Carotid Endarterectomy Procedures Research Articles

High glucose promotes atherosclerosis by regulating miRNA let7d-5p level.

MiRNA let7d-5p has been recently reported to be abnormally expressed in diabetes-associated atherosclerosis (AS). However, it still remains unknown how let7d-5p contributes to the process of atherosclerosis. Twenty fresh tissues and a total of 28 wax block specimens from carotid endarterectomy procedures were obtained from the Luoyang Central Hospital affiliated to Zhengzhou University. The expression of let7d-5p was assessed using quantitative RT-PCR (qRT-PCR). A series of in vitro experiments was used to determine the roles of let7d-5p knockdown and overexpression in vascular smooth muscle cells (VSMCs). We discovered that the carotid plaques from diabetic patients had lower expression levels of miR let7d-5p. In VSMCs, the expression of miRNA let7d-5p was significantly lower in high glucose conditions compared with low glucose situations. The proliferation and migration of VSMCs were also inhibited by the overexpression of let7d-5p, whereas the opposite was true when let7d-5p was inhibited, according to gain and loss of function studies. Mechanically, let7d-5p might activate the GSK3β/β-catenin signaling pathway via binding to the high mobility group AT-Hook 2 (HMGA2) mRNA in VSMCs. Additionally, GLP-1RA liraglutide may prevent the migration and proliferation of VSMCs by raising let7d-5p levels. High glucose stimulated the proliferation and migration of VSMCs by regulating the let7d-5p/HMGA2/GSK3β/β-catenin pathway, and liraglutide may slow atherosclerosis by increasing the levels of miR let7d-5p.

Abstract TP50: Ensuring Safe Post-Procedure Throughput for CEA and CAS Patients

Background: A new policy was implemented in November 2021 to reduce the length of post-anesthesia-care-unit (PACU) stay from 6 hours to 4 hours to reduce the nursing care burden and decrease the length of stay, yet how it affected patients’ events after PACU discharge needed close evaluation. Thus, the QI project aimed to retrospectively examine unexpected or safety events of patients who underwent carotid artery stenting or carotid endarterectomy procedures before versus after implementing the new policy. Objective: To compare and examine the rates of unexpected or safety events that occurred before (5/1/2021 - 10/31/2021; PRE) vs. after (2/1/2022 - 7/31/2022; POST) adoption of the new policy. Methods: A determination of IRB review was granted for the retrospective QI project. The unexpected or safety events included patient issues (rapid response calls, STAT calls to service, or bounce back to a higher level of care) and issues with VS or neuro assessment variability. For group comparison, Fisher’s Exact tests were used for dichotomous information, and the Mann-Whitney U tests were performed for continuous data. Results: A total of 145 patients were identified during the study period composing 75 (51.7%) PRE and 70 (48.3%) POST patients. The rates of VS or neuro assessment variability were similar in both groups (PRE: 1.3% vs. POST: 1.3%, p =1.000). Though we saw a lower rate of patient issues within 24 hours on the floor in POST (4.3%), the difference was not statistically significant (PRE: 8.0%, p =0.496). Conclusion: Inefficient patient throughput can impact currently strained hospital resources. Findings of the QI project confirmed that the new policy did not incur a higher rate of instability on the nursing unit. This data lends confidence to Vascular Surgery and Stroke programs as they seek to streamline patient care and manage hospital resources.

Duplex ultrasound and cross-sectional imaging in carotid artery occlusion diagnosis

ObjectiveInvestigations into imaging modalities in the diagnosis of extracranial carotid artery occlusion (CAO) have raised questions about the inter-modality comparability of duplex ultrasound (DUS) and cross-sectional imaging (CSI). This study examines the relationship between DUS and CSI diagnoses of extracranial CAO. MethodsThis single-institution retrospective analysis studied patients with CAO diagnosed by DUS from 2010 to 2021. Patients were identified in our office-based accredited vascular laboratory database. Imaging and clinical data was obtained via our institutional electronic medical record. Primary outcome was discrepancy between DUS and CSI modalities. Secondary outcomes included incidence of stroke and intervention subsequent to CAO diagnosis. ResultsOf our 140-patient cohort, 95 patients (67.9%) had DUS follow-up (mean, 42.7 ± 31.3 months). At index duplex, 68.0% of individuals (n = 51) were asymptomatic. Seventy-five patients (53.6%) had CSI of the carotids after DUS CAO diagnosis; 18 (24%) underwent magnetic resonance imaging and 57 (76%) underwent computed tomography. Indications for CSI included follow-up of DUS findings of carotid stenosis/occlusion (44%), stroke/transient ischemic attack (16%), other symptoms (12%), preoperative evaluation (2.7%), unrelated pathology follow-up (9.3%), and outside institution imaging with unavailable indications (16%). When comparing patients with CSI and those without, there were no differences with regard to symptoms at diagnosis, prior neck interventions, or hypertension. There was a significant difference between cross-sectionally imaged and non-imaged patients in anti-hypertensive medications (72% vs 53.8%; P = .04). Despite initial DUS diagnoses of carotid occlusion, 10 patients (13.3%) ultimately had CSI indicating patent carotids. Four of these 10 patients had stenoses of ∼99% (with 1 string sign), four of 70% to 99%, one of 50% to 69%, and one of less than 50% on CSI. The majority of patients (70%) had CSI within 1 month of the index ultrasound. There were no significant relationships between imaging discrepancies and body mass index, heart failure, upper body edema, carotid artery calcification, and neck hardware. Eight individuals (10.7%) underwent ipsilateral revascularization; 62.5% (n = 5) were carotid endarterectomy procedures, and the remaining three procedures were a transcervical carotid revascularization, subclavian to internal carotid artery bypass, and transfemoral carotid artery stenting. Eight patients (10.7%) underwent contralateral revascularization, with the same distribution of procedures as those ipsilateral to occlusions. Two of the 10 patients with discrepancies underwent carotid endarterectomy, and one underwent carotid stenting. ConclusionsIn our experience, duplex diagnosis of CAO is associated with a greater than 10% discordance when compared with CSI. These patients may benefit from closer surveillance as well as confirmatory computed tomography or magnetic resonance angiography. Further work is needed to determine the optimal diagnostic modality for CAO.

Polyvascular Disease Influences Long-Term Cardiovascular Morbidity in Carotid Endarterectomy

Introduction/ObjectiveCarotid stenosis (CS) is an important cause of ischemic stroke. Secondary prevention lies in performing a carotid endarterectomy (CEA) procedure, the recommended treatment in most cases. When two or more vascular regions are simultaneously affected by atherosclerosis, mainly the carotid arteries, coronary arteries, or limb arteries, a multivessel disease polyvascular disease (PVD) is present. This study aims to assess the potential role of PVD as a long-term predictor of major adverse cardiovascular events (MACE) and all-cause mortality in patients submitted to CEA. MethodsFrom January 2012 to December 2021, patients submitted to CEA for carotid stenosis in a tertiary care and referral center were eligible from a prospective database. A post hoc survival analysis was performed using the Kaplan-Meier survival curve method. The primary outcome was the incidence of long-term MACE and all-cause mortality. Secondary outcomes included acute myocardial infarction (AMI), major adverse limb events (MALE), stroke, and acute heart failure (AHF). ResultsA total of 207 patients were enrolled, with a median follow-up of 63 months. The mean age was 70.4±8.9, and 163 (78.7%) were male. There were 65 (31.4%) patients that had two arterial vascular territories affected, and 29 (14.0%) patients had PVD in 3 arterial beds. On multivariable analysis, both MACE and all-cause mortality had as independent risk factors age (aHR 1.039, P=0.003; aHR 1.041, P=0.019), chronic kidney disease (aHR 2.524, P=0.003; aHR 3.377, P<0.001) and PVD2 (aHR 3.381, P<0.001; aHR 2.665, P=0.013). PVD1 was only associated with MACE as a statistically significant risk factor (aHR 2.531, 1.439-4.450, P<0.001). ConclusionPVD in patients with cerebrovascular disease (CVD) was revealed to carry a two-fold increased risk for all-cause mortality and MACE during long-term follow-up. PVD may be a simple yet valuable tool in predicting all-cause mortality, MACE, AMI, and MALE after CEA.

Surgical Specialty Impacts Quality of Operative Training in Carotid Endarterectomy

Carotid endarterectomy (CEA) is currently performed by multiple surgical specialties. The impact of surgical specialty and operative volume on post-CEA outcomes has been well described. However, it is unclear whether trainees of different surgical specialties have similar quality of operative training. Data from Accreditation Council for Graduate Medical Education annual reports were collected and compared between graduating vascular surgery (VS) residents, VS fellows, and neurological surgery (NS) residents. Only cases reported as chief/senior/lead resident, surgeon junior, or surgeon fellow were included in analysis. Linear regression analysis was utilized to evaluate trends in case-mix and volume. From 2013 to 2022, total CEA case volume was higher among VS residents and fellows, compared to NS residents (52.8±0.8 vs. 44.3±1.4 vs. 12.9±0.6, P<0.0001). Additionally, VS residents and fellows performed other carotid operations including transfemoral or transcarotid artery stenting (11.1±0.9 vs. 11.2±0.8 vs. 0), carotid body tumor resection (0.7±0.1 vs. 0.7±0.0 vs. 0), and extracranial cervical bypass (6.7±0.3 vs. 6.3±0.3 vs. 0) that were not reported by the NS resident cohort (P<0.0001 each). On linear regression analysis, total CEA procedures did not change for VS residents (R2=0.03, P=0.62), decreased for VS fellows (-1.29 cases/yr, R2=0.75, P<0.0001), and decreased among NS residents (-0.41 cases/yr, R2=0.44, P=0.01) over the study period. Although residents of multiple surgical specialties are trained in CEA, vascular training offers significantly greater numbers and diversity of extracranial carotid cases. It also appears that CEA volume is decreasing among neurosurgical trainees. In light of recent reports on the volume-outcome effect in carotid surgery, these data may have implications for future practice patterns in the domain of extracranial carotid artery disease.

Carotid Endarterectomy in the Very Elderly: Short-, Medium-, and Long-Term Outcomes.

: Carotid endarterectomy (CEA) has an established effect on stroke-free survival in patients with carotid artery stenosis. Most landmark trials excluded patients ≥80 years of age due to their perceived high risk and uncertainty regarding the benefits of CEA. Despite the ongoing global increase in life expectancy, guidelines have not changed. The current study aimed to assess CEA outcomes in patients ≥80 years of age. : Data from patients ≥80 years of age, who underwent CEA between April 2016 and April 2022, were collected. Demographic information, comorbidities, surgical details, operative details, outcomes, and post-CEA survival were reviewed, and long-term data up to April 2023 were collected. : Over the 6-year study period, 258 CEA procedures were recorded, of which 70 (27.1%) were performed in patients ≥80 years of age; the mean age was 84 years (range, 80-96 years), 47 (67.1%) were males, and 69 (98.6%) were symptomatic. Twenty-three (32.9%) patients were American Society of Anesthesiologists (ASA) grade 2, and 47 (67.1%) were grade 3. The 30-day stroke and mortality rates were 4.3% and 1.4%, respectively. At 1, 3, and 5 years, the cumulative freedom-from-stroke rates were 95.7%, 92.9%, and 91.4%, respectively, and the cumulative survival rates were 94.3%, 75.7%, and 61.4%, respectively. No risk factors affected early or late stroke or early mortality rates. Patients with ASA grade 3 had significantly lower cumulative survival than those with grade 2 (HR, 5.29; 95% CI, 1.590-17.603; P<0.01). : CEA was safe and effective in average-risk, elderly patients. Higher risk patients (i.e., ASA 3) showed no increased 30-day risk for stroke or mortality but exhibited significantly worse long-term survival. Hence, careful consideration of the benefits before performing CEA is crucial.

Study on Microsurgical Anatomy of External Branch of Superior Laryngeal Nerve Related to Carotid Endarterectomy.

To explore the methods of protecting the external branch of the superior laryngeal nerve during carotid endarterectomy through microsurgical anatomic study of the external branch of the superior laryngeal nerve in cadaveric specimens. A total of 30 cadaveric specimens (60 sides) were dissected to measure the thickness of the external branch of the superior laryngeal nerve. A triangular area was exposed, bounded by the lower border of the digastric muscle superiorly, the medial edge of the sternocleidomastoid muscle laterally, and the upper border of the superior thyroid artery inferiorly. The probability of the occurrence of the external branch of the superior laryngeal nerve in this area was observed and recorded. The distance among the midpoint of the external branch of the superior laryngeal nerve in this area with the tip of the mastoid process and the angle of the mandible as well as the bifurcation of the common carotid artery was measured and recorded. Among 30 specimens of cadaveric heads (60 sides) examined 53 external branches of the superior laryngeal nerve were observed while 7 were absent. Of the 53 branches observed, 5 were located outside the anatomic triangle region mentioned above, while the remaining 48 branches were located within the anatomic triangle region with a probability of ~80%. The thickness of the midpoint of the external branches of the superior laryngeal nerve within the anatomic triangle region was 0.93mm (0.72-1.15mm [±0.83 SD]), located 0.34cm [-1.62-2.43cm (±0.96 SD)] posterior to the angle of the mandible, 1.28cm (-1.33 to 3.42cm (±0.93 SD)] inferiorly; 2.84cm (0.51-5.14cm±1.09 SD) anterior to the tip of the mastoid process, 4.51cm (2.82-6.39cm±0.76 SD) inferiorly; 1.64cm [0.57-3.78cm (±0.89 SD)] superior to the bifurcation of the carotid artery. During carotid endarterectomy procedure, using the cervical anatomic triangle region, as well as the angle of the mandible, the tip of the mastoid process, and the bifurcation of the carotid artery as anatomic landmarks, is of significant clinical importance for protecting the external branches of the superior laryngeal nerve.

Intraoperative Neuromonitoring of Hypoglossal Nerves Using Transcranial and Direct Electrical Stimulation During Extracranial Internal Carotid Artery Surgery.

We explored whether the electromyogram (EMG) and the motor evoked potential (MEP) are useful for monitoring the function of the hypoglossal nerve during surgery targeting the cervical segment of the internal carotid artery. The present study included 6 patients with internal carotid arterial stenosis (1 patient underwent bilateral surgeries) and 1 patient with a cervical carotid artery aneurysm. In 5 of the 8 procedures, the EMGs were recorded. We examined whether changes in the MEP and/or EMG were capable of predicting postoperative hypoglossal nerve deficits. None of the 6 patients who underwent a total of 7 carotid endarterectomy (CEA) procedures experienced postoperative hypoglossal nerve morbidity. In 2 of the 7 procedures, the MEP disappeared or decreased significantly during CEA. In all 4 cases in which the hypoglossal nerve was directly stimulated during CEA, stable and reproducible EMGs were obtained throughout the manipulation of the internal carotid artery. Hypoglossal nerve morbidity was observed in the one case that underwent aneurysm removal and end-to-end anastomosis of the internal carotid artery. In this case, while the MEP decreased significantly during the operation, the EMG showed true-positive results and false-negative results, depending on the stimulation site. The monitoring of hypoglossal nerve function using EMG appears to be accurate if an appropriate stimulation site is selected. Hypoglossal nerve monitoring using MEP can produce false-positive results. Combined monitoring using both MEP and EMG is recommended in cases where exposure of the hypoglossal nerve is expected to be technically difficult.

Association between Hospital Carotid Endarterectomy Procedure Volumes and In-Hospital Mortality in São Paulo State.

Previous studies indicate an inverse relationship between hospital volume and mortality after carotid endarterectomy. However, data at the level of Brazil are lacking. To assess the relationship between hospital carotid endarterectomy procedure volumes and mortality in the state of São Paulo. Data from the São Paulo State Hospital Information System on all carotid endarterectomies performed between 2015 and 2019 were analyzed. Hospitals were categorized into clusters by annual volume of surgeries (1-10, 11-25, and ≥26). Multiple logistic regression models were used to determine whether the volume of carotid endarterectomy procedures was an independent predictor of in-hospital mortality among patients undergoing this procedure. Crude in-hospital mortality was nearly 60 percent lower in patients who underwent carotid endarterectomy at the highest volume hospitals than among those who underwent endarterectomy at the lowest volume hospitals (unadjusted OR of survival to hospital discharge, 2.41; 95% CI, 1.11-5.23; p = 0.027). Although this lower rate represents 1.5 fewer deaths per 100 patients treated, high-volume centers are more likely than low-volume centers to perform elective procedures, thus the analysis did not retain statistical significance when adjusted for admission character (OR, 1.69; 95% CI, 0.74-3.87; p = 0.215). In a contemporary Brazilian registry, higher volume carotid endarterectomy centers were associated with lower in-hospital mortality than lower volume centers. Further studies are needed to verify this relationship considering the presence of symptoms in patients.

Strategy of carotid artery stenting as first-line treatment and carotid endarterectomy for carotid artery stenosis: A single-center experience.

The main surgical options for stenosis of the carotid artery are carotid endarterectomy (CEA) and carotid artery stenting (CAS). The number of CAS procedures performed in Japan greatly exceeds that of CEA procedures. In this study, we used data from a single center to examine CAS and CEA for carotid artery stenosis. The subjects were patients with carotid artery stenosis who underwent CAS or CEA between January 2012 and May 2020. CAS was the first-choice treatment. CEA was used in cases with vulnerable plaques, a relatively low risk of general anesthesia, and no anatomical features disadvantageous for endarterectomy. A total of 140 cases (102 CAS and 38 CEA) were examined. There were more elderly patients in the CAS group. The CEA group had a higher rate of vulnerable plaques and only one case with an unfavorable anatomy for CEA. Major adverse events (stroke) occurred in two CAS cases. In multivariate logistic analysis, postoperative ischemic lesions were independently associated with age (odds ratio [OR] = 1.13, 95% confidence interval [CI]: 1.01-1.26, P = 0.026) and vulnerable plaque (OR = 5.54, 95% CI: 1.48-20.70, P = 0.011) in the CAS group, but not in the CEA group. The results reflect the treatment algorithm at our hospital, indicating that triage is accurate. Thus, it is beneficial to assign cases based primarily on plaque vulnerability and anatomical risk for CEA, and to not hesitate to perform CEA simply because of old age. CAS as first-line treatment and CEA are effective and safe, which reflect the treatment situation in Japan.

Carotid Endarterectomy Surgeries: A Multimodality Intraoperative Neurophysiological Monitoring Approach.

Patients with untreated carotid artery stenosis remain at high risk for stroke. Carotid endarterectomy (CEA) is a surgical procedure for the treatment of symptomatic and severe asymptomatic carotid stenosis. A small percentage of patients who do not have good collateral circulation are at high risk of cerebral ischemia during the cross-clamping of the carotid artery. Aspects of CEA, such as cross-clamping and routine shunting, can also carry the risk of perioperative stroke through dislodgement of emboli causing thrombosis, therefore, selective shunting is highly recommended during the CEA procedure. A multimodality approach of intraoperative neurophysiological monitoring (IONM) techniques such as somatosensory evoked potential (SSEP) and electroencephalography (EEG) can be used to monitor cerebral perfusion throughout the duration of the surgery and to predict the need for a selective shunt after cross-clamping. Additional use of transcranial Doppler (TCD) in the multimodality approach can aid in visualizing the cerebral blood flow and detecting any microemboli that may also cause a stroke. A multimodality IONM approach has been reported as more sensitive and specific for predicting and minimizing any postoperative neurological deficits.

Short-Term Outcomes of Transfemoral Carotid Artery Stenting and Carotid Endarterectomy in Symptomatic Patients: Data from a Multicentric Prospective Registry in Brazil

Transfemoral carotid artery stenting (TF-CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. Because their main objective is to prevent future ischemic events, regular reassessment of the outcomes is mandatory for providing the best therapy. The purpose of this study was to describe the practice and the outcomes of TF-CAS and CEA in symptomatic patients in public university hospitals in Brazil, using data from a prospective multicentric registry. A prospective 8-year observational study of patients with symptomatic carotid artery atherosclerotic disease that underwent TF-CAS and CEA in 5 public university hospitals affiliated with the RHEUNI (Registry Project of Vascular Disease in the Public University Hospitals of São Paulo). All consecutive procedures were included. The indications for the procedures were determined by each surgeon's individual discretion, in accordance with a preoperative risk evaluation. The outcome measures were any 30-day follow-up death, stroke, myocardial infarction (MI), and their combined outcome (major adverse cardiovascular events [MACE]). The registration of the study was made at clinicaltrials.gov NCT02538276. From January 2012 through December 2019, 376 consecutive and symptomatic patients were included in the study records. There were 152 TF-CAS procedures (40.4%) and 224 CEA procedures (59.5%). All completed the 30-day follow-up period. Occurrence of death (TF-CAS: 0.66% × CEA: 0.66%, P=0.99), stroke (TF-CAS: 4.61% × CEA: 4.46%, P=0.99), and MI (TF-CAS: 0.66% × CEA: 0%, P=0.403) were similar in both groups, without statistically significant differences. MACE rate did not differ in both groups (TF-CAS: 5.92% × CEA: 4.46%, P=0.633). Data from a prospective registry of 5 Brazilian university hospitals showed that TF-CAS and CEA in symptomatic patients had similar 30-day perioperative rates of death, stroke, and MI and their combination.

A novel ultrasound-assisted laser technique to remove atherosclerotic plaques

Atherosclerosis is a medical condition in which arteries hardens and narrows due to the buildup of fat, cholesterol, calcium, and other substance. It can affect arteries of heart, brain, arms, legs, pelvis, and kidney, resulting in ischemic heart disease, carotid artery disease, peripheral artery disease, and chronic kidney disease. Laser based treatment techniques like laser angioplasty and carotid artery laser endarterectomy can be used to treat most common atherosclerosis disease like ischemic heart disease and carotid artery disease. Excimer laser coronary angioplasty (ELCA) is a clinical technique to remove the arterial plaque. However, the use of ELCA remains low due to higher risk of complication and its low efficacy in removing plaques as compared with balloon angioplasty. In this study, we developed a novel technology that uses ultrasound along with laser to assist the removal of atherosclerotic plaque. Spatio-temporally synchronized pulsed laser and ultrasound was used. The preliminary experiments were performed on pig belly fat sample to find the optimal ultrasound and laser parameters. The final experiment was performed on the plaque samples collected from patient during carotid endarterectomy procedure. Our results show that the addition of ultrasound can effectively reduce the needed laser power, which could result in improved treatment safety and efficiency.

Comprehensive comparison of carotid endarterectomy primary closure and patch angioplasty: A single-institution experience.

Background: Carotid endarterectomy (CEA) is an effective intervention for the treatment of high-grade carotid stenosis. Technical preferences exist in the operative steps including the use patch for arteriotomy closure. The goals of this study are to compare the rate of postoperative complications and the rate of recurrent stenosis between patients undergoing primary versus patch closure during CEA.Methods: Retrospective chart review was conducted for patients who underwent CEA at single institution. Vascular surgeons mainly performed patch closure technique while neurosurgeons used primary closure. Patients’ baseline characteristics as well as intraprocedural data, periprocedural complications, and postprocedural follow-up outcomes were captured.Results: Seven hundred and thirteen charts were included for review with mean age of 70.5 years (SD = 10.4) and males representing 64.2% of the cohort. About 49% of patients underwent primary closure while 364 (51%) patients underwent patch closure. Severe stenosis was more prevalent in patients receiving patch closure (94.5% vs. 89.4%; P = 0.013). The incidence of overall complications did not differ between the two procedures (odds ratio = 1.23, 95% confidence intervals = 0.82–1.85; P = 0.353) with the most common complications being neck hematoma, strokes, and TIA. Doppler ultrasound imaging at 6 months postoperative follow-up showed evidence of recurrent stenosis in 15.7% of the primary closure patients compared to 16% in patch closure cohort.Conclusion: Both primary closure and patch closure techniques seem to have similar risk profiles and are equally robust techniques to utilize for CEA procedures.

Savremeni tretman pacijenata sa karotidnom stenozom

Narrowing of the carotid arteries, carotid stenosis, (CS) is a frequent manifestation of atherosclerosis. It can be associated with other diseases of peripheral blood vessels, stenotic occlusive or aneurysmal, but also coronary arteries. Almost 15% of ischemic strokes are caused by this disease, which shares common risk factors with other atherosclerotic manifestations (age, male gender, hypertension, diabetes, smoking). The disease is progressive and with progression comes the progression of the degree of stenosis, the volume and morphological characteristics of the plaque. As these features progress, they increase the risk of clinical manifestations. Ischemic stroke, transient ischemic attack or transient blindness in the ipsilateral eye (amaurosis fugax) are the only clinical manifestations that can be directly related to carotid stenosis. Ischemic changes in the brain parenchyma, which can be seen on magnetic resonance imaging or computed tomography, are also associated with carotid stenosis. All the mentioned parameters are taken into account when making decisions about further treatment. Available drug therapy includes antiplatelet and statin therapy with control of risk factors (body weight correction, smoking cessation) and associated diseases (hypertension, diabetes, etc.). Invasive treatment includes carotid endarterectomy (CEA) as vascular or carotid stenting (CAS) as endovascular treatment. KEA is performed under local or general anesthesia, increasingly under local anesthesia, and after accessing the carotid arteries through a cervicotomy, they are clamped, the flow is interrupted, and after the artery is opened, plaque removal and endarterectomy are performed. In addition to the anesthesiological management of the patient and the performance of the surgical technique, the monitoring of cerebral perfusion during clamping is an important technical detail in these operations. KAS is performed through a percutaneous transfemoral approach under local anesthesia when a stent is implanted in the carotid artery at the site of the carotid stenosis. To perform this procedure, adequate access is required in terms of the quality of the femoral and iliac blood vessels, i.e. the aortic arch. KAS was introduced into practice much later, and in the last 20 years, there has been a significant improvement both in terms of performance and technology with the development of modern stents and the materials used in their installation. A special contribution to this technique was the introduction of embolization protection. KAS is a complementary method to CEA and an individual approach to the patient enables the choice of method, taking into account the advantages and disadvantages of one and the other method. When it comes to symptomatic patients, CEA certainly has a significantly greater advantage and when the use of CAS should be avoided. Complications of both methods are general, local and neurological, with the latter being the most important. Current recommendations state that performing these procedures is beneficial for the patient if the risk of neurological complications is less than 3% in asymptomatic patients, or less than 6% in symptomatic patients. At the Clinic for Vascular and Univascular Surgery of the Clinical Center of Serbia, in the last fifteen years, almost 9.000 procedures have been performed due to carotid stenosis, of which about 10% (960) were CAS. We opt for this method in patients who are at cardiorespiratory risk for CEA or in whom access to the carotid bifurcation is difficult. All, the CEA procedures are performed under conditions of the cervical block. The improvement of patient stratification and the use of artificial intelligence should in the future help doctors decide on the method of examination and treatment of these patients.

Surgical Procedure and Results of Carotid Endarterectomy with Routine Shunt Placement

Surgical Procedure and Results of Carotid Endarterectomy with Routine Shunt Placement

The Effect of Hemodynamic Parameters on Cerebral Oxygenization During Carotid Endarterectomy.

Objective/IntroductionNear-infrared spectroscopy (NIRS) is a non-invasive technique to detect cerebral ischemia by monitoring changes in regional cerebral oxygenation (rSO2) in the frontal lobes. However, there are no studies showing the changes in NIRS values in response to hemodynamic variations during stages of carotid endarterectomy (CEA) procedure and clinical implications of these changes. The aim of this study was to determine if hemodynamic changes affect NIRS values during carotid endarterectomy and if our results may help to provide strategies for hemodynamic management in these patients.MethodsA total of 50 consecutive patients undergoing CEA were prospectively included in the study. NIRS was measured at first minute after clamping of carotid artery, and then systolic blood pressure was increased above 150 mmHg. NIRS values from both hemispheres were recorded simultaneously at certain time points and were analyzed to evaluate the changes at different stages of operation and to assess correlations with hemodynamic parameters.ResultsNIRS values on the right and left sides were correlated with systolic (right P<0.001, R2:0.24; left P=0.02, R2:0.10) diastolic (right P<0.001, R2:0.36; left P=0.001, R2:0.18) and mean (right P<0.001, R2:0.33; left P=0.003, R2:0.17) blood pressures when the patient was under general anaesthesia. NIRS values were significantly lower than pre-incision values just after clamping of carotid artery in both hemispheres (P=0.005 for the right and P<0.001 for the left side).ConclusionNIRS values measured in our study show that there is a correlation between hemodynamic changes and cerebral oxygenation. This effect is especially pronounced while the patient is asleep and intubated, which implies the importance of close monitoring of patients with carotid disease during any surgery requiring general anaesthesia.

Factors Affecting the Outcome of Symptomatic Carotid Stenosis Surgical Treatment in a Single Center Series

The aim of this study is to evaluate the role of preoperative ischemic brain lesion (IBL) volume, assessed by Diffusion-weighted magnetic resonance brain imaging (DW-MRI) with RAPID® processing, and surgery timing in predicting post-operative neurological outcomes in symptomatic carotid stenosis (SCS) patients treated with carotid endarterectomy (CEA). All patients with SCS who underwent CEA between January 2010 and June 2020 were considered. IBLs ipsilateral to the stenosis were identified in the preoperative magnetic resonance brain (MRI). The volume was quantified in mL and correlated with 30-day rates of stroke and stroke/death by χ2 and receiver operating characteristic (ROC) curve. One hundred thirty-four patients were surgically treated for SCS during the entire study period. CEA procedures were defined as emergent, urgent, or elective if performed within 48 hr, between 48 hr and 14 days, or after 14 days from symptoms onset, respectively. Cumulative new ipsilateral stroke rate was 4,5%, with a statistically higher neurological complications in emergent patients compared to urgent and elective patients (10,6%, 1,47% and 0% respectively, P 0,039). ROC curve analysis showed a volume of 10 mL was predictive of postoperative stroke with 100% sensitivity and 80% specificity. An IBL volume >10 mL was an independent risk factor for postoperative stroke. In fact, the perioperative neurological complication rate was significantly different in high-IBL volume patients (>10 mL) compared with low-IBL volume patients (<10 mL) (P 0,003) CONCLUSIONS: The present study suggests that the optimal timing for CEA is between 48 hr and 14 days. Furthermore, the present study suggests that the presence of the IBL, by itself, is not definitively related with an unsatisfactory neurological outcome. However, an IBL higher than 10 mL should be as a reliable threshold value adverse neurological result in SCS patients.

Carotid Endarterectomy for Symptomatic Carotid Stenosis.

What are the benefits of carotid endarterectomy for people with symptomatic carotid stenosis?Carotid stenosis is a narrowing of the carotid arteries caused by atherosclerosis, the formation of plaque or fatty deposits on the artery walls.1 The buildup of plaque reduces blood flow to the brain and can lead to an embolus and potentially to an ischemic stroke.2Most patients with carotid stenosis are asymptomatic until the artery becomes severely narrowed or a clot forms. Common first symptoms are related to a transient ischemic attack resulting from a temporary blockage of blood flow to the brain, which subsequently returns to normal. The symptoms are similar to those of stroke and include weakness or numbness on one side of the body, aphasia, facial droop, and diplopia and other vision impairments.3The risk of a stroke resulting from severe carotid stenosis warrants evaluation of all treatment options, with a goal to prevent a stroke from occurring. The World Health Organization lists stroke as the second leading cause of death globally4; more than 13 million people have a stroke each year, and more than 5 million die because of it.5Treatment options for carotid stenosis combine lifestyle changes, medication, and surgical procedures. The most common surgical procedure is carotid endarterectomy, which removes the plaque from the carotid artery with a goal to restore blood flow and prevent a cerebral embolism.1The carotid endarterectomy procedure was first introduced in the 1950s as a stroke-preventing measure; by the early 1980s, more than 100 000 procedures were performed annually. In 1985, a study was published in which investigators stated that the procedure provided no benefit, leading researchers to conduct further studies to assess the efficacy of the procedure.6 As a result, the number of carotid endarterectomies varied each year. The randomized controlled studies that followed regarding the benefit of carotid endarterectomy found different outcomes and used different methods, making it challenging to determine which practices should be recommended.Among these studies was a risk-benefit analysis of carotid endarterectomy related to factors such as the percentage of stenosis (eg, &gt; 60%) and symptoms of transient ischemic attack at presentation. The purpose of this systematic review was to determine the risks and benefits of carotid endarterectomy with appropriate medical management, compared with those of only appropriate medical management, in patients who recently experienced symptomatic carotid stenosis.This summary is an update to a previously published systematic review that was conducted in 2017.7 As new evidence on a topic becomes available, updates are necessary to account for the results that the new evidence presents. This update, conducted by Rerkasem et al,8 included 3 randomized controlled trials comprising 6092 adult participants.The primary outcome was the 5-year cumulative risk for any type of stroke or operative death. The indicator was defined as any stroke or death that occurred within 30 days after carotid endarterectomy.Rerkasem et al8 independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication biases. They resolved any disagreements by reviewing the data together and through discussion.The authors used risk ratios (RRs) with 95% CIs for dichotomous outcomes as measures of treatment effect between the comparisons and outcomes. They used the internationally approved Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to determine the certainty of evidence— high, moderate, low, or very low— for each outcome9: The outcome varied depending on the percentage of carotid stenosis: This systematic review provides guidance related to the risks of carotid endarterectomy that can help inform nurses and other clinicians when they are advocating for the best available care and helping patients understand their options. As always, several factors can determine the outcome of a procedure. With carotid endarterectomy, however, the degree of carotid stenosis is the most important factor to consider. For patients with at least 30% stenosis, the evidence indicates that the procedure would provide benefit. That benefit increased for patients with 70% to 99% stenosis.One of the limitations of this review by Rerkasem et al8 is that the included studies are dated— they had been conducted in the 1990s—as no more recent studies were available that met the inclusion criteria. That being the case, we must consider that during the past 20 years medical treatments have advanced and now help both control atherosclerosis and prevent strokes. As a result, a comparison between the groups studied in this review (only medical treatment vs medical treatment and endarterectomy) would likely not be as significant. Studies are currently underway to explore such a comparison.As nurses caring for critically ill patients, we must advocate for the best evidence-based treatment remaining an important piece of our role. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is most appropriate to implement in our individual context.

The mid-term effects of carotid endarterectomy on cognition and regional neural activity analyzed with the amplitude of low frequency fluctuations technique

PurposeThe study aims to evaluate the mid-term effects of carotid endarterectomy (CEA) on cognition and resting-state functional magnetic resonance imaging (rs-fMRI) using the Amplitude of Low Frequency Fluctuations (ALFF) technique.MethodsIn this observational study, patients eligible for CEA were prospectively included. On the same day, within 1 week of the CEA procedure performed and 12 months after the CEA procedure, all patients underwent (i) an MRI examination for rs-fMRI analysis and (ii) a cognitive evaluation using the Italian version of the Mini-Mental State Examination (MMSE) corrected for age and schooling. Pre-CEA and post-CEA MMSE scores were evaluated using paired sample t-tests, adopting a p-value < 0.05 as statistical threshold. The ALFF technique was used for analyzing the differences between pre-CEA and post-CEA rs-fMRI scans in terms of regional neural activation. This was accomplished by applying non-parametric statistics based on randomization/permutation for cluster-level inferences, adopting a cluster-mass p-value corrected for false discovery < 0.05 for cluster threshold, and a p-uncorrected < 0.01 for the voxel threshold.ResultsTwenty asymptomatic patients were enrolled. The mean MMSE score resulted improved following CEA procedure (p-value = 0.001). The ALFF analysis identified a single cluster of 6260 voxels of increased regional neural activity following CEA, and no cluster of reduced activity. The majority of voxels covered the right precentral gyrus, the right middle frontal gyrus, and the anterior division of the cingulate gyrus.ConclusionMid-term cognitive improvements observed after CEA are associated to increased regional neural activity of several cerebral regions.