Contralateral Carotid Endarterectomy Research Articles

Ultrasound Examination Without Axial Imaging is Sufficient for Preoperative Planning in Transcarotid Artery Revascularization (TCAR)

Duplex ultrasound is frequently used to determine the degree of carotid stenosis. However, axial imaging is typically obtained for operative planning for transcarotid artery revascularization (TCAR). We examined if ultrasound alone is sufficient prior to TCAR. Data from the Vascular Quality Initiative TCAR Surveillance Project registry between 2016 and 2021 was obtained. Patients were divided into two groups - those with preoperative ultrasound alone (US) versus those with additional axial imaging (AX). Peri-operative outcomes were compared utilizing univariate chi-square, independent t-test, multivariate logistic regression, and Kaplan Meier analysis. There were 3,418 patients identified: 682 in the US group and 2,736 in the AX group. More pre-operative hypertension was reported in US (16.1% vs 10.2%, p<.001) while cardiovascular disease (23% vs 28.9%, p=.006) and prior ipsilateral stroke (22%,vs 32.7%, p=.002) were more prevalent in AX. More patients had history of contralateral carotid endarterectomy (13.6% vs 16.7%, p=.035) or either ipsilateral (2.6% vs 1.2%, p=.002) or contralateral (7.9% vs 4.9%, p=.008) carotid artery stenting in the US group. Lower pre-operative creatinine was reported in the US cohort (1.09±-0.01 vs 1.18±0.02, p<.001) while more were symptomatic in AX (28.2% vs 36.2%, p<.001). There were no significant differences between lesion characteristics or operative decision making were noted. A slightly higher total procedure time was seen in AX (73.7±0.6 vs 68.6±1.3 min, p=.017). No difference existed in peri-operative TIA/stroke or other immediate complications. At two-year follow-up, both groups reported no significant differences in stroke-free survival (p=.750) and independent functional status remained near-identical (97.3% vs 97.4%, p=.921). Kaplan Meier analysis yielded no significant difference between mortality at two years (p=.563). Bivariate logistic regression modeling did reveal a statistically significant increase in likelihood of long-term ipsilateral stroke/TIA at long-term follow-up (OR 1.77, p = .015) and non-stroke related complication in the post-operative period (OR 4.81, p = .005). However, only a statistically significant relationship persistent when the model was controlled for significant between-group differences. No significant differences in post-operative or long-term complications were noted with additional axial imaging in pre-operative TCAR planning. Thus, duplex ultrasound offers a safe and effective alternative for those with contraindication or axial imaging.

Rates of Stroke in Patients With Different Presentations of Carotid Artery Stenosis

Carotid artery stenosis may present without the classical symptoms of transient ischaemic attack or stroke but the rates of stroke for these presentations is unknown. The aim of this study was to examine the rates of stroke in patients with different presentations of carotid artery stenosis. A multicentre prospective cohort study was conducted across three Australian vascular centres with low rates of surgical treatment of patients without transient ischaemic attack or stroke. Patients with a 50 - 99% carotid artery stenosis presenting with non-focal symptoms (e.g., dizziness or syncope; n= 47), prior contralateral carotid endarterectomy (n= 71), prior ipsilateral symptoms more than six months earlier (n= 82), and no symptoms (n = 304) were recruited. The primary outcome was ipsilateral ischaemic stroke. Secondary outcomes were any ischaemic stroke and cardiovascular death. Data were analysed using Cox proportional hazard and Kaplan-Meier analyses. Between 2002 and 2020, 504 patients were enrolled (mean age 71 years, 30% women) and followed for a median of 5.1 years (interquartile range 2.5, 8.8; 2 981 person years). Approximately 82% were prescribed antiplatelet therapy, 84% were receiving at least one antihypertensive drug, and 76% were prescribed a statin at entry. After five years the incidence of ipsilateral stroke was 6.5% (95% confidence interval [CI] 4.3 - 9.5). There were no statistically significant differences in the annual rate of ipsilateral stroke among people with non-focal symptoms (2.1%; 95% CI 0.8 - 5.7), prior contralateral carotid endarterectomy (0.2%; 0.03 - 1.6) or ipsilateral symptoms > 6 months prior (1.0%; 0.4 - 2.5) compared with those with no symptoms (1.2%; 0.7 - 1.8; p= .19). There were no statistically significant differences in secondary outcomes across groups. This cohort study showed no large differences in stroke rates among people with different presentations of carotid artery stenosis.

Change in Peak Systolic Velocity Estimation in Internal Carotid Artery Following Contralateral Near Occlusive Carotid Endarterectomy

Carotid artery stenosis (CAS) is one of the main causes of stroke, as the internal carotid artery (ICA) is a major source of cerebral blood supply. A common surgical intervention for CAS is carotid endarterectomy (CEA), which carries a high risk of stroke and mortality. CEA is indicated for 50% to 99% stenosis in symptomatic patients and 60% to 99% stenosis in asymptomatic patients. Carotid duplex ultrasound is frequently used to estimate peak systolic velocity (PSV), end diastolic velocity (EDV), and ICA/common carotid artery (CCA) ratio to determine the extent of stenosis. This does not account for other factors that can artificially change PSV and EDV, such as a contralateral carotid artery near occlusion with >90% stenosis. Although >70% contralateral stenosis has been previously studied, limited research exists on the impact of ICA near occlusions. We hypothesize that the degree of stenosis in an ipsilateral patent vessel can be more accurately estimated by examining the change in PSV pre- vs post-CEA of the contralateral ICA near occlusion. A retrospective study was conducted on 239 patients, at least 18 years of age, who underwent standard, routine carotid duplex ultrasound at a single institution. Patients who qualified for the study had bilateral carotid stenosis with ICA near occlusive disease on at least one side and underwent CEA. Near occlusion was determined by either a carotid duplex ultrasound >70% with one of the following criteria: PSV >400, EDV >140, or ratio of ICA/CCA >6, or a carotid computed tomography angiography showing near occlusion interpreted by a physician. Preoperative duplex velocities contralateral to the CEA were recorded and compared postoperatively. Interestingly, in the presence of contralateral >50% ICA stenosis, the PSV, EDV, and ICA/CCA ratio in the unoperated artery increased significantly following contralateral CEA (P < .001). In greater than 70% contralateral ICA occlusion, PSV, EDV, and ICA/CCA ratio increased to a greater extent compared with >50% contralateral ICA stenosis (P < .001). In detecting ≥70% stenosis of the patent vessel pre-CEA, PSV ≥250 cm/s had 87.2% sensitivity. In predicting ≥70% stenosis of the patent vessel pre-CEA, PSV >300 cm/s had 96.0% sensitivity. The present study deviates from the current theoretical model and shows that ultrasound PSV, EDV, ICA/CCA ratios can be significantly elevated in the patent vessel pre-CEA and post-CEA of the contralateral ICA near occlusion. This study provides novel insight into customized duplex ultrasound criteria for estimation of stenosis and to avoid unnecessary high-risk surgery.

Frequency and Significance of Maneuvers to Dissect the Distal Internal Carotid Artery During Carotid Endarterectomy.

To describe the frequency, factors associated with, and significance of surgical dissection maneuvers of the distal internal carotid artery (ICA) during carotid endarterectomy (CEA). In this retrospective analysis of prospectively collected information in patients undergoing CEA, we recorded information on demographics, risk factors and comorbidities, dissection maneuvers of the distal ICA, other operative variables and neurological outcome measures. During the period July 2008 and February 2020 inclusive, 218 consecutive patients (180 males, median age 69.5 years) underwent 240 CEAs. In 117 (48.8%) of them, CEA was performed for a symptomatic stenosis. Dissection maneuvers of the distal ICA were required in 77 cases (32.1%), including division and ligation of the sternocleidomastoid vessels in 66 cases (27.5%), mobilization of the XII cranial nerve in 69 cases (28.7%, with concomitant transection of the superior root of the ansa cervicalis in 11 cases, 4.6%) and division of the posterior belly of the digastric muscle in 8 cases (3.3%). Styloid osteotomy was not required in any case. Smoking was the single predictive factor associated with the use of an adjunctive dissection maneuver (odds ratio 2.23, p = 0.009). The use of a patch was more common in smokers (16% vs 7.1% in non-smokers, odds ratio 2.48, p = 0.05). Perioperative stroke and/or death rate was 0%, not allowing testing for associations with maneuver performance. Two patients (0.8%) developed a transient ischemic attack and 4 patients (1.7%) a cranial nerve injury (CNI), including 2 patients with recurrent laryngeal nerve palsy, diagnosed on routine laryngoscopy during planning of a contralateral CEA. There was no association between CNI and dissection of the distal ICA using an operative adjunct (p = 0.60). Several surgical maneuvers are often required to accomplish dissection of the distal ICA beyond the point of atherosclerotic disease. When dictated by operative findings, such maneuvers are deemed safe.

Single-stage ruptured internal carotid artery aneurysm clipping with contralateral carotid endarterectomy: Tips and tricks

Concomitant ruptured intracranial aneurysm and severe contralateral internal carotid artery (ICA) stenosis pose a surgical dilemma. There are no guidelines. Most reports suggest an ipsilateral association. The outcome depends on planning and strategy. This 49-year-old male with ruptured C6 segment ICA aneurysm had 90% calcific carotid stenosis contralaterally. He underwent simultaneous surgery for both. The surgical steps involved and the reason behind the sequence of steps are unique to this situation and led to a good outcome. The strategy and the technicalities involved are discussed in this report.

Transcarotid trancatheter aortic valve implantation under local anesthesia in real life, a retrospective observational comparison with femoral access

Abstract Background Trans-femoral approach is the most commonly used access for trans-catheter aortic valve implantation (TAVI). However, in case of unsuitability, several alterative access routes have been described, namely trans-axillary, trans-aortic and trans-apical. The trans-carotid approach, rarely used, can be of particular help. Purpose To compare trans-carotid with trans-femoral access for TAVI, regarding epidemiological, clinical, procedural features and in hospital prognosis. Methods We retrospectively analyzed the data of 1272 patients treated with TAVI between January 2013 and December 2019. Patients were divided into 2 groups and compared according to the vascular approach: trans-carotid group (n=84) and trans-femoral group (n=1188). Results The trans-carotid group, representing 6.6% of all patients undergoing TAVI, had significantly more hypertension (89.9% vs 75.8%; p=0.002), history of coronary artery disease (78.6% vs 50.5%; p&amp;lt;0.001), peripheral arteriopathy (58.7% vs 9.3%; p&amp;lt;0.0001), ischemic stroke (24% vs 10.5%; p=0.03), chronic obstructive pulmonary disease (30.8% vs 18.4%; p=0.004), surgical aortic valve replacement (12% vs 4.3%; p=0.008) and contralateral carotid endarterectomy (4% vs 0.4%; p=0.012). Average scores of LOGISTIC EUROSCORE and EUROSCORE II were significantly higher in this group (respectively 22.4 vs 15.2 and 8.3 vs 5.56; p&amp;lt;0.0001) and patients were more frequently considered by the Heart Team as at high surgical risk (91.3% vs 68.2%; p&amp;lt;0.0001). When performing TAVI, balloon predilatation and postdilatation were significantly less frequent in the trans-carotid group (respectively 13.3% vs 26.4%; p=0.03 and 21.7% vs 37.6%; p=0.006). However, there was no significant difference between the 2 groups concerning neither the implantation of self-expanding/balloon-expandable valves nor in the fluoroscopy time and dose-area product averages. On post-procedural echocardiographic findings, transaortic mean gradient average and the incidence of significant paravalvular leak were similar. During intra-hospital follow-up, patients in the trans-carotid group had significantly less vascular complications (9.3% vs 23%; p=0.02) and less urgent need of endovascular repair (0% vs 15.8%; p=0.013) without any impact on the need for transfusion. However, the incidence of atrial fibrillation was significantly higher (17.4% vs 9.4%; p=0.036). There was no significant difference between the two groups for the incidence of haemodynamic and neurological complications, high-degree atrioventricular block and in-hospital mortality. Conclusion According to our study, trans-carotid TAVI under local anesthesia can be feasible and safe, especially in more friable patients at higher risk. It was associated with lower incidence of vascular complications but a higher incidence of atrial fibrillation, without impact on in-hospital mortality. Randomized controlled trials are needed to establish a firm conclusion about this novel approach. Funding Acknowledgement Type of funding source: None

Carotid endarterectomy in patients with symptomatic occlusions of the contralateral internal carotid artery

The main aim of the study was to investigate the effect of carotid endarterectomy on the prognosis of chronic cerebral ischemia in patients with symptomatic occlusions of the contralateral internal carotid artery, assess risks of surgical complications, and substantiate the staged surgical approach for treatment of patients with this pathology. The article analyzes the experience in surgical treatment of 83 patients with symptomatic ICA occlusions who underwent surgery for contralateral carotid artery stenosis. In 40 patients, only carotid endarterectomy (CEA) was performed on the side of hemodynamically significant stenosis (group 1). In 43 (52%) cases, apart from CEA, extracranial-intracranial (EC-IC) bypass was performed at the second stage (23 cases, group 2) or the first stage (19 cases, group 3). A surgical treatment approach was chosen based on clinical symptoms, severity of contralateral carotid artery stenosis, and the magnitude of perfusion deficiency in the territory of carotid occlusion. The conducted analysis revealed that patients with symptomatic occlusions and contralateral carotid artery stenoses represented a heterogeneous group with a different efficacy of carotid endarterectomy and with risks of perioperative complications. As cerebrovascular insufficiency in the territory of carotid occlusion and a related neurological deficit worsen, the risks of complications of contralateral carotid endarterectomy increase, and its clinical efficacy decreases. In these cases, cerebral revascularization on the ICA occlusion side should be performed at the first stage.

Extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases in conjunction with carotid endarterectomy for contralateral cervical carotid stenosis: clinical results and cognitive performance.

Clinical results as well as cognitive performances after extracranial to intracranial (EC-IC) bypass in conjunction with contralateral carotid endarterectomy (CEA) are poorly understood. Data from 14 patients who underwent unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease in conjunction with CEA for contralateral cervical carotid stenosis were retrospectively reviewed. Postoperative results were evaluated by MRI imagings. Nine patients also underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R) before and about 6months after bilateral surgeries. Postoperative MRI follow-up (median, 8months; interquartile range, 7-8months) confirmed successful bypass in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypass and contralateral smooth patency at CEA portion in all patients. In the group rate analysis, all five postoperative NPE scores (Verbal IQ, Performance IQ, WMS-memory, WMS-attention, and Average scores of all those four scores) were improved relative to preoperative NPE scores. Performance IQ and Average score improvements were statistically significant. Clinical results after EC-IC bypass in conjunction with contralateral CEA were feasible. Based on the group rate analysis, we conclude that successful unilateral EC-IC bypass and contralateral carotid endarterectomy does not adversely affect postoperative cognitive function.

A comparison of results with eversion versus conventional carotid endarterectomy from the Vascular Quality Initiative and the Mid-America Vascular Study Group

Carotid endarterectomy (CEA) is usually performed with eversion (ECEA) or conventional (CCEA) technique. Previous studies report conflicting results with respect to outcomes for ECEA and CCEA. We compared patient characteristics and outcomes for ECEA and CCEA. Deidentified data for CEA patients were obtained from the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) database for years 2003 to 2013. Second (contralateral) CEA, reoperative CEA, CEA after previous carotid stenting, or CEA concurrent with cardiac surgery were excluded, leaving 2365 ECEA and 17,155 CCEA for comparison. Univariate analysis compared patients, procedures, and outcomes. Survival analysis was also performed for mortality. Multivariate analysis was used selectively to examine the possible independent predictive value of variables on outcomes. Groups were similar with respect to sex, demographics, comorbidities, and preoperative neurologic symptoms, except that ECEA patients tended to be older (71.3 vs 69.8 years; P < .001). CCEA was more often performed with general anesthesia (92% vs 80%; P < .001) and with a shunt (59% vs 24%; P < .001). Immediate perioperative ipsilateral neurologic events (ECEA, 1.3% vs CCEA, 1.2%; P = .86) and any ipsilateral stroke (ECEA, 0.8% vs CCEA, 0.9%; P = .84) were uncommon in both groups. ECEA tended to take less time (median 99 vs 114 minutes; P < .001). However, ECEA more often required a return to the operating room for bleeding (1.4% vs 0.8%; P = .002), a difference that logistic regression analysis showed was only partly explained by differential use of protamine. Life-table estimated 1-year freedom from any cortical neurologic event was similar (96.7% vs 96.7%). Estimated survival was similar comparing ECEA with CCEA at 1 year (96.7% vs 95.9%); however, estimated survival tended to decline more rapidly in ECEA patients after ∼2 years. Cox proportional hazards modeling confirmed that independent predictors of mortality included age, coronary artery disease, chronic obstructive pulmonary disease, and smoking, but also demonstrated that CEA type was not an independent predictor of mortality. The 1-year freedom from recurrent stenosis >50% was lower for ECEA (88.8% vs 94.3%, P < .001). However, ECEA and CCEA both had a very high rate of freedom from reoperation at 1 year (99.5% vs 99.6%; P = .67). ECEA and CCEA appear to provide similar freedom from neurologic morbidity, death, and reintervention. ECEA was associated with significantly shorter procedure times. Furthermore, ECEA obviates the expenses, including increased operative time, associated with use of a patch in CCEA, and a shunt, more often used in CCEA in this database. These potential benefits may be reduced by a slightly greater requirement for early return to the operating room for bleeding.

Severe Contralateral Carotid Stenosis or Occlusion Does Not Impact Risk of Ipsilateral Stroke Following CEA

The impact of severe (>70%) contralateral carotid stenosis or occlusion (SCSO) on outcomes following carotid endarterectomy (CEA) is controversial. This study evaluated the effect of SCSO on outcomes following CEA. All patients undergoing carotid endarterectomy at a single institution were retrospectively stratified according to the presence of SCSO. The peri-operative outcomes of CEA in the presence of SCSO were analyzed using univariate and multivariable methods. There were 2945 CEA performed from 1/89 to 1/06, including 736 (25%) patients with SCSO. Patients identified with SCSO had a higher rate of prior contralateral CEA (44% vs 21%; P < .01), positive intra-operative EEG changes (31% vs 17%; P < .01), and use of an intra-operative shunt (40% vs 28%; P < .01). Univariate analysis identified SCSO as a risk factor for any stroke (2.8% vs 1.5%; P = .02), death (2.2% vs 1.1%; P = .03), and any stroke/death (4.3% vs 2.4%; P < .01), but not ipsilateral stroke (1.6% vs 1.2%; P = .4). Multivariable regression demonstrated SCSO as an independent predictor of any stroke (OR1.8 [95% CI: 1-3.3]; P = .05) and any stroke/death (OR1.7[95% CI: 1.1-2.7]; P = .02), without increasing risk of ipsilateral stroke (OR1.3[95% CI: 0.6-2.7]; P = .2). The presence of SCSO was also associated with a higher risk of late mortality (HR1.3 [95% CI: 1.1-1.4]; P < .01). Although the presence of SCSO is a risk factor for any stroke/death with CEA, it does not increase the risk of ipsilateral stroke. These data suggest that increased attention to peri-operative medical and hemodynamic management should be especially considered in this patient cohort as the observed strokes do not occur in the territory at risk from the surgical procedure.

Overestimation of contralateral internal carotid artery stenosis before ipsilateral surgical endarterectomy

The aim of this study was to investigate a possible overestimation of the degree of contralateral carotid artery stenosis by duplex in patients with significant bilateral carotid stenoses who are to undergo carotid endarterectomy (CEA). A retrospective analysis was performed of all patients undergoing CEA in our center over a period of 11 years. Pre- and postoperative duplex ultrasonography measurements of peak systolic velocity (PSV) and end diastolic velocity (EDV) were compared and used to classify the degree of stenosis. Univariate analysis was performed to indicate possible predictors for contralateral stenosis overestimation. A total of 384 CEA procedures in 357 patients were performed in our hospital. Pre- and postoperative bilateral duplex measurements were available in 135 patients. Forty-four out of 135 patients (33%) were preoperatively identified as having significant stenosis (>60%) of the internal carotid artery on both sides. In these patients, postoperative duplex measurements of the contralateral carotid showed a decrease in mean (SD) PSV from 2.53 (1.11) m s(-1) to 1.97 (0.87) m s(-1) (P<0.01) and a decrease in EDV from 0.87 (0.60) m s(-1) to 0.60 (0.36) m s(-1) (P<0.01). The absolute changes in contralateral PSV and EDV after CEA were larger among patients with a higher degree of stenosis preoperatively. These changes led to reclassification of stenosis to a lesser degree in 24 (55%) patients. In 16 cases (36%), this resulted in a measured stenosis on the contralateral side of less than 60%. One-third of the patients with duplex measurements consistent with bilateral significant carotid stenosis did not have a significant contralateral stenosis by duplex after CEA. Therefore, additional postoperative duplex measurement is advisable before planning contralateral CEA.

The strategy of management for bilateral carotid atherosclerotic stenosis

To evaluate the indication, time and strategy of surgery for patients with bilateral carotid atherosclerotic stenosis. Seventy-four patients with bilateral carotid atherosclecrotic stenosis were admitted to our hospital from February 1987 to December 2007. In 34 patients who presented with unilateral symptoms and underwent ipsilateral carotid endarterectomy (CEA), contralateral CEA or carotid artery stenting (CAS) was performed in 8 because of severe stenosis (> 70%) or unstable plaque. Thirty-eight patients presented with bilateral symptoms. Among them, 15 underwent CEA on both sides, 3 were performed CEA on one side and CAS on the other side, while 20 underwent unilateral CEA only. In 2 asymptomatic patients, CEA was also performed. Ninety-three cases of CEA were performed in 74 patients. Sixty-eight patients were uneventful after operation. Neurological deficits deteriorated in 2 patients. Four patients developed cardiac ischemia, cerebral hemorrhage and hoarseness respectively. Sixty-seven patients were followed-up for 4.9 years. No cerebral ischemia relevant to operated carotid artery developed in 63 patients. If the indication is obvious, CEA should be performed no matter how contralateral carotid artery is. The strategy of therapy is individual. Whether using shunt depends on intra-operative monitoring.

Outcome Analysis of Carotid Artery Occlusion

The outcome of carotid artery occlusion was studied through the retrospective identification of 115 affected patients. The majority were white (77%) males (61%) with multiple atherogenic risk factors and suffering ipsilateral stroke (57%). Those patients presenting with stroke were not distinguished by demographic features, risk factors, lipid profile, medical regimen, or subsequent mortality when compared with those without. Overall, 36 patients (31%) required contralateral carotid endarterectomy (CEA), with one (2.8%) perioperative stroke, whereas 4 (3%) underwent ipsilateral external CEA without incident. With 81% follow-up (mean 3.9 years), the overall mortality of the group was 46%; the annualized risk of ipsilateral stroke was 1.6%. This study documents a significant risk of stroke and contralateral occlusive disease with ipsilateral carotid artery occlusion, which cannot be reliably predicted by clinical criteria. Duplex surveillance is valuable, but flow velocity measurements alone may be misleading. Surgical endarterectomy can be performed with an acceptable rate of perioperative stroke.

Natural History of Symptomatic and Asymptomatic Carotid Artery Occlusion Contralateral to Carotid Endarterectomy: A Prospective Study

The natural history of carotid occlusion (CO) has generally been analyzed in the presence of a contralateral patent but diseased internal carotid artery (ICA). Few previous studies have focused on the fate of CO contralateral to the side of a prior carotid endarterectomy (CEA). The aim of this study was to analyze the mortality rate and the incidence of cerebrovascular events in the hemisphere ipsilateral to CO (HICO) in patients who had undergone contralateral CEA. The 30-day and long-term outcomes of 153 consecutive patients who had CEA for severe symptomatic and asymptomatic ICA lesions contralateral to a symptomatic or asymptomatic CO over a 15-year period were considered. The endpoints of the study were mortality and neurological events in the HICO. Overall, the 30-day mortality and stroke rates were 0.6% (1/153) and 1.9% (3/153), respectively; the only death was stroke-related and the stroke was ipsilateral to the operated side. The other 2 strokes were ipsilateral to a symptomatic CO. The follow-up was completed for all patients (mean, 7.7 years; range, 1-172 months). Overall, there were 4 late strokes (2.6%), one of them lacunar in a patient with a symptomatic CO, whereas the other 3 were atheroembolic and ipsilateral to the operated ICA. The risk of late stroke in the HICO at 5 and 12 years was 2%. Overall, there were 19 late deaths, none of them stroke-related. CO, with or without symptoms, contralateral to CEA could be considered a locally benign condition in the long term.

Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Grafting: Results in Specific Patient Groups

We examined the safety of performing synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in specific groups of patients with coexistent cerebral and coronary vascular disease. Between 1981 and 2003, 8,277 patients who underwent CABG in our institution had noninvasive screening for carotid disease. Two hundred seventy-seven (3.34%) patients were found to have severe (>70%) carotid stenosis. This patient population was divided into three subgroups: group A had unilateral carotid disease (n = 200), group B had bilateral carotid disease (n = 55), and group C had contralateral carotid occlusion (n = 22). In 29 patients (10.4%), the carotid disease was symptomatic. A simultaneous CABG and CEA was performed in all three subgroups. Patients in group B underwent initially repair of the most dominant lesion, soon followed by contralateral CEA. Patients who underwent only CABG (n = 8,000) served as controls. Overall combined hospital mortality regardless of etiology for the combined group was 3.61% vs. 1.7% for the patients who had CABG only (P > 0.1). The stroke and/or myocardial infarction-associated mortality for the simultaneous CEA-CABG group was 2.52%. There were six deaths in group A (3%), two in group B (3.6%), and two in group C (9.09%). Early stroke complicated the course of four (2%) patients in group A, one (1.8%) patient in group B, and three (13.64%) patients in group C compared to a stroke rate of 1.28% in controls. Overall stroke rate in the combined group was 2.8%. History of previous stroke and age 70-80 were the most important predictors of postoperative stroke and death. In the combined surgery group, the postoperative myocardial infarction rate was 0.72% vs. 0.58% in the control group. The mean length of hospital stay was 9 days for patients who had the combined procedure vs. 8.1 days for patients who had CABG only. Use of the combined procedure for patients with concomitant carotid and coronary artery disease was justified in the patients under study.

Increased incidence of cerebral clamping ischemia during early contralateral carotid endarterectomy

The aim of our study was to assess the influence of previous contralateral carotid endarterectomy (CEA) and of the timing of the procedures on cerebral clamping ischemia during the second operation in patients undergoing staged bilateral CEA. We reviewed the 251 patients who presented with bilateral carotid stenosis of > or =70% at the time of the first admission and underwent staged bilateral CEA between January 2001 and December 2004. Surgery was performed under locoregional anesthesia. Cerebral perfusion was monitored with mental status and contralateral motor function evaluation in awake patients. Selective carotid shunting was performed for patients who manifested neurologic deficits. Univariate and multivariate analyses were performed for the variables of interest. Twenty-two patients (8.8%) required carotid shunting during the first procedure and 28 (11.1%) during the second one. Nine of the latter also had shunts during the first CEA, whereas 19 tolerated cross-clamping during the first operation. Among the patients who underwent contralateral CEA < or =30 days, 23 of 146 required carotid shunting; between 31 and 60 days, 4 of 73; and after 61 days, 1 of 32 (P = .023; univariate analysis). The chi2 for trend was statistically significant (P = .009). Patients operated on the second side < or =30 days had a nearly fourfold risk of shunting during the second procedure compared with patients operated on > or =31 days. The highest risk was observed in patients with a shunt during the first operation who underwent the second CEA < or =30 days. Multivariate analysis also identified the time intervals between CEAs and the need of shunting during the first procedure as independent risk factors (P = .042 and P < .001). These data show an increased incidence of cerebral clamping ischemia during contralateral endarterectomy performed < or =30 days; whereas after longer intervals between CEAs, the need for shunting is significantly reduced.

Cerebral Hemodynamics after Contralateral Carotid Endarterectomy in Patients with Symptomatic and Asymptomatic Carotid Occlusion: A 10-Year Follow-Up

We sought to investigate whether carotid endarterectomy (CEA) can achieve long-term cerebral hemodynamic improvement and reduce recurrence of cerebral ischemic events in symptomatic and asymptomatic patients with severe (>70%) carotid artery stenosis contralateral to carotid occlusion (CO). Thirty-nine patients with severe carotid lesion contralateral to CO were studied before (1 day) and after CEA (at 7 days, 1, 3 and 6 months, and then yearly thereafter). Collateral flow and cerebral vasomotor reactivity (VMR) were assessed by transcranial Doppler sonography (TCD). A total of 32 unoperated patients with severe carotid lesion contralateral to CO, who were comparable with respect to age and sex, served as a control group. The average period of TCD follow-up was 10 years and was obtained in all patients; during this period, major clinical events (stroke, acute myocardial infarction and death) were also recorded. The proportion of patients with collateral flow via the anterior communicating artery increased significantly from 61.5% before to 89.7% after CEA (P = 0.01). Cerebral VMR ipsilateral to CO improved in 85.7% of patients (30 of 35) within 30 days of CEA, and in all patients within 90 days. No significant spontaneous VMR recovery was recorded in the control group. After the initial recovery, no significant change in VMR was observed in the surgical group or the control group during the follow-up. In conclusion, in patients with severe carotid stenosis, CEA contralateral to symptomatic and asymptomatic CO determines a durable cerebral hemodynamic improvement not only on the side of the CEA but also on the contralateral side, with no difference between symptomatic and asymptomatic patients.

Fate of the non-operated carotid artery after contralateral endarterectomy.

The long-term fate of the non-operated internal carotid artery (ICA) in 219 patients undergoing contralateral carotid endarterectomy was studied; 151 patients underwent serial postoperative imaging of the vessel. Cumulative freedom from stroke in the non-operated hemisphere was 99, 96 and 86 per cent at 1, 5 and 10 years respectively, giving a mean incidence of stroke of 1 per cent per annum. Only one stroke was preceded by a transient ischaemic attack and no stroke was associated with severe (70 per cent or greater) stenosis of the ICA. Ten patients (7 per cent) with initially mild or moderate disease of the non-operated ICA progressed to severe stenosis during follow-up, but only three became symptomatic and, in each case, the onset of symptoms preceded recognition of disease progression. The long-term risk of stroke in the non-operated ICA territory is very small. Of practical importance is that none of the observed strokes could have been prevented by postoperative surveillance of this type.

Carotid endarterectomy impairs blood pressure homeostasis by reducing the physiologic baroreflex reserve

To assess the impact of carotid endarterectomy on blood pressure homeostasis and baroreflex function, with particular reference to the presence or absence of significant contralateral carotid artery disease, we conducted a prospective study in 80 patients with symptomatic extracranial carotid disease undergoing carotid endarterectomy in a regional teaching hospital over 2 years. Patients were divided into two groups: the control group (n = 37) had no significant contralateral carotid disease; patients in the diseased group (n = 23) had either >70% stenosis or occlusion of the contralateral carotid artery. Seventeen patients with abnormal heart rhythms, poor quality recordings, or with intermediate degrees of contralateral carotid stenosis were excluded. Three patients who had previously undergone contralateral carotid endarterectomy were separately evaluated. Atheromatous plaque was removed from carotid lumen and the baroreflex mechanism received direct intraoperative stimulation before and after carotid endarterectomy. The main outcome measures were (1) the hemodynamic response to the carotid endarterectomy, baroreflex sensitivity, and operating set point (the resting blood pressure, which the baroreflex mechanism maintains) before and after removal of the atheromatous plaque, and (2) the responsiveness of the ipsilateral baroreceptor mechanism to direct stimulation. The impact of the presence of contralateral carotid stenosis on these variables was also evaluated. Patients in the two groups were comparable for preoperative demographic, medication, and hemodynamic variables. Carotid endarterectomy led to a rise in mean arterial pressure from 81.3 +/- 3.9 mm Hg to 103.5 +/- 4.6 mm Hg ( P < .00001) and from 87.6 +/- 4.3 mm Hg to 94.0 +/- 4.5 mm Hg ( P < .003) in the diseased and control groups, respectively. The magnitude of blood pressure response was significantly greater in the diseased group than in the control group ( P < .00001). This hypertensive shift was not accompanied by the expected fall in heart rate. Direct baroreflex stimulation prior to carotid endarterectomy caused a significantly greater response in the diseased group, suggesting sensitization of the ipsilateral carotid baroreceptor in the presence of contralateral carotid disease. Furthermore, the baroreflex response was obliterated after endarterectomy. There were significant reductions in baroreflex sensitivity and a hypertensive shift in the operating set point, the magnitude of which was significantly greater in patients with contralateral carotid disease. Carotid endarterectomy impairs blood pressure homeostasis through surgical destruction of the ipsilateral carotid baroreflex mechanism. Patients with contralateral carotid stenosis have a reduced baroreflex reserve and show greater baroreflex dysfunction and hemodynamic instability after endarterectomy. These patients are at greater risk of postendarterectomy complications and should be monitored closely.

&lt;b&gt;Simultaneous Carotid Endarterectomy and Coronary Revascularization is Safe Using Either On-Pump or Off-Pump Technique&lt;/b&gt;

The appropriate surgical strategy for patients with combined carotid and coronary artery disease remains controversial. We retrospectively compared our surgical results for 2 types of approaches in this disorder. The records of 76 patients consecutively operated on for carotid and coronary artery disease between August 1993 and October 2004 were reviewed. There were 18 males (66.6%) and 9 females (33.3%) in group I. Group II consisted of 35 males (71.4%) and 14 females (28.5%). The patients were divided into two groups: patients with combined off-pump coronary artery bypass and carotid endarterectomy (group I, n = 27), and those with one-stage on-pump coronary artery bypass and carotid endarterectomy (group II, n = 49). Surgical mortality and morbidity and late outcome were compared among the two groups. The average number of grafts was 1.2 +/- 0.4, with the average operative time of 3.3 +/- 0.3 hours in group I, and 2.3 +/- 0.5 grafts with operative time of 4.6 +/- 0.4 hours in group II (P < 0.001 and P < 0.001, respectively). There was 1 death (3.7%) in group I and 2 deaths (4.8%) in group II (P = 0.937). No patient from either group I or group II had postoperative stroke. Mean hospital stay was 7.4 +/- 1.9 days in group I and 11.3 +/- 1.7 days in group II (P < 0.001). At a mean follow-up of 5.5 +/- 3.3 years in group I, 1 patient had contralateral carotid endarterectomy (3.7%). Group II had a mean follow-up of 5.2 +/- 3.0 years and contralateral carotid endarterectomy was performed in 1 patient (2.0%). There were no late strokes or deaths in either group. Combined coronary artery bypass grafting and carotid endarterectomy using 2 different types of technique is a safe and effective procedure in patients with significant concomitant monolateral carotid and coronary artery disease.