
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Affiliation(s)
- Norman R Hertzer
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Hobson RW. Cerebrovascular Disease: Carotid Endarterectomy. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50039-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Shah DM, Darling RC, Chang BB, Paty PS, Kreienberg PB, Roddy SP, Ozsvath KJ, Mehta M. Analysis of factors contributing to improved outcome for carotid endarterectomy. Semin Vasc Surg 2004. [DOI: 10.1053/j.semvascsurg.2004.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ballotta E, Da Giau G, Piccoli A, Baracchini C. Durability of carotid endarterectomy for treatment of symptomatic and asymptomatic stenoses. J Vasc Surg 2004; 40:270-8. [PMID: 15297820 DOI: 10.1016/j.jvs.2004.04.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Although many studies have well established that carotid endarterectomy (CEA) is beneficial in selected patients with severe carotid disease, only a few large studies have focused on the durability of the surgical procedure. Carotid artery angioplasty and stenting (CAS) has recently been proposed as a potential alternative to CEA. We analyzed the incidence of late occlusion and recurrent stenosis after CEA. METHODS Over 13 years 1000 patients underwent 1150 CEA procedures to treat symptomatic and asymptomatic high-grade carotid stenosis. CEA procedures involving either traditional CEA with patching (n = 302) or eversion CEA (n = 848) were all performed by the same surgeon, with patients under deep general anesthesia and cerebral protection involving continuous electroencephalographic monitoring for selective shunting. All patients underwent postoperative duplex ultrasound scanning and clinical follow-up at 1, 6, and 12 months, and yearly thereafter. New neurologic events, late occlusions, and recurrent stenoses 50% or greater were recorded. Complete follow-up (mean, 6.2 years; range, 6-156 months) was obtained in 95% of patients (949 of 1000), for an overall average of 95% of procedures (1092 of 1150). Survival analysis was performed with the Kaplan-Meier life table method. RESULTS Perioperative (30-day) mortality rate was 0.3% (3 of 1000), and stroke rate was 0.9% (11 of 1150), with a combined mortality and stroke rate of 1.2%. The incidence of late occlusion and recurrent stenosis 70% or greater was 0.6% and 0.5%, respectively, with a combined occlusion and restenosis rate of 1.1%. Kaplan-Meier analysis showed that the rate of freedom from occlusion, restenosis 70% or greater, and combined occlusion and restenosis 70% or greater at 12 years was 99,4%, 99.5%, and 98.8%, respectively. Occlusion and restenosis developed asymptomatically. CONCLUSIONS CEA is a low-risk procedure for treating severe symptomatic and asymptomatic carotid disease, with excellent long-term durability. Proponents of CAS should bear this in mind before considering CAS as a routine alternative to CEA.
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Affiliation(s)
- Enzo Ballotta
- Vascular Surgery Section, Department of Surgical and Gastroenterological Sciences, Department of Medical and Surgical Sciences, Padua, Italy.
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Bond R, Rerkasem K, AbuRahma AF, Naylor AR, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev 2004:CD000160. [PMID: 15106145 DOI: 10.1002/14651858.cd000160.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke. OBJECTIVES The objective of this review was to assess the safety and efficacy of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched November 2002). In addition, we searched the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to December 2001), EMBASE (1980 to December 2001) and Index to Scientific and Technical Proceedings (1980 to 2001). We also handsearched eight journals and five conference proceedings. Reference lists were checked and we contacted experts in the field to identify further published and unpublished studies. SELECTION CRITERIA Randomised and quasi-randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed eligibility, trial quality and extracted the data. MAIN RESULTS The previous review included six trials involving 794 patients undergoing 882 operations. Since the last review only one study of adequate quality to be included has been reported. This added 399 operations randomised to either primary closure, vein patch or synthetic patch groups resulting in 1127 patients undergoing 1307 operations being available for analysis. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Carotid patch angioplasty was associated with a reduction in the risk of stroke of any type (OR = 0.33, p = 0.004), ipsilateral stroke (OR = 0.31, p = 0.0008), and stroke or death, during the perioperative period (OR = 0.39, p = 0.007) and long term follow-up (OR = 0.59, p = 0.004). It was also associated with a reduced risk of perioperative arterial occlusion (odds ratio 0.15, 95% confidence interval 0.06 to 0.37 p = 0.00004), and decreased restenosis during long-term follow-up in five trials, (odds ratio 0.20, 95% confidence interval 0.13 to 0.29 p < 0.00001). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow-up. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long-term all-cause death rates REVIEWERS' CONCLUSIONS Limited evidence suggests that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and restenosis. It would appear to reduce the risk of combined death or stroke and there is a non significant trend towards a reduction in all-cause mortality.
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Affiliation(s)
- R Bond
- Stroke Prevention Research Unit, Gibson Building, Radcliffe Infirmary, Woodstock Road, Oxford, OXON, UK, OX2 6HE
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Camiade C, Maher A, Ricco JB, Roumy J, Febrer G, Marchand C, Neau JP. Carotid bypass with polytetrafluoroethylene grafts: a study of 110 consecutive patients. J Vasc Surg 2003; 38:1031-7; discussion 1038. [PMID: 14603212 DOI: 10.1016/s0741-5214(03)00708-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. We describe the technique and outcome of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an elective alternative to CEA. PATIENTS AND METHODS This retrospective analysis of prospectively collected data came from a series of 110 consecutive PCBs, that is, 9.6% of 1140 carotid revascularization procedures performed in our department between September 1986 and July 2002. Primary indications for PCB were extensive atherosclerotic lesions (n = 45, 40.9%), carotid stenosis associated with kinking (n = 29, 26.4%), recurrent stenosis (n = 18, 16.4%), and stenosis after radiation therapy (n = 7, 6.4%). RESULTS The combined stroke and death rate at 30 days was 0.9%. Mean duration of follow-up was 647 +/- 71 days. Four carotid bypass grafts (3.6%) became occluded, and stenosis recurred in 1 (0.9%). At 3 years, overall actuarial survival was 81.4 +/- 11.5 and actuarial stroke-free rate was 97.7 +/- 2.3. There were no fatal strokes. CONCLUSION PCB is a viable technique for treatment of extensive atherosclerotic carotid lesions, recurrent carotid stenosis, and carotid stenosis after radiation therapy. Postoperative stroke, occlusion, and recurrent stenosis rates are comparable to those associated with CEA performed under optimal conditions.
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Affiliation(s)
- Christophe Camiade
- Vascular Surgery Department, Jean Bernard University Hospital, Poitiers, France
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Grego F, Antonello M, Lepidi S, Bonvini S, Deriu GP. Prospective, randomized study of external jugular vein patch versus polytetrafluoroethylene patch during carotid endarterectomy: perioperative and long-term results. J Vasc Surg 2003; 38:1232-40. [PMID: 14681620 DOI: 10.1016/s0741-5214(03)00912-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the relative risks and advantages of using external jugular vein (EJV) patch, compared with polytetrafluoroethylene (PTFE) patch, during carotid endarterectomy. The primary end point was the relevant neurologic complication rate (RNCR; fatal or disabling stroke) at any time during follow-up. Secondary end points included stroke-free survival, 30-day and long-term mortality, recurrent stenosis rate (> or =50%), occlusion, patch infection, aneurysm formation, and other local complications. METHODS The study, a prospective randomized clinical trial carried out at a single center, was divided into two 3-year phases: December 1996 to March 1999, when patients were enrolled, and March 1999 to March 2002, which was the follow-up period. Inclusion criteria included an external jugular vein suitable for patching, defined as vein diameter 3 mm or larger and absence of collateral vessels noted on preoperative color duplex ultrasound scans. Patients were prospectively randomized 1:1 to receive either the EJV (n = 80; group A) or synthetic (n = 80; group B) patch. RESULTS Carotid endarterectomy and patching was performed by one surgeon. At 30 months the RNCR-free rate, analyzed with the Kaplan-Meier method, was 98.7% for group A (1 ipsilateral lethal stroke) and 94.6% for group B (4 ipsilateral disabling strokes), and remained stable to 60 months. No statistical difference was observed with the log-rank test. Stroke-free survival rate was 100% for group A and 98.7% for group B at 1 year, 98.7% for group A and 93.6% for group B (1 ipsilateral minor stroke) at 30 months, and was unchanged at 60 months. Life table analysis demonstrated freedom from significant recurrent stenosis (> or =50%) of 97.5% for both groups at 6 months, 93.6% for group A and 92.2% for group B at 30 months, and 90.2% for group A and 86.7% for group B at 60 months. No statistical difference was observed with the log-rank test. In no patients was recurrent stenosis greater than 70%. No aneurysm formation was noted during follow-up. CONCLUSIONS We can conclude, with the power limitation of the study, that carotid endarterectomy can be safely performed with either the EJV or PTFE patch. Advantages of the EJV for carotid angioplasty include no cost for material, low risk for graft infection, and preservation of the saphenous vein.
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Affiliation(s)
- Franco Grego
- Division of Vascular Surgery, Department of Medical and Surgical Sciences, University of Padua, Via Giustiniani 2, Padua 35125, Italy.
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Abstract
Background and Purpose—
We sought to determine the incidence of recurrent stenosis after carotid endarterectomy.
Methods—
One thousand consecutive carotid endarterectomy patients were followed prospectively. The surgery was performed in a standard fashion. Cerebral protection was provided with intraoperative electroencephalographic monitoring and selective shunting. All arteriotomies were repaired with a patch graft. Each patient was seen 3 months after surgery and then yearly, with a duplex ultrasound obtained at each visit. Evidence for new ischemic events or recurrent stenosis of ≥70% was recorded.
Results—
The 30-day combined minor and major stroke and death rate was 1.9%. At 7.1-year follow-up, 0.1% of patients had recurrent stenosis ≥70%, the majority of which were asymptomatic.
Conclusions—
Carotid endarterectomy is a low-risk procedure for the treatment of carotid occlusive disease, with excellent long-term durability. Although less invasive, carotid angioplasty must demonstrate equal robustness in long-term follow-up before it is considered a routine alternative to surgery.
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Affiliation(s)
- Robert D Ecker
- Department of Neurosurgery, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Borazjani BH, Wilson SE, Fujitani RM, Gordon I, Mueller M, Williams RA. Postoperative complications of carotid patching: pseudoaneurysm and infection. Ann Vasc Surg 2003; 17:156-61. [PMID: 12616349 DOI: 10.1007/s10016-001-0400-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Patch angioplasty after carotid endarterectomy has been advocated to improve results by decreasing the incidence of recurrent stenosis and postoperative carotid thrombosis. Aneurysmal and infectious complications may be secondary to use of prosthetic materials in arterial reconstruction. We report four patients who developed late operative site complications related to carotid patching. All four of our patients had delayed pseudoaneurysms and three had infection related to the Dacron patch. In a typical case, a 57-year-old who had a right carotid endarterectomy in 1994 presented with a 1-month history of an enlarging right neck mass 7 years later. Imaging revealed a 6 x 4 cm pseudoaneurysm originating from an opening between the patch graft and the old endarterectomized carotid wall. Analysis of the literature disclosed an additional 45 patients who had pseudoaneurysms and/or infection related to carotid patching, most frequently with Dacron. We postulate that a low-grade Staphylococcus epidermidis infection of the foreign body patch may be the etiology. Autogenous saphenous vein interposition graft and antimicrobials effective against gram-positive organisms corrected the pseudoaneurysm. Although the benefits of routine carotid patching may include a decrease in restenosis, this advantage must be weighed against the risk of late pseudoaneurysm and/or infection when a prosthetic patch is used to closed the endarterectomy site.
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Affiliation(s)
- Boris H Borazjani
- Department of Surgery, University of California, San Diego, CA , USA
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Moneta GL, Foley MI, Giswold ME, Musicant SE. Vascular surgery for peripheral arterial disease. CLINICAL CORNERSTONE 2003; 4:41-55. [PMID: 12425183 DOI: 10.1016/s1098-3597(02)90015-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The North American Symptomatic Carotid Endarterectomy Trial (NASCET) confirmed that carotid endarterectomy (CEA) can significantly cut the risk of stroke in patients with moderate and severe blockage. The standard today is that patients who have internal carotid artery stenosis > 70% with associated symptoms and who are appropriate surgical candidates should be offered CEA. Aneurysmal disease, a growing public health concern, poses the threat of death from rupture, and lower extremity arterial occlusive disease poses a significant risk of critical leg ischemia and limb loss. Both conditions involve surgical options. In treating their patients, primary care physicians should become familiar with the benefits and risks of vascular surgery to manage the various aspects of peripheral arterial disease.
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Affiliation(s)
- Gregory L Moneta
- Division of Vascular Surgery, Oregon Health & Science University, Portland, Oregon, USA.
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O'Hara PJ, Hertzer NR, Mascha EJ, Krajewski LP, Clair DG, Ouriel K. A prospective, randomized study of saphenous vein patching versus synthetic patching during carotid endarterectomy. J Vasc Surg 2002; 35:324-32. [PMID: 11854731 DOI: 10.1067/mva.2002.120047] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was the determination of whether the choice of either autogenous saphenous vein (ASV) or synthetic material for patch angioplasty significantly influences the results after carotid endarterectomy (CEA). METHODS With Institutional Review Board approval, 195 patients (145 men and 50 women; mean age, 69 years) who underwent 207 CEAs were prospectively randomized to arteriotomy closure with ASV or synthetic patches from July 1996 to January 2000. One hundred and one patients (52%) were randomized to the ASV cohort, and 94 (48%) were randomized to the synthetic cohort. Aside from a slight gender imbalance (70% versus 79% male in the ASV versus the synthetic group), there were no clinically important differences in baseline demographic variables, risk factors, or surgical indications between the ASV and synthetic groups. RESULTS With all 207 randomized procedures on an intent-to-treat basis, there were two early (<30 days) postoperative deaths (1%). There were three perioperative strokes in the ASV cohort (3.0%) and two in the synthetic cohort (2.1%; P =.99). Two of these early strokes occurred in a subset of nine patients who received neither patch material, all after randomization but before CEA. Two patients in each group had late strokes. The cumulative freedom from stroke rate at 1 year (ASV, 94%; synthetic, 95%) was virtually identical for both cohorts. With the 125 patients who had at least one postoperative duplex scan, the incidence rate of recurrent (>or=60%) carotid stenosis was 4.8% (three of 62) for the ASV group and 6.3% (four of 63) for the synthetic group (P =.99). CONCLUSION No significant differences in the stroke, mortality, or restenosis rates were shown between the ASV and the synthetic cohorts. While conceding the power limitations inherent in this study, we conclude that CEA may be safely performed with similar early results with ASV or synthetic patches.
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Affiliation(s)
- Patrick J O'Hara
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA.
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Archie JP. Long-term geometric stability of saphenous vein patched carotid endarterectomy. J Vasc Surg 2002; 35:131-6. [PMID: 11802144 DOI: 10.1067/mva.2002.119036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE This study was designed to determine whether there is a generalized trend of progressive enlargement of the common and internal carotid bulbs after carotid endarterectomy (CEA) reconstruction with saphenous vein patches. METHODS Twenty-nine autologous greater saphenous vein-patched CEAs performed between 1983 and 1994 were examined with five to nine sequential duplex scans each that included B-mode measurements of both the common carotid bulb (CCB) and internal carotid bulb (ICB) diameters. A total of 186 scans of each of the two segments were performed from 2 to 182 months after CEA (mean, 64 months). The time from the first to the last scan ranged from 30 to 120 months (mean, 76 months). Repeated measures analysis of variance was used as a means of testing the relationship of CCB and ICB diameters with time from CEA and with time from the first scan. Simple linear regression was used as a means of analyzing the variability of individual CCB and ICB diameters and pooled normalized diameters in both time frames. RESULTS The CCB diameters ranged from 8.4 to 18.5 mm (mean, 13.1 mm), and the ICB diameters ranged from 6.4 to 16.0 mm (mean, 11.2 mm). No significant relationship between both CCB and ICB diameters in the time from CEA or the time from the first scan (P =.643 to.913), for sex (P =.403 to.917), or for early and late post-CEA time of study onset (P =.135 to.773) was shown by means of repeated measures analysis. Low R(2) values (CCB mean, 0.17; ICB mean, 0.21) and non-significant P values for regression slope (CCB mean, 0.46; ICB mean, 0.54) were given by means of individual regression analysis. There was no correlation between individual regression coefficients and the mean diameters of the arteries. The mean change in CCB diameter was 0.023 mm/year (range, -0.37 to 0.30 mm/year), and the mean change in ICB diameter was -0.030 mm/year (range, -0.33 to 0.37 mm/year). Regression of normalized CCB and ICB diameters versus time gave R(2) values less than 0.02 and slopes not statistically significantly different from zero. The predicted 10-year average percent change in normalized diameters ranged from 0.8% to 3.3%. CONCLUSION In a 15-year period after CEA and a 10-year sequential B-mode scan study period, there was no evidence of significant enlargement of saphenous vein-patched CEAs. This is also true for CEAs in men and women and for subsets with larger and smaller CCB and ICB diameters and early and late scan onset times. Dilatation after saphenous vein patching is most likely a rare isolated event and not the result of generalized or frequent progressive enlargement.
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Affiliation(s)
- Joseph P Archie
- Carolina Cardiovascular Surgical Associates, PA, 3000 New Bern Ave., Suite 3100, Raleigh, NC 27610, USA
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