Carotid Bifurcation Endarterectomy Research Articles

Carotid Endarterectomy With Simultaneous Proximal Common Carotid Endovascular Intervention is Beneficial for Symptomatic Stenosis and Likely Confers No Advantage for Asymptomatic Lesions.

Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis. Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined. We noted a statistically significant (P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90day mortality and combined neurological event and 90day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA. Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.

Revisiting carotid endarterectomy: Neobulb technique using external carotid artery as a patch.

This study describes an alternative carotid bifurcation endarterectomy technique in which the external carotid artery is used as a suture patch. Charts of ten patients with atherosclerotic carotid stenosis that were treated using the neobulb technique between 2002 and 2019 were reviewed. No major surgical adverse event was observed in the postoperative assessments. No postoperative common or internal carotid stenosis was observed in the mid- or long-term follow-up. The neobulb technique allows carotid endarterectomy closure without a synthetic or venous patch, using the external carotid artery as an autologous patch, while preserving distal flow into the external carotid artery branches.

Wall Shear Stress Topological Skeleton Independently Predicts Long-Term Restenosis After Carotid Bifurcation Endarterectomy

Wall Shear Stress (WSS) topological skeleton, composed by fixed points and the manifolds linking them, reflects the presence of blood flow features associated to adverse vascular response. However, the influence of WSS topological skeleton on vascular pathophysiology is still underexplored. This study aimed to identify direct associations between the WSS topological skeleton and markers of vascular disease from real-world clinical longitudinal data of long-term restenosis after carotid endarterectomy (CEA). Personalized computational hemodynamic simulations were performed on a cohort of 13 carotid models pre-CEA and at 1 month after CEA. At 60 months after CEA, intima-media thickness (IMT) was measured to detect long-term restenosis. The analysis of the WSS topological skeleton was carried out by applying a Eulerian method based on the WSS vector field divergence. To provide objective thresholds for WSS topological skeleton quantitative analysis, a computational hemodynamic dataset of 46 ostensibly healthy carotid bifurcation models was considered. CEA interventions did not completely restore physiological WSS topological skeleton features. Significant associations emerged between IMT at 60 months follow-up and the exposure to (1) high temporal variation of WSS contraction/expansion (R2 = 0.51, p < 0.05), and (2) high fixed point residence times, weighted by WSS contraction/expansion strength (R2 = 0.53, p < 0.05). These WSS topological skeleton features were statistically independent from the exposure to low WSS, a previously reported predictor of long-term restenosis, therefore representing different hemodynamic stimuli and potentially impacting differently the vascular response. This study confirms the direct association between WSS topological skeleton and markers of vascular disease, contributing to elucidate the mechanistic link between flow disturbances and clinical observations of vascular lesions.

Routine Shunting is Safe and Reliable for Cerebral Perfusion during Carotid Endarterectomy in Symptomatic Carotid Stenosis

BackgroundThe purpose of this report is to describe the perioperative outcomes of standard carotid endarterectomy (CEA) with general anesthesia, routine shunting, and tissue patching in symptomatic carotid stenoses.Materials and MethodsBetween October 2007 and July 2011, 22 patients with symptomatic carotid stenosis (male/female, 19/3; mean age, 67.2±9.4 years) underwent a combined total of 23 CEAs using a standardized technique. The strict surgical protocol included general anesthesia and standard carotid bifurcation endarterectomy with routine shunting. The 8-French Pruitt-Inahara shunt was used in all the patients.ResultsDuring the ischemic time, the shunts were inserted within 2.5 minutes, and 5 patients (22.7%) revealed ischemic cerebral signals (flat wave) in electroencephalographic monitoring but recovered soon after insertion of the shunt. The mean shunting time for CEA was 59.1±10.3 minutes. There was no perioperative mortality or even minor stroke. All patients woke up in the operating room or the operative care room before being moved to the ward. One patient had difficulty swallowing due to hypoglossal nerve palsy, but had completely recovered by 1 month postsurgery.ConclusionRoutine shunting is suggested to be a safe and reliable method of brain perfusion and protection during CEA in symptomatic carotid stenoses.

Eversion endarterectomy of the internal carotid artery combined with open endarterectomy of the common carotid artery

The author presents a technique for endarterectomy and reconstruction of the carotid bifurcation in difficult cases when the plaque extends high into the internal carotid artery. The technique combines the aspects of the 2 most commonly performed procedures: carotid endarterectomy after a longitudinal arteriotomy extending from the common carotid artery into the internal carotid artery and eversion endarterectomy in which the plaque is removed from the internal carotid artery sectioned from the common carotid artery and everted. The author suggests applying this technique selectively in patients in whom the atherosclerotic plaque extends very high into the internal carotid artery. The technique offers the advantages of removing the plaque into the common carotid artery under direct vision and leaving the original dimensions and geometry of the internal carotid artery, theoretically decreasing the probability of early thrombosis and recurrent carotid disease. For routine cases, the author prefers and recommends standard carotid bifurcation endarterectomy with patch closure when the size of the arteries is reduced like in women and selected male patients.

Hybrid treatment of common carotid artery occlusion with ring-stripper endarterectomy plus stenting

Symptomatic occlusion of the common carotid artery with preserved circulation in the internal carotid artery is an uncommon occurrence. We describe a hybrid technique whereby a patient was treated with eversion carotid bifurcation endarterectomy, fluoroscopically guided retrograde ring-stripper common carotid endarterectomy, and stenting of residual stenosis in the disobliterated artery. Successful recanalization was achieved without adverse anatomic or neurologic sequelae. The patient remains asymptomatic with a radiographically patent reconstruction at 1 year. This combination of endovascular and open surgery enables the surgeon to address long occlusions of the common carotid arteries with control of the distal and proximal endarterectomy margins and obviates the need for general anesthesia or sternotomy.

Routine Shunting Is a Safe and Reliable Method of Cerebral Protection during Carotid Endarterectomy

The purpose of this report is to describe the perioperative and long-term outcomes of standard carotid endarterectomy (CEA) with general anesthesia, routine shunting, and patching and to show that routine shunting is a safe and reliable method of cerebral protection. Between January 1998 and December 2004, 700 patients attending our Department of Vascular Surgery underwent 786 CEAs performed using a standardized technique. Forty-four patients were excluded from the analysis because they underwent combined CEA and coronary artery bypass grafting, so the analysis is based on the results of 742 CEAs in 656 patients (86 bilateral CEAs). The strict surgical protocol included general anesthesia and standard carotid bifurcation endarterectomy with routine shunting (Javid's shunt) and Dacron patching. The Javid shunts were easily inserted in 738 cases (99.4%) but could not be used in four cases (0.5%) because of the presence of a very small internal carotid artery. The mean ischemic time required to insert the shunt and complete the suture was 4.7 min (+/-1.15), and the mean time to perform the endarterectomy was 34.3 min (+/-6.7). The mean follow-up was 24.4 months (+/-17.3). Overall 30-day mortality was 0.1% (one patient) due to a contralateral major stroke. The 1-month perioperative neurological complication rate was 0.7%, with three major and two minor strokes. The cumulative stroke and death rate was 0.8%. Preoperative symptoms such as hypertension, contralateral occlusion, or an age of more than 80 years were not independent risk factors for perioperative stroke. In the long-term follow-up, Kaplan-Meier analysis indicated an estimated 5-year stroke-free rate of 98.0%. There were eight cases (1%) of >70% restenosis (four cases) or thrombosis (four cases) of the operated internal carotid artery during the follow-up in asymptomatic patients: in four cases, carotid stenting due to >70% restenosis led to good results. The Kaplan-Meier estimate of the restenosis-free rate was 97.8%. The combined stroke and mortality rate of 0.8%, and the restenosis rate of 1% support the argument that standard CEA performed with routine shunting as brain protection leads to excellent early and long-term results.

Derivação carótido-carotídea por via retrofaríngea: seguimento tardio

Existem diversas opções para o tratamento da doença oclusiva dos troncos supra-aórticos, de acordo com a apresentação clínica e a localização das lesões arteriais. As abordagens cervicais são aceitas como alternativas de baixa morbimortalidade, com elevada perviedade em longo prazo. Os autores relatam um caso tratado com sucesso através de derivação carótido-carotídea cruzada por via retrofaríngea associada à endarterectomia da bifurcação carotídea. São discutidos também os aspectos clínicos e as opções cirúrgicas ou endovasculares para o melhor tratamento desses pacientes.

Angioplasty and primary stenting of the subclavian, innominate, and common carotid arteries in 83 patients

Purpose: The initial and long-term results of angioplasty and primary stenting for the treatment of occlusive lesions involving the supra-aortic trunks were studied. Methods: All patients in whom angioplasty and stenting of the supra-aortic trunks was attempted were included in a prospective registry. Results are, therefore, reported on an intent-to-treat basis. The preprocedural and postprocedural clinical records, arteriograms, and noninvasive vascular laboratory examinations of 83 patients (41 men [49.4%] and 42 women [50.6%]; mean age at intervention, 63 years) in whom endovascular repair of the subclavian (66, 75.9%), left common carotid (14, 16.1%), and innominate (7, 8.0%) arteries was attempted were retrospectively reviewed. Results: Initial technical success was achieved in 82 of 87 procedures (94.3%). The inability to cross 4 complete subclavian occlusions and the iatrogenic dissection of 1 common carotid artery lesion accounted for the 5 initial failures. Complications occurred in 17.8% of 73 subclavian and innominate procedures, including access-site bleeding in 6 and distal embolization in 2. Ischemic strokes occurred in 2 of 14 common carotid interventions (14.3%), both of which were performed in conjunction with ipsilateral carotid bifurcation endarterectomy. The 30-day mortality rate was 4.8% for the entire group. By means of life-table analysis, 84% of the subclavian and innominate interventions, including initial failures, remain patent by objective means at 35 months. No patients have required reintervention or surgical conversion for recurrence of symptoms. Of the 11 patients available for follow-up study who underwent common carotid interventions, 10 remain stroke-free at a mean of 14.3 months. Conclusion: Angioplasty and primary stenting of the subclavian and innominate arteries can be performed with relative safety and expectations of satisfactory midterm success. Endovascular repair of common carotid artery lesions can be performed with a high degree of technical success, but should be approached with caution when performed in conjunction with ipsilateral bifurcation endarterectomy. (J Vasc Surg 1998;28:1059-65.)

Technical report: Combined carotid bifurcation endarterectomy and intra-operative transluminal angioplasty of a proximal common carotid artery stenosis: an alternative to extrathoracic bypass

A method of management of a dual stenoses affecting the proximal common carotid artery and the internal carotid artery, the tandem lesion, is described in two cases. The combination of a surgical endarterectomy of the internal carotid artery narrowing and percutaneous balloon dilatation of the more proximal common carotid artery narrowing, via the arteriotomy site, with clamping of the internal carotid artery was successfully employed to avoid an extrathoracic bypass procedure.

Blowout of Carotid Venous Patch Angioplasty

Two cases of vein patch blowout were observed five and seven days after carotid bifurcation endarterectomy with patch angioplasty. Both patients died in spite of emergency reoperation. One patient developed respiratory failure with subsequent fatal cardiac arrest seven days after reoperation; the other died of extensive hemispheric infarction on the fifth postoperative day. At reoperation both ruptures were found to be located in the middle of the patch whereas the suture lines were intact. Both patients were hypertensive. In the first case, an accessory saphenous vein retrieved from the calf had been the only venous material available for the patch, while the other patient had varicose veins in the contralateral leg. Pathology revealed central transmural tissue necrosis in one of the disrupted patches. A review of the literature regarding morphologic alterations of free vein grafts placed within the arterial circulation as well as hemodynamics in patched arterial segments may provide additional insight as to the inherent benefits and risks of vein patch angioplasty after carotid endarterectomy. When considering vein patch angioplasty, particular attention should be directed to the gross aspect of the vein to be used as well as to any antecedent history of phlebitis.

Antiplatelet therapy following carotid bifurcation endarterectomy. Evaluation of a controlled clinical trial. Prognostic significance of histologic plaque examination on behalf of survival

To determine whether antiplatelet therapy following carotid bifurcation endarterectomy influences postoperative survival and whether signs of progression in the plaques harvested at the time of surgery might be a prognostic indicator, a controlled clinical trial was undertaken. During 1982 to 1985, 66 patients were recruited, operated on (carotid endarterectomy) and assigned, using the method of adaptive randomisation to the therapy group (n = 32) receiving 1.0 g acetylsalicylic acid (ASA) per day, starting day two prior to surgery, or to the control group (n = 34), which remained without antiplatelet medication. The plaques harvested at the time of surgery were processed using standard histopathological methods and examined "blindly" by light microscopy for signs of arterio-sclerotic progression. The final endpoint was patient survival. The last assessment of the participants survival status was done by June 1989. During follow-up, 20 patients died, six in the treatment group and 14 in the untreated group, the difference being statistically significant (P less than 0.013 Breslow, P less than 0.029 Mantel). In 27 instances the histo-pathological examination showed signs of progression. In this subgroup ASA yielded a significant prolongation of patient survival (P less than 0.017 Breslow, P less than 0.048 Mantel). In the remaining patients no signs of cellular infiltration were evident and no influence of ASA on patient survival was demonstrable (P less than 0.503 Breslow, P less than 0.390 Mantel).

Operative angiography by intraarterial digital subtraction angiography: a new technique for quality control of carotid endarterectomy.

Fifty patients who had carotid bifurcation endarterectomy as their sole surgical procedure underwent intraoperative completion angiography by means of portable intraarterial digital subtraction angiography. All had subsequent intravenous digital subtraction angiography or duplex scanning during early follow-up. After the endarterectomy site was closed and before the wound was closed, 6 to 8 ml of contrast was injected through a 21-gauge needle while fluoroscopy was performed with a conventional C-arm. The C-arm was coupled to a Quantel IDIS Mobile Digital Subtraction Angiogram Unit (Quantel Medical Products Group, Clemmons, N.C.) for image enhancement and immediate playback. There were no postoperative deaths or neurologic complications. Abnormal radiographic results led to reopening of endarterectomy sites in eight patients, which resulted in successful correction of the defects. There was a single asymptomatic occlusion of the internal carotid artery at 3 weeks in the patient with the only false-negative result on the completion study. Intraarterial digital subtraction angiography is a safe and useful technique for intraoperative quality control of carotid endarterectomy. It provides visual images that can be easily repeated in several projections, uses small volumes of contrast, and has no timing requirements for filming and injecting.

Operative angiography by intraarterial digital subtraction angiography: A new technique for quality control of carotid endarterectomy

Fifty patients who had carotid bifurcation endarterectomy as their sole surgical procedure underwent intraoperative completion angiography by means of portable intraarterial digital subtraction angiography. All had subsequent intravenous digital subtraction angiography or duplex scanning during early follow-up. After the endarterectomy site was closed and before the wound was closed, 6 to 8 ml of contrast was injected through a 21-gauge needle while fluoroscopy was performed with a conventional C-arm. The C-arm was coupled to a Qauntel IDIS Mobile Digital Subtraction Angiogram Unit (Qauntel Medical Products Group, Clemmons, N.C.) for image enhancement and immediate playback. There were no postoperative deaths or neurologic complications. Abnormal radiographic results led to reopening of endarterectomy sites in eight patients, which resulted in successful correction of the defects. There was a single asymptomatic occlusion of the internal carotid artery at 3 weeks in the patient with the only false-negative result on the completion study. Intraarterial digital subtraction angiography is a safe and useful technique for intraoperative quality control of carotid endarterectomy. It provides visual images that can be easily repeated in several projections, uses small volumes of contrast, and has no timing requirements for filming and injecting.

Carotid eversion endarterectomy revisited

Carotid eversion endarterectomy appears to be a safe and anatomically acceptable alternative to the standard carotid bifurcation endarterectomy, as evidenced by the absence of permanent neurologic morbidity and mortality in 98 operations. Preliminary clinical, angiographic, and noninvasive laboratory parameters suggest that there is a significant reduction of both residual technical defects and early recurrent stenosis. Specifically, no perioperative thrombosis or early restenosis was encountered in the 98 endarterectomies. Furthermore, only two technical defects have been noted, and one of these occurred in one patient who required a longitudinal arteriotomy and attendant suture line when the common carotid artery was transected too proximally and the eversion maneuver could not be accomplished. Serial long-term clinical and noninvasive laboratory follow-up evaluation, in addition to indicated postoperative angiography, will continue in an effort to assess the durability of a technical approach to carotid endarterectomy that may minimize residual defects and early restenosis.

Early postoperative angiographic findings after carotid endarterectomy.

This report reviews the early postoperative evaluation of 70 patients who underwent carotid bifurcation endarterectomy within our department (before patients' releasing). Angiography was performed by femoral catheterization or the retrograde brachial route; three times only digital venous techniques were employed. No complications due to radiological procedures occurred. Postoperative angiographic findings include asymptomatic occlusion of ICA, occlusion of ECA, the presence of mural thrombi, diffuse surface roughness, intimal flaps and kink of ICA. Dilatation of the arteriotomized segment was detected with a high rate of frequency. Postoperative vascular changes are then analyzed in relation to surgical techniques, to early postoperative clinical course and to the occurrence of late re-stenoses.

Turbulence occurring after carotid bifurcation endarterectomy: A harbinger of residual and recurrent carotid stenosis

The goal of carotid endarterectomy is to remove an obstructing or embologenic lesion and reconstruct a durable arterial segment free of flow abnormality. The technical adequacy of 250 endarterectomy sites in 235 patients was assessed at operation by pulsed Doppler spectral analysis and arteriography and was correlated with postoperative patency, the incidence of residual and recurrent stenosis, and clinical outcome. Duplex scanning was used after operation to categorize disease severity. At operation, 10 patients (4%) had angiographic and Doppler flow abnormalities identified in the internal carotid artery. Vessel exploration identified intimal flaps, platelet aggregation, or stricture. Residual flow disturbances at the endarterectomy site correlated with perioperative thrombosis and stroke, angiographic abnormalities, primary closure of the arteriotomy, and a postoperative duplex scan consistent with stenosis. In 175 patients (182 sites) with normal arterial flow after carotid bifurcation endarterectomy, no thrombotic events occurred and the incidence of recurrent stenosis (life-table analysis) was zero at 3 months, 5% at 1 year, and 9% at 2 years. The incidence of occlusion and recurrent stenosis was increased (8% at 3 months, 18% at 1 year, and 21% at 2 years) in 68 arteries with residual flow disturbance identified at operation. Assessment of endarterectomy sites for turbulence identifies anatomic lesions that threaten patency and increase the incidence of residual and recurrent stenosis.

Diagnosis and Treatment of Carotid Artery Disease: With Special Emphasis on Noninvasive Diagnosis and Surgical Technique

ABSTRACT Carotid bifurcation endarterectomy is currently the single most common vascular reconstruction performed in the United States. The second edition of this monograph is a timely summary of the subject. The book is clearly written and easily read. The management approaches advocated are well balanced and documented. This is an excellent book for both the surgical resident and the vascular surgeon.The pathophysiology of extracranial disease as well as the clinical evaluation of the patient are nicely summarized. Noninvasive laboratory evaluation has been brought up-to-date with the addition of a discussion of real time B-mode imaging of the carotid artery combined with Doppler spectrum analysis of the flow signal in the carotid arteries (duplex scanning). The authors emphasize that noninvasive testing is most useful in patients without symptoms or with obscure symptoms since classic ischemic symptoms usually indicate arteriography. They also emphasize that the role of the laboratory in the asymptomatic

Management of occlusive lesions of the branches of the aortic arch

The clinical progress of 157 patients with atherosclerotic occlusive lesions of the major branches of the aortic arch is reviewed, with emphasis on the relation of the lesions to cerebral symptoms or stroke. Fifty per cent of these patients were free of significant symptoms from the onset or were made so by a prior carotid bifurcation endarterectomy. No operations were performed on the major arch branches in these patients. The subclavian artery was the prominent site of the proximal lesion. Follow-up examinations indicate that the lesions in these patients do not in themselves lead to stroke and that the indications for operation, therefore, are determined by the need for relief of symptoms. Revascularization operations were performed on eighty patients with genuine disabling symptoms. The innominate and common carotid lesions were more prone to cause disability than were the subclavian. Removal or bypass of the obstructing lesion was generally satisfactory in relieving symptoms.

KINKED INTERNAL CAROTID ARTERY. CLINICAL EVALUATION AND SURGICAL CORRECTION.

Arteriosclerotic occlusive lesions of the brachiocephalic system were well described by Broadbent in 1875 2 and Penzoldt in 1881. 13 The significance of these lesions in the production of cerebral insufficiency was later emphasized by Chiari in 1905 3 and Hunt in 1914. 7 The most common pathological process is an occlusive atheromatous plaque at the level of the common carotid bifurcation. The surgical management of this lesion is well established. Endarterectomy has been regarded as the procedure of choice. 1,4,5,9 Obstruction of the extracranial portions of the carotid and vertebral systems can also occur due to external pressure by bony projection or by kinking of the vessels. 10,11,14 The purpose of this presentation is to report our experience with kinked internal carotid artery. Clinical Material In a series of 308 patients subjected to carotid surgery, 248 underwent carotid bifurcation endarterectomy and 15 were operated upon for the relief of