Consecutive Carotid Endarterectomy Research Articles

Cranial nerve injuries post carotid endarterectomy: a 15-year prospective study with routine otolaryngologist and neurological evaluation

ObjectiveThe aim of this prospective monocentric cohort study was to analyze the risk of otolaryngologist-assessed cranial nerve injuries (CNIs) following carotid endarterectomy (CEA) in our academic center during a 15-year period, and to identify possible risk factors for CNI development. MethodsFrom January 2007 to December 2022, 3749 consecutive CEAs were performed and their data prospectively recorded in a dedicated database. CNIs were assessed and defined according to a standardized protocol. Instrumental ear, nose, and throat (ENT) evaluations were conducted within 30 days before intervention and before discharge. Preoperative neurological assessments were carried out in all patients with symptomatic carotid stenosis, whereas postoperative neurological evaluations were performed in all patients. Patients with newly onset CNIs underwent follow-up assessments at 30 days and, if necessary, at 6, 12, and 24 months. Perioperative results, including mortality, major central neurological events, and postoperative CNIs, were analyzed. Regression or persistence of lesions during follow-up visits was assessed, and multivariate analysis (binary logistic regression) was conducted to evaluate clinical, anatomical, and surgical technique factors influencing the occurrence of CNIs. ResultsCEAs were performed more frequently in male patients (2453 interventions; 65.5%) than in females (1296 interventions; 34.5%). The interventions were performed in asymptomatic patients in 3078 cases (82%). In 66 cases, the interventions followed a previous ipsilateral CEA. At preoperative ENT evaluation, no cases of ipsilateral pre-existent CNI were recorded. The 30-day stroke and death rate was 1%. In 113 patients (3%), a postoperative neck bleeding requiring surgical revision and drainage was noted. Pre-discharge ENT evaluations identified 259 motor CNIs, accounting for 6.9% of the entire study group. Eighteen patients had lesions in more than one cranial nerve. ENT and neurological evaluations at 30 days showed the complete resolution of 161 lesions, whereas in 98 cases (2.6%), the CNI persisted. At 1 year, the rate of persistent CNI was 0.4% (10 patients), whereas at 2 years, it was 0.25% (6 cases), in all but one asymptomatic. At multivariate analysis, urgent intervention in unstable patients, secondary intervention, a clamping time >40 minutes, a hematoma requiring revision, and a postoperative stroke were independent predictors of CNIs. ConclusionsData from this prospective monocentric cohort study showed that the occurrence of CNI following CEA was low, even when an independent multi-specialist evaluation was performed. The percentage of persistent lesions at 2 years was negligible and, in most cases, asymptomatic.

Our Experience in Carotid Endarterectomy. A Retrospective Study

Introduction: Carotid endarterectomy (CEA) operations have been more frequent in our practice in recent years, primarily for asymptomatic patients. In this article, we present our experience in this field.
 Ojectives. Primary endpoints were death and stroke within 30 days of the procedure for asymptomatic patients. Secondary endpoints were acute myocardial infarction within 30 days of the process and peripheral nerve injury in all patients.
 Patients and Method: This is a retrospective review of our recent experience. Data of 219 consecutive CEA, 177 in asymptomatic patients, operated on from January 2004- February 2009 by our equip are collected; all the patients were diagnosed with Duplex scanner and confirmed with multi-slice CT scanner angiography. Endarterectomy was performed either with loco-regional or general anesthesia with selective use of a shunt. Combined anti-aggregation with Clopidogrel and Aspirin was the rule at discharge. Patients were controlled for new neurological and cardiac events 30 days after the operation.
 Results: One asymptomatic patient had a major stroke and died. In this group, the stroke and mortality rate is 1,69%. No peri-operative new acute myocardial infarction happened in any patient. Peripheral nerve lesions occurred in 2,7 %of all procedures.
 Conclusions: CEA is a safe treatment for asymptomatic internal carotid stenoses in the hands of an experienced vascular surgeon. Our results for asymptomatic carotid stenoses are according to international guidelines' recommendations.

Timing of Heparin Administration During Carotid Endarterectomy Affects Wound Hematoma Evacuation Rate

The aim of this study was to investigate whether timing of heparin administration during carotid endarterectomy (CEA) could affect postoperative outcomes. Consecutive elective CEAs in two tertiary hospitals were enrolled for asymptomatic carotid stenosis ≥70% performed between 2011 and 2020. We grouped patients according to timing of heparin administration during CEA: (Group A) Heparin was given immediately before skin incision in the first group, whereas in the second group (Group B), heparin was given 2 minutes before internal carotid artery clamping. Primary outcomes were 24-hour postoperative major adverse events (MAEs: myocardial infarction, major and minor stroke, death), surgical site hematoma, and wound hematoma evacuation rate. Secondary outcomes were 30-day MAEs and cranial nerves lesions rate. A total of 2167 patients underwent CEA: 1191 patients (55%) were treated in group A, whereas 979 (45%) were treated in group B with a similar mean operation time of 79 minutes. Weight-adjusted (70 IU/kg) heparin was administered in both groups. A higher number of patients under dual antiplatelet (7% vs 15%) and anticoagulation (4.5% vs 11%) therapy were recorded in group B due to the presence of a higher rate of coronary heart disease (P < .001). Eversion CEA was 89% and 56% in group A and B, respectively. Protamine was administered in 3% vs 90% of patients in group A and B, respectively. Primary and secondary outcomes are summarized in Table. After multivariate analysis, just wound hematoma evacuation rate was affected by the timing of heparin administration during CEA. The strategy of heparin administration before skin incision during CEA protects against wound hematoma evacuation without increasing the procedural risk.TableOutcomesGroup A, n = 1191 n (%)Group B, n = 979 n (%)P24-hour postoperative outcomes: primary outcomes Myocardial infarction5 (0.4%)4 (0.4%)1 Major stroke1 (0.1%)4 (0.4%).18 Minor stroke0 -2 (0.2%).2 Death0 (0%)1 (0.1%).45 Major adverse events6 (0.5)11 (1.1%).14 Surgical site hematoma48 (4%)29 (3%).2 Wound hematoma evacuation1 (0.1%)15 (1.5%).000130-day outcomes: secondary outcomes Myocardial infarction0 -4 (0.4%).04 Major stroke1 (0.1%)1 (0.1%)1 Minor stroke0 -2 (0.2%).2 Death00– Major adverse events1 (0.1%)7 (0.7%).02 Cranial nerve lesion1 (0.1%)1 (0.1%)1Boldface P values indicate statistical significance. Open table in a new tab

Assessment of Preoperative and Postoperative Cognitive Performance in Asymptomatic Patients Undergoing Carotid Endarterectomy: A Pilot Study

The association between vascular cognitive impairment and carotid stenosis and the possible improvements in vascular cognitive impairment favored by the intervention of carotid endarterectomy (CEA) have not yet been clearly defined. The aim of this pilot study was to prospectively evaluate whether cognitive functions can be influenced by carotid endarterectomy performed in patients with asymptomatic severe carotid stenosis. From January to August 2022, 105 consecutive CEAs were performed in patients with severe asymptomatic carotid stenosis at our institution. Of these, 28 provided informed consent for inclusion in the study and were therefore enrolled, representing our study group. The evaluation of the cognitive functions was made by using the Montreal Cognitive Assessment (MoCA), which was administered to the participants at the moment of the preoperative anesthesiologic assessment, usually between 1 and 7 days prior to surgery. Following the intervention and within the third postoperative month, a clinical and instrumental control visit was performed and during that visit the MoCA questionnaire was again administered to the patients. A comparison between the mean corrected pre- and postoperative values of the MoCA questionnaire was performed using Student t test. Multivariate analysis for the factors affecting the lack of postoperative improvement was performed. Patients were more frequently male (18 patients, 64%) with a mean age of 74.4 ± 7.9 years. The mean MoCA test value in the preoperative was 22.68 ± 3.34, thus slightly below the threshold value for identifying the presence of cognitive impairment. The distribution of the values followed a normal pattern. There were nor perioperative deaths neither neurological events. All the patients had their 3-month reevaluation; no neurological events were detected in this period. At the three-month follow-up, the mean MoCA test score was 23.4 ± 3.4, with a statistical trend toward significant improvement (P = .08; 95% confidence interval, −1.8 to 0.34). The most noticeable improvements were found in the visuospatial, language and abstraction domains, while they were less marked in the domains of attention and memory. Multivariate analysis for the factors affecting the lack of postoperative improvement showed a trend toward worse results in diabetic patients, in those with silent ipsilateral brain lesions and in those on neuropsychiatric drug therapy. Our pilot study, consistently with the literature, confirmed a mild cognitive improvement after CEA performed in asymptomatic patients; however, larger studies with a higher number of patients and a longer follow-up are necessary before considering the possibility of suggesting CEA in order to prevent or reverse cognitive decline.

O065 Does modified Rankin score (mRS) matter? the impact of stroke severity on carotid endarterectomy (CEA) outcomes

Abstract Introduction Carotid endarterectomy (CEA) is recommended to reduce the risk of future stroke in patients with non-disabling ischaemic stroke events (modified Rankin Score mRS&amp;lt;3). We reviewed CEA outcomes in patients with more devastating consequences of stroke (mRS 3+). Methods Data from 1021 consecutive CEA cases at a single unit were collected from the UK National Vascular Registry, over a 15-year period. Patient demographics, co-morbidities and postoperative outcomes were compared in those with pre-operative mRS &amp;lt;3 (Group 1) and those with mRS 3+ (Group 2). P&amp;lt;0.05 was considered significant. Results 91 (9%) patients with mRS 3+ underwent CEA. Age, gender ratio and operated side were not significantly different between the two groups. Group 2 had significantly higher rates of diabetes, atrial fibrillation, renal failure, lung disease, frailty and a higher ASA score. Time to surgery from the stroke event was similar in the two groups, but time spent on high dependency and overall in hospital following surgery was longer in Group 2. There was no difference in the type of anaesthetic given. Group 2 had a higher incidence of postoperative confusion, but there was no significant difference between the two groups in cardiac, respiratory, operative complications and 30-day mortality. Fewer patients in Group 2 returned to their home on discharge. Conclusion Patients with a higher mRS are frailer and have more pre-operative co-morbidities. Surgery is associated with delayed discharges, but in the short-term, perioperative complication rate is not significantly different. Patient selection, however, should be undertaken withcare.

Complication Rate After Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure: Long-Term Outcome

Objective: In patients with symptomatic or asymptomatic severe internal carotid artery stenosis, carotid endarterectomy (CEA) has been shown to reduce risk for stroke. The optimal surgical technique remains subject of debate. In the latest European Society of Vascular Surgery (ESVS) guidelines on the management of atherosclerotic carotid disease, routine patching is preferred to routine primary closure. However, there are no RCT’s evaluating selective patching strategies. This follow-up study aimed to assess long term complication rate and restenosis after carotid endarterectomy with selective patching. Methods: Two hundred thirteen consecutive carotid endarterectomies over a 3-year period from January 5th 2011 to December 19th 2013 were prospectively analyzed in a follow-up study over 5 years (mean 4.6, range 3.17-6.17). Patient population consisted of 141 procedures on males and 72 on females with mean age 73 years at the time of surgery (standard deviation (SD) 8.57, range 53-95). There was a follow-up of 89%. Postoperative risk factors were assessed such as hypertension, diabetes mellitus, coronary artery disease and smoking. Postoperative symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to the operative technique to evaluate patency of the carotid artery after carotid endarterectomy. Results: Primary closure was used in 110 operations, and patch angioplasty in 103 procedures (Dacron patch). Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation or when the contralateral carotid artery was occluded. There were no significant differences among groups' baseline characteristics at the time of surgery. Primary closure was performed significantly more in male patients (P= .02). Overall complication rate was 3.76% postoperatively (1.8% after primary closure, 5.8% after patch angioplasty) and after 5 years 5.29% (2.0% after primary closure, 9.1% after patch angioplasty). There are no significant differences in results between the two groups (P= .09 and P= .05). In four cases patients experienced symptoms of cranial nerve damage postoperatively, two in each group. In one of the two cases in each group, the patient fully recovered and the other had persistent complaints (P-value= 1). None of the patients experienced amaurosis fugax during the 5-year follow up period. In five cases a patient had an ipsilateral cerebrovascular thrombosis in the group after patch angioplasty compared to zero in the primary closure group (P-value= .02). In the group of primary closure there was a mortality of 26 patients (23.6%) compared to 26 (25.2%) patients after patch angioplasty (P-value = .70). One was caused by cerebral hyperperfusion syndrome within one month postoperative after patch angioplasty and none were caused by an ipsilateral ischemic stroke. Objective duplex ultrasound showed no significant difference comparing restenosis in both groups (P-value= .43). In twelve cases patients showed a restenosis between 50-70% (6 primary closure and 6 patch angioplasty), none of the patients had high grade restenosis of more than 70%. Patient characteristics did not show a significant effect on long term outcomes. There was a correlation between postoperative use of antihypertensive medication and long-term stroke (P-value= .006), restenosis (P-value= .01) and mortality (P-value= .003). Conclusion: After long-term follow-up we found primary closure and patch angioplasty to be equivalent with respect to complication rate and restenosis when used in selected cases. Best medical treatment and especially the use of antihypertensive medication should be emphasized.

3615 consecutive carotid endarterectomies without intraluminal shunt

3615 consecutive carotid endarterectomies without intraluminal shunt

Elective or Urgent Carotid Endarterectomy in Symptomatic Patients: Analysis Based on the Type and Timing of Neurological Symptoms

The aim of this study was to retrospectively analyse perioperative and long-term outcomes of carotid endarterectomy (CEA) performed in symptomatic patients in a high-volume academic vascular centre, stratifying them according to the type of preoperative symptoms and the timing of surgery with respect to the indexed neurological event. From January 2014 to December 2020, 1,369 consecutive CEAs were performed at our institution. Data concerning these interventions were prospectively collected in a dedicated database including data concerning preoperative assessment, surgical details, perioperative (<30days) outcomes, and long-term outcomes. A retrospective analysis of the database was performed, and 213 interventions performed in symptomatic patients were found. We identified 2 subgroups of patients: patients with stable neurological symptoms (not recent transient ischemic attack (TIA) or stable major disabling stroke, stable group, and 157 patients) and patients with unstable neurological symptoms (recent TIA, crescendo TIAs, stroke in evolution, acute/recent minor stroke, unstable group, and 56 patients). Perioperative outcomes were analysed in terms of mortality, major neurological events, and local or systemic complications The results were compared using the χ2 test; these were also analysed on the basis of the presenting symptom (isolated TIA, crescendo TIA, stroke in evolution, acute/recent minor stroke, stabilized stroke) and the timing of the intervention relative to the onset of the symptom. Long term results were analysed using the life-table analysis and Kaplan-Meier curves in terms of survival, stroke-free survival, absence of neurological symptoms, and absence of significant restenosis. Overall, 30-day stroke and death rate were 4.2%. (3.1% vs. 7%, P=0.2). Two deaths occurred at 30days, both in the stable group (mortality 1.2%, P=0.4 compared to the unstable group), but no fatal strokes were recorded in the overall sample. No differences were found in terms of new perioperative neurological events and local complications between the 2 groups. We found a trend toward poorer perioperative results in patients operated on within 48hr from the indexed event and in patients operated on for stroke in evolution or acute/recent stroke, whereas we found a trend toward better results in favour of patients operated on between 8 and 14days (P=0.08). The median duration of follow-up was 24.8months (range 1-78); at 5years we did not find significant differences in terms of survival and stroke-free survival rates between 2 groups. In our experience, carotid surgery in symptomatic patients provided satisfactory results, particularly in patients with stable neurological status. Among unstable patients, the rate of complications significantly increases, mainly among treated in the very early (<48hr) period for stroke in evolution or acute/recent stroke. Once the perioperative risk is overcome, the results in the long-term setting are similarly good, both in stable and in unstable patients.

A Stepwise Haemostasis Intraoperative Protocol Driven Reduction of Haematoma Rate Following Symptomatic Carotidendarterectomy.

Carotid endarterectomy (CEA) for symptomatic stenosis reduces further stroke risk. Post-CEA haematoma increases the risk of complications including stroke. There are few studies considering protocols aimed at reducing post-CEA haematoma rates. Presented are the outcomes of a protocol developed to reduce this surgical complication. The protocol was implemented in 112 consecutive CEA. It involves stepwise additional measures to ensure haemostasis before wound closure. Attention to bleeding points is followed by light compression for 10min. Protamine is then given if haemostasis has not been achieved. If after 20min the problem persists Tranexamic acid is given. Following a further 20min if haemostasis is not yet achieved a platelet transfusion is undertaken. Haematoma rates, return to theatre for post-operative haematoma and other complications were compared with 100 consecutive pre-protocol introduction CEA cases. Of 112 CEA patients, 19 received protamine, 8 protamine and tranexamic acid. One case required platelet transfusion. Neck haematoma rate fell from 10 to 3 cases (P = .02, OR: 0.25 [95% CI .07-.94]), of which returned to theatre for haematoma evacuation fell from 6 to 1 case (P = .03, OR: 0.14 [95% CI .02-1.19]). 30day stroke and death rate reduced from 5% to 1.8% (P = .11, OR: 0.35 [95% CI .07-1.82]). The stepwise haemostasis intraoperative protocol can reduce post-CEA haematoma rates.

Intraoperative Flow Measurement as a Quality Control during Carotid Endarterectomy in a Teaching Hospital Setting

Background: To evaluate the technical results of an arterial repair, a variety of intraoperative imaging and assessment techniques can be used during carotid endarterectomy (CEA). The aim of the study was to evaluate the usefulness of intraoperative ultrasound flow measurement as a quality control after primary CEA in a teaching hospital setting. Methods: Over 36 months, 107 consecutive CEAs were performed at our institution. Retrospectively acquired demographics, intraoperative flow measurements, duplex results, revisions, and surgical outcomes were reviewed. Postoperative 30-day transient ischemic attack (TIA), stroke, and death rates were analyzed. Results were compared with ultrasound flow measurement and duplex ultrasonography. Results: From March 2012 to March 2015, 107 primary consecutive CEAs were performed in 107 patients (71% male, 29% female), whose age ranged from 51 to 81 years with a mean age of 68 ± 4 years. Associated risk factors included diabetes for 89 (83%), smoking for 92 (86%), hypertension for 94 (87.8%), chronic renal insufficiency for 71 (66%), and coronary artery disease for 57 (53%) of the patients. Early postoperative duplex scans in all 107 patients showed no significant changes from intraoperative findings. The ipsilateral stroke and death rate in this study was 0 (0/107) and the 30-day death and stroke rate was also 0 (0/107), with no significant difference between trainees and senior surgeons. Three patients (2.8%) had flow &lt; 100 mL/Min and two of them were revised after completion of contrast angiography. Conclusions: The findings of this study indicate that the intraoperative flow measurement is an alternative method for detecting technical errors and a tool for quality-control imaging. Especially for trainees, it makes sense to ensure effectiveness of the procedure upon its completion and to assess the technical adequacy of CEA.

Management of postoperative internal carotid artery intimal flap after carotid endarterectomy: a cohort study and systematic review.

Postoperative internal carotid artery (ICA) intimal flap (IF) is a potential complication after carotid endarterectomy (CEA) for carotid artery stenosis. There are no clear recommendations in the current literature on the management of this condition due to sparse evidence. Some authors advocate carotid stent placement or reoperation, while others suggest watchful waiting. The aim of this study was to analyze incidence and management strategies of postoperative ICA-IF, and moreover, to put these findings into context with a systematic literature review. The authors retrospectively reviewed all consecutive CEA cases performed at the University Hospital of Bern over a decade (January 2008 to December 2018). The incidence of postoperative ICA-IF, risk factors, management strategies, and outcomes were analyzed. These results were put into context with a systematic review following the PRISMA guidelines. A total of 725 CEAs were performed between January 2008 and December 2018. Postoperative ICA-IF was detected by routine duplex neurovascular ultrasound (NVUS) in 13 patients, corresponding to an incidence rate of 1.8% (95% CI 1.0%-3.1%). There were no associated intraluminal thrombi on the detected IF. Intraoperative shunt placement was used in 5.6% and one or more intima tack sutures were performed in 42.5% of the 725 cases. There was no significant association between intraoperative shunt placement and the occurrence of an IF (p > 0.99). Two patients (15.4%) with IF experienced a transient postoperative neurological deficit (transient ischemic attack). In these cases, the symptoms resolved spontaneously without any interventions or change in the antiplatelet regimen. All other cases (84.6%) with IF were asymptomatic. In 1 patient (7.7%) with IF, the antiplatelet treatment was switched from a mono- to a dual-antiaggregating regimen because the IF led to a stenosis > 70%; this patient remained asymptomatic. All cases of IFs were managed conservatively with close radiological follow-up evaluations, without reoperation or stenting of the ICA. All 13 IFs vanished spontaneously after a mean duration of 6.9 months (median 1.5 months, range 0.5-48 months). A systematic literature review revealed a postoperative ICA-IF incidence of 3.0% (95% CI 2.1%-4.1%) with relatively heterogenous management strategies. Postoperative ICA-IF is a rare finding after CEA. Conservative therapy with close NVUS follow-up evaluations appears to be an acceptable and safe management strategy for asymptomatic IFs without associated intraluminal thrombi.

Influence of Eversion Endarterectomy and Patch Reconstruction on Postoperative Blood Pressure After Carotid Surgery

Post carotid blood pressure fluctuation and hypertension (PEH) are associated with increased risk for adverse outcome; there is limited evidence on the impact of eversion endarterectomy (E-CEA) versus conventional endarterectomy with patch closure (C-CEA) on postoperative blood pressure course. In this retrospective observational study, 859 consecutive carotid endarterectomy procedures between 2004 and 2014 (C-CEA n=585 vs. E-CEA n=274), were evaluated. Pre- and postoperative blood pressure values were recorded from recovery room until third postoperative day and compared between both techniques; influences on the dichotomous target variable "at least one postoperative blood pressure peak", that is need for postoperative vasodilators, were analyzed by a logistic regression model. Influences on postoperative systolic blood pressure were evaluated by a linear mixed effects regression model. Preoperative baseline blood pressure was not different between both comparison groups. During postoperative course, significantly increased mean systolic blood pressure values in the E-CEA group from recovery room to second postoperative day (recovery room C-CEA: 129.2 mm Hg vs. E-CEA: 136.5 mm Hg; P < 0.001; first postoperative day C-CEA: 132.4 mm Hg vs. E-CEA: 139.3 mm Hg; P=0.0002; second postoperative day C-CEA: 138.6 mm Hg vs. E-CEA: 143.1 mm Hg; P=0.023) were observed. No hyperperfusion syndrome was detected as wells as no difference in postoperative complication rate. Frequency of antihypertensive interventions was also elevated in E-CEA group (C-CEA 22.1 % vs. E-CEA 31.8 %; P=0.003). E-CEA (OR 1.591, 95% CI [1.146; 2.202]; P=0.005) and presence of preoperatively elevated systolic readings (OR 1.015, 95%CI [1.006;1.024]; P < 0.001) was also associated with increased need for antihypertensive interventions. E-CEA was associated with significantly elevated postoperative blood pressure, compared to C-CEA. C-CEA was associated with postoperative blood pressure decrease; however, no difference as to neurologic and surgical complications was detected between both surgical techniques in clinical practice.

Influence of Anatomic Conditions on Efficacy and Safety of Combined Intermediate Cervical Plexus Block and Perivascular Infiltration of Internal Carotid Artery in Carotid Endarterectomy: A Prospective Observational Trial

Ultrasound-guided intermediate cervical plexus blockade with perivascular infiltration of the carotid artery bifurcation perivacular block (PVB) is a reliable technique for regional anesthesia in carotid endarterectomy (CEA). We investigated the effect of the carotid bifurcation level (CBL) on PVB efficacy and safety in patients undergoing CEA. This prospective observational cohort study included 447 consecutive CEA patients who received PVB over a 6-y period. Vascular and neurologic puncture-related complications were recorded. The CBL was localized at the low level (C4 and C5 vertebra, low-level [LL] group) in 381 (85.2%) patients and at the high level (C2 and C3 vertebra, high-level [HL] group) in 66 (14.8%) patients. Local anesthetic supplementation by surgeons was necessary in 64 (14.3%) patients in the LL group and 38 (59.4%) patients in the HL group (p < 0.001) and was associated with a higher rate of central neurologic complications in the HL group (p = 0.031). Therefore, the efficacy of the PVB may be influenced by the CBL.

Aortic Valve Sclerosis as an Important Predictor of Long-Term Mortality in Patients With Carotid Atheromatous Plaque Requiring Carotid Endarterectomy.

Background: A strong association between aortic valve sclerosis (AVSc), the earliest manifestation of calcific aortic valve disease, and atherosclerosis exists. The aim of the study was to evaluate the predictive capabilities of AVSc on long-term all-cause mortality, in patients requiring carotid endarterectomy (CEA).Methods and Results: 806 consecutive CEA patients were enrolled. Preoperative echocardiography was used to assess AVSc. Computed tomography angiography was applied for plaque characterization. Kaplan-Meier curves, Cox linear regression, and area under the receiving operator characteristic (AUC) curve analyses were used to evaluate the predictive capability of AVSc. Overall, 348 of 541 patients had AVSc (64%). Age, diabetes, and estimated glomerular filtration rate (eGFR) were associated with AVSc. In the 5-year follow-up, AVSc group had a mortality rate of 16.7% while in no-AVSc group was 7.8%. Independent predictors of all-cause mortality were age, sex, eGFR, left ventricular ejection fraction, and AVSc. After adjustments, AVSc was associated with a significant increase in all-cause mortality risk (hazard ratio, HR = 1.9; 95%CI: 1.04–3.54; p = 0.038). We stratify our cohort based on carotid atheromatous plaque-type: soft, calcified, and mixed-fibrotic. In patients with mixed-fibrotic plaques, the mortality rate of AVSc patients was 15.5% compared to 2.4% in no-AVSc patients. In this group, AVSc was associated with an increased long-term all-cause mortality risk with an adjusted HR of 12.8 (95%CI: 1.71–96.35; p = 0.013), and the AUC, combing eGFR and AVSc was 0.77 (p < 0.001).Conclusions: Our findings indicate that AVSc together with eGFR may be used to improve long-term risk stratification of patients undergoing CEA surgery.

Comparison of Single and Dual Monitoring during Carotid Endarterectomy

We compared the rate of selective shunt and pattern of monitoring change between single and dual monitoring in patients undergoing carotid endarterectomy (CEA). A total of 121 patients underwent 128 consecutive CEA procedures. Excluding five procedures using internal shunts in a premeditated manner, we classified patients according to the monitoring: Group A (n = 72), patients with single somatosensory evoked potential (SSEP) monitoring; and Group B (n = 51), patients with dual SSEP and motor evoked potential (MEP). Among the 123 CEAs, an internal shunt was inserted in 12 procedures (9.8%) due to significant changes in monitoring (Group A 5.6%, Group B 15.7%, p = 0.07). The rate of shunt use was significantly higher in patients with the absence of contralateral proximal anterior cerebral artery (A1) on magnetic resonance angiography (MRA) than in patients with other types of MRA (p <0.001). Significant monitor changes were seen in 16 (12.5%) in both groups. In four of nine patients in Group B, SSEP and MEP changes were synchronized, and in the remaining five patients, a time lag was evident between SSEP and MEP changes. In conclusion, the rate of internal shunt use tended to be more frequent in patients with dual monitoring than in patients with single SSEP monitoring, but the difference was not significant. Contralateral A1 absence may predict the need for a shunt and care should be taken to monitor changes throughout the entire CEA procedure. Use of dual monitoring can capture ischemic changes due to the complementary relationship, and may reduce the rate of false-negative monitor changes during CEA.

A Machine Learning Approach for Predicting Early Phase Postoperative Hypertension in Patients Undergoing Carotid Endarterectomy

This study aimed to establish and validate a machine learning-based model for the prediction of early phase postoperative hypertension (EPOH) requiring the administration of intravenous vasodilators after carotid endarterectomy (CEA). Perioperative data from consecutive CEA procedures performed from January 2013 to August 2019 were retrospectively collected. EPOH was defined in post-CEA patients as hypertension involving a systolic blood pressure above 160mm Hg and requiring the administration of any intravenous vasodilator medications in the first 24hr after a return to the vascular ward. Gradient boosted regression trees were used to construct the predictive model, and the featured importance scores were generated by using each feature's contribution to each tree in the model. To evaluate the model performance, the area under the receiver operating characteristic curve was used as the main metric. Four-fold stratified cross-validation was performed on the data set, and the average performance of the 4 folds was reported as the final model performance. A total of 406 CEA operations were performed under general anesthesia. Fifty-three patients (13.1%) met the definition of EPOH. There was no significant difference in the percentage of postoperative stroke/death between patients with and without EPOH during the hospital stay. Patients with EPOH exhibited a higher incidence of postoperative cerebral hyperperfusion syndrome (7.5% vs. 0, P<0.001), as well as a higher incidence of cerebral hemorrhage (3.8% vs. 0, P<0.001). The gradient boosted regression trees prediction model achieved an average AUC of 0.77 (95% CI 0.62 to 0.92). When the sensitivity was fixed near 0.90, the model achieved an average specificity of 0.52 (95% CI 0.28 to 0.75). We have built the first-ever machine learning-based prediction model for EPOH after CEA. The validation result from our single-center database was very promising. This novel prediction model has the potential to help vascular surgeons identify high-risk patients and reduce related complications more efficiently.

Results of Carotid Endarterectomy in Patients With Asymptomatic Carotid Artery Stenosis With or Without Criteria for Surgery on the Basis of the Recent European Guidelines

The objective was to retrospectively compare perioperative outcomes of carotid endarterectomy (CEA) performed for >60% asymptomatic stenosis in patients with or without preoperative clinical and imaging features suggesting the need for intervention on the basis of the 2018 European Society of Cardiology-European Society for Vascular Surgery guidelines. From January 2008 to December 2018, there were 2501 consecutive CEAs performed in a single academic institution. Data concerning these interventions were prospectively collected in a dedicated database. A retrospective analysis of the database was performed, and 1956 interventions performed in asymptomatic patients were found. Those patients were divided in two subgroups: patients not candidates for intervention on the basis of the 2018 European Society of Cardiology-European Society for Vascular Surgery guidelines (life expectancy <5 years, predominantly hyperechoic plaques on preoperative duplex ultrasound, absence of silent brain infarction at preoperative computed tomography scan; 876 interventions, group 1) and patients fulfilling the suggested indications (1080 interventions, group 2). The two groups were compared in terms of clinical, anatomic, and surgical characteristics and perioperative (<30 days) outcomes with the χ2 test. There were no differences between the two groups in terms of demographics, risk factors, and comorbidities and preoperative features, except for the cited characteristics. Intraoperative features were also similar in the two groups, with >85% of the interventions performed under clinical monitoring of the neurologic status and about 95% of polyurethane patch angioplasty closures in both groups. Shunt insertion rate was significantly higher in group 1 (19.7%) than in group 2 (16%; P = .03). Perioperative mortality was 0.3% in group 1 (three patients) and 0.3% in group 2 (three cases; P = .7). At 30 days, there were seven neurologic events in group 1 (0.8%) and eight events in group 2 (0.7%; P = .8), of which six and five were strokes, respectively. Thirty-day stroke and death rates were 1% in group 1 and 0.75% in group 2 (P = .5). There were no differences between the two groups in terms of neck hematoma requiring surgical revision, cranial nerve injuries, and perioperative myocardial infarction. Patients in group 1 more frequently experienced a perioperative atrial fibrillation (13 cases [1.4%]) than patients in group 2 (5 cases [0.4%]; P = .02). CEA performed in patients who should not undergo intervention on the basis of the recent guidelines provided excellent perioperative results, similar to those of patients inside the suggested indications. A long-term comparison is necessary.

Predictive Factors for 30-Day Stroke and Death Rate in a Contemporary Series of Carotid Endarterectomies Performed for Asymptomatic Stenosis of the Internal Carotid Artery

The objective was to retrospectively analyze the perioperative outcomes of carotid endarterectomy (CEA) performed for asymptomatic carotid stenosis in the last decade and to identify predictors of increased risk of stroke and death in a single-center experience. From January 2008 to December 2018, 2501 consecutive CEAs were performed in a single academic institution. Data concerning these interventions were prospectively collected in a dedicated database. A retrospective analysis of the database was performed, and 1956 interventions performed in asymptomatic patients were found. Univariate and multivariate (forward logistic regression) analyses were used to identify potentially significant predictors of stroke and death rate at 30 days and to calculate their weight in determining it. Thirty-day stroke and death rates were then assessed for each subgroup of different predictors. Overall, 30-day stroke and death rate was 0.9% (17 cases). On multivariate analysis, male sex, diabetes, and combined cardiac surgery and the need for selective shunting were identified as independent predictors of stroke and death at 30 days; 22.3% of patients did not have any predictor, whereas 51.3%, 23.1%, and 3.2% of the patients had one, two, or three predictors, respectively. No patient had four predictors. Thirty-day stroke and death rate for patients without any of the identified predictors was 0.2% (1 case/436 interventions), whereas the corresponding figures for patients with one, two, or three predictors were 0.7% (7 cases/1006 interventions; P = .7 in comparison with patients with no predictors), 1% (4 cases/451 interventions; P = .1 in comparison with patients with no predictors and P = .7 in comparison with patients with one predictor), and 8.5% (5 cases/63 interventions; P < .001 in comparison with patients with no predictor, one predictor, or two predictors). A subgroup of asymptomatic patients undergoing CEA with a prohibitive perioperative risk does exist, thus questioning the indication for surgery in such patients.

Association of biomarker S100B and cerebral oximetry with neurological changes during carotid endarterectomy performed in awake patients.

Background: This study attempted to correlate neurological symptoms in awake patients undergoing carotid endarterectomy (CEA) under local anaesthesia (LA) with serum concentration of S100B protein and measurement of cerebral oximetry with near-infrared spectroscopy (NIRS). Patients and methods: A total of 64 consecutive CEAs in 60 patients operated under LA during an 18-month period were prospectively evaluated. A cerebral oximeter was used to measure cerebral oxygen saturation (rSO2) before and after cross-clamping along with serum concentration of the S100B protein. Selective shunting was performed when neurological changes occurred, regardless of NIRS. Neurological deterioration occurred (neurological symptoms group) in 7 (10.9%) operations. In 57 (89.1%) operations, the patients were neurologically stable (no neurological symptoms group). Results: The neurological symptoms that occurred after clamping correlated with an increase in the serum level of S100B (P=.040). The cut-off of 22.5% of S100B increase was determined to be optimal for identifying patients with neurological symptoms. There was no correlation between rSO2 decline and neurological symptoms (P=.675). Two (3.1%) perioperative strokes occurred. Conclusions: We found a correlation between neurological symptoms and serum S100B protein increase. However, because of the long evaluation time of serum S100B, this monitoring technique cannot be performed during CEA.

Five-year Follow-up After Carotid Endarterectomy Shows Primary Closure to be an Equivalent Closure Technique Compared to Patch Angioplasty when Used in Selected Patients with Broad Carotid Artery, High Carotid Bifurcation or Occlusion of the Contralateral Carotid Artery

Introduction: In patients with symptomatic or asymptomatic severe internal carotid artery stenosis, carotid endarterectomy (CEA) reduces risk for stroke. The optimal surgical technique remains subject of debate. Our previous study based on perioperative results within 30 days after surgery showed no difference in complication rate comparing primary closure or patch angioplasty when used in selected patients.1This follow-up study aimed to assess long-term complication rate and restenosis after CEA with selective patching. Methods: Two hundred thirteen consecutive CEAs over a 3-year period from January 5th 2011 to December 19th 2013 were prospectively analyzed in a follow-up study over 5 years (mean 4.6, range 3.17-6.17). Postoperative risk factors and symptoms of cranial nerve injury, transient ischemic events, cerebrovascular events and mortality were evaluated. Duplex ultrasound was performed by a radiologist blinded to operative technique to evaluate patency of the carotid artery. Mann-Whitney U test was used to compare both group. Risk differences were calculated with 95% confidence intervals using Newcomb's method. Kaplan-Meier estimates of survival were plotted for 1-year and 5-year survival. The log rank test was used to compare survival between both groups (superiority test). Results: Patient population consisted of 141 males and 72 females with mean age 73 years at the time of surgery (SD 8.57, range 53-95). There was a follow-up of 89%. Primary closure was used in 110 operations, and patch angioplasty in 103 procedures (Dacron patch). Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation or when the contralateral carotid artery was occluded. There were no significant differences among groups' baseline characteristics at the time of surgery. Primary closure was performed significantly more in male patients (P= .02). Overall complication rate postoperatively was 3.76% (1.8% after primary closure, 5.8% after patch angioplasty) and after 5 years 5.29% (2.0% after primary closure, 9.1% after patch angioplasty). These results are not significantly different between the two groups (P= .09 and P= .05). Four patients experienced cranial nerve damage postoperatively, two in each group. In each group one of the two fully recovered and the other had persistent complaints (P= 1). Complications during the 5-year follow-up period are summarized in Table 1. In the group of primary closure there was a mortality of 26 patients (23.6%) compared to 26 (25.2%) patients after patch angioplasty (P = .70; Figure 1). Objective duplex ultrasound showed no significant difference comparing restenosis in both groups (P= .43). Twelve patients showed a restenosis between 50-70% (6 primary closure; 6 patch angioplasty), none of the patients had high restenosis > 70%. Patient characteristics did not show a significant effect on long-term outcome. There was a correlation between postoperative use of antihypertensive medication and long-term stroke (P= .006), restenosis (P= .01) and mortality (P= .003). Conclusion: After long-term follow-up we found primary closure and patch angioplasty to be equivalent with respect to complication rate and restenosis when used in selected patients. Best medical treatment and especially the use of antihypertensive medication should be emphasized. Disclosure: Nothing to disclose