Bilateral Carotid Endarterectomy Research Articles

Qualitative Analysis of Length of Stay and Readmission after Carotid Endarterectomy

Length of stay (LOS) and readmissions are common measures to evaluate quality of health care. The objective of this study was to evaluate factors related to hospital LOS and readmission within 90days following carotid endarterectomy (CEA) in patients who have not had a stroke. Using a single institution database, patients who underwent CEA for carotid stenosis between 2014 and 2019 were identified. Asymptomatic carotid stenosis (no history of any stroke or transient ischemic attack (TIA) within 6months prior to CEA), and patients who had a TIA without stroke were included. Demographic and perioperative factors were collected. Primary outcomes analyzed were increased LOS (>1day) and readmission within 90days after surgery. There were 125 patients identified who underwent CEA for 133 carotid stenosis, and 8 patients had bilateral CEA; of which 36.8% were asymptomatic carotid stenosis with the remaining being operated on for TIA without any stroke. The mean age was 68years old and 36.1% of cases were female. The median postoperative LOS was 2days. Increased LOS occurred in 81 cases (60.9%). Increased LOS, compared to no increased LOS, occurred more often in patients with diabetes (48.1% vs. 30.8%, P=0.047), in those with operations starting after 12:00 pm (45.7% vs. 21.2%, P=0.004) and those with any minor complications such as neck swelling, neck pain, and urinary retention (30.9% vs. 15.4%, P=0.044). Readmission within 90days after CEA occurred in 24 (18%) of cases. Readmission within 90days, compared to no readmission within 90days, occurred more often in patients with a history of coronary artery disease (58.3% vs. 27.5%, P=0.004), congestive heart failure (37.5% vs. 11%, P=0.001), and atrial fibrillation (29.2% vs. 8.3%, P=0.004). More than half of patients undergoing CEA for carotid stenosis were discharged after postoperative day 1. Interventions on modifiable clinical risk factors, such as morning CEA scheduling and management of comorbidities, may decrease LOS and 90-day readmission rates.

Plaque Vulnerability Index Predicts Cardiovascular Events: A Histological Study of an Endarterectomy Cohort.

BackgroundThe balance between stabilizing and destabilizing atherosclerotic plaque components is used in experimental studies and in imaging studies to identify rupture prone plaques. However, we lack the evidence that this balance predicts future cardiovascular events. Here we explore whether a calculated histological ratio, referred to as vulnerability index (VI), can predict patients at higher risk to suffer from future cardiovascular events.Methods and ResultsCarotid plaques and clinical information from 194 patients were studied. Tissue sections were used for histological analysis to calculate the VI (CD68 [cluster of differentiation 68], alpha‐actin, Oil red O, Movat pentachrome, and glycophorin A). Postoperative cardiovascular events were identified through the Swedish National Inpatient Health Register (2005–2013). During the follow‐up (60 months) 45 postoperative cardiovascular events were registered. Patients with a plaque VI in the fourth quartile compared with the first to third quartiles had significantly higher risk to suffer from a future cardiovascular event (P=0.0002). The VI was an independent predictor and none of the 5 histological variables analyzed separately predicted events. In the 13 patients who underwent bilateral carotid endarterectomy, the VI of the right plaque correlated with the VI of the left plaque and vice versa (r=0.7, P=0.01).ConclusionsOur findings demonstrate that subjects with a high plaque VI have an increased risk of future cardiovascular events, independently of symptoms and other known cardiovascular risk factors . This strongly supports that techniques which image such plaques can facilitate risk stratification for subjects in need of more intense treatment.

The Impact of Unilateral and Bilateral Eversion Carotid Endarterectomy on Postoperative Hemodynamic Parameters.

Background:Carotid endarterectomy (CEA) is an effective and safe treatment of stenosed carotid arteries, and is a preventive operation with well-defined indications. It is associated with a loss of the baroreceptor reflex and postoperatively increased hemodynamic parameters.Objective:The aim of the study was to confirm the sensitivity of baroreceptors and the impact on arterial pressure and heart rate in unilateral and bilateral eversion carotid endarterectomies.Methods:A retrospective study was conducted with 30 patients treated with E-CEA in local anesthesia at the Clinic for cardiovascular surgery from December 2019 to May 2021, due to stenosis of the carotid arteries. Patients were divided into two groups: 15 patients in group A (patients with unilateral E-CEA; 15 patients in group B: patients with bilateral E-CEA).Results:Out of the total of 30 patients included in the research, 15 patients in groups A and B respectively, there were no statistically significant differences in regards to gender (p= 0,245) and preoperative risk factors: smoking (p=0,449); hypertension (p=0,388); diabetes (p= 0,714); hyperlipidemia (p=0.388), coronary disease (p=0.461) and symptomatic stenosis of the carotid arteries (p=0.449). Noted were the statistically significant differences in values of systolic and diastolic pressure on the 3rd postoperative days in patients with bilateral E-CEA (p=0,001; p=0,001), a statistically significant difference in the heart rate was not found in the analyzed groups in the postoperative period (p=0,225; p=0,994).Conclusion:This study identified statistically significant differences in values of systolic and diastolic pressure in the early postoperative period. In his period, early detection and correction of these hemodynamic disorders are needed.

Sequential Surgical Procedures in Vascular Surgery Patients Are Associated With Perioperative Adverse Cardiac Events.

Patients at elevated cardiovascular risk are prone to perioperative cardiovascular complications, like myocardial injury after non-cardiac surgery (MINS). We have demonstrated in a mouse model of atherosclerosis that perioperative stress leads to an increase in plaque volume and higher plaque vulnerability. Regulatory T cells (Tregs) play a pivotal role in development and destabilization of atherosclerotic plaques. For this exploratory post-hoc analysis we identified 40 patients recruited into a prospective perioperative biomarker study, who within the inclusion period underwent sequential open vascular surgery. On the basis of protein markers measured in the biomarker study, we evaluated the perioperative inflammatory response in patients' plasma before and after index surgery as well as before and after a second surgical procedure. We also analyzed available immunohistochemistry samples to describe plaque vulnerability in patients who underwent bilateral carotid endarterectomy (CEA) in two subsequent surgical procedures. Finally, we assessed if MINS was associated with sequential surgery. The inflammatory response of both surgeries was characterized by postoperative increases of interleukin-6,−10, Pentraxin 3 and C-reactive protein with no clear-cut difference between the two time points of surgery. Plaques from CEA extracted during the second surgery contained less Tregs, as measured by Foxp3 staining, than plaques from the first intervention. The 2nd surgical procedure was associated with MINS. In conclusion, we provide descriptive evidence that sequential surgical procedures involve repeat inflammation, and we hypothesize that elevated rates of cardiovascular complications after the second procedure could be related to reduced levels of intraplaque Tregs, a finding that deserves confirmatory testing and mechanistic exploration in future populations.

ATRİAL FİBRİLASYON NEDENİYLE KAROTİS ENDARTEREKTOMİSİ GEÇİREN HASTALARDA POSTOPERATİF ANTİKOAGÜLAN VE ANTİAGREGAN STRATEJİSİ - TEK MERKEZ TECRÜBESİ

<div><!--block-->Objective: Literature does not contain a standard procedure about anticoagulant therapy aimed at patients with atrial fibrillation and carotid artery stenosis following carotid endarterectomy. In this paper, we present our therapy modality at these patients in our clinic.&nbsp;<br><br>Material and Method: The study includes 424 patients and 498 carotid endarterectomy operations performed by two surgeons with the same technique between June 2010 and December 2017. Fourty-five patients had chronic or paroxysmal atrial fibrillation. Therefore, the patients were receiving Coumadin and aspirin. The median age was 63.4±7.9. There were 27 female and 18 male patients. Thirty seven patients were hypertensive and 17 patients were diabetic. Nine patients underwent bilateral carotid endarterectomy operations. Thirty three patients were symptomatic. Eleven patients had coronary artery disease and 5 patients had cardiac valvular pathologies.&nbsp;<br><br>Results: The whole carotid endarterectomy operations were performed under locoregional anesthesia. Early mortality occured in one patient because of hypertensive intracranial bleeding. The median follow up period was 68.4±19.2 months. One patient was lost due to aging and co-morbid factors and one patient was lost due to malignancy in late follow up period. Three patients required revisions for hematoma at incision region but an active bleeding focus could not be detected. There was no re-stenosis in any patient during follow-up.&nbsp;<br><br>Conclusion: The large and multi-centered studies are needed for the anticoagulant therapy protocol for the patients with atrial fibrillation following carotid endarterectomy. We prefer combination of warfarin, providing INR value between 2-3, and 100 mg aspirin per day at our patients as therapy modality.</div>

Carotid Endarterectomy: The Need for In vivo Optical Spectroscopy in the Decision-Making on Intraoperative Shunt Usage - A Technical Note.

Background:Carotid endarterectomy (CEA) is the surgical excision of the atherosclerotic plaque in patients with severe carotid artery stenosis. It is a common surgical technique required by neurosurgeons that should be mastered. In this article, we provide an outline of the technique and multimodality adjuncts involved in performing an effective CEA with a better surgical outcome.Materials and Methods:We have operated a total of 14 patients in our institute from 2015 to 2018. The male to female ratio is 13:1. Four (28.5%) patients were symptomatic and 10 (71.5%) were asymptomatic; with an average percentage of carotid stenosis being 81.2% in symptomatic and 76.6% in asymptomatic patients. Two patients have undergone bilateral CEA. Intraoperative monitoring was done with continuous in vivo optical spectroscopy (INVOS). Furui's double balloon shunt system was used to maintain blood flow from common carotid artery to the internal carotid artery, thus preventing cerebral ischemia in selected cases with significantly lateralized cerebral oximetry (CO) recordings.Results:Of the 14 patients with 16 CEA procedures, continuous INVOS monitoring was used in 12 CEA procedures. Of the 12 cases, only 5 (41.6%) needed a shunt. Furui's shunt was not used in 7 (58.3%) CEA procedures, where there were no changes in the intraoperative CO and these patients had an uneventful postoperative period. INVOS monitoring not only reduced the use of routine intraoperative shunt but also reduced the total surgical time and thus aided in preventing neurological complications.Conclusion:CEA should be strongly considered for symptomatic patients with >70% of carotid stenosis and in patients with 50%–69% stenosis if no other etiological basis for the ischemic symptoms can be identified. Continuous INVOS monitoring is mandatory for the decision of the use of intraoperative shunt, which reduces the perioperative morbidity and mortality significantly.

Clinical experience of carotid endarterectomy for the treatment of carotid stenosis

Objective To investigate the clinical outcomes and prognosis of carotid endarterectomy (CEA) for moderate to severe carotid stenosis. Method The clinical data of 78 patients with moderate or severe carotid stenosis treated with CEA from March 2015 to December 2017 at Department of Neurosurgery, the First Affiliated Hospital of Zhengzhou University (18 cases) and Department of Neurosurgery, General Hospital of Tianjin Medical University (60 cases) were retrospectively analyzed. There were 72 cases of symptomatic stenosis, 6 cases of asymptomatic stenosis. Among them, there were 66 cases of unilateral stenosis and 12 cases of bilateral stenosis. All patients were treated with standard CEA. There were 72 cases of unilateral CEA and 6 cases of bilateral CEA. A total of 84 CEA operations were performed. Results All operations were performed successfully. The clamping duration was 18.0 to 52.0 minutes, with an average of 28.0±4.2 minutes. During perioperative period, there were 3 new cases of cerebral infarction, including 1 case of massive cerebral infarction and 1 case of transient ischemic attack. The incidence of cerebral ischemic events was 4.8% (4/84). No intracranial hemorrhage or death occurred after operation. All patients were followed up for 6.0 to 38.0 months, with an average of 18.0±3.2 months. There were 4 (4.8%) cases of restenosis (stenosis degree ≥50%) after operation, including 2 cases of cerebral infarction, 1 case of transient ischemic attack and 1 asymptomatic case. Conclusions CEA is an effective treatment for moderate to severe carotid stenosis. Standardized perioperative management and operative procedures could help to reduce postoperative complications and achieve good clinical results. Key words: Endarterectomy, cartoid; Carotid stenosis; Atherosclerosis; Complication

Evaluation of the relationship between plaque formation leading to symptomatic carotid artery stenosis and cytomegalovirus by investigating the virus DNA.

IntroductionThe most common etiologic factor of coronary artery disease (CAD), carotid artery disease, and peripheral artery disease is atherosclerosis. In our study, we aimed to show the effect of cytomegalovirus (CMV), which can occur almost everywhere in the human body, on triggering the chronic inflammatory process in the pathophysiology of atherosclerosis, and its presence and impact in the plaques leading to carotid artery stenosis.Material and methodsThirty-six patients, who underwent carotid endarterectomy at the Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty between April 2017 and April 2018, were included in this study upon their consent. Patients with additional immunosuppressive conditions were not included in the study. Unilateral atheromatous plaque was preferred for patients undergoing bilateral carotid endarterectomy and all risk factors (DM, HT, hyperlipidemia, etc.) were evaluated together for all patients.ResultsWhen the relationship between CMV (DNA) presence in samples taken from patients’ plaques and sex, age and comorbidities was examined, CMV (DNA) positivity (45.8%) was significantly higher in DM patients than non-DM patients (8.3%) (p = 0.024). Likewise, CMV(DNA) positivity (40%) was significantly higher in HT patients than in non-HT patients (25%) (p = 0.008). CMV(DNA) positivity (63%) was significantly higher in patients with bilateral carotid artery stenosis than patients without bilateral carotid artery stenosis (0%) (p < 0.001).ConclusionsIt has not yet been clarified whether CMV is a primary trigger for atherosclerosis on the vascular wall, or whether it presents incidentally due to its affinity. When CMV (DNA) positivity was examined according to the presence of bilateral carotid artery stenosis in our study, CMV (DNA) positivity was found to be significantly higher in patients with bilateral carotid artery stenosis (63.16%).

A single center large cohort study on perioperative complications of carotid endarterectomy of 547 cases

Objective: To analyze the risk factors of perioperative complications within 30 days of carotid endarterectomy(CEA) in the treatment of carotid atherosclerosis stenosis(CAS) during 2011-2017, and to discuss the techniques for reducing the perioperative complication rates. Methods: From August 2011 to August 2017, 486 patients with CAS were retrospective included, and 61 of them underwent bilateral CEA, with a total of 547 cases of CEA included. Perioperative complications were collected within 30 days after operation, and the risk factors related to perioperative complications were analyzed by statistical analysis. Results: In total 547 cases, 12 cases had a postoperative stroke, while 1 case died. A total of 7 cases underwent cranial nerve injury, and 5 cases had an incision related complications. In chi-square test analysis, data suggested that there was a significant difference in the incidence of complications in patients with heart disease, preoperative neurological score difference, contralateral carotid serious stenosis or occlusion and intraoperative shunt in CCA/ICA technique application (P<0.05). In the multivariate Logistic regression, it suggested that poor preoperative neurological score and contralateral carotid serious stenosis or occlusion were independent risk factors for perioperative stroke and death. Conclusion: Our results showed that CEA is effective to prevent stroke and treat patients with CAS. Patients with poor preoperative neurological score and contralateral carotid serious stenosis or occlusion may increase the risk of postoperative stroke rates.

Carotid Endarterectomy in Women versus Man: Patient Characteristics and Perioperative Complication (

AIM:Compare the basic characteristics of patients and to examine the existence of higher rates of perioperative complications (0 - 30 days) in women versus men after carotid endarterectomy (CEA).METHODS:This is a retrospective-prospective study included 270 patients with significant stenosis of carotid in whom CEA was performed, during the period from 2012 to 2017. Patients they were divided: group 1 - 100 female patients, group 2 - 170 male patients.RESULTS:No statistically significant age difference was observed between the two groups, group 1 - 66.01 years (SD 8.42, 46 to 86 years), group 2 - 66.46 years (SD 8.03, 47 to 85 years) (p = 0.659). Risk factors represent a greater prevalence in group 2, but the observed difference is not statistically significant. The average duration of surgery and the time of carotid artery clamping time were longer in group 1: (p = 0.002; p = 0.005). The number of classic endarterectomy with the patch was higher in women (41 (41%) versus 31 (18. 2%), p = 0.005), while the number of bilateral CEAs was not statistically significant.CONCLUSION:The results of this study of this study did not indicate a greater presence of perioperative complications (< 30 days) in women versus male patients after CEA.

Staging bilateral CEA perioperative management of blood pressure

Objective To evaluate the perioperative management of blood pressure in patients with bilateral carotid artery severe stenosis underwent staging carotid endarterectomy (CEA). Methods This retrospective study included 31 patients with bilateral carotid stenosis who underwent bilateral revascularizations in our department from April 2012 to November 2015. Patients were recorded with general information, and the changes of blood pressure in preoperative, intraoperative and postoperative were observed, respectively. Regulation and control of blood pressure were performed according to individual patient's condition. Results Thirty one patients underwent a total of 62 consecutive procedures successfully. Postoperative symptoms disappeared or significantly reduced. Twenty three cases (74.2%) had high perfusion symptoms in the ipsilateral CEA, and 5 cases (16.1%) with high perfusion syndrome in the contralateral surgery. Patients were improved after strict control of blood pressure and dehydration reduced intracranial pressure. The high perfusion symptoms in patients were significantly improved or disappeared after 1 week. Doppler ultrasound was used to evaluate the carotid artery before discharge. Conclusions For patients with bilateral carotid stenosis, staging purposes CEA is safe and effective. However, perioperative blood pressure management is very important. Individual control of blood pressure can significantly reduce the risk of postoperative high perfusion and cerebral infarction. Blood pressure control is recommended after 1 week in about 85% of preoperative blood pressure. Key words: Endarterectomy, carotid; Intraoperative period; Blood pressure

A Retrospective 10-Year, Single-Institution Study of Carotid Endarterectomy with a Focus on Elderly Patients.

Background and PurposeThis study evaluated the outcome following surgery for carotid artery stenosis in a single institution during a 10-year period and the relevance of aging to access to surgery.MethodsBetween January 2001 and December 2010, 649 carotid endarterectomies (CEAs) were performed in 596 patients for internal carotid artery occlusive disease at our institution; 596 patients received unilateral CEAs and 53 patients received bilateral CEAs. Data regarding patient characteristics, comorbidities, stroke, mortality, restenosis, and other surgical complications were obtained from a review of medical records. Since elderly and high-risk patients comprise a significant proportion of the patient group undergoing CEAs, differences in comorbidity and mortality were evaluated according to age when the patients were divided into three age groups: <70 years, 70-79 years, and ≥80 years.ResultsThe mean age of the included patients was 67.5 years, and 88% were men. Symptomatic carotid stenosis was observed in 65.7% of patients. The rate of perioperative stroke and death (within 30 days of the procedure) was 1.84%. The overall mortality rate was higher among patients in the 70-79 years and >80 years age groups than among those in the <70 years age group, but there was no significant difference in stroke-related mortality among these three groups.ConclusionsCEA over a 10-year period has yielded acceptable outcomes in terms of stroke and mortality. Therefore, since CEA is a safe and effective strategy, it can be performed in elderly patients with acceptable life expectancy.

Dynamics of cognitive functions condition in patients after bilateral carotid endarterectomy

Dynamics of cognitive functions condition in patients after bilateral carotid endarterectomy

Treatment Strategy for Bilateral Severe Carotid Artery Stenosis: One Center's Experience

To describe 1 center's experience using carotid artery stenting (CAS) or carotid endarterectomy (CEA) as a treatment strategy in patients with bilateral carotid artery stenosis. Patients with severe carotid artery stenosis, including bilateral carotid artery stenosis, treated by CEA or CAS during the period 2008-2013 were reviewed retrospectively. The selection of treatment depended on the individual patient's medical comorbidities, neurologic condition, and clinical and anatomic arterial factors. The main adverse events included death from any cause, major stroke within 30 days, and death between 30 days and 1 year later from the treated carotid artery or ipsilateral major stroke. There were 27 patients with bilateral carotid artery stenosis treated, including 11 patients with bilateral CEA, 9 patients with CEA on one side and CAS on the other side, and 7 patients with bilateral CAS. Of patients with unilateral carotid artery stenosis, 69 were treated with CEA, and 75 were treated with CAS. The incidence of main adverse events for the bilateral patients was 7.4%, similar to the unilateral patients undergoing CEA and CAS (8.7% and 6.7%, respectively). Restenosis occurred in 4 treated carotid arteries in bilateral patients within 1 year (4 of 54 [7.4%]); this was not significantly different from unilateral patients undergoing CEA and CAS (4 of 69 [5.8%] and 6 of 75 [8.0%], respectively). Local complications were not more frequent in bilateral patients. Good outcomes can be achieved in patients with bilateral carotid artery stenosis when treatment selection is based on each individual patient's clinical characteristics and with a proper combination of staged CEA and CAS.

Clinical outcomes of staged bilateral carotid endarterectomy for bilateral carotid artery stenosis.

PurposeThis retrospective cohort study aimed to determine the clinical outcomes of staged bilateral carotid endarterectomy (CEA) for bilateral internal carotid artery (ICA) stenosis performed with a short interval between the primary and secondary CEA procedures.MethodsIn our institution, 574 consecutive patients underwent CEA between September 2007 and August 2014. Bilateral significant ICA stenosis was identified in 43 patients (7.5%) who underwent staged bilateral CEA within 30 days or less. Patients with unilateral CEA and staged bilateral CEA were compared in terms of CEA outcomes. The primary endpoint was the composite of any stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke within 3 years after the CEA.ResultsStaged bilateral CEA was not associated with ipsilateral stroke (P = 0.178) during postoperative follow-up. The two groups did not differ in terms of estimated 3-year primary endpoint rates (2.8% vs. 4.7%, P = 0.456) or ipsilateral stroke-free (P = 0.225), any stroke-free (P = 0.326), or overall (P = 0.739) survival rates.ConclusionPatients with bilateral significant ICA stenosis can undergo staged bilateral CEA within 30 days or less with outcomes that compare favorably with those of patients undergoing unilateral CEA.

The clinical evaluation of staged bilateral carotid endarterectomy

Objective To evaluate the clinical efficacy and strategy of staged bilateral carotid endarterectomy(SBCEA) for patients with bilateral severe carotid atherosclerotic stenosis.Methods 33 patients with bilateral carotid atherosclerotic severe stenosis (70％-99％) were admitted to our hospital from March 2009 to March 2013.The patients all were diagnosed carotid atherosclerotic stenosis according to clinical manifestations,carotid CDFI,TCD,carotid and brain DSA/CTA/MRA.All of patients underwent staged bilateral CEA by general anesthesia without intraoperative shut,therein 13 of them by sCEA and the others by eCEA.The time interval between two stages was from 0.5 to 10 months,and the average was 1.5 months.Results The clinical manifestations were all improved after operation,and there was no mortality and stroke complications postoperatively.All of the patients were followed-up for 1-36 months after surgery,no stroke or other severe complications were found and the quality of life was improved.Conclusions It is safe and effective that patients with bilateral severe carotid atherosclerotic stenosis undergo staged bilateral carotid endarterectomy.There is no significant difference in prognosis,even though the time interval between two stages has no influence on outome. Key words: Staged bilateral carotid endarterectomy; Bilateral carotid atherosclerotic stenosis; Clinical efficacy; Surgical strategy; Time interval

Letter to the Editor Fracture of a carotid stent and restenosis of common carotid artery

Letter to the Editor Fracture of a carotid stent and restenosis of common carotid artery

The incidence of microemboli to the brain is less with endarterectomy than with percutaneous revascularization with distal filters or flow reversal

Current data suggest microembolization to the brain may result in long-term cognitive dysfunction despite the absence of immediate clinically obvious cerebrovascular events. We reviewed a series of patients treated electively with carotid endarterectomy (CEA), carotid artery stenting (CAS) with distal filters, and carotid stenting with flow reversal (FRS) monitored continuously with transcranial Doppler scan (TCD) during the procedure to detect microembolization rates. TCD insonation of the M1 segment of the middle cerebral artery was conducted during 42 procedures (15 CEA, 20 CAS, and 7 FRS) in 41 patients seen at an academic center. One patient had staged bilateral CEA. Ipsilateral microembolic signals (MESs) were divided into three phases: preprotection phase (until internal carotid artery [ICA] cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection phase (until clamp/shunt was removed, filter removed, or antegrade flow re-established), and postprotection phase (after clamp/shunt was removed, filter removed, or antegrade flow re-established). Descriptive statistics are reported as mean ± SE for continuous variables and N (%) for categorical variables. Differences in ipsilateral emboli counts based on cerebral protection strategy were assessed using nonparametric methods. TCD insonation and procedural success were obtained in 33 procedures (79%; 14 CEA, 14 CAS, and 5 FRS). Highest ipsilateral MESs were observed for CAS (319.3 ± 110.3), followed by FRS (184.2 ± 110.5), and CEA (15.3 ± 22.0). Pairwise comparisons revealed significantly higher ipsilateral MESs with both FRS and CAS when compared to CEA (P = .007 for FRS and P < .001 for CAS vs CEA, respectively), whereas the difference in MESs between FRS and CAS was not significant (P = .053). Periods of maximum embolization were postprotection phase for CEA, protection phase for CAS, and preprotection phase for FRS. Preprotection MESs were frequently observed during both CAS and FRS (20.4% and 63.3% of total MESs across all phases, respectively), and the primary difference between these two methods seemed to be related to lower MESs during the protection phase with FRS. CEA is associated with lower rates of microembolization compared with carotid stenting. Flow reversal may represent a procedural modification with potential to reduce microembolization during carotid stenting; further investigation is warranted to determine the relationship between cerebral protection strategies and outcomes associated with carotid stenting.

Carotid Artery Pseudoaneurysm

Introduction The development of a carotid artery pseudoaneurysm (PA) after carotid endarterectomy is a rare complication with a reported incidence of 0.25% to 0.74%. It results from suture line failure or disruption, degeneration of the arterial wall, or patch material and/or infection. Patients present with neck swelling and pain that can be complicated by thrombosis, rupture, or infection. Case Report We describe a 72-year-old man who underwent bilateral carotid endarterectomies in 1987. He presented with bilateral upper-extremity swelling after a kidney transplant. An upper-extremity venous duplex performed with a Philips iU22 (Bothell, WA) with an 8-4 MHZ linear transducer revealed normal phasic pulsed Doppler waveforms. Compression images of the patient's left side of the neck revealed acute thrombus within the internal jugular vein. An incidental finding of bilateral common carotid PAs at their proximal patch surgical sites was noted. The right carotid PA measured 1.8 × 2.6 cm, whereas the left measured 2 × 1.3 cm. Discussion Carotid artery PA has been reported within 2 days or as late as 22 years after surgery. A true carotid aneurysm is usually caused by atherosclerosis or arteritis, whereas a carotid artery PA develops after endarterectomy as the result of infection, suture line disruption, or degeneration of the arterial wall or at the patch angioplasty site. A potential for rupture, embolization, thrombosis, or compression of the cranial nerves requires urgent attention. The conventional treatment approach is excision and repair via a vein graft. However, the risk of complications, especially cranial nerve injury, is high. A reasonable alternative to open surgery is covered carotid artery stenting if infection is excluded as the etiology of the pseudoaneurysm. Conclusion Although the diagnosis of carotid artery PA is usually suspected clinically, an imaging procedure is necessary for confirmation. Duplex scanning is the gold standard that can be augmented by arteriography or magnetic resonance imaging.

Predictors of Electroencephalographic Changes Needing Shunting During Carotid Endarterectomy

Carotid endarterectomy (CEA) is associated with a risk of cerebral ischemia during carotid clamping, hence various cerebral protection strategies, including pharmacological management and routine or selective shunting, are commonly available. This study aimed to analyze the results of CEA with intraoperative electroencephalographic (EEG) monitoring to identify factors associated with EEG changes consistent with cerebral ischemia which needed shunting. A prospectively compiled, computerized database of all primary CEAs performed at our institution with EEG monitoring for symptomatic or asymptomatic severe carotid lesions between January 1990 and June 2009 was analyzed. In all, 1,914 CEA procedures were performed on 1,696 patients, of which 218 had staged bilateral CEAs. EEG changes were recorded in 392 patients (20.5%), but a shunt was inserted during 312 CEA procedures (16.3%). Multivariate analysis showed that a symptomatic presentation (odds ratio [OR], 1.37; 95% confidence intervals [CI], 1.07-1.76; p = 0.012), prior stroke (OR, 2.28; 95% CI, 1.66-3.13; p < 0.001), contralateral carotid occlusion (OR, 2.14; 95% CI, 1.18-3.91; p = 0.019), and moderate (<80%) ipsilateral carotid disease (OR, 1.95; 95% CI, 1.08-3.52; p = 0.033) predicted the need for shunting. EEG was an excellent detector of cerebral ischemia and a valuable tool in guiding the need for shunting. Patients who were symptomatic or had a history of stroke, a contralateral carotid occlusion, or an ipsilateral moderate carotid stenosis were more prone to EEG changes consistent with cerebral ischemia. Surgeons should consider EEG changes during clamping as an effective criterion for selective shunting.