Carotid Artery Surgery Research Articles

Mizagliflozin, a selective SGLT1 inhibitor, improves vascular cognitive impairment in a mouse model of small vessel disease.

Previously, we showed that sodium/glucose cotransporter 1 (SGLT1) participates in vascular cognitive impairment in small vessel disease. We hypothesized that SGLT1 inhibitors can improve the small vessel disease induced‐vascular cognitive impairment. We examined the effects of mizagliflozin, a selective SGLT1 inhibitor, and phlorizin, a non‐selective SGLT inhibitor, on vascular cognitive impairment in a mouse model of small vessel disease. Small vessel disease was created using a mouse model of asymmetric common carotid artery surgery (ACAS). Two and/or 4 weeks after ACAS, all experiments were performed. Cerebral blood flow (CBF) was decreased in ACAS compared with sham‐operated mice. Phlorizin but not mizagliflozin reversed the decreased CBF of ACAS mice. Both mizagliflozin and phlorizin reversed the ACAS‐induced decrease in the latency to fall in a wire hang test of ACAS mice. Moreover, they reversed the ACAS‐induced longer escape latencies in the Morris water maze test of ACAS mice. ACAS increased SGLT1 and proinflammatory cytokine gene expressions in mouse brains and phlorizin but not mizagliflozin normalized all gene expressions in ACAS mice. Hematoxylin/eosin staining demonstrated that they inhibited pyknotic cell death in the ACAS mouse hippocampus. In PC12HS cells, IL‐1β increased SGLT1 expression and decreased survival rates of cells. Both mizagliflozin and phlorizin increased the survival rates of IL‐1β‐treated PC12HS cells. These results suggest that mizagliflozin and phlorizin can improve vascular cognitive impairment through the inhibition of neural SGLT1 and phlorizin also does so through the improvement of CBF in a mouse model of small vessel disease.

Association of carotid ultrasonography with perioperative stroke after thoracic aortic aneurysm treatment: a retrospective study.

The purpose of this study was to verify whether carotid ultrasonography (CUS) findings could be associated with the occurrence of perioperative stroke after thoracic aortic aneurysm (TAA) treatment. Patients with TAAs who were treated by either total arch replacement or thoracic endovascular aortic repair (TEVAR) were retrospectively enrolled. Left subclavian artery (LSA) embolization and bypass surgery of the left common carotid artery (CCA) to the LSA before TEVAR were additionally performed for some patients. CUS was performed before TAA treatment to evaluate carotid atherosclerosis and flow velocities of bilateral cervical arteries. After dividing patients into those with and without perioperative stroke, their background, atherosclerotic risk factors, history of stroke, TAA location and size, treatment procedures, and CUS parameters were compared between the two groups. Of the 60 patients (18 women, 42 men; mean age 73.5 ± 10.2years) with TAA, four (7.5%) developed perioperative stroke. There were no significant differences in the patients' characteristics and their TAAs between those with and without perioperative stroke. For the CUS parameters, end-diastolic velocity (EDV) of bilateral CCAs was significantly decreased in perioperative stroke patients (with vs without stroke; right: 9.2 ± 1.8 vs. 14.5 ± 4.6cm/s, P = 0.025, left: 9.1 ± 0.3 vs. 15.0 ± 4.5cm/s, P = 0.012), whereas the resistance index (RI) of bilateral CCAs was significantly elevated (right: 0.76 vs. 0.87, P = 0.008, left: 0.76 vs. 0.87, P < 0.001). Lower EDV and higher RI of bilateral CCAs were significantly associated with perioperative stroke after TAA treatment. Thus, CUS findings may help predict the occurrence of perioperative stroke.

The use of curved sheath technique to facilitate difficult internal carotid artery occlusions

Carotid Artery Occlusive Disease or Carotid Artery Stenosis (CAS), a widely prevalent disease, involves blockage of the arterial wall through atherosclerotic plaques. Due to the high prevalence of carotid artery stenosis, innovative approaches to improve the outcome are required, particularly for more difficult and unique cases. Within this report, we present a particularly difficult case of Type III Aortic Arch – Right Internal Carotid Artery (ICA) stenosis making it a challenging case. We describe a symptomatic 87-year-old male who presented to Cardiology clinic. CT angiogram showed 70% occlusion of right internal carotid artery and patient was deemed high risk for carotid artery surgery; hence, the patient underwent internal carotid artery stenting. After the procedure, angiogram results were excellent, and the patient was transferred to CICU in stable hemodynamic condition. This case demonstrates the significance of innovative new techniques in the development of medical treatment.&#x0D; Keywords: Carotid Artery Stenting, Curve Sheath Technique, Type 3 Aortic Arch, Right Internal Carotid Artery Stenosis

Blockade of the carotid sinus in endovascular surgery of the internal carotid arteries: why and to whom? Prospective single-center study

Introduction. The widespread use of transluminal balloon angioplasty with stenting of the internal carotid arteries as part of the prevention of ischemic stroke has led to an increase in the number of publications in the world literature indicating the development of carotid sinus syndrome (“hemodynamic instability”) in the perioperative period, cerebral and cardiac complications, and deaths. requires the development of other approaches to providing medical care to patients with atherosclerotic carotid stenosis. Objectives. To assess the efficacy and safety of carotid sinus blockade when performing angioplasty with stenting of the internal carotid arteries and to determine indications for its implementation. Materials and Methods. The study included 120 patients with atherosclerotic stenosis of the internal carotid arteries who underwent transluminal balloon angioplasty with stenting. 60 of them underwent carotid sinus blockade. Results. The incidence of SCS in the group of patients with BCS was 68.3 % (n = 41) versus 71.6 % (n = 43) in the group of patients without BCS (p &gt; 0.05). However, none of the patients who underwent BCS had asystole and AV block (p &lt; 0.05). With vasodepressor and cardio-inhibitory types, there is no significant difference in the time of occurrence of SCS between the groups (p &gt; 0.05). With the most frequently developing type of SCS, mixed, the incidence of SCS with balloon dilatation is significantly lower with BCS — 16.7 % (BCS) versus 83.3 % (without BCS) (p &lt; 0.05). When performing BCS in the group without SCS, in all cases there was no contralateral occlusion of the ICA (p &lt; 0.05). Conclusions. BCS does not prevent the development of SCS, but eliminates such life-threatening complications as asystole and AV block. BCS can be indicated in patients with a history of cardiac pathology and is inappropriate for contralateral carotid occlusion.

Redo surgery of carotid arteries in patients with contraindications to carotid angioplasty and stenting

The study was aimed at analysing the in-hospital results of carotid re-endarterectomy and plasty of the zone of reconstruction with a biological patch in patients with haemodynamically significant restenosis and contraindications to carotid angioplasty with stenting. During the period from 2008 to 2019, we operated on a total of 22 patients presenting with carotid restenosis and found to have contraindications to carotid angioplasty with stenting (an extended lesion, unstable neointima, calcification, pronounced tortuosity). Carotid re-endarterectomy was performed according to the classical technique. The time period after the first intervention to regression of pathology amounted to 48.5±21.3 months. All patients with clinical manifestations of angina pectoris were at the preoperative stage subjected to coronarography, as a result of which in one case a hybrid intervention was performed in the scope of percutaneous coronary intervention and carotid endarterectomy. The endpoints included death, myocardial infarction, acute impairment of cerebral circulation, and lesions of craniocerebral nerves. Carotid re-endarterectomy was most often carried out according to the classical technique with plasty of the zone of reconstruction using a xenopericardial patch. Only in 1 case it was required to perform eversion carotid re-endarterectomy due to tortuosity of the internal carotid artery. During the in-hospital postoperative period no lethal outcomes, myocardial infarctions, nor haemorrhagic complications were registered. One patient was found to develop acute impairment of cerebral circulation. The most frequent complication was unilateral laryngeal paresis caused by lesions of craniocerebral nerves (n=3; 13.6%), with reversible neurological deficit. No cases of either thrombosis/restenosis or elevated pressure gradient in the area of implantation of the xenopericardial patch were revealed. The composite endpoint amounted to 18.2% (n=4). The classical carotid re-endarterectomy was not accompanied by cases of thrombosis and restenosis during either the in-hospital or remote period of follow up, however turned out to be associated with a high frequency of the development of complications such as acute impairment of cerebral circulation and lesions of craniocerebral nerves.

Minimally invasive carotid artery surgery

To determine the criteria for choosing a surgical approach and compare an effectiveness of carotid endarterectomy (CEAE) via 3 approaches. The study included 120 patients who underwent CEAE via 3 different approaches. Intraoperative skin marking included lower jaw angle, skin fold closest to common carotid artery bifurcation. Carotid artery bifurcation and borders of atherosclerotic plaque were visualized using ultrasound. An effectiveness of each access was evaluated in accordance with the following criteria: neurological complications, cosmetic effect and quality of life after 1 and 12 months. The patients were divided into 2 groups. Group I - 80 patients with CEAE with access through the natural skin fold (NSF); group II - 40 patients with CEAE using the classical longitudinal access. The 1st group was divided into 2 subgroups. Subgroup I A - 39 patients with CEAE using mini-access via NSF; subgroup I B - 41 patients with CEAE using extended access via NSF. There were no strokes and transient ischemic attacks in a month after surgery in both groups. After 12 months, stroke occurred in 2 (%) patients of group II, cranial neuropathy - 8 (21%) patients in the same group. The best cosmic effect was achieved in subgroup I A after 1 and 12 months (37.1±6.7 scores). Mean score of physical health was 51.59±5.9 scores in subgroup I A, 46.03±7.53 scores - in subgroup I B, 38.84±5.28 scores - in group II. Index of mental health was 49.63±6.69, 45.68±5.6, and 48.59±7.29 scores, respectively. Considering these data, we developed a personalized computer program ensuring fast choice of optimal surgical approach.

Carotid Artery Surgery to Reduce Long-Term Stroke Rates: Individual Patient Data Meta-Analysis of the Randomised Trials in Asymptomatic Patients

Background: Among patients with severe carotid artery stenosis but no recent symptoms from it, carotid surgery involves hazards, but then reduces long-term stroke rates. Triple-drug therapy (statin, anti-thrombotic, anti-hypertensive) also reduces long-term stroke rates in these asymptomatic patients. Past trials of carotid endarterectomy (CEA) can help assess the proportional reduction by carotid surgery in long-term stroke rates before and since triple-drug therapy became common. Methods: Intention-to-treat analyses used individual data from all 3 properly randomised trials among asymptomatic patients of immediate CEA vs deferral of any CEA until definitely indicated. Analyses of long-term stroke rates, censored at non-stroke death, used Kaplan-Meier life-tables and logrank methods. Findings: 2599 patients were allocated immediate CEA vs 2627 allocated deferral, with 89% vs 7% operated on within 1 year. Non-perioperative stroke rates were halved by allocation to immediate CEA (10-year stroke rate ratio [RR]=0.54, 95%CI 0.46-0.65, p<0.0001; 5.8% vs 11.7% by year 5); for fatal/disabling strokes, RR=0.55 (0.40-0.77, p<0.0001). Proportional reductions depended little on gender, or other patient characteristics. Ipsilateral and contralateral strokes were both reduced. In analyses restricted to strokes occurring on triple-drug therapy, absolute hazards and long-term stroke rates were lower than in the overall findings, but allocation to immediate CEA still halved long-term stroke rates (RR=0.56, 0.41-0.76; p=0.0002; 3.5% vs 7.0% by year 5). Of all CEAs undertaken, 3.1% involved perioperative stroke/death (71/3348; 40 dead/disabled, 31 not). Interpretation: Successful CEA halves long-term stroke rates. Net benefits will depend on surgical risks, long-term stroke rates without surgery, and life expectancy. Trial Registration: The trial is registered with the ISRCTN registry, ISRCTN21144362. Funding: MRC. Declaration of Interest: None to declare.

Real-time measurement of adenosine and ATP release in the central nervous system

This brief review recounts how, stimulated by the work of Geoff Burnstock, I developed biosensors that allowed direct real-time measurement of ATP and adenosine during neural function. The initial impetus to create an adenosine biosensor came from trying to understand how ATP and adenosine-modulated motor pattern generation in the frog embryo spinal cord. Early biosensor measurements demonstrated slow accumulation of adenosine during motor activity. Subsequent application of these biosensors characterized real-time release of adenosine in in vitro models of brain ischaemia, and this line of work has recently led to clinical measurements of whole blood purine levels in patients undergoing carotid artery surgery or stroke. In parallel, the wish to understand the role of ATP signalling in the chemosensory regulation of breathing stimulated the development of ATP biosensors. This revealed that release of ATP from the chemosensory areas of the medulla oblongata preceded adaptive changes in breathing, triggered adaptive changes in breathing via activation of P2 receptors, and ultimately led to the discovery of connexin26 as a channel that mediates CO2-gated release of ATP from cells.

Carotid endarterectomy for symptomatic carotid stenosis.

Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. This is an update of a Cochrane Review, originally published in 1999, and most recently updated in 2017. To determine the balance of benefit versus risk of endarterectomy plus best medical management compared with best medical management alone, in people with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke). We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) portal to October 2019. We also reviewed the reference lists of all relevant studies and abstract books from research proceedings. We included randomised controlled trials (RCTs) comparing carotid artery surgery plus best medical treatment with best medical treatment alone. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risk of bias, and extracted the data. We assessed the results and the quality of the evidence of the primary and secondary outcomes by the GRADE method, which classifies the quality of evidence as high, moderate, low, or very low. We included three trials involving 6343 participants. The trials differed in the methods of measuring carotid stenosis and in the definition of stroke. Using the primary electronic data files, we pooled and analysed individual patient data on 6092 participants (35,000 patient-years of follow-up), after reassessing the carotid angiograms and outcomes from all three trials, and redefining outcome events where necessary, to achieve comparability. Surgery increased the five-year risk of any stroke or operative death in participants with less than 30% stenosis (risk ratio (RR) 1.25, 95% confidence interval (CI) 0.99 to 1.56; 2 studies, 1746 participants; high-quality evidence). Surgery decreased the five-year risk of any stroke or operative death in participants with 30% to 49% stenosis (RR 0.97, 95% CI 0.79 to 1.19; 2 studies, 1429 participants; high-quality evidence), was of benefit in participants with 50% to 69% stenosis (RR 0.77, 95% CI 0.63 to 0.94; 3 studies, 1549 participants; moderate-quality evidence), and was highly beneficial in participants with 70% to 99% stenosis without near-occlusion (RR 0.53, 95% CI 0.42 to 0.67; 3 studies, 1095 participants; moderate-quality evidence). However, surgery decreased the five-year risk of any stroke or operative death in participants with near-occlusions (RR 0.95, 95% CI 0.59 to 1.53; 2 studies, 271 participants; moderate-quality evidence). Carotid endarterectomy reduced the risk of recurrent stroke for people with significant stenosis. Endarterectomy might be of some benefit for participants with 50% to 69% symptomatic stenosis (moderate-quality evidence) and highly beneficial for those with 70% to 99% stenosis (moderate-quality evidence).

Vascular surgery presence in carotid endarterectomy YouTube videos

ObjectiveYouTube videos have become a common resource for trainees to learn about surgical procedures. Carotid endarterectomy (CEA) is one example procedure that may be performed by multiple specialties and with a variety of techniques. Little is known about educational content and the representation of vascular surgeons in these videos. We sought to compare the educational quality of CEA YouTube videos, techniques demonstrated, and prevalence of each specialty. MethodsYouTube was programmatically searched for the terms “carotid endarterectomy,” “carotid endarterectomy surgery,” “carotid endarterectomy technique,” “carotid endarterectomy CEA,” and “carotid artery surgery.” Videos that met inclusion criteria were analyzed for surgical technique, procedural steps, surgeon specialty, video length, and date. Videos were determined to have high-quality educational content if the video included English-language captions or narration and demonstrated key steps of the procedure: division of the common facial vein; exposure of the common, external, and internal carotid arteries; vascular control and clamping; and arteriotomy, endarterectomy, and arteriotomy closure. ResultsForty-six videos met inclusion criteria. Vascular surgery was associated with 12 (26.1%) CEA videos, cardiac surgery with 13 (28.3%), and neurosurgery with 14 (30.4%). Surgeon specialty was unknown for seven (17.4%) videos. Eight videos were high quality, of which vascular surgery was associated with three (37.5%). Conventional endarterectomy was the most common technique demonstrated, whereas a total of seven videos demonstrated eversion technique. Vascular and cardiac surgeons were more likely to demonstrate patch angioplasty than neurosurgeons, who exclusively performed primary closure (P < .05). Compared with cardiac surgeons, vascular surgeon CEA videos had more views (25,956 ± 9613 vs 1200 ± 368; P < .05) and were more likely to be published by user accounts with an academic affiliation (11 vs 6; P < .05). Vascular surgery videos were older than videos by cardiac surgeons (6.0 ± 1.1 years vs 3.0 ± 0.5 years; P < .05) and neurosurgeons (6.0 ± 1.1 years vs 3.1 ± 0.8 years; P < .05). ConclusionsDespite more views, the field of vascular surgery is under-represented in YouTube videos demonstrating CEA. Vascular surgery videos tend to be older and make up a minority of high-quality videos. As more learners turn to YouTube for information about surgical procedures, vascular surgeons should expand their online presence through the production and collection of high-quality videos for trainees.

Sphenoparietal sinus transposition technique: optimization of the surgical corridor with preservation of prominent bridging veins between the brain and the cranial base during aneurysm clipping via the pterional approach.

The sylvian bridging veins between the brain and the dura on the inner surface of the sphenoid wing can restrict brain retraction for widening of the lateral retrocarotid space during clipping surgery for internal carotid artery (ICA)-posterior communicating artery (PCoA) and basilar apex (BX) aneurysms. In such cases, the authors perform extradural anterior clinoidectomy with peeling of the temporal dura propria from the periosteal dura and inner cavernous membrane around the superior orbital fissure, with the incision of the dura mater stretching from the base of the temporal side to just before the distal dural ring of the ICA (termed by the authors as the sphenoparietal sinus transposition [SPST] technique). This technique displaces the bridging segment of the sylvian vein posteriorly and enables widening of the surgical space without venous injury. In this study, the authors observed the operative nuances and investigated the usefulness of this technique. The authors retrospectively reviewed the medical charts of 66 consecutive patients with ICA-PCoA and BX aneurysms between January 2016 and July 2018. This technique was performed in 8 patients (5 patients with PCoA aneurysms and 3 with BX aneurysms) in whom the bridging segments of the sylvian veins between the brain and the skull base restricted brain retraction for widening of the surgical space. The surface areas of the lateral retrocarotid space and the aneurysm were measured at the most visible working angle before and after the SPST technique was performed. With the use of the SPST technique, an adequate surgical space for aneurysm clipping was obtained with preservation of the bridging veins in all patients. The mean surface areas of the lateral retrocarotid space (p = 0.002) and aneurysm (p = 0.001) were significantly increased from 18.3 ± 18.8 and 2.8 ± 2.5 cm2 before to 64.2 ± 21.1 and 20.9 ± 20.6 cm2, respectively, after the SPST technique was performed. The SPST technique enables displacement of the bridging segments of the sylvian veins without venous injury and enables widening of the surgical space around the lateral retrocarotid area.

Evaluation of the performance of an endoscopic 3-mm electrothermal bipolar vessel sealing device intended for single use after multiple use-and-resterilization cycles.

To evaluate the performance of an endoscopic 3-mm electrothermal bipolar vessel sealing device (EBVS) intended for single use after multiple use-and-resterilization cycles. Ex vivo study. Eight 3-mm EBVS handpieces. Handpieces were subjected to a maximum of 15 cycles of testing, including simulated surgery, sealing and burst pressure testing of porcine carotid arteries, reprocessing, and hydrogen peroxide plasma resterilization. Failure was defined as two sequential vascular seal leakage events occurring at <250 mm Hg. Histological evaluation, maximum external temperature of the jaws, sealing time, tissue adherence, jaw surface characterization, and mechanical deterioration were studied. Failure rate was analyzed by using a Kaplan-Meier curve. Linear and ordinal logistic mixed models were used to analyze sealing time, handpiece jaw temperature, and adherence score. Mean ± SD diameter of arteries was 3.22 ± 0.35 mm. Failure was observed starting at cycle 10 and going up to cycle 13 in 37.5% (3/8) of the handpieces. Tissue adherence increased after each cycle (P < .001). Maximum external temperature (79.8°C ± 13.9°C) and sealing time (1.8 ± 0.5 seconds) were not significantly different throughout cycles up to failure. A flatter surface and large scratches were observed microscopically throughout the jaw surface after repeated use and resterilization. The 3-mm EBVS handpiece evaluated in this study can be considered safe to use for up to nine reuse-and-resterilization cycles. These data provide the basis for establishing preliminary guidelines for the reuse and hydrogen peroxide plasma resterilization of an endoscopic 3-mm EBVS handpiece.

Desflurane-based balanced anesthesia in reconstructive carotid artery surgery

The aim of the research was to examine the influence of isoflurane inhalation on the circulatory dynamics, encephalic bloodstream and oxygen balance of the patients’ brain during the carotid endarterectomy. 26 patients were examined. There were detected the parameters of central and systemic circulatory dynamics, the speed of the bloodstream in the middle encephalic artery in M, sector, the results of transcranial cerebral oxymetry. The first stages of the operation, the stage of temporary breakoff of the blood circulation in damaged artery territory were accompanied with moderate lowering of indicators of circulatory dynamics. In the process of reinitiation of the bloodstream the reperfusion of brain declared itself moderately. Isoflurane anesthesia to 1 MAK (minimum alveolar concentration) in combination with phentanyl allows to maintain appropriate pain management, stable circulatory dynamics and well-timed awakening of patients during carotid endarterectomy.

Animal Models of Chronic Cerebral Hypoperfusion: From Mouse to Primate.

Vascular cognitive impairment (VCI) or vascular dementia occurs as a result of brain ischemia and represents the second most common type of dementia after Alzheimer’s disease. To explore the underlying mechanisms of VCI, several animal models of chronic cerebral hypoperfusion have been developed in rats, mice, and primates. We established a mouse model of chronic cerebral hypoperfusion by narrowing the bilateral common carotid arteries with microcoils, eventually resulting in hippocampal atrophy. In addition, a mouse model of white matter infarct-related damage with cognitive and motor dysfunction has also been established by asymmetric common carotid artery surgery. Although most experiments studying chronic cerebral hypoperfusion have been performed in rodents because of the ease of handling and greater ethical acceptability, non-human primates appear to represent the best model for the study of VCI, due to their similarities in much larger white matter volume and amyloid β depositions like humans. Therefore, we also recently developed a baboon model of VCI through three-vessel occlusion (both the internal carotid arteries and the left vertebral artery). In this review, several animal models of chronic cerebral hypoperfusion, from mouse to primate, are extensively discussed to aid in better understanding of pathophysiology of VCI.

Duplex Ultrasound for Carotid Arteries Must be Done as Screening for All Patients with Coronary Artery Surgery Regardless of Age Group and Risk Factors

Aim: Routine utilizes of Doppler ultrasonography in the clinical examination of the patients for carotid artery stenosis varies according to the age groups. In the present work, predictive level of age groups and co-occurrence risk factors are examined in terms of the necessity of Doppler ultrasonography to be routinely used in the examination of the carotid artery in isolated coronary and associated with carotid artery surgery. Material and Method: 86 patients underwent carotid endarterectomy in our center between April 2016 and June 2018. Thirty-eight (44.18%) of these patients had been detected during the screening before the coronary artery by-pass graft surgery, whereas 48 (55.82%) were patients referred from the neurology clinic because of severe carotid artery stenosis. Retrospectively reviewed of all patients in terms of gender and age group, as well the existence of hypertension, diabetes, and smoking. Division of patients into two groups: those &lt; 65years age (Group 1) and those equals 65 and over (Group2). Results: Thirty-one (36%) of the patients that underwent carotid endarterectomy was &lt; 65 years’ age (Group 1). Fifteen (17.4%) of these patients were those that would undergo coronary bypass surgery. When the patients had submitted isolated and concomitant carotid artery endarterectomy were evaluated in terms of risk factors, hypertension and diabetes were found significantly higher in group one as compared to group two (p&lt;0.05). Conclusion: Our opinion Doppler ultrasonography should routinely use together with physical examination in the preoperative evaluation of the patients with coronary artery disease in order not to underestimate such critical carotid artery stenosis that would require surgical intervention.

The Dutch Audit for Carotid Interventions; Transparency in Quality of Carotid Artery Surgery in the Netherlands

Introduction - In June 2013, the Dutch Audit for Carotid Interventions (DACI) group started a nationwide registration of all patients undergoing carotid intervention because of a symptomatic or asymptomatic high-grade carotid artery stenosis.1 The quality indicators ‘mortality’ and ‘stroke’ are used to provide an insight in variation between hospitals. We describe the initiation and design of the DACI and the results of interventions in patients with a symptomatic carotid artery stenosis. Methods - We identified all patients with a recent symptomatic carotid artery stenosis, undergoing a carotid endarterectomy (CEA) between June 2013 and December 2015, registered in the DACI. Descriptive analysis on patient characteristics, process of care and outcomes were performed. A multivariable logistic regression analysis was performed to adjust outcomes for patient characteristics, based on the V(p)-POSSUM predictive scoring system. Case-mix adjusted hospital outcomes were compared for mortality and the combined outcome measures stroke/death and major stroke/death. Results - In 2,5 year, 6052 patients with a carotid artery stenosis were registered in the DACI, of which 5961 (98,5%) were eligible for analysis. After exclusion of all asymptomatic patients (425, 7,1%) and patient treated with a stenting procedure (79, 1.6%), a total of 5439 CEA patients were included. 76% (4154) was treated with CEA with a patch angioplasty, 13% (692) with eversion CEA and 11% (593) with CEA without patch angioplasty. The majority (3835, 71%) was treated within 2 weeks after their first consultation at the hospital, according to the national guideline. The postoperative mortality within 30 days after surgery was 0.9%. A postoperative stroke was seen in 3.2% and the combined stroke/death and major stroke/death rates were respectively 3.5% and 1.6%. Cranial nerve injury and postoperative hemorrhage were seen in respectively 3.0% and 3.7%. Case-mix adjusted major stroke/death rates per hospital varied between 0-6.6%. On this outcome, 14 hospitals performed significantly better than the national mean. There were no hospitals that performed significantly worse. (Figure 1.) Conclusion - The first results of the DACI show that the current quality of carotid artery surgery in the Netherlands is good, with an overall low mortality and (major) stroke/death rate. Nevertheless, quality indicators as mortality and (major) stroke/death do not seem to be very distinctive between hospitals, due to the current volumes and low event rates. This makes these outcomes measures not ideal to identify fields for quality improvement. In order to optimally use the audit as a tool for quality improvement, new quality indicators should be developed to provide a better insight in the potential hospital variation.

Structural Analysis of the Retina and Choroid before and after Carotid Artery Surgery

ABSTRACTPurpose: To evaluate retinal and choroidal changes in patients with internal carotid artery stenosis who had undergone carotid artery stenting or endarterectomy.Methods: The study included 43 patients with internal carotid artery (ICA) stenosis that required stenting or endarterectomy and 40 healthy controls. Patients were divided into two groups according to the degree of stenosis evaluated by magnetic resonance angiography. Group 1 consisted of patients having ICA stenosis of 50 to 70%, and Group 2 has more than 70%. Enhanced depth imaging optical coherence tomography (EDI-OCT) was used to measure the retinal thickness (RT) and choroidal thickness (CT) in all subjects before surgery and at 1, 3, and 6 months after surgery.Results: Subfoveal and parafoveal CT were significantly lower in patients with ICA stenosis than the control group (p < .05, respectively). Patients with 50-70% stenosis had a significant increase in the CT at 1, 3, and 6 months after ICA stenting or endarterectomy (p < .05). Patients with >%70 stenosis did not have a significant increase in the CT at any time after ICA stenting or endarterectomy. Retinal thickness was not statistically different between the patients with ICA stenosis and the control subjects, and RT showed no significant change in patients with ICA stenosis before and after the surgery.Conclusion: Choroidal thickness was significantly thinner in patients with internal carotid artery stenosis. ICA stenting provided a recovery in the choroidal thickness in patients with moderate to advanced stenosis.

The Consequences of Negligence Claims in Arterial Surgery – An Analysis of Two Periods with an Increasing Use of Endovascular Treatment

Patient treatment within the Swedish medical service system can claim negligence injuries to the malpractice insurance review board and request financial compensation. The aim of this paper was to analyse the consequences of a negligence claim after arterial surgery between two periods with increasing use of endovascular treatment. This was a retrospective cohort study of the arterial surgery negligence claims from two three year periods 2005-2007 (Period A) and 2012-2014 (Period B) from the County Council's Mutual Insurance Company. The analysis was restricted to aortic, carotid, and lower limb arterial diseases. The magnitude of surgery for vascular diseases was obtained from the Swedish vascular register (Swedvasc). The number of patients undergoing arterial procedures increased from 16628 to 20709 (p=.01). There was an increase of 54% in the number of negligence claims between the periods. In Period A, the number of compensated claims was 22 out of 83 (29%) and in Period B 60 out of 151 (41%) (p=.06). Patients treated for aortic disorders and peripheral arterial surgery received compensation with increasing frequency whereas carotid diseases decreased. Claimants treated for aortic disorders were compensated in four out of 23 (17%) and 21 out of 54 (39%) in the two periods (p=.07), and after lower limb arterial surgery in six out of 34 (18%) and in 24 out of 71 (34%) (p=.09). After carotid surgery the corresponding figures were 12 out of 26 (46%) and 14 out of 25 (46%) (p=.48). The increasing use of endovascular procedures (but not in carotid artery surgery) did not seem to influence the pattern of negligence claims. Between the two three year periods there has been an increase in negligence claims but not in compensated ones. The increased use of endovascular procedures has not influenced the pattern of compensated negligence claims.

Long-term Cardiovascular Disease Risk Among Firefighters After the World Trade Center Disaster

Published studies examining the association between World Trade Center (WTC) exposure on and after September 11, 2001, and longer-term cardiovascular disease (CVD) outcomes have reported mixed findings. To assess whether WTC exposure was associated with elevated CVD risk in Fire Department of the City of New York (FDNY) firefighters. In this cohort study, the association between WTC exposure and the risk of CVD was assessed between September 11, 2001, and December 31, 2017, in FDNY male firefighters. Multivariable Cox regression analyses were used to estimate CVD risk in association with 2 measures of WTC exposure: arrival time to the WTC site and duration of work at the WTC site. Data analyses were conducted from May 1, 2018, to March 8, 2019. The primary CVD outcome included myocardial infarction, stroke, unstable angina, coronary artery surgery or angioplasty, or CVD death. The secondary outcome (all CVD) included all primary outcome events or any of the following: transient ischemic attack; stable angina, defined as either use of angina medication or cardiac catheterization without intervention; cardiomyopathy; and other CVD (aortic aneurysm, peripheral arterial vascular intervention, and carotid artery surgery). There were 489 primary outcome events among 9796 male firefighters (mean [SD] age on September 11, 2001, was 40.3 [7.4] years and 7210 individuals [73.6%] were never smokers). Age-adjusted incident rates of CVD were higher for firefighters with greater WTC exposure. The multivariable adjusted hazard ratio (HR) for the primary CVD outcome was 1.44 (95% CI, 1.09-1.90) for the earliest arrival group compared with those who arrived later. Similarly, those who worked at the WTC site for 6 or more months vs those who worked less time at the site were more likely to have a CVD event (HR, 1.30; 95% CI, 1.05-1.60). Well-established CVD risk factors, including hypertension (HR, 1.41; 95% CI, 1.10-1.80), hypercholesterolemia (HR, 1.56; 95% CI, 1.28-1.91), diabetes (HR, 1.99; 95% CI, 1.33-2.98), and smoking (current: HR, 2.13; 95% CI, 1.68-2.70; former: HR, 1.55; 95% CI, 1.23-1.95), were significantly associated with CVD in the multivariable models. Analyses with the all-CVD outcome were similar. The findings of the study suggest a significant association between greater WTC exposure and long-term CVD risk. The findings appear to reinforce the importance of long-term monitoring of the health of survivors of disasters.

Research progress on management and nursing for carotid artery stenting related hemodynamic depression

Carotid artery stenting (CAS) is a common surgery for carotid artery stenosis at present. However, hemodynamic depression easily occurs during and after CAS, and then increases the risk of complications such as stroke, arrhythmia, myocardial infarction as well as cardiac arrest. This paper reviewed the epidemiological features, influencing factors, correlation with postoperative complication of hemodynamic depression during CAS and intraoperative management for CAS related hemodynamic depression so as to provide a basis for the coordination efficiency of nurses during interventional operation. Key words: Review; Carotid artery stenting; Hemodynamic depression; Nursing cooperation; Management; Intervention operation