Medical complications associated with carotid endarterectomy. North American Symptomatic Carotid Endarterectomy Trial (NASCET)

Investigating the potential of catheter-assisted pulsed focused ultrasound ablation for atherosclerotic plaques

BACKGROUND

Atherosclerosis is a condition in which an adhesive substance called plaque accumulates over time inside the arteries. Plaque buildup results in the constriction of arteries, causing a shortage of blood supply to tissues and organs. Removing atherosclerotic plaques controls the development of acute ischemic stroke and heart diseases. It remains imperative for positive patient outcomes.

PURPOSE

This study sought to develop a minimally invasive technique for removing arterial plaques by applying focused ultrasound (FUS) energy on the metal surface of a nitinol catheter wire to induce inertial cavitation. The induced cavitation can deplete plaque mechanically inside the arteries, leading towards improved recanalization of blood vessels.

METHODS

The enhanced cavitation effect induced by combining FUS with a metal catheter was first verified by exposing agar phantom gels with or without a 0.9-mm diameter nitinol wire to an acoustic field produced by a 0.5-MHz FUS transducer. The phenomenon was further confirmed in pork belly fat samples with or without a 3-mm diameter nitinol catheter wire. Cavitation was monitored by detecting the peaks of emitted ultrasound signals from the samples using a passive cavitation detector (PCD). Cavitation threshold values were determined by observing the jump in the peak amplitude of signals received by the PCD when the applied FUS peak negative pressure (PNP) increased. To simulate arterial plaque removal, FUS with or without a catheter was used to remove tissues from pork belly fat samples and the lipid cores of human atherosclerotic plaque samples using 2500-cycle FUS bursts at 10% duty cycle and a burst repetition rate of 20 Hz. Treatment outcomes were quantified by subtracting the weight of samples before treatment from the weight of samples after treatment. All measurements were repeated 5 times (n = 5) unless otherwise indicated, and paired t-tests were used to compare the means of two groups. A p-value of <0.05 will be considered significant.

RESULTS

Our results showed that with a nitinol wire, the cavitation threshold in agar phantoms was reduced to 2.6 MPa from 4.3 MPa PNP when there was no nitinol wire in the focal region of FUS. For pork belly fat samples, cavitation threshold values were 1.0 and 2.0 MPa PNP, with and without a catheter wire, respectively. Pork belly fat tissues and lipid cores of atherosclerotic plaques were depleted at the interface between a catheter and the samples at 2 and 4 MPa FUS PNP, respectively. The results showed that with a catheter wire in the focal region of a 3-min FUS treatment session, 24.7 and 25.6 mg of lipid tissues were removed from pork belly fat and human atherosclerotic samples, respectively. In contrast, the FUS-only group showed no reduction in sample weight. The differences between FUS-only and FUS-plus-catheter groups were statistically significant (p < 0.001 for the treatment on pork belly samples, and p < 0.01 for the treatment on human atherosclerotic samples).

CONCLUSION

This study demonstrated the feasibility of catheter-assisted FUS therapy for removing atherosclerotic plaques.

Is a one percent occurrence of high-dose patients significant?

Risk-free society is utopian. We come across risks in everyday life, and we use probabilities to get a feel of how risky a situation is. Risk probability numbers of around 1% are comforting, but an intercomparison of numbers among various low risks in popular situations can be enlightening. In this article, we compare risks of complications or death in several surgeries and risks in commercial air travel with risks for patients getting cumulative effective dose (CED) of 100 mSv or more, as the latter is a hot and controversial topic currently. The analysis shows that many common surgeries are a few tens or hundreds of times less risky than the risk from a 100 mSv dose, even though the former often frightens us more. Despite there being a much higher chance of developing cancer from radiation than being involved in a commercial plane accident, there is much less emphasis on patient radiation safety than aviation safety. Further, a look at the system of control on prescription drugs indicates that there is much to learn for policy planning. This analysis may help the International Commission on Radiological Protection (ICRP) in their review of recommendations.

One month follow-up of carotid endarterectomy with in-hospital preoperative aspirin monotherapy and postoperative dual antiplatelet therapy in asymptomatic and symptomatic patients: A multi-center study

Background

There is currently no consensus regarding the optimal perioperative antiplatelet strategy for carotid artery surgery. This multicentre study aimed to analyse the association between preoperative aspirin monotherapy following postoperative dual antiplatelet therapy (DAPT) and the risk for stroke and death after carotid endarterectomy (CEA).

Methods

This cohort study included 821 patients with carotid artery stenosis who underwent CEA. Primary outcomes included any stroke or death up to the one-month postoperative follow-up. Multilevel multivariate regression analyses and descriptive statistics were performed.

Results

Patients were predominantly male (53 %), with a mean age of 66.2 years. The primary outcome occurred in 1.6 % of patients. Univariate and multivariate analyses revealed that patients with chronic obstructive pulmonary disease (COPD) exhibited a high risk for stroke or death (P = 0.011). The occurrence of any local complications in the neck was accompanied by an increase in diastolic blood pressure (DBP) (P = 0.007). Patients with a high systolic blood pressure (SBP) (P = 0.002) experienced a longer operative duration. The length of hospital stay was longer in the patients with COPD (P = 0.020), minor stroke (P = 0.011), and major stroke (P = 0.001). A positive linear correlation was found between SBP and operative duration in the overall population (β 0.4 [95 % confidence interval (CI) 0.1-0.7]; P = 0.002). The resultant curve for DBP and any local complications in the neck exhibited a two-stage change and one breakpoint in the entire population (k = 68 mmHg, <68; odds ratio [OR] 0.9 [95 % CI 0.7-1.1], P = 0.461; ≥68: OR 1.1 [95 % CI 1.0-1.1], P = 0.003).

Conclusions

Preoperative aspirin monotherapy and postoperative DAPT were safe and effective antiplatelet treatments for patients who underwent CEA.

Long non-coding RNA RMST serves as a diagnostic biomarker in patients with carotid artery stenosis and predicts the occurrence of cerebral ischemic event: A retrospective study

OBJECTIVES

The purpose of this retrospective study is to explore the diagnostic and prognostic roles of serum RMST in carotid artery stenosis (CAS).

METHODS

Serum levels of RMST were detected in CAS patients, and the relationship between degree of carotid stenosis and RMST levels was analyzed. The ROC curve was drawn to evaluate RMST value in predicting the risk of CAS. Then, all CAS patients received a 5-year follow-up. K-M curve was used to analyze the significance of RMST on prognosis of CAS patients. Multi-factor cox logistic regression analysis was conducted to evaluate independent factors for outcome of CAS patients.

RESULTS

An increased RMST expression was certified in CAS patients when compared with healthy controls. The increase of serum RMST expression was related to high degree of carotid stenosis. In addition, serum RMST was a possible diagnosis and an independent influencing factor of prognosis in patients with CAS.

CONCLUSIONS

Raised serum RMST level was found in patients with CAS. Detecting RMST expression levels was of high value for predicting the occurrence and outcomes in CAS.

Sex differences in outcome after carotid revascularization in symptomatic and asymptomatic carotid artery stenosis

OBJECTIVE

Sex differences regarding the safety and efficacy of carotid revascularization in carotid artery stenosis have been addressed in several studies with conflicting results. Moreover, women are underrepresented in clinical trials, leading to limited conclusions regarding the safety and efficacy of acute stroke treatments.

METHODS

A systematic review and meta-analysis was performed by literature search including four databases from January 1985 to December 2021. Sex differences in the efficacy and safety of revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), for symptomatic and asymptomatic carotid artery stenoses were analyzed.

RESULTS

Regarding CEA in symptomatic carotid artery stenosis, the stroke risk in men (3.6%) and women (3.9%) based on 99,495 patients (30 studies) did not differ (P = .16). There was also no difference in the stroke risk by different time frames up to 10 years. Compared with men, women treated with CEA had a significantly higher stroke or death rate at 4 months (2 studies, 2565 patients; 7.2% vs 5.0%; odds ratio [OR], 1.49; 95% confidence interval [CI], 1.04-2.12; I2 = 0%; P = .03), and a significantly higher rate of restenosis (1 study, 615; 17.2% vs 6.7%; OR, 2.81; 95% CI, 1.66-4.75; P = .0001). For CAS in symptomatic artery stenosis, data showed a non-significant tendency toward higher peri-procedural stroke in women, whereas for asymptomatic carotid artery stenosis, data based on 332,344 patients showed that women (compared with men) after CEA had similar rates of stroke, stroke or death, and the composite outcome stroke/death/myocardial infarction. The rate of restenosis at 1 year was significantly higher in women compared with men (1 study, 372 patients; 10.8% vs 3.2%; OR, 3.71; 95% CI, 1.49-9.2; P = .005). Furthermore, CAS in asymptomatic patients was associated with low risk of a postprocedural stroke in both sexes, but a significantly higher risk of in-hospital myocardial infarction in women than men (8445 patients, 1.2% vs 0.6%; OR, 2.01; 95% CI, 1.23-3.28; I2 = 0%; P = .005).

CONCLUSIONS

A few sex-differences in short-term outcomes after carotid revascularization for symptomatic and asymptomatic carotid artery stenosis were found, although there were no significant differences in the overall stroke. This indicates a need for larger multicenter prospective studies to evaluate these sex-specific differences. More women, including those aged over 80 years, need to be enrolled in randomized controlled trials, to better understand if sex differences exist and to tailor carotid revascularization accordingly.

Carotid Plaque Composition and the Importance of Non-Invasive in Imaging Stroke Prevention

Luminal stenosis has been the standard feature for the current management strategies in patients with atherosclerotic carotid disease. Histological and imaging studies show considerable differences between plaques with identical degrees of stenosis. They indicate that specific plaque characteristics like Intraplaque hemorrhage, Lipid Rich Necrotic Core, Plaque Inflammation, Thickness and Ulceration are responsible for the increased risk of ischemic events. Intraplaque hemorrhage is defined by the accumulation of blood components within the plaque, Lipid Rich Necrotic Core is composed of macrophages loaded with lipid, Plaque Inflammation is defined as the process of atherosclerosis itself and Plaque thickness and Ulceration are defined as morphological features. Advances in imaging methods like Magnetic Resonance Imaging, Ultrasound, Computed Tomography and Positron Emission Tomography have enabled a more detailed characterization of the plaque, and its vulnerability is linked to these characteristics, changing the management of these patients based only on the degree of plaque stenosis. Studies like Rotterdam, ARIC, PARISK, CAPIAS and BIOVASC were essential to evaluate and prove the relevance of these characteristics with cerebrovascular symptoms. A better approach for the prevention of stroke is needed. This review summarizes the more frequent carotid plaque features and the available validation from recent studies with the latest evidence.

Synthetic role of miR-200b-3p, ABCD2 score, and carotid ultrasound in the prediction of cerebral infarction in patients with transient ischemic attack

BACKGROUND

Transient ischemic attack (TIA) is a major risk factor for the occurrence of cerebral infarction (CI). This study aimed to evaluate the predictive value of the synthetic role of miR-200b-3p, ABCD2 score, and carotid ultrasound for CI onset in patients with TIA.

METHODS

Expression of miR-200b-3p was detected by reverse transcription quantitative PCR and carotid stenosis degree was evaluated using carotid ultrasound examination. Association of miR-200b-3p with ABCD2 scores and carotid stenosis degree was assessed using t-test and chi-square test. Logistic regression analysis was used to judge the ability of miR-200b-3p, ABCD2 score, and carotid ultrasound to predict the occurrence of CI. Receiver operating characteristic curve was used to analyze the diagnostic value of miR-200b-3p and the accuracy of miR-200b-3p, ABCD2 score, and carotid ultrasound in predicting CI development.

RESULTS

Expression of serum miR-200b-3p was significantly increased in TIA patients compared with healthy controls, and had diagnostic value in TIA patients. Serum miR-200b-3p was significantly associated with dyslipidemia, ABCD2 score, and carotid stenosis degree in TIA patients. ABCD2 score, carotid stenosis degree, and serum miR-200b-3p were independently associated with CI onset, and the synthetic role of these three indicators had the best accuracy in the prediction of CI onset in TIA patients.

CONCLUSION

Serum miR-200b-3p expression was increased in TIA patients with considerable diagnostic value to screen TIA cases from healthy controls. Moreover, we speculated that the combination of miR-200b-3p, ABCD2 score, and carotid stenosis degree by ultrasound may propose as an efficient predictive strategy for the prediction of CI in TIA patients.

Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis

OBJECTIVE

A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents.

DATA SOURCES

The Web of Science, Pubmed, and Embase databases were searched from inception to July 2021. The corresponding authors of excluded articles were contacted to obtain additional data for possible inclusion.

REVIEW METHODS

The main outcomes included ischaemic complications (stroke, transient ischaemic attack [TIA], and transcranial Doppler [TCD] measured micro-emboli), haemorrhagic complications (haemorrhagic stroke, neck haematoma, and re-operation for bleeding), and composite outcomes. Pooled estimates using odds ratios (ORs) were combined using a random or fixed effects model based on the results of the chi square test and calculation of I².

RESULTS

In total, 47 411 patients were included in 11 studies, with 14 345 (30.2%) receiving DAPT and 33 066 (69.7%) receiving aspirin only. There was no significant difference in the rates of peri-operative stroke (OR 0.87, 95% confidence interval [CI] 0.72 - 1.05) and TIA (OR 0.78, 95% CI 0.52 - 1.17) despite a significant reduction in TCD measured micro-emboli (OR 0.19, 95% CI 0.10 - 0.35) in the DAPT compared with the aspirin monotherapy group. Subgroup analysis did not reveal any significant difference in ischaemic stroke risk between patients with asymptomatic and symptomatic carotid artery stenosis. DAPT was associated with an increased risk of neck haematoma (OR 2.79, 95% CI 1.87 - 4.18) and re-operation for bleeding (OR 1.98, 95% CI 1.77 - 2.23) vs. aspirin. Haemorrhagic stroke was an under reported outcome in the literature.

CONCLUSION

This meta-analysis found that CEA while on DAPT increased the risk of haemorrhagic complications, with similar rates of ischaemic complications, vs. aspirin monotherapy. This suggests that the risks of performing CEA on DAPT outweigh the benefits, even in patients with symptomatic carotid stenosis. The overall quality of studies was low, and improved reporting of CEA outcomes in the literature is necessary.

Single-Cell Analysis Uncovers Osteoblast Factor Growth Differentiation Factor 10 as Mediator of Vascular Smooth Muscle Cell Phenotypic Modulation Associated with Plaque Rupture in Human Carotid Artery Disease

(1) Background: Vascular smooth muscle cells (VSMCs) undergo a complex phenotypic switch in response to atherosclerosis environmental triggers, contributing to atherosclerosis disease progression. However, the complex heterogeneity of VSMCs and how VSMC dedifferentiation affects human carotid artery disease (CAD) risk has not been clearly established. (2) Method: A single-cell RNA sequencing analysis of CD45⁻ cells derived from the atherosclerotic aorta of Apolipoprotein E-deficient (Apoe^−/−) mice on a normal cholesterol diet (NCD) or a high cholesterol diet (HCD), respecting the site-specific predisposition to atherosclerosis was performed. Growth Differentiation Factor 10 (GDF10) role in VSMCs phenotypic switch was investigated via flow cytometry, immunofluorescence in human atherosclerotic plaques. (3) Results: scRNAseq analysis revealed the transcriptomic profile of seven clusters, five of which showed disease-relevant gene signature of VSMC macrophagic calcific phenotype, VSMC mesenchymal chondrogenic phenotype, VSMC inflammatory and fibro-phenotype and VSMC inflammatory phenotype. Osteoblast factor GDF10 involved in ossification and osteoblast differentiation emerged as a hallmark of VSMCs undergoing phenotypic switch. Under hypercholesteremia, GDF10 triggered VSMC osteogenic switch in vitro. The abundance of GDF10 expressing osteogenic-like VSMCs cells was linked to the occurrence of carotid artery disease (CAD) events. (4) Conclusions: Taken together, these results provide evidence about GDF10-mediated VSMC osteogenic switch, with a likely detrimental role in atherosclerotic plaque stability.

Diagnostic value of miR-186-5p for carotid artery stenosis and its predictive significance for future cerebral ischemic event

BACKGROUND

MicroRNAs (miRNAs) serve as novel promising biomarkers for the diagnosis and prognosis of many human diseases. This study investigated the diagnostic value of miR-186-5p for asymptomatic carotid artery stenosis (CAS), and its predictive value for future cerebral ischemic events (CIEs).

METHODS

Sixty-seven cases with asymptomatic CAS and 60 healthy individuals were recruited. Serum levels of miR-186-5p were tested by using qRT-PCR. Receiving-operator characteristic (ROC) curve was drawn based on sensitivity and specificity analyses. All asymptomatic CAS cases were followed up for 5 years. Kaplan-Meier method was applied for the evaluation of the predictive value of miR-186-5p for the occurrence of CIE.

RESULTS

The serum level of miR-186-5p was increased significantly in asymptomatic CAS patients. MiR-186-5p was the most significant factor associated with the high degree of carotid stenosis in asymptomatic CAS patients. In the ROC curve analysis, the AUC was 0.919, with the sensitivity of 89.6% and specificity of 81.7% at the cutoff value of 1.221. Kaplan-Meier method results revealed that high miR-186-5p level was associated with the occurrence of CIEs. High miR-186-5p level and high degree of carotid stenosis were independent factors for the occurrence of CIEs.

CONCLUSION

MiR-186-5p serves as a potential diagnostic biomarker for patients with asymptomatic CAS, and predicts the occurrence of future CIEs.

Circulating miR-106b-5p serves as a diagnostic biomarker for asymptomatic carotid artery stenosis and predicts the occurrence of cerebral ischemic events

This study aimed to investigate the expression and diagnostic value of miR-106b-5p in asymptomatic carotid artery stenosis (CAS) patients, and further explore its predictive value for the occurrence of cerebral ischemic events (CIE). A total of 58 asymptomatic CAS cases and 61 healthy controls were recruited. Quantitative RT-PCR was applied for the measurement of the miR-106b-5p level. The receiver operating characteristic (ROC) curve was plotted to assess the diagnostic value of miR-106b-5p for CAS. Kaplan–Meier methods and Cox regression analysis were performed to assess the predictive value of miR-106b-5p for the occurrence of CIE. In patients with asymptomatic CAS, miR-106b-5p was highly expressed. The miR-106b-5p level showed a significant association with dyslipidemia, hypertension, and the degree of carotid stenosis. miR-106b-5p had a relative accuracy in differentiating patients with asymptomatic CAS from healthy individuals, with a sensitivity of 89.7% and specificity of 83.6% at the cutoff value of 0.198. Patients with high miR-106b-5p expression experienced more CIE. miR-106b-5p was highly expressed in patients with asymptomatic CAS. Our present results provide evidence for miR-106b-5p as a promising biomarker for CAS diagnosis, and for predicting the risk of future CIE in patients with asymptomatic CAS.

Usefulness of plateletcrit in the prediction of major adverse cardiac and cerebrovascular events in patients with carotid artery stenosis

Objectives

Platelets play an important role in the pathogenesis of atherosclerosis and the physiopathology of cardiovascular events. Plateletcrit provides complete information on total platelet mass. The relationship between plateletcrit values and long-term outcomes in patients with carotid stenosis is not known. The purpose of the present study is to evaluate the reliability of plateletcrit for predicting major adverse cardiac and cerebrovascular events (MACCE) in patients with carotid stenosis.

Methods

A total of 230 patients with more than 50% stenosis of the carotid artery were retrospectively included in this study. All cases were divided into two groups according to the calculated threshold value of plateletcrit with receiver operating characteristics curve and baseline parameters and clinical outcomes were compared. Univariate and multivariate analyses were used to evaluate the association between the plateletcrit and MACCE.

Results

The cut-off value for plateletcrit was found to be 0.233 for predicting MACCE, with 56.2% sensitivity and 68.0% specificity. High plateletcrit levels were demonstrated to be statistically higher in patients with MACCE (0.247 in the MACCE (+) group vs. 0.213 in the MACCE (–) group, p < 0.001). In the Kaplan–Meier survival analysis, the long-term mortality rate was higher in the high plateletcrit group ( p = 0.006). Multivariate regression analysis showed that plateletcrit was independently associated with MACCE (OR: 2.196, CI: 1.200–4.018; p = 0.011).

Conclusions

Our data suggest that plateletcrit has an independently predictive value for long-term mortality and MACCE, and it can be used as a marker to predict the long-term adverse outcomes in patients with carotid stenosis.

Refusal of PEG Feeding Following a Carotid Endarterectomy

This case study presents a patient who has undergone right carotid endarterectomy complicated by glossopharyngeal nerve (or cranial nerve (CN) IX) injury. The patient had one transient ischaemic attack (TIA) three weeks before admission. A computed tomography (CT) scan two days after admission illustrated a right-sided parietal infarct. The patient subsequently had a CT angiogram, which showed a large, calcified plaque in the right internal carotid artery. He then underwent a right carotid endarterectomy. After the procedure, he developed dysphagia. A discussion was had with the patient about using percutaneous endoscopic gastrostomy (PEG) to provide a means of feeding. The patient subsequently refused this in favor of nasogastric tube (NGT) feeding despite the doctor's advice. This highlights an important learning point with regards to patient autonomy and their right to refuse treatment. Further research is required into the quality of life after PEG to help patients make an informed decision.

Imaging characteristics and pathogenesis of intracranial artery stenosis in patients with acute cerebral infarction

The current study aimed to investigate the imaging characteristics and pathogenesis of intracranial artery stenosis in patients with acute cerebral infarction. In total, 84 patients diagnosed with acute cerebral infarction were recruited. Magnetic resonance angiography was performed to detect the existence of intracranial artery stenosis or occlusion. In addition, magnetic resonance imaging and diffusion weighted imaging were employed to analyze the infarction types and characteristics. In the majority of patients, the infarction resulted from internal carotid stenosis (77 cases; 91.7%), while it was caused by vertebral artery stenosis in a small number of cases (7 cases; 8.3%). Multiple infarction was identified the most common type of infarction among all cases (69.0%). The most common types of infarctions in the internal carotid system were multiple infarction implicating both the cortex and centrum ovale (23.4%), and internal watershed infarction (22.1%). Although the number of cases was relatively small, multiple infarction was observed to have a high incidence in the vertebral artery system. Bedside electrocardiogram was also recorded to determine the sinus rhythm and examine the abnormal hemodynamics. The sinus bradycardia rate of patients with multiple infarction was markedly greater in comparison with that in single infarction patients (χ²=0.01, P<0.05). Transcranial Doppler plus microembolus monitoring was utilized to explore the possible pathogenesis of all types of infarctions, such as arterial embolization. As compared with the single infarction patients, the embolus rate in patients with multiple infarction was notably increased by ~3.7-fold (χ²=8.65, P<0.05). In conclusion, the cerebral infarction was common in the internal carotid system, with multiple infarction observed in the majority of cases. The pathogenesis of cerebral infarction included arterial embolization and inadequate hemoperfusion.

Carotid Endarterectomy with Routine Shunt for Patients with Contralateral Carotid Occlusion

This study aimed to report the clinical features and early and long-term outcomes of patients treated with carotid endarterectomy (CEA) combined with a routine shunt for carotid stenosis with the occlusion of the contralateral carotid artery (CCO), and to compare them with patients without contralateral occlusion (NO-CCO). A retrospective analysis included 301 patients who had carotid artery stenosis treated with CEA using a routine shunt. Of these patients, 35 patients and 266 patients were categorized into a CCO group and NO-CCO group, respectively. Demographics and short-term and long-term outcomes were documented and compared. The demographic characteristics were not significantly different between the two groups. The periprocedural mortality, stroke rate, and rate of periprocedural myocardial infarction were not significantly different between both groups. The mean follow-up period for long-term outcomes was 34.45 ± 22.99 months, and the Kaplan-Meier analysis showed no statistical difference between both groups regarding stroke, myocardial infarction, and mortality. CEA combined with the routine shunt is an effective and durable procedure for carotid artery stenosis patients with CCO.

Eagle syndrome: A case report of stylocarotid syndrome with internal carotid artery dissection

Eagle syndrome is defined by an elongated styloid process or a calcified stylohyoid ligament that impinges on surrounding structures and causes a variety of symptoms. Classically, Eagle syndrome presents as neck, throat, or ear pain. The vascular variant, stylocarotid syndrome, can present as headache, transient ischemic attack, or stroke. Carotid artery dissection is a rare complication of stylocarotid syndrome. We report a case of stylocarotid syndrome in a 60-year-old man who presented with a right internal carotid artery (ICA) dissection and focal neurological deficits. Computed tomography with three-dimensional reformatting was used in the evaluation of his pathology. His dissecting right ICA was stented with subsequent symptom resolution. Improved recognition of the relationship between an elongated styloid or calcified stylohyoid ligament and symptomatology may lead to optimal etiology recognition and directed treatment.

Post-Carotid Endarterectomy Hypertension. Part 1: Association with Pre-operative Clinical, Imaging, and Physiological Parameters

OBJECTIVE/BACKGROUND

Post-endarterectomy hypertension (PEH) is a well recognised, but poorly understood, phenomenon after carotid endarterectomy (CEA) that is associated with post-operative intracranial haemorrhage, hyperperfusion syndrome, and cardiac complications. The aim of the current study was to identify pre-operative clinical, imaging, and physiological parameters associated with PEH.

METHODS

In total, 106 CEA patients undergoing CEA under general anaesthesia underwent pre-operative evaluation of 24 hour ambulatory arterial blood pressure (BP), baroreceptor sensitivity, cerebral autoregulation, and transcranial Doppler measurement of cerebral blood flow velocity (CBFv) and pulsatility index. Patients who met pre-existing criteria for treating PEH after CEA (systolic BP [SBP] > 170 mmHg without symptoms or SBP > 160 mmHg with headache/seizure/neurological deficit) were treated according to a previously established protocol.

RESULTS

In total, 40/106 patients (38%) required treatment for PEH at some stage following CEA (26 in theatre recovery [25%], 27 while on the vascular surgical ward [25%]), while seven (7%) had SBP surges > 200 mmHg back on the ward. Patients requiring treatment for PEH had a significantly higher pre-operative SBP (144 ± 11 mmHg vs. 135 ± 13 mmHg; p < .001) and evidence of pre-existing impairment of baroreceptor sensitivity (3.4 ± 1.7 ms/mmHg vs. 5.3 ± 2.8 ms/mmHg; p = .02). However, PEH was not associated with any other pre-operative clinical features, CBFv, or impaired cerebral haemodynamics. Paradoxically, autoregulation was better preserved in patients with PEH. All four cases of hyperperfusion associated symptoms were preceded by PEH. Length of hospital stay was significantly increased in patients with PEH (p < .001).

CONCLUSION

In this study, where all patients underwent CEA under general anaesthesia, PEH was associated with poorly controlled pre-operative BP and impaired baroreceptor sensitivity, but not with other peripheral or central haemodynamic parameters, including impaired cerebral autoregulation.

Comparative results of conventional and eversion carotid endarterectomy

Purpose

Comparative results of conventional carotid endarterectomy (cCEA) and eversion carotid endarterectomy (eCEA) have been reported in many studies. But in Korea, there have been no reports to compare the outcome of the two techniques. Thus, we investigated the results of eCEA compared to cCEA in Yeungnam University Medical Center.

Methods

A total of 120 subjects who underwent CEA were included in this study. Of them, cCEAs were performed in 63 patients and eCEAs were performed in 57 patients. We analyzed the results divided into the early (within 30 days after surgery), midterm (from 30 days up to 1 year after surgery) and late (over 1 year after surgery).

Results

Mean age of the patients was 65.9 ± 7.1 years in cCEA group and 66.8 ± 7.7 years in eCEA group (P = 0.523). Carotid shunt frequency was higher in the cCEA group (39.7% vs. 19.3%, P = 0.015). There were no statistical differences in the early complications with the exception of a significantly higher risk for new brain lesions in the cCEA group (34.9% vs. 14.0%, P = 0.008). The frequency of complication was same between cCEA group and eCEA group in the midterm. Although there was no statistical significance, the frequency of late complications was higher in the cCEA group compared to eCEA group. Mean follow-up duration was 29.4 ± 23.5 months.

Conclusion

These data showed that eCEA was an acceptable procedure and had some advantage compared to cCEA in the aspect of the early and late complication.

Postoperative ICU management of vascular surgery patients

Critical care management of vascular surgical patients poses significant challenges owing to patients' comorbidities and the magnitude of the surgical procedures. The primary goals of the anesthesiologist and intensivist are reestablishing preoperative homeostasis, optimizing hemodynamics until return of normal organ function, and managing postoperative complications promptly and effectively. Postoperative critical care management demands a detailed knowledge of the various vascular surgical procedures and the potential postoperative complications. In this review, the authors describe the postoperative complications related to the major specific vascular surgical procedures and their perioperative management.

Remote ischaemic preconditioning versus no remote ischaemic preconditioning for vascular and endovascular surgical procedures

BACKGROUND

Despite advances in perioperative care, elective major vascular surgical procedures carry a significant risk of morbidity and mortality. Remote ischaemic preconditioning is initiated by brief, non-lethal periods of ischaemia in a vascular bed different from the one which will be subjected to ischaemic insult during surgery. It has the potential to provide local tissue protection from further prolonged periods of ischaemia.

OBJECTIVES

The aim of this review was to compare the outcomes from vascular and endovascular surgical procedures with and without the use of remote ischaemic preconditioning.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (June 2011) and CENTRAL (2011, Issue 2). The authors searched MEDLINE via PubMed (July 2011), EMBASE (June 2011), and Science Citation Index Expanded (July 2011).

SELECTION CRITERIA

We considered for inclusion all randomised controlled trials that evaluated the role of remote ischaemic preconditioning in reducing mortality and systemic injury in patients undergoing open vascular or endovascular surgery.

DATA COLLECTION AND ANALYSIS

We collected the data on characteristics of the trial, methodological quality, the remote ischaemic preconditioning stimulus used, mortality, morbidity, operating time and hospital stay from each trial. We analysed the data with both the fixed-effect and the random-effects models using RevMan analysis. For each outcome we calculated the risk ratio (RR) or mean difference with 95% confidence interval (CI) based on an intention-to-treat analysis.

MAIN RESULTS

We included four studies with a total of 115 patients randomised to undergo a vascular procedure with remote ischaemic preconditioning and 117 patients randomised to have the procedure without remote ischaemic preconditioning. None of the trials were of low risk of bias. There was no significant difference in mortality between the two groups (RR 1.70, 95% CI 0.51 to 5.72). Similarly, there was no statistically significant difference between the two groups for all other outcomes except reduced risk of myocardial infarction in the remote ischaemic preconditioning group, which was significant by the fixed-effect model (RR 0.31, 95% CI 0.10 to 0.90) but not by the random-effects model (RR 0.34, 95% CI 0.11 to 1.08). This positive effect was from the results of only one trial and was not consistently observed. Furthermore, it was noted that there was an observed trend of high incidence of unplanned critical care admission in the remote ischaemic preconditioning group, although this was not statistically significant (RR 2.15, 95% CI 0.87 to 5.33).

AUTHORS' CONCLUSIONS

Based on current evidence from small pilot trials, there are too few data to be able to say whether remote ischaemic preconditioning has any beneficial or harmful effects. The safety of this technique needs to be confirmed in adequately powered trials. Therefore, further randomised trials on this technique are required.

Carotid artery stenting: rationale, technique, and current concepts

Carotid stenosis is a major risk factor for stroke. With the aging of the general population and the availability of non-invasive vascular imaging studies, the diagnosis of a carotid plaque is commonly made in medical practice. Asymptomatic and symptomatic carotid stenoses need to be considered separately because their natural history is different. Two large randomized controlled trials (RCTs) showed the effectiveness of carotid endarterectomy (CEA) in preventing ipsilateral ischemic events in patients with symptomatic severe stenosis. The benefit of surgery is much less for moderate stenosis and harmful in patients with stenosis less than 50%. Surgery has a marginal benefit in patients with asymptomatic stenosis. Improvements in medical treatment must be taken into consideration when interpreting the results of these previous trials which compared surgery against medical treatment available at the time the trials were conducted. Carotid artery stenting (CAS) might avoid the risks associated with surgery, including cranial nerve palsy, myocardial infarction, or pulmonary embolism. Therefore and additionally to well-established indications of CAS, this endovascular approach might be a valid alternative particularly in patients at high surgical risk. However, trials of endovascular treatment of carotid stenosis have failed to provide enough evidence to justify routine CAS as an alternative to CEA in patients suitable for surgery. More data from ongoing randomized trials of CEA versus CAS will be soon available. These results will help determining the role of CAS in the management of patients with carotid artery stenosis.

Preoperative assessment of adult patients for intracranial surgery

The preoperative assessment of the patient for neurosurgical and endovascular procedures involves the understanding of the neurological disease and its systemic presentation, and the requirements of the procedure. There is a wide spectrum of different neurosurgical disorders and procedures. This article provides an overview of the preoperative evaluation of these patients with respect to general principles of neuroanesthesia, and considerations for specific intracranial and vascular neurosurgical and interventional neuroradiological procedures.

Carotid endarterectomy benefits patients with CKD and symptomatic high-grade stenosis

Endarterectomy is generally recommended for symptomatic high-grade (70 to 99%) stenosis of the internal carotid artery, but whether this procedure is beneficial among patients with chronic kidney disease (CKD) is unknown. In this re-analysis of data from the North American Symptomatic Carotid Endarterectomy Trial, we included patients with symptomatic stenosis and either stage 3 CKD (n = 524) or preserved kidney function (n = 966; estimated GFR > or = 60). For medically treated patients with high-grade stenosis, risk for ipsilateral stroke at 2 yr was significantly higher in patients with CKD than in those with preserved renal function (31.6 versus 19.3%; P = 0.042); carotid endarterectomy significantly reduced this risk by 82 and 51%, respectively. To prevent one ipsilateral stroke, the number needed to treat by endarterectomy was four for patients with CKD and 10 for patients with preserved renal function. Compared with patients with preserved renal function, those with CKD had similar rates of perioperative stroke and death but higher rates of cardiac events. In conclusion, patients with stage 3 CKD and symptomatic high-grade carotid stenosis gain a large benefit in stroke risk reduction after endarterectomy.

Acute cerebral rescue during carotid artery stenting: a stroke of good fortune?

Major stroke is a potentially devastating complication of carotid artery revascularization. Carotid artery stenting, unlike endarterectomy, offers the opportunity to attenuate this complication by allowing for the instantaneous detection and early endovascular treatment of neurologic defects complicating the procedure. We report a case that highlights the utility of aggressive endovascular cerebral rescue during a carotid artery stent procedure.

Remote ischemic preconditioning in major vascular surgery

Remote ischemic preconditioning is a physiologic mechanism in mammalian species whereby brief exposure to nonlethal ischemia in one tissue confers protection against a prolonged ischemic insult in a distant tissue. First described almost 15 years ago, it has been slow to translate into clinical practice. Several clinical trials have recently reported that remote ischemic preconditioning reduces myocardial injury after major cardiovascular surgery. In addition, a randomized trial in patients undergoing open abdominal aortic aneurysm repair reported a significant reduction in perioperative myocardial infarctions. Remote ischemic preconditioning is easily performed and likely to prove highly cost-effective. large-scale trials of the technique are warranted in patients undergoing major vascular surgery.

Higher risk factor burden and worse outcomes in urban carotid endarterectomy patients

BACKGROUND AND PURPOSE

Previous multicenter carotid endarterectomy (CEA) studies had screening criteria for patient comorbidities and very few blacks. We assessed the hypothesis that CEA results from two urban hospitals would approximate those of the previous multicenter trials.

METHODS

A retrospective chart review was completed at two urban hospitals for CEA procedures done in 2003 and 2004. Demographic information and past medical history was recorded. In hospital perioperative complications (stroke or myocardial infarction [MI]) were noted. We calculated an expected perioperative stroke rate based on trial figures and our proportion of symptomatic and asymptomatic patients.

RESULTS

Patients in our cohort had significantly higher rates of hypertension, diabetes, smoking, black race, and elderly status compared to previous trials. The expected perioperative stroke was 3.1%, and the observed stroke rate was 4.7% (P=0.36). Observed rates of MI (6.7%, P<0.001)) and stroke or MI (11.3%, P<0.0001) were higher than expected based on the previous trials. The stroke or MI rate in black subjects was higher (15.4% versus 5.6%, P=0.065) and this was significant at the hospital with lower CEA volume.

CONCLUSIONS

In two urban hospitals, CEA results were significantly worse than previous trials. Patient selection is likely to play a role because our cohort had higher numbers of hypertensives, diabetics, smokers, blacks, and elderly patients. Clinicians need to carefully consider the risk/benefit ratio of CEA in urban patients because our study shows that these patients have a large number of medical comorbidities and worse outcomes after CEA.

Current status of carotid endarterectomy and stenting for symptomatic carotid stenosis

There is still considerable uncertainty about the place of carotid stenting in patients with recently symptomatic carotid bifurcation stenosis. Most reviews of carotid endarterectomy versus carotid stenting concentrate on technical aspects and advances in stenting, but the techniques involved in both carotid endarterectomy and stenting are evolving. In addition to reviewing the results of the various randomised controlled trials of carotid endarterectomy versus stenting for symptomatic carotid stenosis, this review considers recent advances and current best practice for endarterectomy. Ongoing randomized trials will determine whether or not the procedural risk of stroke and death is definitely lower with endarterectomy than with stenting, but the key issue that remains to be determined reliably is how the procedural risks of stenting vary with patient characteristics - perhaps the most important question being not whether endarterectomy is better than stenting or vice versa, but for whom is one technique likely to be better than the other.

Effects of clonidine and superficial cervical plexus block on hemodynamic stability after carotid endarterectomy

OBJECTIVES

To evaluate the effects of 2 interventions (intravenous clonidine and superficial cervical block) on hemodynamic stability after carotid endarterectomy and to identify variables associated with hemodynamic instability.

DESIGN

Prospective, observational study, sequential enrollment.

SETTING

University hospital.

PARTICIPANTS

Two hundred seventy-five patients undergoing elective carotid endarterectomy under general anesthesia.

INTERVENTIONS

Group NN (n = 50) received no intervention. In group CN (n = 85), 3 mug/kg of clonidine were administered intravenously 30 minutes before the end of the operation. Group CB (n = 140) additionally received a superficial cervical plexus block (SCB) with 20 mL of naropine 0.5% before the induction of anesthesia.

MEASUREMENTS AND MAIN RESULTS

Clonidine alone (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.45-3.76) and clonidine combined with an SCB (OR, 4.99; 95% CI, 3.19-7.82) resulted in a significant increase in hemodynamic stability after CEA (p < 0.001) from 53.3% (NN) to 70.0% (CN) and 83.3% (CB), respectively. The need for rescue medication decreased from 40.0% to 17.6% and 13.6% (p < 0.001). Both interventions significantly reduced the need for postoperative opioid analgesics (p < 0.01). Logistic regression analysis showed preoperative systolic blood pressure values greater than 170 mmHg (OR, 3.23; 95% CI, 1.76-5.93), previous cardiac interventions (OR, 3.3; 95% CI, 1.54-7.11), and the need for rescue medication in the awakening period (OR, 5.8; 95% CI, 2.88-11.52) to be independent risk factors for postoperative hemodynamic instability (p < or = 0.002).

CONCLUSIONS

Intravenous clonidine and superficial cervical block significantly improve cardiovascular stability after carotid endarterectomy. Patients with pre-existing excessive hypertension and previous coronary interventions must be considered a high-risk group.

Symptomatic and asymptomatic carotid stenosis: just when we thought we had all the answers

The management of symptomatic and asymptomatic carotid stenosis has been a hotly debated topic for decades. The publication of four randomized controlled trials of carotid endarterectomy has clarified many of the issues. Patients with symptomatic carotid stenosis >70% benefit most with an absolute risk reduction of 17% over 2 years with numbers needed to treat of 3-6, whereas in patients with asymptomatic carotid stenosis >60%, the absolute risk reduction is 1% per annum (numbers needed to treat = 14-17). There is doubt about the benefit in women >70 years of age with asymptomatic stenosis. Carotid angioplasty and stenting is in its infancy and may one day supplant carotid endarterectomy as the treatment of choice; however, currently indications for this procedure include participation in randomized controlled trials, surgically inaccessible stenosis, in patients with combined symptomatic carotid and symptomatic coronary artery disease or in patients with severe co-morbidities that preclude formal carotid endarterectomy.

European Carotid PROCAR Trial: Prospective Multicenter Trial to Evaluate the Safety and Performance of the ev3 Protegetm Stent in the Treatment of Carotid Artery Stenosis-1- and 6-Month Follow-Up

BACKGROUND

The purpose of the European PROCAR Trial was to evaluate the safety and performance of the Protégé stent in the treatment of common and/or internal carotid artery stenoses with adjunctive use of a filter embolic protection device.

METHOD

The Protégé GPS stent is a self-expanding Nitinol stent system mounted on a 6 Fr 0.018'' (6-9 mm stent) or 7 Fr 0.035'' (10 mm stent) over-the-wire delivery system. Study patient assessments were conducted at baseline, periprocedure, discharge, and 1 and 6 months postprocedure. A total of 77 patients have been enrolled in the trial.

RESULTS

In the 77 lesions treated (31 symptomatic, 46 asymptomatic), the procedure was technically successful in 76 (99%), with an average residual stenosis of less than 30%. One procedure failed because the embolic protection device could not be retrieved and the patient was sent to surgery. Within 30 days, there were four (5.2%) major adverse neurological events (MANEs). Three of the MANEs were major strokes (3.9%), one a minor stroke. The fifth MANE occurred prior to the 6-month follow-up visit; this patient had a major stroke 75 days after the procedure and died 36 days later. One additional death occurred because of urosepsis.

CONCLUSIONS

The PROCAR trial shows that the Protégé stent with adjuvant use of a filter embolic protection device satisfies safety and performance criteria for the treatment of carotid artery stenosis. The incidence of MANEs for the Protégé stent is comparable to the incidence of these events in other recent carotid stent studies and standard carotid endarterectomy (CEA).

Incidence and risk factors for medical complications after carotid artery stenting

OBJECTIVE

Carotid angioplasty and stenting (CAS) is being evaluated as an alternative to carotid endarterectomy for the treatment of carotid artery stenosis; however, to date little is known about the incidence of medical complications after CAS. The goal of this study was to determine the frequency of, and to identify potential clinical risk factors for, the development of medical complications after CAS.

METHODS

Medical complications that occurred < or = 30 days after CAS in 327 consecutive patients (241 men, 86 women; mean age, 69 +/- 9 years; range, 45 to 90 years) treated for symptomatic (n = 182, 56%) or asymptomatic (n = 145, 44%) carotid artery stenosis were recorded. The effect of clinical characteristics on the subsequent development of medical complications was analyzed by logistic regression.

RESULTS

Fifty-one patients (15%) had 62 medical complications: 3 (0.9%) myocardial infarctions, 3 (0.9%) cardiac arrhythmias, 4 (1.2%) episodes of angina pectoris, 3 (0.9%) episodes of symptomatic hypertension, 16 (4.9%) episodes of symptomatic hypotension, 10 (3.1%) chest infections, 9 (2.7%) had periods of confusion, 5 (1.5%) had urinary retention, and 9 (2.7%) urinary tract infections. One chest infection was fatal and 16 complications prolonged the intensive care unit monitoring period > 24 hours. Advanced age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.05 to 1.14) and a symptomatic carotid stenosis (OR, 2.1; 95% CI, 1.07 to 4.1) independently predicted the occurrence of medical complications.

CONCLUSION

Although life-threatening or fatal non-neurologic events were uncommon in this series, the overall incidence of medical complications after CAS might be higher than currently anticipated. Older and symptomatic patients are at the highest risk, and these subgroups should be monitored closely.