Complication Of Carotid Endarterectomy Research Articles

The Circle of Willis Status Influences Neurological Complications of Carotid Endarterectomy with Contralateral Carotid Occlusion

ObjectiveTo evaluate the impact of anatomical variations in the Circle of Willis (CoW) on immediate neurological events (INE) after carotid endarterectomy (CEA) without shunting in patients with contralateral carotid occlusion (CCO). Materials and MethodsSingle centre, retrospective study. Patient’s demographic and clinical outcomes data were prospectively collected. CoW segments were reviewed retrospectively. Between January 2013 and May 2018, 2090 patients underwent CEA under general anaesthesia, CCO was found in 113 (5.4%) patients. CoW segments were classified as normal, hypoplastic (diameter ˂ 0.8 mm), or absent based on Computed Tomography Angiography (CTA). We studied the CoW segments as two collateral networks connecting the basilar artery and the ipsilateral middle cerebral artery (MCA): a short semicircle (first segment of the ipsilateral posterior cerebral artery [P1] and posterior communicating artery [Pcom] segment) and a long semicircle (contralateral P1, Pcom, and both first segments of the anterior cerebri artery (A1) anterior communicating artery (Acom)). INE was defined as any transient ischemic attack (TIA) or stroke diagnosed immediately after the procedure. ResultsOut of the 113 patients, 46 underwent endarterectomy with shunting. We further excluded 16 patients from the assessment of the CoW due to unavailability or inadequate quality of CTA. Of the 113 patients, 2 had strokes, one with shunting that occurred hours after surgery. Besides the other stroke case, 4 INE were observed, all without the use of a shunt. Of the 51 patients with CoW assessment, 10 (19.6%) had a complete CoW, while 21 (41.2%) patients had only one semicircle intact (10 short and 11 long intact semicircles), and none of these patients experienced an INE. A total of 20 (39%) patients had both the long and short semicircles incomplete, of which 4 (7.8%) cases had an INE. In all INE cases, at least one of the Pcom was absent or hypoplastic. The absence of both Pcom was a strong predictor of incident INE [odds ratio=11.10 (confidence interval: 1.04-118.60)] for INE. ConclusionPatients with CCO and insufficient CoW collateral flow support are at an increased risk of INE, including stroke, in the absence of shunt protection during CEA cross-clamping. Shunting should always be considered when the collateral flow between the ipsilateral MCA and the basilar artery is compromised in CCO patients.

Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case.

Carotid endarterectomy (CEA) and carotid artery stenting are common surgical interventions for internal carotid artery stenosis. Cerebral hyperperfusion syndrome (CHS) is a well-known complication of both procedures that can lead to intracranial hemorrhage and worsen clinical outcomes. Here, the authors report a rare case of non-aneurysmal subarachnoid hemorrhage (SAH) following CEA and review the relevant literature. A 70-year-old woman with hypertension and diabetes presented with progressive visual loss in the right eye and was diagnosed with ocular ischemic syndrome. Imaging revealed severe right cervical carotid artery stenosis. CEA was performed with no complications. Postoperatively, the patient's blood pressure was tightly controlled, with no evidence of CHS. However, an asymptomatic SAH was detected on postoperative day 7. Careful observation and blood pressure control were maintained. Since follow-up magnetic resonance imaging (MRI) showed no enlarging of the SAH and the patient was asymptomatic, she was discharged on postoperative day 15 with a modified Rankin scale score of 0. This case highlights the potential occurrence of non-aneurysmal SAH as a rare complication of CEA, even in asymptomatic patients. Repeated postoperative MRI is necessary to detect such complications. It is crucial to carefully control blood pressure after CEA regardless of symptoms.

Impaired Dynamic Cerebral Autoregulation as a Predictor for Cerebral Hyperperfusion After Carotid Endarterectomy: A Prospective Observational Study

Cerebral hyperperfusion syndrome (CHS) is a severe complication of carotid endarterectomy (CEA). Because cerebral hyperperfusion (CH) reduces the benefits of CEA, it is important to identify patients at high risk of developing CH. We investigated dynamic cerebral autoregulation (dCA) as a potential predictor of CH after CEA. In a prospective observational study of 90 patients, we defined CH as a ≥100% increase in the transcranial Doppler ultrasound-derived mean flow velocity of the middle cerebral artery compared to baseline, with or without clinical manifestations. We examined dCA in the supine position and during squat-stand maneuvers using the transfer function, analyzing phase, gain, and coherence. Logistic regression analysis and receiver operating characteristic (ROC) curves were used to assess the relationships between variables and outcomes. Cerebral hyperperfusion (CH) occurred in 18 patients after CEA. The CH group had a lower ipsilateral phase for both body postures than the non-CH group at very low and low frequencies, respectively (both P<0.01). Postoperative CH was independently associated with the preoperative peak systolic velocity (PSV)sten/PSVdis ratio and the ipsilateral phase in both body postures at a very low frequency. Receiver operating characteristic (ROC) curve analysis showed that the ipsilateral phase had excellent CH predictive accuracy in the supine position and squat-stand maneuvers at a very low frequency (areas under the curve: 0.809 and 0.839, respectively, both P<0.001; cutoff values: 24.7 and 11.7, respectively). The lower ipsilateral phase may serve as a predictor of CH after CEA.

CarotidSCORE.RU — risk stratification for complications after carotid endarterectomy

Aim. To demonstrate the first Russian computer program (carotidscore.ru) for risk stratification of postoperative complications of carotid endarterectomy (CE).Material and methods. The present study is based on the analysis of a multicenter Russian database including 25812 patients after CE operated on from January 1, 2010 to April 1, 2022. The following types of CE were implemented: conventional CE with patch angioplasty — 6814 patients; eversion CE — 18998 patients. Following postoperative complications were assessed during the study: death, stroke, myocardial infarction (MI), composite endpoint (death + stroke + MI).Results. During inhospital postoperative period, 0,18% of participants died, while 0,14% had MI, 0,35% — stroke. The composite endpoint was recorded in 0,68%. For each factor present in patients, a predictive coefficient was estimated. The predictive coefficient was considered as a numerical parameter reflecting the strength of the effect of each factor on the development of postoperative complications. Based on this equation, predictive coefficients were calculated for each factor present in patients in our study. The total contribution of these factors was reflected as a percentage and denoted the risk of postoperative complications with a minimum of 0% and a maximum of 100%. On the basis of obtained calculations, a CarotidSCORE program was created. Its graphical interface is based on the QT framework. It is possible not only to estimate the risk of a complication, but also to save all data about a patient in JSON format. The CarotidSCORE program contains 47 patient parameters, including clinical, demographic, anamnestic and angiographic characteristics. It makes it possible to choose one of the four CE types, which will provide an accurate stratification of the complication risk for each of them.Conclusion. CarotidSCORE (carotidscore.ru) may determine the probability of postoperative complications in patients undergoing CE.

A Retrospective Study of 320 Patients Treated with Carotid Artery Stenting at 4 General Hospitals in Zhejiang Province to Establish a Risk Score for Cerebral Hypoperfusion Syndrome.

BackgroundCerebral hypoperfusion syndrome (CHS) includes a spectrum of clinical symptoms, ranging from focal neurologic deficit to intracerebral hemorrhage. CHS was initially described as a complication of carotid endarterectomy but also occurs following carotid artery stenting. This retrospective study included 320 patients treated with carotid artery stenting at 4 general hospitals in Zhejiang Province between June 2019 and June 2021 and aimed to establish a risk score for CHS.Material/MethodsThrough retrospective case analysis, a risk model and scoring model for CHS were established and evaluated.ResultsPoor integrity of the circle of Willis, preoperative cerebrovascular resistance, mean transit time, peak time at CTP, and preoperative cerebral circulation time were significant in the univariate analysis and were entered into the regression equation to establish the logistic and additive scoring model for predicting the risk of CHS after carotid stenting. The area under the receiver operating characteristic (ROC) curve of the logistic scoring system for the early warning risk of CHS after carotid stenting was 0.964 (95% confidence interval [CI] [0.931–0.996]), and the area under the ROC curve of the CHS early risk additive scoring model after carotid stenting was 0.968 (95% CI [0.936–1.000]), The Hosmer-Lemeshow test chi-square values were 0.037 (P=0.848) and 2.671 (P=0.102).ConclusionsTwo methods of scoring risk for CHS were developed from a retrospective analysis of 320 patients treated with carotid artery stenting at 4 general hospitals in Zhejian Province between June 2019 and June 2021.

Impact of implementing good care and management practice guidelines in carotid revascularization procedures.

Studies assessing the effect of implementing good practice management guidelines (GPMG) in carotid revascularization within the same hospital are scarce. Thus, we aimed to evaluate the impact of GPMG implementation on the clinical outcomes of carotid revascularization procedures within a quaternary hospital. We retrospectively studied 177 patients with atherosclerotic carotid disease who underwent revascularization (carotid endarterectomy and carotid artery stenting) at a quaternary hospital between January 2012 and December 2019. The patients were divided into two groups: the pre-guideline group with 73 patients and the post-guideline group with 104 patients who underwent the procedures before and after the implementation of GPMG, respectively. Twelve (16.4%) and 3 (2.9%) patients had neurological complications in the pre- and post-guideline groups, respectively (p = 0.001); most complications were cases of ischemic stroke. There were fewer complications in men than in women (OR = 0.22; 95% CI 0.06-0.77). A significant decrease in neurological complications was observed in the carotid artery stenting group (pre-guideline 25.7% vs post-guideline 13.2%; p = 0.004). Logistic regression analysis of the predisposing factors for neurological complications in carotid endarterectomy and carotid artery stenting demonstrated that the implementation of GPMG was a determining factor for the improved results (odds ratio = 0.11, 95% CI 0.02-0.59). Implementing GPMG for carotid revascularization resulted in better clinical results, with decreased neurological complications in patients that underwent angioplasty and endarterectomy.

Manajemen Neuroanestesi pada Operasi Carotid Endarterectomy: Pasien dengan Riwayat Stroke Berulang

Carotid endarterectomy (CEA) is a surgical procedure performed to restore carotid blood flow and reduce the incidence of embolic and thrombotic strokes. Although it is a preventive procedure, CEA carries the risk of perioperative complications: neurologic and cardiac. Major complications of CEA are intra and postoperative stroke, myocardial infarction, and death. To reduce the number of intraoperative stroke events, one of them is to develop intraoperative monitoring technology with electroencephalogram (EEG). In this case, a male patient, 62 years old, with statistics of recurrent stroke and left leg weakness was approved for CEA under general anesthesia. Surgeons decide to use shunt selectively by assessing EEG monitoring when clamping. Finally the shunt was not performed, the operation lasted for 6 hours, tinged with hemodynamic shocks that often occur in patients with carotid disease due to baroreceptor disorders. By managing anesthesia meticulously during and after surgery, the operation was successfully performed, and the results of the post on the left leg strengthening motor increased from 2 to 4.

Učestalost restenoze nakon karotidne endarterektomije

Introduction: Carotid artery restenosis is a significant long-term complication of carotid endarterectomy. Carotid artery restenosis is the result of neointimal hyperplasia in the early postoperative period or recurrent atherosclerotic lesions in the following period. Numerous studies have incriminated several risk factors as predisposing conditions for restenosis. The definite role of each predisposing factor, however, is still widely debated. Aim: Investigation of frequency and risk factors for restenosis after carotid endarterectomy. Material and methods: Data of 295 patients who underwent carotid endarterectomy was reviewed between 2008 and 2010. Postoperative duplex studies were performed on control examinations in the following period between 2011 and 2019. Retrospective analysis was performed to assess the effect of demographic, clinical and laboratory characteristics of patients on the development of restenosis after carotid endarterectomy. Results: Restenosis occurred in 76 (26%) patients after carotid endarterectomy, with the highest incidence during the third (33%) and fourth (25%) year of follow-up. Patients with diabetes (p = 0.048) and peripheral arterial occlusive disease (p = 0.041) had significant statistical correlation with the occurrence of restenosis, as well as parameters of lipid status - cholesterol values (p = 0.025), serum low-density lipoprotein (p = 0.036) and non highdensity lipoprotein (p = 0.041). Conclusion: The results of our study confirm the significant role of atherosclerotic risk factors in the development of carotid artery restenosis in the later postoperative period. More frequent monitoring and control of systemic risk factors in these patients is necessary in order to prevent the development of carotid artery restenosis.

Rare complications of carotid endarterectomy requiring surgical treatment

<h3></h3> Методом выбора в лечении стеноза внутренней сонной артерии является каротидная эндартерэктомия. Послеоперационные осложнения развиваются в малом проценте случаев и, как правило, требуют консервативной терапии. Крайне редко встречаются местные осложнения в отдаленном периоде, требующие оперативного лечения. Авторы показали варианты повторных операций у пациента с ложной аневризмой и у больного с рестенозом сонной артерии после каротидной эндартерэктомии.

Endovascular treatment of acute tandem occlusion of the left internal carotid and middle cerebral arteries, which is a complication of carotid endarterectomy

Case of endovascular treatment of a patient with tandem left internal carotid artery (ICA) and middle cerebral artery (MCA), which was a complication of carotid endarterectomy, are presented. The rupture at the location of the suture in the bulb of the ICA during endovascular intervention required implantation of a graft-stent and subsequent removal of the hematoma in the neck soft tissues.A 51 year old man in the residual period of ischemic stroke in the left carotid basin with elements of sensory speech disorders, with subtotal stenosis in the bulb of the left ICA, stenosis 35 % in the bulb of the right ICA and severe hypoplasia of the A1-segment of the left anterior cerebral artery underwent left-side carotid endarterectomy. The next morning after surgery, 1 hour after awakening, a right-sided hemiparesis progressing to hemiplegia, total aphasia. The level of consciousness deteriorated to the sopor. A computer tomography was performed immediately. New ischemic lesions were not identified. Cerebral angiography revealed the occlusion from the mouth of the left ICA, occlusion in the M1-segment of the left MCA. Thrombospiration from MCA and ICA was performed with Sofia Plus distal approach catheter. The MCA was recanalized in one pass (mTICI 3), but the patency of the left ICA was not recovered. The anti-embolic device SpiderFX was introduced and opened in the C2-segment of the left ICA. Then, a slow inflation of the Submarine 5 × 20 mm balloon catheter was performed in the left ICA bulb. At a pressure of 4.0 atm, the balloon opened like an hourglass, indicating a rough rigid stenosis in the ICA bulb. At a pressure of 4.5 atm, the balloon fully opened. Immediately after balloon deflation, intense contrast extravasation is determined at the level of the ICA bulb. Inflation of the balloon at a pressure of 4 atm was performed again. Intubation of the trachea of ​​the patient was performed. Intravenous administration of 300 mg acetylsalicylic acid was initiated. The balloon catheter is deflated and withdrawn from vessels, the carotid stent Protégé 8–6×40 mm was implanted into the left ICA bulb and the left common carotid bifurcation segment. The bloodstream above the stent is not determined, but extravasation through the stent cells at the level of the former defect is determined. Stent graft Graftmaster 4×15 mm was implanted into the carotid stent at the level of the defect in the ICA. Stent graft was additionally opened in its lower part by a 5×20 mm balloon-catheter. Thrombaspiration from the left ICA was performed again. Patency of the ICA and intracranial arteries was totally restored – mTICI3, stenosis in the left ICA bulb was completely eliminated. The patient’s neurological status was restored to baseline. A large hematoma in the soft tissues of the neck to the left was determined. Only “old” ischemic foci in the left temporal lobe were determined on brain CT, a large hematoma laterally and anteriorly to the carotid artery was determined in the soft tissues of the left side of the neck on computer tomography. Ticagrelor was added to aspirin therapy. Hematoma was removed surgically. The postoperative period was unremarkable. The patient was discharged from the clinic in good condition with an level modified Rankin scale 1.In the presented case, the friendly work of different profiles specialists avoided the devastating consequences of such a relatively rare complication of carotid endarterectomy as cerebral arteries tandem thrombosis. The availability of graft-stents in access to interventional neuroradiologists is extremely important in such cases.

Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy

Anesthesia modalities for carotid endarterectomy continue to vary nationally. We evaluated and compared short-term outcomes after carotid endarterectomy with general anesthesia (GA) and regional anesthesia (RA) in both symptomatic and asymptomatic patients. The 2011-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (PUFs) with merged Vascular Procedure-Targeted PUFs for carotid endarterectomy were queried for patients undergoing carotid endarterectomy. Postoperative complications, mortality, and hospital length of stay in patients undergoing GA or RA were compared. A total of 14,447 patients were evaluated: 12,389 (85.7%) with GA and 2,058 (14.3%) with RA. The use of GA was inversely associated with patients' age (88.0% in patients aged 22-64years vs. 83.4% in patients aged ≥80years, P<0.0001) and with symptomatic presentation (odds ratio [OR]=1.25; 95% confidence interval [CI]: 1.13-1.38). There were no differences between GA and RA for in-hospital mortality, 30-day mortality, or postoperative complications of transient ischemic attack, stroke, bleeding, acute renal failure, or restenosis. However, rates of cranial nerve injury were significantly higher in GA than in RA (2.9% vs. 1.7%, respectively; P<0.002) and confirmed by multivariable analysis (OR=1.68; 95% CI: 1.19-2.39). Total operative time was also longer for GA than for RA (median: 115minutes; Interquartile range (IQR): 89-145 versus median: 93minutes; IQR: 76-119, respectively; P<0.0001). Hospital length of stay was greater in GA than in RA (median: 1day; IQR 1-2 vs. median: 1day; IQR 1-1, respectively; P<0.0001), as were 30-day readmission rates (6.7% vs. 5.4%, respectively; P=0.02). Iatrogenic nerve injury is a feared complication of carotid endarterectomy, especially in elective asymptomatic patients. RA reduces the rate of cranial nerve injury compared with GA. RA is also not inferior to GA for postoperative complications with the benefit of shorter operative times, lengths of hospital stay, and decreased 30-day readmission rates. Consideration should be given to more widespread adoption of this underused anesthesia modality.

Advantages and Disadvantages of Carotid Endarterectomy and Carotid Artery Stenting:Notes from a Hybrid Neurosurgeon

Carotid endarterectomy(CEA)is well-established and performed for carotid artery stenosis all over the world. However, some severe complications and pitfalls have been reported. Carotid artery stenting(CAS)in high-surgical-risk patients is considered an effective alternative to CEA. We reviewed our clinical experience of CEA and CAS and discuss the advantages and disadvantages of each treatment. For 13 years, we performed CEA for 133 patients(135 lesions)and CAS for 127 patients with carotid artery stenosis(129 lesions). CAS is indicated for the CEA high-risk patients. Perioperative imaging studies and post-operative statuses were evaluated especially in cases with complications. In our CEA series, ischemic stroke occurred in 3 cases, myocardial infarction in 1, cranial nerve palsy in 2, internal carotid artery occlusion in 1, wound hematoma in 2, and hyperperfusion syndrome in 4. The procedure was halted in one case because of an internal shunt problem. All cases of CAS were successfully performed except for one case complicated with myocardial infarction. Ischemic stroke occurred in 7 cases, hyperperfusion syndrome in 2, stent occlusion in 2, and puncture site hematoma in 2. Restenosis appeared in CAS significantly more than in CEA. CEA is a first-line treatment for carotid artery stenosis. However, complications of CEA may result in severe situations. Recognizing pitfalls and careful perioperative management is required. The results of CAS are comparable to those of CEA. Radiological evaluation for the presence of plaque and appropriate selection of an embolus protection device are important.

An unusual cause of delayed hematoma after carotid endarterectomy: a case report

BackgroundNeck hematoma is a complication of carotid endarterectomy, usually occurring in the comparatively early stage postoperatively.Case presentationWe described a patient developing life-threatening hemorrhage and non-clotting hematoma at a comparatively later stage after CEA. DIC was diagnosed according to the lab results, and the patient underwent re-operation and was supported with blood products until the coagulopathy was corrected. The patient had a history of prostatic hyperplasia and experienced malaise during the hospitalization. Prostate cancer with bone metastases was diagnosed.ConclusionsThis case report describes a rare underlying cause of hematoma after CEA, which reminds us to pay attention to prostate symptoms or related medical history, especially malignancy, in surgical patients, which may result in severe complications.

Surgical Treatment of Post-Carotid Endarterectomy Carotid Pseudoaneurysm

Post-endarterectomy pseudoaneurysms (PEPA) are a rare complication of carotid endarterectomy (CEA), but are associated with high morbidity risk. Therefore, once they are diagnosed, treatment is urgent to prevent possible complications such as rupture, embolisation, thrombosis, or airway and cranial nerve compression. In this video, the surgical procedure is shown in a case of PEPA 10 years after CEA with patch angioplasty, which was successfully managed by surgical excision and interposition of great saphenous vein graft. Follow up duplex examination at six months was normal, with patency of the vein graft. This case reiterates the importance of open surgery as the treatment of choice for this difficult clinical setting.

Association between perioperative stroke and 30-day mortality in carotid endarterectomy: A meta-analysis

ObjectivesPerioperative stroke is a known complication of carotid endarterectomy (CEA) for patients with symptomatic and asymptomatic carotid stenosis. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) has shown that stroke following CEA is associated with nearly a 3-fold increase in the 4-year mortality compared to patients without such an event. However, no studies to date can establish whether the stroke was the cause of the short term mortality. Thus, our objective is to evaluate if perioperative stroke after CEA increases the risk of 30-day mortality. Patients and MethodsWe performed a meta-analysis of the literature from PubMed and the World Science Database on studies reporting perioperative strokes and 30-day mortality in symptomatic and asymptomatic CEA patients. 3400 articles were retrieved, and abstracts were further screened using the inclusion criteria to obtain a final set of 83 randomized controlled trials and retrospective/prospective studies. ResultsA total of 123,507 CEA procedures were included among the 83 studies. The 30-day perioperative stroke rate for all included studies was 2.15%. The 30-day all-cause mortality rate was 0.93%. In patients with perioperative strokes, the 30-day mortality rate was found to be 17.01%. Among patients without perioperative strokes, the 30-day mortality rate was much lower at 0.57%. The summary odds ratio of perioperative stroke and 30-day mortality was 39.86 (95% CI, 29.30–54.23, p < 0.001). ConclusionPatients with perioperative stroke have an almost 40 times increased risk of 30-day stroke-related mortality. This study highlights the importance of developing a preoperative risk assessment and neuroprotective treatment trial for perioperative stroke.

Surgical repair of common carotid artery aneurysm insix years after carotid endarterectomy

Surgical repair of common carotid artery aneurysm as an extremely rare complication of carotid endarterectomy in long-term period is described. Aneurysmectomywasfollowed by patch repair of the artery. It was concluded that this intervention is effective approach for this complication. The main causes of this adverse event are identified.

Carotid Endarterectomy for Medical Therapy-Resistant Symptomatic Low-Grade Stenosis

Plaque characteristics play pivotal roles in ischemic events, but stenosis severity does not accurately reflect carotid plaque volume due to expansive remodeling in some patients with low-grade stenosis (LGS). This study aimed to assess the safety, efficacy, and durability of carotid endarterectomy (CEA) for symptomatic LGS. Study participants comprised 61 consecutive patients who underwent CEA for symptomatic carotid stenosis. Patients were divided into an LGS group (<50%, n= 17) and a non-LGS group (≥50%, n= 44). Patient characteristics and short-term (within 30 days of CEA) and long-term outcomes were compared between groups for selective usage of internal shunt and known complications of CEA. Magnetic resonance imaging-detected intraplaque hemorrhage was more significant in LGS than in non-LGS (P= 0.04). For short-term outcomes, no symptomatic infarcts, hyperperfusion syndrome, or acute myocardial infarction was confirmed in either group. Internal shunts were used in 4 LGS (23.5%) and 6 non-LGS (13.6%). Asymptomatic diffusion-weighted imaging-positive lesions were confirmed in 2 LGS patients (11.8%) and 5 non-LGS patients (11.4%), neck hematoma in 1 LGS patient, and transient cranial nerve palsy in 1 LGS patient and 2 non-LGS patients, with no significant differences apparent between groups. For long-term outcomes, 5 non-LGS patients showed restenosis (P= 0.17). Hemorrhagic stroke was not observed in either group. No significant differences were seen for infarct in the ipsilateral carotid territory, any ischemic stroke, AMI, or mortality. CEA represents a safe and feasible therapeutic option for a subset of patients with symptomatic LGS.

Prior Intravenous Stroke Thrombolysis Does not Increase Complications of Carotid Endarterectomy

Retrospective single-center review from Helsinki University Hospital between January 2005 and December 2016. There were 128 carotid endarterectomies (CEAs) performed in patients who had preceding intravenous thrombolysis (IVT) for acute stroke and 777 CEAs without IVT. About two-thirds of patients underwent CEA within 14 days after IVT. There were no statistically significant differences between individual outcomes for patients who underwent CEA within 2 days after IVT compared to those who underwent surgery later than 2 days. However, stroke recurrence in IVT DEA patients was 5.5% at median 4 days after IVT (range, 0-8 days). The CEA-related stroke rate was similar to that of the operation without IVT. Time between IVT and CEA was not associated with CEA-related complications. The high rate (5.5%) of stroke recurrence during the waiting time for CEA underscores the importance of shortening surgery delays.

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

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

Prior Intravenous Stroke Thrombolysis Does Not Increase Complications of Carotid Endarterectomy.

Background and Purpose- Carotid endarterectomy (CEA) is recommended within 14 days after carotid artery stroke to prevent recurrence. However, the optimal timing of CEA after intravenous thrombolysis (IVT) remains unclear. We studied the safety of CEA after IVT while taking into account both stroke recurrence and CEA-related complications. Methods- Patients who underwent IVT followed by CEA in Helsinki University Hospital 2005 to 2016 were withdrawn from prospectively collected registers. The incidence of stroke recurrence during the time between IVT and CEA, peri/postoperative stroke, hyperperfusion syndrome or drug-resistant high blood pressure, and 3-month outcome measured by modified Rankin Scale was recorded. Stroke patients treated with CEA without preceding IVT were used as controls. Results- Altogether 128 CEAs with preceding IVT and 777 CEAs for stroke without IVT were identified. The median time from IVT to CEA was 9 days (range, 0-349 days; interquartile range, 16). Seven patients (5.5%) underwent CEA within 24 hours, 20 (15.6%) within 48 hours and 87 (68.0%) within 2 weeks from IVT. Stroke recurrence in IVT-CEA patients was 5.5% at median 4 days after IVT (range, 0-8 days). Outcome from CEAs performed within 48 hours from IVT did not differ from CEAs performed later with respect to peri/postoperative ischemic strokes (5.0% and 3.7%), hemorrhagic strokes (5.0% and 1.9%), neck hematomas (5.0% and 8.3%), myocardial infarctions (0.0% and 0.9%), or 3-month modified Rankin Scale. There was a tendency toward higher incidence of hyperperfusion syndrome in the patients operated within 48 hours from IVT (20.0% versus 6.5%; P=0.070). The CEA-related stroke rate was similar to that of the operation without thrombolysis. Only smoking was significantly associated with peri/postoperative stroke (odds ratio, 21.82; 95% confidence interval, 1.08-439.58). Conclusions- Time between IVT and CEA was not associated with CEA-related complications. The high rate of stroke recurrence during the waiting time for CEA underscores the importance of shortening surgery delays.