Carotid Artery Cross-clamping Research Articles

Co-administration of dexmedetomidine with total intravenous anaesthesia in carotid endarterectomy reduces requirements for propofol and improves haemodynamic stability: A single-centre, prospective, randomised controlled trial.

Total intravenous anaesthesia guided by electroencephalography and neurophysiological monitoring may be used for carotid endarterectomy. Reduction of brain metabolic demand during cross-clamping of the internal carotid artery with propofol titrated to burst suppression requires effect-site concentrations that may delay emergence and interfere with intraoperative neurophysiological monitoring. To test the hypothesis that dexmedetomidine decreases the effect-site concentration of propofol required for burst-suppression in patients undergoing carotid endarterectomy. Randomised controlled trial. Patients undergoing carotid endarterectomy. University Hospital of Berne, Switzerland, from October 2018 to September 2024. Patients were randomised into a control (n = 23) and a dexmedetomidine groups (n = 22). Total intravenous anaesthesia was administered to both groups. Patients in the dexmedetomidine group received an intravenous bolus of dexmedetomidine (0.4 μg kg-1 over 10 min) before induction, followed by a continuous intravenous infusion (0.4 μg kg-1 h-1). The effect-site concentrations of propofol were titrated against frontal electroencephalography parameters. Burst suppression was induced with propofol during cross-clamping of the internal carotid artery. The primary outcome was the effect-site concentration of propofol required for burst-suppression. The secondary outcomes were the requirement for vasoactive substances, neurophysiological monitoring parameters, and postoperative delirium. The effect-site concentration of propofol required for burst suppression was 4.0 μg ml-1 [3.50 to 4.90] (median [interquartile range]) in the dexmedetomidine group compared with 6.0 μg ml-1 [5.5 to 7.3] in the control group (P < 0.001). Less norepinephrine was required in the dexmedetomidine group (total 454 μg [246 to 818] compared with 1000 μg [444 to 1326] (P = 0.015) in the control group). Dexmedetomidine did not affect intraoperative neurophysiological monitoring. Co-administration of dexmedetomidine to total intravenous anaesthesia for carotid endarterectomy decreased the effect-site concentrations of propofol required for burst suppression by 33%. The propofol-sparing effect and peripheral alpha-agonism of dexmedetomidine may explain the reduced requirement for vasopressors. Clinicaltrials.gov identifier: NCT04662177.

Prospective single-center study on the reliability of ipsilateral cerebral oximetry using near-infrared spectroscopy as a predictor for selective shunting during carotid endarterectomy.

Many techniques are available for the intraoperative assessment of brain perfusion during carotid endarterectomy, such as carotid stump pressure, near-infrared spectroscopy, somatosensory evoked potentials, transcranial Doppler, electroencephalography, and clinical assessment. The decision for selective carotid shunt insertion is dependent on clinical deterioration or the detection of cerebral hypoperfusion after cross-clamping of the internal carotid artery. Monitoring cerebral oximetry using near-infrared spectroscopy is a noninvasive technique for cerebral oxygen saturation measurement, reflecting changes in cerebral blood flow during carotid endarterectomy. The aim of this study was to evaluate the reliability of near-infrared spectroscopy as a predictor of selective shunting during carotid endarterectomy. In total, 47 conventional carotid endarterectomy surgeries were performed at our hospital between March 2016 and December 2021. All surgeries were performed under a regional cervical block supplemented with local infiltration anesthesia. All patients were monitored by cerebral oximetry using bilateral near-infrared spectroscopy probes and clinical assessment through communication with the patient (numerical, visual, and verbal) to indicate a selective shunt. Near-infrared spectroscopy values were recorded before and after internal carotid cross-clamping and after declamping. Any decrease in ipsilateral cerebral oximetry-near-infrared spectroscopy values equal to or more than 20% from the pre-clamping baseline reading associated with deterioration in neurological status (hemiparesis, aphasia, or deterioration in level of consciousness) after internal carotid artery cross-clamping was considered an indication for intraluminal carotid shunting. After internal carotid artery cross-clamping, 5 of 47 patients (10.6%) developed a significant drop in cerebral oxygen saturation associated with obvious clinical assessment deterioration in verbal communication and weakness in contralateral arm power. A Pruitt-Inahara carotid shunt was subsequently inserted, and 42 patients remained stable throughout surgery. The average decline in ipsilateral near-infrared spectroscopy values was 23.8% in patients with clinical deterioration. The average decline was 8.6% in patients who remained stable. Monitoring ipsilateral cerebral oximetry using near-infrared spectroscopy is an easy and reliable method for indicating selective shunting during carotid endarterectomy. A 20% decrease in ipsilateral brain tissue oximetry after internal carotid artery cross-clamping provides a reliable cut-off value for selective intraluminal carotid shunting during carotid endarterectomy.

Application of Artificial Intelligence to Assess the Risks of Simultaneous Operations for Patients with Concomitant Atherosclerotic Damage of Coronary and Carotid Arteries.

The aim of the study is to assess the possibility of using artificial intelligence to determine the most significant predictors of the operative correction outcomes for patients with damaged coronary and carotid arteries.Materials and MethodsThe retrospective study of the simultaneous (or single-stage) surgical intervention results has been carried out in patients with combined atherosclerotic damage of the coronary bed and cerebral arteries (n=42), which was severe and extensive. The parameters which may be predictors of the cardiovascular risk were analyzed using the TADA program. Ten models were built for program learning. The model with 92% predictive accuracy appeared to be the most successful.ResultsSimultaneous correction resulted in the absence of 30-day coronary complications in all patients. With respect to the cerebral vascular territory, acute ischemic stroke developed in 2 patients. The lethality rate was 2.4%, the fatal outcome was caused by postoperative gastrointestinal bleeding.The TADA program model considered the following parameters to be the most significant predictors: internal carotid artery cross-clamping time in minutes (51.24%); damage to the left coronary artery stem (30.42%); diastolic AP (18.28%). If cross-clamping of the internal carotid artery lasts for less than 18 min, complications are not likely to occur, while they are practically inevitable if the time exceeds 46 min. The probability of complications grows nonlinearly with the increase of the extent of the left coronary artery stem injury. A high diastolic AP never virtually coincides with the presence of complications, nor does the low one. The highest probability of complications is at the values from 70 to 80 mm Hg.In patients with a triple vessel injury of the coronary arteries, a representative picture of a nonsignificant feature is observed.ConclusionApplication of artificial intelligence for determining risk predictors for patients with concurrent atherosclerotic damage of the coronary and carotid arteries is an effective method for prognosticating the risks of simultaneous interventions.

Prediction of Cross-Clamp-Induced Cerebral Ischemia During Carotid Endarterectomy Using Arterial Blood Flow Assessment

BackgroundCross-clamping during carotid endarterectomy (CEA) is associated with the risk of cerebral ischemia. Various studies have evaluated different criteria for detecting cerebral ischemia, but difficulties arise when ischemic changes appear after the carotid artery is cross-clamped and incised. Here, we explored a parameter that can predict cerebral ischemia prior to cross-clamping during CEA using a blood-flow meter. MethodsThe carotid arterial blood flow was measured directly (direct ABF) in the common carotid artery prior to cross-clamping. The anatomical information in preoperative magnetic resonance imaging, cerebral blood flow in xenon-enhanced computed tomography, and carotid peak systolic flow velocity by carotid echo from the skin surface were also evaluated. A decrease in the short-latency somatosensory evoked potentials (SSEP) during cross-clamping to insert a shunt was assessed, and a decrease in amplitude of ≥ 50% was considered an indicator for cerebral ischemia. Surgery was performed under general anesthesia, and a shunt was inserted in all cases. ResultsOf 156 CEA patients between April 2013 and March 2020, 30 had decreased SSEP during cross-clamping. The baseline characteristics and intra- and postoperative findings were not significantly different between patients with and without a decrease in SSEP. Among the evaluated parameters, only the direct-ABF ratio (ABF-internal carotid artery/ABF-common carotid artery) differed significantly between the 2 groups (P = 0.011). The direct-ABF ratio ≤ 0.58 was predictive of cerebral ischemia during CEA. ConclusionsDirect-ABF measurement with an ultrasonic blood-flow meter can be useful for predicting cerebral ischemia prior to carotid artery cross-clamping during CEA.

The effect of normotensive arterial pressure on cerebral saturation during carotid endarterectomy

Aim: Monitoring of cerebral perfusion during carotid endarterectomy helps to institute early intervention to prevent risk of ischemia during the operation.&#x0D; We aimed to evaluate if the disadvantages of high systemic pressure can be avoided by keeping arterial blood pressure below 150mmHg during cross-clamping of the internal carotid artery by correlating our findings of NIRS values with clinical results&#x0D; Material and Method: This was designed as a prospective study that included elective patients scheduled for an operation of carotid artery stenosis under general anesthesia. A total of 60 patients operated on between August and October 2019 were included in the study. &#x0D; Results: Patients' NIRS findings on the right and left hemispheres were analyzed separately to be able to differentiate any possible changes of NIRS of the cerebral hemisphere ipsilateral to the clamped carotid artery. The analysis of the right and left NIRS findings in these 60 patients revealed a significant decrease between intubation and incision NIRS values (p=0.008 and p= 0.02respectively). &#x0D; Conclusion: Considering the NIRS findings and clinical observations of the patients in the postoperative period, we think that ICA endarterectomy operations may be safe to perform in a suitable patient group while the systolic arterial blood pressure is maintained below 150mmHg during cross-clamping.

Benefit of selective shunt use during carotid endarterectomy under regional anesthesia.

Carotid cross-clamping during endarterectomy exposes the patient to intraoperative neurological deficits due to embolism or cerebral hypoperfusion. To prevent further cerebrovascular incidents, resorting to shunt is frequently recommended. However, since this method is also considered a stroke risk factor, the use is still controversial. This study aims to shed some light on the best approach regarding the use of shunt in symptomatic cerebral malperfusion after carotid artery cross-clamping. From January 2012 to January 2018, 79 patients from a tertiary referral hospital who underwent carotid endarterectomy with regional anesthesia for carotid artery stenosis and manifested post-clamping neurologic deficits were prospectively gathered. Shunt use was left to the decision of the surgeon and performed in 31.6% (25) of the patients. Demographics, comorbidities, imaging tests, and clinical/intraoperative features were evaluated. For data assessment, univariate analysis was performed. Regarding 30-day stroke, 30-day postoperative complications (stroke, surgical hematoma, hyperperfusion syndrome), and cranial nerve injury, no significant differences were found (P = 0.301, P = 0.460, and P = 0.301, respectively) between resource to shunt and non-shunt. Clamping and surgery times were significantly higher in the shunt group (P < 0.001 and P = 0.0001, respectively). Selective-shunting did not demonstrate superiority for patients who developed focal deficits regarding stroke or other postoperative complications. However, due to the limitations of this study, the benefit of shunting cannot be excluded. Further randomized trials are recommended for precise results on this matter with current sparse clinical evidence.

Application of near-infrared spectroscopy in carotid endarterectomy

Carotid endarterectomy (CEA) is effective treatment approach to prevent stroke in both symptomatic and asymptom-atic patients with carotid artery stenosis. However, cerebral hypoperfusion during carotid artery cross-clamping may lead to periopera-tive stroke, and nerve monitoring can be helpful in detection of cerebral ischemia, so as to take relevant treatment therapy. Near-infra-red spectroscopy (NIRS) measures the changes of regional cerebral oxygen saturation (rSO2) which can reflect intracranial perfusion, so as to determine the occurrence of cerebral ischemia. Its technique is simple and non-invasive, and can perform continuous and re-al-time monitoring during CEA. In this paper, the practicality and accuracy of various intraoperative neuro-monitoring techniques for CEA were analyzed in combination with the latest domestic and foreign studies in recent years. This paper focuses on various intraoper-ative neuro-monitoring techniques in CEA, the correlation between NIRS and other monitoring techniques, and the role of NIRS in pre-dicting intraoperative ischemia and postoperative hyperperfusion, which can further understand the clinical role of NIRS, so as to facili-tate its application in clinical setting. Key words: Carotid endarterectomy; Near-infrared spectroscopy; Cerebral ischemia; Cerebral oximetry; Cerebral hy-perperfusion syndrome

Cerebral protection from ischaemia during carotid endarterectomy

The purpose of this study was to assess efficacy of cerebral protection during carotid endarterectomy by means of controlled systemic hypertension in patients presenting with various levels of retrograde pressure in the internal carotid artery. The study enrolled a total of 150 patients subjected to carotid endarterectomy. The operation was carried out under general anaesthesia with artificial pulmonary ventilation and was accompanied by haemodynamic monitoring with invasive control of arterial pressure, as well as primary and additional correction of central haemodynamics. Cerebral perfusion was assessed by measuring retrograde pressure in the internal carotid artery. The retrograde pressure index was calculated, according to which the patients were subdivided into three groups: those with values less than 30, with values from 30 to 39, and with values of 40 and more. Controlled systemic arterial hypertension was used as cerebral protection during the period of cross-clamping of the internal carotid artery, with phenylephrine and norepinephrine administered for this purpose. The parameters of central haemodynamics, time intervals of the operation, and the duration of internal carotid artery cross-clamping in the groups did not statistically differ (p>0.05). A statistically significant difference was revealed in the level of systolic arterial pressure necessary for cerebral protection (p<0.05). There were no cerebral circulation impairments, myocardial infarctions, nor lethal outcomes. A conclusion was drawn that individualized correction of central haemodynamics ensured a sufficient level of collateral compensation of the cerebral blood flow, thus making it possible to refuse from using intraluminal shunts.

Meta-analysis of the results of eversion carotid endarterectomy and endarterectomy with patch plasty

The study was aimed at comparing the results of eversion carotid endarterectomy and carotid endarterectomy with patch plasty in the immediate and remote postoperative periods. The literature was retrieved by means of electronic databases, with the dates of publications ranging from 1970 to 2019. According to the inclusion and exclusion criteria we selected the literature making it possible to carry out a meta-analysis in the immediate and remote postoperative periods. The results were obtained with the help of the Stata 14 software package. Eventually, we retrieved and analysed a total of 2139 articles. Of these, ten were included into the study and contained 3568 patients subjected to 3672 operations (eversion carotid endarterectomy - 1718 and carotid endarterectomy with a patch - 1954). The results of the meta-analysis were as follows: the mean time of carotid artery cross-clamping for eversion carotid endarterectomy was shorter than that for carotid endarterectomy with a patch (4.1±2.9 min); the frequency of using intraoperative temporary bypass in eversion carotid endarterectomy turned out to be significantly less compared with carotid endarterectomy with patch plasty - 13.5% (91/672) and 62.0% (492/793), OR=0.183, 95% CI: 0.136-0.254, p<0.001; the incidence rate of ischaemic stroke in the immediate and remote postoperative periods was significantly lower after eversion carotid endarterectomy than that after carotid endarterectomy with patch plasty - OR=0.452, 95% CI: 0258-0.792, p=0.005 and OR=0.300, 95% CI; 0.155-0.579, p=0.000. The development of restenosis in the immediate and remote postoperative periods was observed less often for eversion carotid endarterectomy compared with carotid endarterectomy with patch plasty - OR=0.604, 95% CI: 0.422-0.864, p=0.006. Eversion carotid endarterectomy was associated with shorter time of carotid artery cross-clamping, lower frequency of intraoperative temporary bypass, lower number of cases of ischaemic stroke in the immediate and remote postoperative periods, as well as those of restenosis in the long-term postoperative period.

Limitations of median nerve somatosensory evoked potential monitoring during carotid endarterectomy.

Hypoperfusion during carotid artery cross-clamping (CC) for carotid endarterectomy (CEA) may result in the major complication of perioperative stroke. Median nerve somatosensory evoked potential (MNSSEP) monitoring, which is an established method for the prediction of cerebral ischemia, has low sensitivity in detecting such hypoperfusion. In this study the authors sought to explore the limitations of MNSSEP monitoring compared to tibial nerve somatosensory evoked potential (TNSSEP) monitoring for the detection of CC-related hypoperfusion. The authors retrospectively analyzed data from patients who underwent unilateral CEA with routine shunt use. All patients underwent preoperative magnetic resonance angiography and were monitored for intraoperative cerebral ischemia by using MNSSEP, TNSSEP, and carotid stump pressure during CC. First, the frequency of MNSSEP and TNSSEP changes during CC were analyzed. Subsequently, variables related to stump pressure were determined by using linear analysis and those related to each of the somatosensory evoked potential (SSEP) changes were determined by using logistic regression analysis. A total of 94 patients (mean age 74 years) were included in the study. TNSSEP identified a greater number of SSEP changes during CC than MNSSEP (20.2% vs 11.7%; p < 0.05). Linear regression analysis demonstrated that hypoplasia of the contralateral proximal segment of the anterior cerebral artery (A1 hypoplasia) (p < 0.01) and hypoplasia of the ipsilateral precommunicating segment of the posterior cerebral artery (P1 hypoplasia) (p = 0.02) independently and negatively correlated with stump pressure. Both contralateral A1 hypoplasia (OR 26.25, 95% CI 4.52-152.51) and ipsilateral P1 hypoplasia (OR 8.75, 95% CI 1.83-41.94) were independently related to the TNSSEP changes. However, only ipsilateral P1 hypoplasia (OR 8.76, 95% CI 1.61-47.67) was independently related to MNSSEP changes. TNSSEP monitoring appears to be superior to MNSSEP in detecting CC-related hypoperfusion. Correlation with stump pressure and SSEP changes indicates that TNSSEP, and not MNSSEP monitoring, is a reliable indicator of cerebral ischemia in the territory of the anterior cerebral artery.

Safety of perioperative cerebral oxygen saturation during debranching in patients with incomplete circle of Willis.

The consequences of common carotid artery (CCA) cross-clamping during debranching before thoracic endovascular aortic repair are unclear. We examined the safety of a simple CCA cross-clamping procedure under regional cerebral oxygen saturation monitoring (rSO2) in patients with a complete or incomplete circle of Willis (CoW) anatomy. Twenty-eight patients with thoracic aneurysm underwent elective debranching thoracic endovascular aortic repair with bilateral frontal rSO2 monitoring at our institution between January 2012 and October 2015. Before CCA cross-clamping, we maintained a systemic mean arterial pressure of >100 mm Hg with a vasopressor. We recorded the bilateral frontal rSO2 before, during and after CCA cross-clamping. The CoW was incomplete in 11 (39.3%) patients. Of these, 6 patients had a complication of ischaemic potential. The left frontal rSO2 was <50% in 3 patients but did not fall below 40%. Compared with baseline values (mean ± SD 64.6 ± 6.9%), the left frontal rSO2 showed no significant change perioperatively in those with a complete CoW on the left CCA cross-clamping (during: 61.0 ± 7.9%, P = 0.17; after: 65.1 ± 5.9%, P = 0.09). In patients with an incomplete CoW with ischaemic potential, the left frontal rSO2 did not change significantly after cross-clamping (baseline: 59.8 ± 3.2%, during: 55.5 ± 5.0%; P = 0.10) but increased significantly on declamping (62.8 ± 4.5%, P = 0.023). The extent of the changes in the mean left frontal rSO2 on clamping and declamping decreased and increased by 7.3% and 11.7%, respectively, in patients with an incomplete CoW, when compared with 5.3% and 5.8% in those with a complete CoW (P = 0.65 and 0.31, respectively). No perioperative cerebrovascular events were observed. Simple CCA cross-clamping during debranching was safe when arterial pressure was supported and rSO2 was monitored, even with an incomplete CoW and ischaemic potential.

One-year experience in carotid endarterectomy combining general anaesthesia with preserved consciousness and sequential carotid cross-clamping.

Background and aim of the work: We report 1-year single-centre experience in carotid endarterectomy (CEA) combining general anaesthesia with preserved consciousness (GAPC) and standardized carotid sequential cross-clamping, for our protocol effectiveness evaluation in reduction of perioperative stroke, death or cardiologic complications. Methods: We considered all patients who underwent CEA in 2016. All patients underwent superficial cervical plexus block and GAPC with Remifentanil. The surgical technique consisted of common carotid artery (CCA) cross-clamping, carotid bifurcation isolation, external (ECA) and internal carotid artery (ICA) cross-clamping. After CCA cross-clamping, we performed a neurological tolerance test (NTT); this allowed selective shunting only for positive NTT. Primary end-points were: transient ischemic attack (TIA)/stroke, myocardial infarction, death in perioperative period. Secondary end-points were: carotid shunting, peripheral cranial nerves injuries (PCNI), GAPC intolerance, other complications, reintervention in perioperative period, length of hospital stay. Results: 104 consecutive patients underwent CEA with this protocol in the considered period. Twenty-seven (25.9%) patients were symptomatic. Mean clamping time was 48±13.5 minutes. Five cases (4.8%) requested internal carotid artery shunting. No TIA/stroke, myocardial infarction or death were recorded in the perioperative period. PCNI were observed in 19 cases (18.2%) in the immediate post-operative period; 16 of them (84.2%) showed complete or partial resolution at discharge. Only one patient (0.9%) showed GAPC intolerance. No other complication occurred. Three patients (2.9%) underwent reintervention for neck haematoma drainage. Mean hospital stay were 3±0.9 days. Conclusions: GAPC associated with sequential carotid cross-clamping appeared to be safe and effective in prevention of major neurological and cardiologic complications during CEA. (www.actabiomedica.it)

A “Hybrid” Hybrid Approach - Aortic Debranching Using a Trifurcate Graft for Arch and Descending Thoracic Aortic Aneurysm Repair With the Thoraflex™ Hybrid Graft

Purpose: Pathology of the aortic arch and descending thoracic aorta poses many unique challenges for the cardiovascular surgeon. The Thoraflex™ hybrid device for the “frozen elephant trunk” procedure simplifies management of the descending thoracic aorta, whilst allowing anastomosis of the head and neck vessels to the proximal graft. We report our modification to the technique, involving the use of the Trifurcate Graft with Side Branch (Vascutek-Terumo Ltd, Ann Arbor, MI, USA) to improve the ease of arch vessel control and ensure continuous selective anterior cerebral perfusion. Methodology: Via median sternotomy and central cannulation, the patient is placed on cardiopulmonary bypass and cooled to 20 °C. The arch and neck vessels are identified. After cross-clamping and administration of cardioplegia, the brachiocephalic and left common carotid artery are anastomosed to the trifurcate graft between clamps, and perfusion to the head is maintained via the side branch. Following this, the arch is excised under a short period of circulatory arrest, and the Thoraflex™ hybrid graft is deployed into the descending aorta, and an anastomosis made to the sewing cuff. The proximal anastomosis is then made to the ascending aorta after re-establishment of systemic perfusion. The left subclavian artery is then anastomosed to the trifurcate graft, and the trifurcate graft is anastomosed to residual ascending aorta in an end-to-side fashion. Results: We have two cases that have been solved using this approach. We present surgical pictures, and intraoperative imaging.

Aortic arch reconstruction in surgical treatment of ascending aortic aneurysms and dissections

Aim. The study focused on the analysis of short-term results of aortic arch reconstruction in patients undergoing open heart surgery for ascending aortic aneurysms and dissections, comparison of intra-operative brain protection methods and verification of predictors of complications.Methods. 84 patients (mean age 55.5 ± 11.5 years, 72.6 % (61) males) with ascending aortic aneurysms and Stanford type A ascending aortic and arch dissections underwent surgery over a period from January, 2013, to March, 2015. Patients were divided into 3 groups. The 1st group included patients with ascending aortic aneurysm combined with aortic dilatation at the level of innominate artery &gt;4.0 cm (n = 41). The 2nd group consisted of patients with Stanford type A acute ascending aortic and arch dissection (n = 25). In the 3rd group there were patients with type A chronic ascending aortic and arch dissection (n = 18). No significant differences between the groups were observed. Mean values of the maximum ascending aortic diameter did not differ significantly and were 59.6, 58.4 and 62.4 mm in the 1st, 2nd and 3rd groups, respectively. 3 patients from the 2nd group presented with acute heart failure, 6 – acute myocardial infarction, and 3 – stroke. Higher values of pressure gradient on the aortic valve were registered in the 1st group, as compared to those in the 2nd and 3rd groups (mean value of the peak gradient was 4.5, 8.1 and 12.4 mm Hg, respectively). EuroSCORE II value in the 1st , 2nd and 3rd groups was 9.4 %, 17.7 % and 5.8 %, respectively. Results. Overall hospital mortality was 1.2 %: 1 patient with acute type A aortic dissection and later dissection of innominate artery developed stroke and died due to multiple organ failure. More prolonged cardiopulmonary bypass time and aortic cross-clamp time were required for patients with acute ascending aortic dissections, but the total surgery time and circulatory arrest time differed significantly only in the 2nd and 3rd groups. Lengthy inotropic support, ventilation time and total ICU stay, as well as a higher rate of neurologic disorders in patients with aortic dissections in comparison with patients with aneurysms were observed. We verified correlation of the urgent type of surgery, acute type A aortic dissection, including arch and descending thoracic aortic dissection, also with dissection of cervicocerebral arteries, with a more complicated hospital period, increased inotropic support and prolonged duration of stay in the intensive care unit.Conclusion. Hemiarch repair of aortic arch dilatation in case of ascending aortic replacement is an effective and safe method of treatment of extended ascending aortic aneurysms and dissections. Unilateral anterograde cerebral perfusion with simultaneous crossclamping of contralateral common carotid artery allows to maintain effective cerebral protection in conditions of moderate hypothermia and duration of circulatory arrest for at least 30-40 minutes. Adverse prognostic factors are urgent surgery, ascending aortic, arch and descending thoracic aortic dissection, prolonged extracorporeal circulation and myocardial ischemia, and disuse of the axillary artery for cannulation.Received 6 October 2016. Accepted 24 November 2016.Funding: The study was carried out within the government’s task for 2015-2017, “Cardiovascular pathologies”, theme No. 4 “Research on genome and cellular mechanisms of formation of aorta and aortic valve pathology and development of new methods for its treatment including hybrid technologies”.Conflict of interest: The authors declare no conflict of interest.Author contributionsMaterial acquisition and analysis: Gordeev M.L., Uspenskiy V.E., Bakanov A.Y., Volkov V.V., Ibragimov A.N., Scherbinin T.S., Irtyuga O.B., Naimushin A.V. Article writing: Gordeev M.L., Uspenskiy V.E., Bakanov A.Y. Review &amp; editing: Gordeev M.L., Naimushin A.V.AcknowledgmentThe authors express their gratitude for support in diagnostics and management of patients with aortic abnormalities to I. V. Basek, PhD, Head of X-Ray CT Department, and to the employees of X-ray CT Department; to D.A. Zverev, PhD, Head of X-ray Endovascular Surgery Research Lab and the employees of X-ray Endovascular Surgery Departments; O.M. Moiseyeva, Doc. Sci. (Medicine), Head of Noncoronarogenic Heart Diseases Department and her employees, as well as to the employees of Anesthesiology &amp; Resuscitation and Cardiovascular Surgery Departments.

Validation of non-invasive arterial pressure monitoring during carotid endarterectomy

BackgroundPatients undergoing carotid endarterectomy require strict arterial blood pressure (BP) control to maintain adequate cerebral perfusion. In this study we tested whether non-invasive beat-to-beat Nexfin finger BP (BPfin) can replace invasive beat-to-beat radial artery BP (BPrad) in this setting. MethodsIn 25 consecutive patients (median age 71 yr) scheduled for carotid endarterectomy and receiving general anaesthesia, BPfin and BPrad were monitored simultaneously and ipsilaterally during the 30-min period surrounding carotid artery cross-clamping. Validation was guided by the standard set by the Association for the Advancement of Medical Instrumentation (AAMI), which considers a BP monitor adequate when bias (precision) is <5 (8) mm Hg, respectively. ResultsBPfinvs BPrad bias (precision) was −3.3 (10.8), 6.1 (5.7) and 3.5 (5.2) mm Hg for systolic, diastolic, and mean BP, respectively. One subject was excluded due to a poor quality BP curve. In another subject, mean BPfin overestimated mean BPrad by 13.5 mm Hg. ConclusionMean BPfin could be considered as an alternative for mean BPrad during a carotid endarterectomy, based on the AAMI criteria. In 23 of 24 patients, the use of mean BPfin would not lead to decisions to adjust mean BPrad values outside the predefined BP threshold. ClinicalTrials.govNCT01451294.

Copeptin Levels Do Not Correlate With Cross-Clamping Time in Patients Undergoing Carotid Endarterectomy Under General Anesthesia.

Copeptin is a sensitive and more stable surrogate marker for arginine vasopressin. In this study, we evaluated copeptin levels in carotid endarterectomy (CEA) patients, perioperatively, to determine whether copeptin levels can be related to carotid artery cross clamping (CC) time and to postoperative neurological outcomes. Copeptin, interleukin 6, C-reactive protein, cortisol, and brain natriuretic peptide were measured preoperatively (T1) and 3 hours postoperatively (T3) as well as intraoperatively (T2). We recruited 77 patients. Values of copeptin rose gradually over the observed times: T1 = 7.9 (6.4-9.6), T2 = 12.6 (9.3-16.8), and T3 = 72.3 (49.1-111.2) pmol/L. There was a significant difference for repeated measurement ( P = .000, P = .000, and P = .000). Duration of carotid artery CC during CEA does not affect postoperative copeptin level (CC ≤ 13 minutes: 106.8 ± 93.6 pmol/L, CC > 13 minutes: 96.7 ± 89.1 pmol/L; P = .634). Preoperative copeptin level was significantly higher in patients with ulcerated plaque morphology. Activation of the stress axis in patients undergoing CEA results in copeptin elevation. Duration of CC during CEA does not affect postoperative copeptin levels.

Copeptin for All.

Unic-Stojanovic et al, in this issue of Angiology, evaluated whether or not copeptin levels are associated with carotid cross-clamping in patients undergoing carotid endarterectomy (CEA). Although copeptin levels increased from baseline to postoperatively in all patients, no association was found between serum copeptin levels and the duration of carotid artery cross-clamping. Copeptin (C-terminal fragment of proarginine vasopressin) is a novel surrogate marker released in equimolar amounts to arginine vasopressin in response to several stressful situations/ conditions, such as trauma, sepsis, lower respiratory tract infections, hemorrhagic, and septic shock. Copeptin levels also increase in cardiovascular diseases (such as ischemic stroke, acute myocardial infarction, heart failure, and intracerebral hemorrhage) and traumatic brain injury. In patients with ischemic stroke, copeptin levels predict functional outcome and mortality at 12 months. Furthermore, copeptin levels predict recurrent cerebrovascular events after a transient ischemic attack. Finally, preoperative copeptin levels predict perioperative and postoperative outcomes in patients undergoing vascular surgery. Any stimulus/stress that triggers the activation of the hypothalamic–pituitary axis induces the release of adrenocorticotropic hormone, glucocorticoids/cortisol, and arginine vasopressin into the systemic circulation. Measurements of circulating arginine vasopressin levels are cumbersome because of the molecule’s instability and short half-life. Copeptin is a stable by-product of vasopressin synthesis and can be quantitatively determined in plasma, thus reliably reflecting vasopressin release. An acute ischemic thromboembolic stroke is coupled with acute brain injury, increased oxidative stress, and a complex cascade of metabolic events leading to neuronal cell death. Acute brain ischemia also initiates a complex sequence of events in the central nervous system and the hypothalamic– pituitary–adrenal axis including increase in vasopressin/copeptin levels through induction of vasopressin messenger RNA and protein expression. An earlier study by the authors demonstrated that copeptin levels are increased in patients undergoing CEA but more so in patients with a perioperative stroke. Several inflammatory mediators released during surgery (such as tumor necrosis factor a, interleukin 1, and interleukin-6) have a substantial role in activating the hypothalamic–pituitary–adrenal axis. These results suggest that copeptin levels may be helpful in individual risk assessment in patients with a perioperative stroke during CEA. Besides adults, copeptin levels are useful for evaluation of outcomes in infants/neonates. Copeptin levels increase in conditions associated with perinatal stress, such as birth acidosis, asphyxia, chorioamnionitis, and sepsis. Furthermore, copeptin/vasopressin levels play an important role in impaired glucose homeostasis and insulin resistance-associated disorders. Copeptin levels positively correlate with birth weight in large-for-gestational age infants and are also increased in intrauterine growth restricted infants. Consequently, copeptin levels accurately reflect pathological conditions in the perinatal period associated with increased stress. These changes in copeptin levels support the ‘‘fetal programming’’ (or ‘‘fetal origins of adult disease’’) hypothesis, which implies that alterations in fetal nutrition may result in developmental adaptations that permanently change the physiology and metabolism of the offspring, thereby predisposing individuals to metabolic, endocrine, and cardiovascular disorders later in life. Copeptin is a highly sensitive marker of perinatal stress. Copeptin levels correlate with abnormal conditions such as compromised placental perfusion, estimated fetal weight below the fifth percentile, alterations in umbilical artery pH, and intraventricular hemorrhage. Additionally, copeptin levels could potentially be used as a marker of the effect of various therapeutic measures. Future studies should assess the effect of various treatment strategies indirectly by evaluating copeptin levels. In the study by Unic-Stojanovic et al, copeptin levels were not affected by the duration of the carotid cross-clamping. During carotid cross-clamping, cerebral blood flow is mainly maintained via the contralateral carotid and the vertebral arteries, thus preserving adequate blood supply to the brain.

Surgical management of post carotid artery stenting restenosis

To discuss the feasibility, safety and effectiveness of surgical management of post carotid artery stenting (CAS) restenosis, mainly focusing on the surgical options and indications. This study represented retrospective analysis of 3 kinds of surgical managements of 21 patients with symptomatic post CAS restenosis from April 2012 to April 2014. Patch carotid endarterectomy (pCEA), Eversion carotid endarterectomy (eCEA) or carotid excision and graft interposition (CEGI) was selected to remove the stent and reconstruct the blood flow, based on the preoperative imaging results and intraoperative adhesion degree. Use of carotid shunt, blood loss, operative time, carotid artery cross-clamp time and other data were recorded. Patients were followed for improvement of symptoms, complications and restenosis. Eleven, 4 and 6 patients received pCEA, eCEA or CEGI respectively. All the stents were successfully removed. Shunts were deployed in 14 cases. The mean bleeding was (152.6 ± 38.0) ml, the mean operation time was (100.7 ± 34.8) min and the mean carotid artery clamping time was (29.1 ± 4.6) min. In the early postoperative period, there were no infection, strokes, cranial nerve injury, myocardial infarction or mortalities. One patient developed neck hematoma, while 2 patients had the symptoms of hyperperfusion such as headache, irritability and multi-lingual but no intracranial hemorrhage happened according to the brain CT scan, who all fully recovered within 3 days. Within a median follow-up of (13.2 ± 4.3) months, no strokes, myocardial infarctions or recurrent restenosis (> 50%) on duplex ultrasound imaging or CTA was discovered except for 1 patient who died of lung cancer. Surgical management to remove the stent and reconstruct the blood flow, which offered new options in the treatment of post CAS restenosis, with its initially confirmed simplicity, feasibility, safety and validity.

NEUROMONITORINGO METODŲ VERTĖ ATLIEKANT ENDARTEREKTOMIJŲ OPERACIJAS

Žurnalas „Sveikatos mokslai / Health sciences“ yra recenzuojamas tarptautinis mokslinis žurnalas, skirtas skleisti naujas žinias ir informaciją apie visuomenės sveikatą, sveikatos ugdymą, ligas, klinikinius tyrimus ir klinikinius atvejus, naujas technologijas, slaugą, reabilitaciją, sveikatos ekonomiką ir vadybą. Žurnalas spausdina mokslinius straipsnius lietuvių, anglų ir rusų kalbomis, kasmet išeina 1 tomas (6 numeriai) spausdintiniu ir elektroniniu variantais. Daugiau nei 140 mokslinių straipsnių publikuojami per metus. Žurnalas priklauso Lietuvos mokslo periodikos asociacijai.

Cerebral monitors versus regional anesthesia to detect cerebral ischemia in patients undergoing carotid endarterectomy: a meta-analysis

The aim of this meta-analysis is to compare the ability of different types of brain monitoring systems vs clinical monitoring of the brain function to detect cerebral ischemia during cross-clamping of the carotid artery under regional anesthesia. In May 2012, a search was conducted in PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Ovid MEDLINE for prospective trials with 20 patients or more where a cerebral monitoring system was compared with clinical brain monitoring during a carotid endarterectomy performed under regional anesthesia. The quality of the study was evaluated with the Cochrane Collaboration's tool. Data were extracted independently by the two investigators. Data could be extracted for 4,664 measurements taken from 29 studies: transcranial Doppler (TCD) = 739; cerebral saturation = 320; stump pressure = 2,549; electroencephalography (EEG) = 742; evoked potentials = 187; jugular venous saturation = 79; and jugular venous lactate = 48. The pooled diagnostic odds ratios (DOR) and 95% confidence intervals (CI) were obtained for EEG, TCD, stump pressure, evoked potentials, and cerebral saturation: (DOR 65.3; 95% CI 20.5 to 207.7; I(2) [56.8%]); (DOR 58.1; 95% CI 23.0 to 146.3; I(2) [24.9%]); (DOR 27.8; 95% CI 13.4 to 57.9; I(2) [59.9]); (DOR 17.2; 95% CI 2.4 to 123.9 I(2) [69.1]); and (DOR 12.1; 95% CI 3.5 to 41.2; I(2) [30.8]), respectively. Sequential testing with stump pressure 25 mmHg followed by either TCD or EEG delivered the best post-test probabilities. For EEG, the DOR increases with the number of channels used (P = 0.03). A combination of stump pressure and either TCD or EEG appears to deliver the best results for detecting brain ischemia during carotid artery cross-clamping. Electroencephalography should be used with a high number of channels.