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Paras S, Mina A, Crammond DJ, Visweswaran S, Anetakis KM, Balzer JR, Shandal V, Thirumala PD. Cardiovascular-related mortality after intraoperative neurophysiologic monitoring changes during carotid endarterectomy. Clin Neurophysiol 2022; 139:43-48. [DOI: 10.1016/j.clinph.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
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Contrera KJ, Yong V, Reddy CA, Liu SW, Lorenz RR. Recurrence and Progression of Head and Neck Paragangliomas after Treatment. Otolaryngol Head Neck Surg 2020; 162:504-511. [PMID: 32066331 DOI: 10.1177/0194599820902702] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To characterize the recurrence of head and neck paragangliomas and the factors associated with disease progression after treatment. STUDY DESIGN Retrospective cohort study. SETTING Tertiary care center. SUBJECTS AND METHODS In total, 173 adults with 189 paragangliomas (41.3% carotid body, 29.1% glomus jugulare, 19.0% glomus tympanicum, and 10.6% glomus vagale) treated between 1990 and 2010 were evaluated to determine the incidence and risk of recurrence using Cox proportional hazards. RESULTS The mean (SD) follow-up duration was 8.6 (9.1) years. The incidence was 2.92 recurrences per 100 person-years. The rate of recurrence was 8.2% (95% confidence interval [CI], 3.7-12.7) after 4 years and 17.1% (95% CI, 10.2-24.0) after 10 years. Glomus jugulare tumors were more likely to recur (hazard ratio [HR], 3.69; 95% CI, 1.70-8.01; P < .001) while carotid body tumors were less likely (HR, 0.44; 95% CI, 0.21-0.97; P = .041). Radiation had a lower risk of recurrence or progression compared to surgical excision (HR, 0.30; 95% CI, 0.10-.94; P = .040). Recurrence was associated with right-sided paragangliomas (HR, 3.60; 95% CI, 1.63-7.75; P = .001). The median time to recurrence was 18.4 years. Six (3.2%) patients developed metastasis, which was more common with local recurrence (9.5% vs 1.4%, P = .015). CONCLUSIONS Recurrence is more common with glomus jugulare tumors and less common with carotid body tumors. Radiation may have a lower risk of recurrence or progression than surgery for some paraganglioma types. Metastasis is rare but more likely with recurrent disease. Surveillance neck imaging is recommended every several years for decades after treatment.
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Affiliation(s)
| | - Valeda Yong
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chandana A Reddy
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sara W Liu
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert R Lorenz
- Head & Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Alves-Ferreira J, Rocha-Neves J, Dias-Neto M, Braga SF. Poor long-term outcomes after carotid endarterectomy: a retrospective analysis of two portuguese centers. SCAND CARDIOVASC J 2019; 53:266-273. [PMID: 31251084 DOI: 10.1080/14017431.2019.1638518] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objetives. Carotid endarterectomy (CEA) is an established treatment for carotid stenosis (CS). However, this procedure is not risk-free and it is insufficient to control disseminated atherosclerosis. Our aim was to determine long-term cardiovascular morbidity and mortality after CEA and identify associated risk predictors. Design. Consecutive cohorts of CEAs performed between 2010 and 2018 in two Portuguese hospitals were retrospectively analysed. The major end-points were acute myocardial infarction (AMI), stroke, all-cause death and major adverse cardiovascular events (MACE). Results. 248 patients (mean age 69 years; 79% male) were enrolled in the study. 24% had postoperative complications. At 52 months median follow-up, 9 ± 2.0% (mean ± standard error) of patients experienced an acute myocardial infarction (AMI), 12 ± 2.4% a stroke and 26 ± 3.2% a MACE. All-cause mortality rate was 21 ± 3.0%. Multivariate analysis identified coronary artery disease (CAD) as significant predictor of AMI (p < .001; Hazard Ratio (HR):9.628; 95% Confidence Interval (95%CI):2.805-33.046), whereas no statistically significant risk factor of stroke was found. Predictors of death included left sided CS (p = .042; HR:1.886; 95%CI:1.024-3.475), chronic kidney disease (CKD) (p = .007; HR:2.352; 95%CI:1.266-4.372) and anticoagulant medication (p = .015; HR:2.107; 95%CI:1.216-6.026), while statin use was significantly protective (p = .049; HR:0.482; 95%CI:0.233-0.998). Concerning MACE, male gender (p = .040; HR:1.709; 95%CI:1.025-2.849), tobacco use (p = .004; HR:2.181; 95%CI:1.277-3.726), CAD (p = .002; HR:2.235; 95%CI:1.340-3.727) and CKD (p < .001; HR:3.029; 95%CI:1.745-5.258) were risk predictors. Conclusions. Patients continue to have high rates of AMI, MACE and death after CEA. Prior CAD is a risk factor for future AMI, whereas CKD is a significant predictor of MACE and death. Aggressive best medical treatment and risk factors modification should be advised in all patients with systemic atherosclerosis.
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Affiliation(s)
| | - João Rocha-Neves
- Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Physiology and Surgery - Cardiovascular Research Unit, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Angiology and Vascular Surgery, São João Hospital Center , Porto , Portugal
| | - Marina Dias-Neto
- Department of Physiology and Surgery - Cardiovascular Research Unit, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Angiology and Vascular Surgery, São João Hospital Center , Porto , Portugal
| | - Sandrina F Braga
- Department of Angiology and Vascular Surgery, Senhora de Oliveira Hospital Center , Guimarães , Portugal
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Wangqin R, Krafft PR, Piper K, Kumar J, Xu K, Mokin M, Ren Z. Management of De Novo Carotid Stenosis and Postintervention Restenosis-Carotid Endarterectomy Versus Carotid Artery Stenting-a Review of Literature. Transl Stroke Res 2019; 10:460-474. [PMID: 30793257 DOI: 10.1007/s12975-019-00693-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 01/23/2023]
Abstract
The current literature indicates carotid endarterectomy (CEA) as the preferred treatment for symptomatic, moderate to severe carotid artery stenosis. However, recommendations for the management of acute tandem stenosis and complete occlusion, as well as postintervention restenosis of the carotid artery, remain controversial. Here, we review the literature evaluating these conditions and provide suggestions for clinical decision-making. Acute tandem stenosis or occlusion of the common and internal carotid arteries may be treated with angioplasty alone, reserving carotid artery stenting (CAS) or CEA for severe and complex cases. Patients who underwent CEA and developed ipsilateral restenosis may be subjected to angioplasty followed by CAS, which carries a lower risk of cranial nerve injury and subsequent restenosis of the artery. For post-CAS restenosis, current evidence recommends angioplasty and CAS for the management of moderate stenosis and CEA for severe stenosis of the carotid artery. Given the lack of level 1 evidence for the management of these conditions, the abovementioned recommendations may assist clinical decision-making; however, each case and its unique risks and benefits need to be assessed individually. Future studies evaluating and defining the risks and benefits of specific treatment strategies, such as CEA and CAS, in patients with acute tandem stenosis, occlusion, and postintervention restenosis of the carotid artery need to be conducted.
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Affiliation(s)
- Runqi Wangqin
- Department of Neurology, Duke University Medical Center, 2400 Pratt Street, Durham, NC, 27705, USA
| | - Paul R Krafft
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA
| | - Keaton Piper
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA
| | - Jay Kumar
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA
| | - Kaya Xu
- Department of Neurosurgery, the Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, Guizhou, China
| | - Maxim Mokin
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA
| | - Zeguang Ren
- Department of Neurological Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL, 33606, USA.
- Center for Cerebrovascular Diseases, Shiyan Taihe Hospital, Shiyan, 442000, Hubei, China.
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Kuzkov VV, Obraztsov MY, Ivashchenko OY, Ivashchenko NY, Gorenkov VM, Kirov MY. Total Intravenous Versus Volatile Induction and Maintenance of Anesthesia in Elective Carotid Endarterectomy: Effects on Cerebral Oxygenation and Cognitive Functions. J Cardiothorac Vasc Anesth 2018; 32:1701-1708. [DOI: 10.1053/j.jvca.2017.12.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Indexed: 11/11/2022]
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Abstract
Symptomatic extracranial internal carotid artery stenosis poses a high short-time risk of ischemic cerebral stroke, as high as 20% to 30% in the first three months. Timely performed carotid endarterectomy (CEA) has been shown to be highly effective in reducing this risk although, in recent years, there has been great interest in replacing this procedure with less invasive carotid angioplasty and stenting (CAS). In this update we review recent studies and provide recommendations regarding the indications, methods and timing of surgical intervention as well as the anaesthetic management of CEA, and we report on recently published randomized controlled trials comparing CEA to CAS. We also provide recommendations regarding the sometime neglected but important medical management of patients undergoing carotid intervention, including antithrombotic and antihypertension therapy, lipid lowering agents, assistance with smoking cessation, and diabetes control.
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Spataro EA, Grindler DJ, Paniello RC. Etiology and Time to Presentation of Unilateral Vocal Fold Paralysis. Otolaryngol Head Neck Surg 2014; 151:286-93. [PMID: 24796331 DOI: 10.1177/0194599814531733] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/25/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the etiology, laterality, and time to presentation of unilateral vocal fold paralysis (UVFP) at a tertiary care institution over 10 years. STUDY DESIGN Case series with chart review. SETTING Academic medical center. SUBJECTS AND METHODS All patients seen between 2002 and 2012 by the Department of Otolaryngology at the Washington University School of Medicine (WUSM), with a diagnosis of unilateral vocal fold paralysis, were included. Medical records were reviewed for symptom onset date, presentation date(s), and etiology of UVFP. RESULTS Of the patients, 938 met inclusion criteria and were included. In total, 522 patients (55.6%) had UVFP due to surgery; 158 (16.8%) were associated with thyroid/parathyroid surgery, while 364 (38.8%) were due to nonthyroid surgery. Of the patients, 416 (44.4%) had nonsurgical etiologies, 124 (13.2%) had idiopathic UVFP, and 621 (66.2%) had left-sided UVFP. The diagnosis was more common on the left side in cases of intrathoracic surgeries and malignancies, as expected, but also in idiopathic, carotid endarterectomy, intubation, and skull base tumors. In total, 9.8% of patients presented first to an outside otolaryngologist at a median time of 2.1 months after onset, but these patients presented to WUSM at a median time of 9.5 months. Overall, 70.6% of patients presented to a WUSM otolaryngologist within 3 months of onset. CONCLUSION Iatrogenic injury remains the most common cause of UVFP. Thyroidectomy remains the leading cause of surgery-related UVFP. Patients are typically seen within 3-4 months of onset; however, a significant delay exists for those referred to WUSM.
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Affiliation(s)
- Emily A Spataro
- Department of Otolaryngology-Head and Neck Surgery, Washington, University School of Medicine, St Louis, Missouri, USA
| | - David J Grindler
- Department of Otolaryngology-Head and Neck Surgery, Washington, University School of Medicine, St Louis, Missouri, USA
| | - Randal C Paniello
- Department of Otolaryngology-Head and Neck Surgery, Washington, University School of Medicine, St Louis, Missouri, USA
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Buszman PP, Szymański R, Dębiński M, Milewski K, Król M, Nowakowski P, Kiesz RS, Radvany MG, Wiernek S, Wiernek B, Buszman PE. Long-term results of cephalad arteries percutanoeus transluminal angioplasty with stent implantation (The CAPTAS registry). Catheter Cardiovasc Interv 2012; 79:532-40. [PMID: 22311860 DOI: 10.1002/ccd.23391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 09/19/2011] [Accepted: 10/02/2011] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy. Moreover, percutaneous transluminal angioplasty (PTA) allows other cephalad arteries revascularization. The aim of this study was to evaluate late outcomes of cephalad arteries PTA. METHODS This is an international multicenter registry of 434 consecutive patients in which 497 PTAs were performed. Patients with symptomatic >50% stenosis or asymptomatic >70% stenosis were enrolled. Stenting of 577 internal carotid arteries (ICA) and 13 common carotid arteries was performed, 20.7% procedures were complex in which bilateral carotid stenoses or carotid and vertebral arteries stenoses were revascularized at one stage. In 15.9% patients, one-stage coronary intervention was carried out. Distal protection devices were used in 69.6% of cases. PTAs were divided into high (n = 330) and low (n = 167) risk of major adverse coronary and cerebral events (MACCE). RESULTS At 30 days, there were 15 (3.5%) cases of MACCE [0.9% deaths, 2.1% strokes, and 0.9% myocardial infarction (MI)]. TIAs were observed in 15 (3.9%) patients. There was no significant difference in stroke incidence between procedures with or without neuroprotection (1.8 vs. 3%; P = 0.66) as well as in MACCE occurrence between high and low-risk groups (4.3 vs. 2%; P = 0.34). Bilateral stenoses increased while hypertension decreased the risk of MACCE. Left ICA lesions increased the risk of cerebrovascular accidents (CVA). At 4 years (1-11 years), the mortality rate was 11.5%, 6% of patients had stroke, and 3% MIs. Restenosis occurred in 3%. There was a trend toward higher mortality rate (13.3 vs. 6.9%; P = 0.07) and MACCE risk in high-risk group (23.5 vs.14.7% P = 0.06). Age > 65 y.o. and stent length < 24 mm increased, while the statin therapy on admission decreased the risk of long-term death. Structural valve disease and stent length <30 mm increased the risk of MACCE, while implantation of Acculink stent decreased the risk of CVA. CONCLUSIONS CAS is safe and successful procedure with low early and long-term adverse events. Special attention should be put on patients with bilateral and left ICA stenoses. If possible, longer stents should be applied.
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Affiliation(s)
- Harlan M. Krumholz
- From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine; Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine; and the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
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