Carotid stenting versus endarterectomy

Perioperative Blood Pressure Control in Carotid Artery Stenosis Patients With Carotid Angioplasty Stenting: A Retrospective Analysis of 173 Cases

Background: Carotid angioplasty stenting (CAS) is a currently widely used surgical treatment of carotid artery stenosis. However, the influences of the perioperative blood pressure (BP) on patients' prognosis remain unclear.

Objective: The present study was designed to explore the effects of different perioperative BP control strategies on CAS patients' prognosis.

Methods: One hundred seventy-three consecutive patients admitted between January 2016 and April 2019 were reviewed retrospectively. The outcomes of patients with different systolic BP (<120, 120–130, and >130 mmHg) before CAS and within 24 h after CAS were compared. The primary outcomes were the incidence of secondary cerebral infarction (CI) and intracranial hemorrhage (ICH) after CAS. The secondary outcome was the incidence of unfavorable discharge and in-hospital death. The unfavorable discharge was defined as modified Rankin Scale (mRS) score 3–5 at discharge.

Results: There was no significant difference between the incidences of ICH (P = 0.803) and CI (P = 0.410) in patients with different BP before CAS. The patients with post-CAS BP values of >130 mmHg had a 37.67-fold increased risk (95% CI: 6.79–209.01) of ICH compared with others, while no significant difference was observed on the incidence of CI (P = 0.174) among patients with different post-CAS BP values. The patients with post-CAS BP values of >130 mmHg also had a significantly higher incidence of unfavorable discharge (P = 0.002) and in-hospital death (P = 0.001) compared with others.

Conclusion: High BP (>130 mmHg) within 24 h after CAS significantly increases the risks of secondary cerebral hemorrhage, unfavorable discharge, and in-hospital death. Thus, the BP should be controlled below 130 mmHg in the first 24 h after CAS.

A New Concept for Carotid Artery Stenting: Coating the Atherosclerotic Plaque by Covered Stent before Bare Stent Implantation

In carotid artery stenting (CAS) procedures, distal embolism, periprocedural stent thrombosis, and 30-day stroke due to the plaque fragmentation and protrusion caused by stent implantation and balloon dilation are frequent complications. In this technical case report, a case is presented of extracranial carotid artery stenosis treated with a covered stent and subsequent implantation of a bare stent. In addition, the possibility is discussed that this new technique prevents the distal microembolic complications, periprocedural stent thrombosis, and 30-day stroke of extracranial CAS.

Anesthetic management of endovascular procedures for cerebrovascular atherosclerosis

PURPOSE OF REVIEW

The article reviews the treatment options for cerebrovascular atherosclerosis and highlights the challenges of anesthesia in this complex group of patients.

RECENT FINDINGS

Percutaneous transluminal angioplasty and stenting is a treatment option for cerebrovascular atherosclerosis in patients at high risk of stroke despite maximal medical therapy and control of risk factors. The majority of carotid lesions are treated using regional anesthesia, but general anesthesia is currently the technique of choice for intracranial lesions because of the length of the procedures and the need for immobility. There is no evidence to guide optimal anesthetic management in this group of patients in whom significant comorbidities are common. The risks of myocardial ischemia, cardiovascular instability and cerebral ischemia and hyperperfusion are high, and anesthesia management should be directed towards their prevention, recognition and treatment.

SUMMARY

The anesthetist plays a key role in the endovascular management of patients with cerebrovascular atherosclerosis. Optimization of comorbidities, meticulous control of systemic physiologic variables and aggressive management of complications contribute to enhanced patient outcome.