Contralateral Internal Carotid Artery Stenosis Research Articles

HEMODYNAMIC PARAMETERS OF EXTRACRANIAL CEREBRAL ARTERIES AND HEART IN PATIENTS WITH OCCLUSION OF THE INTERNAL CAROTID ARTERY DURING VASCULAR SURGERY

HighlightsWe have analyzed the parameters of cerebral hemodynamics and left ventricular functional capacity in patients with occlusion and stenosis of the contralateral internal carotid artery during vascular surgery. Considering the importance of the left ventricular functional capacity and treatment options to ensure the stability of cerebral circulation in patients with occlusion and hemodynamically significant stenosis of the contralateral carotid artery, its detailed study at all stages of vascular surgery remains necessary. AbstractAim. To study cerebral hemodynamics and left ventricular functional capacity in patients with occlusion and stenosis of the contralateral internal carotid artery (ICA) to optimize treatment at the preoperative phase.Methods. The study compared the hemodynamic parameters of the blood flow of the ICA, vertebral arteries and left ventricular functional capacity in patients with ICA occlusion and contralateral ICA stenosis, which formed the 1 group (12 patients), and patients with unilateral hemodynamically significant stenosis, which formed the 2 group (52 patients). The blood flow in the extracranial portions of the major arteries of the head and heart was assessed using ultrasound, and the arterial vascular system and brain structure was assessed using MRI and MRA.Results. Before surgery, statistically significant differences in velocity parameters in the vertebral arteries on the occlusion side were found; on the contralateral occlusion side, velocity parameters in ICA were significantly different from the corresponding indicators in the group with unilateral stenosis; after surgery, statistically significant differences were found in the common carotid and vertebral arteries on the occlusion side; on the contralateral occlusion side, differences in velocity parameters in the common carotid, internal, and vertebral arteries were revealed in comparison with the group with unilateral stenosis. Of the indicators of the left ventricular functional capacity, only left ventricular ejection fraction differed significantly when comparing the group of patients with occlusion and stenosis of ICA and the group of patients with unilateral stenosis. Moreover, when evaluating pre- and postoperative outcomes in the group of patients with occlusion, significant differences were obtained only regarding the vertebral artery on the side of occlusion – the peak systolic blood flow velocity and the volumetric blood flow velocity significantly decreased. There were no significant differences between the common carotid, internal carotid arteries on the contralateral occlusion side, and middle cerebral arteries.Conclusion. Carrying out a comprehensive ultrasound examination of the main arteries of the head in combination with magnetic resonance imaging of the brain is a reliable and adequate way to assess cerebral hemodynamics, changes in the vascular bed and structure of the brain. Given the extreme importance of the left ventricular functional capacity to ensure the stability of cerebral circulation in patients with occlusion of the internal carotid artery and contralateral hemodynamically significant stenosis, its detailed study before carotid endarterectomy is necessary to adjust therapeutic measures.

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.

Concomitant occurrence of Cerebral Hyperperfusion Syndrome (CHS) and Reversible Cerebral Vasoconstriction Syndrome (RCVS) after right Carotid Endarterectomy (CEA) (P2-5.018)

<h3>Objective:</h3> To describe an interesting case of CHS and RCVS occurring concomitantly following CEA <h3>Background:</h3> Both CHS and RCVS are known complications of CEA. On rare occasions both complications can occur concomitantly after CEA. <h3>Design/Methods:</h3> Case report <h3>Results:</h3> A 58-year-old female with long-standing history of smoking and hyperlipidemia presented to outside hospital (OSH) with pressure-like headache on top of her head and feeling of facial swelling. CT angiogram of head and neck (CTA) showed right internal carotid artery (ICA) stenosis of 85% and left ICA stenosis of 80%. Three months after the initial presentation she underwent right CEA. Immediately following procedure, she had severe throbbing headache on right side which responded to Toradol. Neurologic examination was otherwise unremarkable, and she was discharged home on dual anti-platelet therapy. After discharge, she continued to have headache. Ten days after the procedure, she developed left sided weakness and presented to an outside hospital where she had a seizure and was started on levetiracetam. MRI of the brain showed edematous changes on the right consistent with CHS without evidence of acute stroke. Right ICA was patent and there was segmental vasoconstriction and dilation of cerebral vasculature consistent with RCVS. Due to increased risk of hemorrhagic strokes with CHS and RCVS, left CEA was not recommended and maximal medical therapy was recommended. There was resolution of edematous changes in right cerebral hemisphere on MRI two months later. CTA at two months follow up showed resolution of segmental vasoconstriction and vasodilation, patent right ICA and unchanged left ICA stenosis. <h3>Conclusions:</h3> CHS and RCVS can occur concomitantly after CEA and can lead to devastating hemorrhagic strokes. In patients who develop CHS and RCVS concomitantly maximal medical therapy should be recommended for contralateral ICA stenosis. <b>Disclosure:</b> Dr. Anjum has nothing to disclose. Dr. Burton has nothing to disclose. Dr. Javalkar has nothing to disclose. Dr. Chernyshev has nothing to disclose.

Abstract Number ‐ 66: Symptomatic Chronic Internal Carotid Artery Occlusion Managed With Bilateral Common Carotid Angioplasty: A Case Report

Introduction Several guidelines have addressed symptomatic or asymptomatic carotid artery stenosis treatment with intensive medical management and surgical management based on the severity of stenosis [1]. In acute occlusions, endovascular treatment (EVT) and carotid endarterectomy (CEA) with or without prior thrombolytics provide the best recanalization and functional outcomes when compared to intravenous or intra‐arterial thrombolysis alone. There is, however, less robust evidence on management of symptomatic chronic internal carotid artery (ICA) occlusion occurring in tandem with significant contralateral ICA stenosis [2]. In chronic ICA occlusion (ICAO), EVT and carotid endarterectomy (CEA) are technically unfeasible, but indirect procedures have been arising as safe and effective alternatives, notably CEA or stenting of contralateral stenotic ICA [3] and CEA or stenting of ipsilateral external carotid artery (ECA) [4]. We hereby report a case of symptomatic chronic ICAO that was managed with staggered angioplasty and stenting of bilateral common carotid artery (CCA) bifurcations. Methods We hereby present a case report. Results A 62‐year‐old male with atrial fibrillation and hypertension woke up with sudden dysarthria and right upper extremity and facial weakness. NIHSS at presentation was 4. Last seen normal 9 hours prior. Non‐contrast head computerized tomography (CT) did not show acute intracranial abnormality, CT angiogram of head and neck showed severe right ICA stenosis and complete occlusion of the left ICA at cervical, petrous and cavernous segments, with distal reconstitution at the supraclinoid segment with left proximal middle cerebral artery (MCA) thrombus. CT perfusion showed a core infarct volume of 8cc in left MCA territory, mismatch volume of 78cc and ratio of 10.8. Risks of acute neuro‐intervention were deemed to outweigh benefits. Given favorable perfusion imaging, and in concordance with the EXTEND trial [5], tPA was administered. The patient remained stable without hemorrhagic complications with residual deficits of mild right upper extremity weakness and mild expressive aphasia. MRI confirmed left ICA territory ischemic infarcts. Patient underwent stenting of the asymptomatic right ICA at the CCA bifurcation first, followed by left CCA stent after one month with impressive improvement in subsequent perfusion imaging. Conclusions Our case encourages consideration of well‐timed angioplasty and stenting in cases of chronic bilateral carotid artery disease especially when the asymptomatic side is also significantly stenotic

Hybrid revascularization: stenting of left internal carotid artery after restenosis, combined with left anterior descending artery stenting and right carotid endarterectomy

We present a description of internal carotid artery restenosis five years after eversion carotid endarterectomy, progression of contralateral internal carotid artery stenosis and coronary atherosclerosis with imaging of haemodynamically significant stenosis of the anterior descending artery. The efficacy of hybrid revascularization is demonstrated: carotid angioplasty with stenting of the left internal carotid artery stenosis + percutaneous coronary intervention for the anterior descending artery + left carotid endarterectomy. We explain the choice of these types of reconstruction and staging of the intervention. We make a conclusion regarding the effectiveness and safety of the implemented treatment strategy.

Risk for Additional Infarction in Emergency Carotid Artery Endarterectomy in Thrombectomy Acute Stroke Patients.

Purpose: Thromboembolic occlusion of the middle cerebral artery with tandem occlusion of the internal carotid artery is a life-threatening condition with unfavorable neurological outcome. We perform emergency carotid endarterectomy in the same anesthesia session as thrombectomy in our angiography suite whenever needed despite the absence of electrophysiological neuromonitoring. Methods: We evaluated 47 thrombectomy patients with emergency CEA in our clinic between June 2013 and November 2020. To determine whether there were additional infarctions due to the surgical procedure, we assessed the initial diagnostic CT imaging for previously infarcted areas, cerebral perfusion, and vascular anatomy, including collateralization in the Circle of Willis (CoW). We then analyzed follow-up imaging with respect to new infarctions that could not be explained by the initial stroke. Results: 5 of 47 (11%) patients had a complete CoW. There was contralateral internal carotid artery (ICA) stenosis or occlusion in 18/47 (38%) patients. Surgical procedure was eversion CEA in 34 (72%) and with a patch graft CEA in 13 (28%) cases. Shunts were used during surgery in 17/47 (36%) patients. Two patients suffered from an additional infarction in a new territory, however this was not caused by the surgical procedure but due to embolism during endovascular thrombectomy. In 1 of these 2 patients a hemodynamic border zone infarction was also observed, which could have developed during thrombectomy as well as during surgery, although this could not be attributed with absolute certainty to the surgery. The final infarction size was significantly larger in patients with contralateral ICA stenosis or occlusion (P = .038). Neither CoW anatomy nor the absence of a shunt during surgery could be identified as risk factors for additional infarction. Conclusion: Emergency surgery in the angiography suite without neuromonitoring was not associated with an increased additional stroke rate in our patient cohort.

Laterality of Posterior Cerebral Artery and White Matter Hyperintensities in Patients with Severe Internal Carotid Artery Stenosis.

Collateral status of the circle of Willis was associated with white matter hyperintensities (WMHs) in patients with internal carotid artery (ICA) stenosis, but few have investigated the effect of leptomeningeal anastomoses. The aim of this study was to observe the association between WMHs and the laterality of the posterior cerebral artery (PCA) that presents leptomeningeal anastomoses in patients with severe ICA stenosis. WMHs and ipsilateral PCA laterality were evaluated in patients with unilateral ICA stenosis ≥70% (including occlusion) and contralateral ICA stenosis <50% or no stenosis. Ipsilateral PCA laterality was compared between two groups of no/mild and severe score of global, deep and periventricular WMHs, respectively. We included 115 patients with unilateral ICA stenosis ≥70%. There were 60 patients with no/mild and 55 with severe global WMHs. The patients with severe global WMHs were older (OR = 1.849, 95% CI: 1.058-3.229, P = 0.031) and had higher incidence of negative PCA laterality (OR = 3.301, 95% CI: 1.140-9.558, P = 0.028). The patients with severe deep WMHs were also older (OR = 2.031, 95% CI: 1.130-3.651, P = 0.018) and had higher incidence of negative PCA laterality (OR = 4.250, 95% CI: 1.501-12.032, P = 0.006). There was no significant difference between the patients with no/mild and severe periventricular WMHs in the incidence of negative PCA laterality. The incidence of negative PCA laterality was higher in patients with severe global and deep WMHs, but not higher in patients with severe periventricular WMHs. The leptomeningeal anastomoses may affect the deep WMHs in patients with severe ICA stenosis.

Somatosound: A review with report of 9 cases with long-term follow-up

Somatosound (somatic tinnitus) is associated with vascular, musculoskeletal, respiratory, or temporomandibular joint disorders. Several studies of its management have been widely reported, but only few presented long-term follow-up results. The purposes of this paper are to review the causes and management, present cases with long-term follow-up, together with previously reported cases in literatures. We treated nine patients with somatosound of vascular, hematologic, endocrinologic, muscular, and cervical origin. Follow-up were conducted routinely, and the final results were collated in 3 to 11 years. Patients with non-life-threatening causes were given counseling and palliative management. Their tinnitus becomes tolerable, gradually decreased, and even disappeared. Patients with life-threatening causes were treated immediately. Among all, there were three cases which to the best of our knowledge, are the first reported of its causes. One case was caused by a compensatory of increasing blood flow in internal carotid artery (ICA) secondary to contralateral ICA stenosis. Another had a combination of anemia and an ipsilateral jugular bulb diverticulum. The tinnitus disappeared after the anemia treated. The last was patient with hyperthyroidism. The tinnitus disappeared by controlling the condition. Even when the causes are benign and the available treatments may carry risks, the patients should not be left unmanaged. Symptomatic treatment should be given, such as counseling, sound therapy, and palliative management. Our long-term observation indicated that overall outcomes are positive when the etiologies are identified early and managed properly.

Carotid Stump Pressure and Contralateral Internal Carotid Stenosis Ratio During Carotid Endarterectomies: 1D-0D Hemodynamic Simulation of Cerebral Perfusion.

Objective: We selectively place carotid shunting when ipsilateral mean stump pressure is less than 40 mmHg during carotid endarterectomy (CEA). This study aimed to assess the validity of our selective shunting criterion by 1D-0D hemodynamic simulation technology.Materials and Methods: We retrospectively reviewed 88 patients (95 cases) of CEA and divided them into two groups based on the degree of contralateral internal carotid artery (ICA) stenosis ratio, which was determined as severe when the peak systolic velocity ratio of the ICA to the common carotid artery was ≥4 by carotid duplex ultrasonography. Patients with severe stenosis or occlusion in contralateral ICA were classified as hypoperfusion group, and those without such contralateral ICA obstruction were classified as control group.Results: Perioperatively, the mean carotid stump pressures were 33 mmHg in hypoperfusion group and 46 mmHg in the control group (P=0.006). We simulated changes in carotid stump pressure according to the changes in the contralateral ICA stenosis ratio. 1D-0D simulation indicated a sharp decline in carotid stump pressure when the contralateral stenosis ratio was >50%, while peripheral pressure of the middle cerebral arteries declined sharply at a ≥70% contralateral stenosis ratio. At this ratio, the direction of the ipsilateral cerebral arterial flow became inverted, the carotid stump pressure became dependent on the basilar artery circulation, and the ipsilateral middle cerebral artery became hypoperfused.Conclusion: Our clinical and computer-simulated results confirmed the validation of our carotid shunting criterion and suggested that contralateral ICA stenosis ratio over 70% is a safe indication of selective shunting during CEA.

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.

Follow-up after carotid endarterectomy and stenting: What to look for and why

Duplex ultrasound testing after open or endovascular extracranial carotid artery interventions is a clinical practice guideline with a strong recommendation from the Society for Vascular Surgery. Neurologic outcomes are improved by the recognition of repair site stenosis or atherosclerotic disease progression in the unoperated carotid artery. The benefit of surveillance outweighs its risk because duplex testing is free of complications and accurate in the detection of internal carotid artery (ICA) stenosis or occlusion. Surveillance for >70% ICA stenosis is recommended within 30 days of the procedure, then every 6 months for 2 years, and annually thereafter. Repair site and contralateral ICA stenosis classification should be based on angle-corrected pulsed Doppler measurements of peak systolic velocity (PSV), end-diastolic velocity (EDV), and the ratio of PSV at the stenosis to a proximal, nondiseased common carotid artery (CCA) segment (ICA/CCA ratio). Interpretation criteria of PSV >300 cm/s, EDV >125 cm/s, and ICA/CCA ratio >4 predicts >70% repair site stenosis. Endovascular intervention is recommended for a carotid repair site stenosis based on the occurrence of an ipsilateral neurologic event and appropriate anatomy for angioplasty. For asymptomatic restenosis, intervention is based on stenosis progression to elevated PSV and EDV >70% stenosis threshold values and the patient is deemed high risk for stroke due to contralateral ICA occlusion or incomplete functional patency of the circle of Willis.

Carotid Endarterectomy With Shunt for Preoperative or Intraoperative Indication Is Associated With Increased Rate of Stroke

Carotid endarterectomy (CEA) is performed frequently both with and without the use of shunting, and previous studies have shown similar 1% to 2% rates of stroke with both techniques in asymptomatic patients. The rate of stroke when shunting is performed for a preoperative or intraoperative indication remains understudied. We aimed to evaluate the rate of stroke by shunt indication and to compare this cohort with routine shunt and no shunt cohorts in a large national registry. The Vascular Quality Initiative CEA registry was used to identify patients undergoing CEA for asymptomatic carotid stenosis from 2013 to 2019. Exclusion criteria included symptomatic patients (defined as ipsilateral transient ischemic attack or stroke within 6 months of operation), concomitant coronary intervention, proximal or distal endovascular intervention, and urgent or emergent procedures. Categorical variables were analyzed using χ2 test, and continuous variables were analyzed using analysis of variance. Multivariable logistic regression was used to evaluate demographic and perioperative predictors of stroke. There were 69,903 CEAs identified, which consisted of 33,459 without shunt, 31,711 routine shunts, 1369 shunts for preoperative indication, and 3364 shunts for intraoperative indication patients. The cohort with shunt for preoperative indication was more likely to be male, to be transferred from an outside hospital, and to have contralateral internal carotid artery (ICA) occlusion. In addition, the cohorts with shunt for indication had slightly increased procedure length, rates of re-exploration at time of initial operation, and protamine use (Table I). The rate of stroke was increased in shunt for preoperative and intraoperative indication cohorts (no shunt, 0.8%; routine shunt, 0.9%; preoperative indication, 1.8%; intraoperative indication, 1.3%; P < .01). On multivariable analysis, both shunt for preoperative indication and shunt for intraoperative indication are associated with stroke. Other perioperative and demographic variables associated with stroke include hypertension, any prior neurologic event, contralateral ICA occlusion, completion angiography, postoperative hemodynamic instability requiring intravenous medications, and re-exploration at the time of initial operation (Table II). The proportion of shunt for preoperative indication varies by region (East, 1.4%; North, 2.2%; South, 1.5%; West, 4.3%; P < .01). Regional variation is present in preoperative indication for shunt as the proportion of patients with contralateral ICA occlusion or >60% contralateral ICA stenosis varied widely (East, 55.3%; North, 62.9%; South, 52.2%; West, 47.6%; P < .01). CEA with shunt for preoperative or intraoperative indication is associated with increased rates of stroke, even in asymptomatic patients, suggesting a high-risk cohort that is poorly defined by registry data. Identifying this cohort may alter the risk-benefit ratio of the operation and inform clinical decision-making.Table IDemographic characteristics, preoperative workup, and intraoperative variablesDemographic characteristicsNo shunt (n = 33459)Routine shunt (n = 31711)Shunt: Preop indication (n = 1369)Shunt: Intraop indication (n = 3364)PAge, years (SD)70.7 (8.7)71.0 (8.8)70.4 (9.1)71.1 (8.9)<.01Sex (male)20263 (60.6)18715 (59.0)876 (64.0)1918 (57.0)<.01Comorbidities HTN29950 (89.5)28615 (90.2)1236 (90.3)3079 (91.5)<.01 CAD9092 (27.2)9061 (28.6)404 (29.5)926 (27.6)<.01 CHF3659 (10.9)3637 (11.5)157 (11.5)391 (11.6).15 Diabetes11988 (35.8)11881 (37.5)508 (37.1)1280 (38.0)<.01 Current Smoker7976 (23.8)8043 (25.4)330 (24.1)885 (26.3)<.01 ESRD352 (1.1)366 (1.2)16 (1.2)49 (1.5).16 ASA Class ≥45539 (16.6)6026 (19.0)274 (20.0)605 (18.0)<.01 Lived at Home33178 (99.2)31343 (99.1)1346 (98.4)3313 (98.5)<.01 Transfer OSH383 (1.1)341 (1.1)35 (2.6)46 (1.4)<.01Neurologic History Ipsi Neuro Event >6 months1891 (5.7)1803 (5.7)147 (10.8)214 (6.4)<.01 Ipsi Stroke >6 months1110 (3.3)1075 (3.4)103 (7.5)138 (4.1)<.01 Contra CEA5213 (15.6)5169 (16.3)156 (11.4)528 (15.7)<.01 Contra ICA Occlusion937 (2.8)1620 (5.2)370 (27.4)336 (10.3)<.01 Ipsi Stenosis ≥70%30362 (92.1)28306 (91.3)1232 (91.4)2932 (90.2)<.01 Contra Stenosis ≥70%6116 (18.6)5888 (19.0)314 (23.3)624 (19.2)<.01 Anatomic High Risk1433 (4.3)1232 (3.9)53 (3.9)147 (4.4).06Operative Factors Procedure Length (SD)114 (44)112 (42)122 (44)121 (43)<.01 Protamine23494 (70.2)21643 (68.3)985 (72.0)2581 (76.8)<.01 Patch27831 (83.3)30607 (96.5)1289 (94.2)3165 (94.1)<.01 Re-explore at Initial Operation459 (1.4)390 (1.2)19 (1.4)72 (2.1)<.01ASA, American Society of Anesthesiologists; CAD, coronary artery disease; CHF, congestive heart failure; Contra, contralateral; ESRD, end stage renal disease requiring dialysis; HTN, hypertension; ICA, internal carotid artery; Ipsi, ipsilateral; Neuro, neurologic event >6 months from procedure; OSH, outside hospital; SD, standard deviation. Open table in a new tab Table IIMultivariable logistic regression: strokeStrokeOdds ratio (OR)95% Confidence intervalPP2Y12 Inhibitor0.640.53-0.77<.01Male Gender0.810.69-0.96.02Shunt for Intraop Indication1.431.02-2.01.04Shunt for Preop Indication1.611.05-2.53.03Completion Angiogram1.691.22-2.35<.01Hypertension1.701.20-2.40<.01Contralateral ICA Occlusion1.781.34-2.38<.01Any Prior Neurologic Event1.931.63-2.29<.01Postop IV Medication for Hemodynamic Instability3.432.91-4.05<.01Re-explore at Initial Operation9.5411.31-17.08<.01 Open table in a new tab

The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database

Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.

Are Cerebral White Matter Lesions Related to the Presence of Bilateral Internal Carotid Artery Stenosis or to the Length of Stenosis Among Patients With Ischemic Cerebrovascular Events?

Background and purpose: Previous studies delivered contradicting results regarding the relation between the presence of an internal carotid artery stenosis (ICAS) and the occurence of white matter lesions (WMLs). We hypothesize that special characteristics related to the ICAS might be related to the WMLs. We examined the relation between the presence of bilateral ICAS, the degree and length of stenosis and ipsi-, contralateral as well as mean white matter lesion load (MWMLL).Methods: In a retrospective cohort, patients with ischemic stroke or transient ischemic attack (TIA) as well as ipsi- and/or contralateral ICAS were identified. The length and degree of ICAS, as well as plaque morphology (hypoechoic, mixed or echogenic), were assessed on ultrasound scans and, if available, the length was also measured on magnetic resonance angiography (MRA) scans, and/or digital subtraction angiography (DSA). The WMLs were assessed in 4 areas separately, (periventricular and deep WMLs on each hemispherer), using the Fazekas scale. The MWMLL was calculated as the mean of these four values.Results: 136 patients with 177 ICAS were identified. A significant correlation between age and MWMLL was observed (Spearman correlation coefficient, ρ = 0.41, p < 0.001). Before adjusting for other risk factors, a significantly positive relation was found between the presence of bilateral ICAS and MWMLL (p = 0.039). The length but not the degree of ICAS showed a very slight trend toward association with ipsilateral WMLs and with MWMLL. In an age-adjusted multivariate logistic regression with MWMLL ≥2 as the outcome measure, atrial fibrillation (OR 3.54, 95% CI 1.12–11.18, p = 0.03), female sex (OR 3.11, 95% CI 1.19–8.11, p = 0.02) and diabetes mellitus (OR 2.76, 95% CI 1.16–6.53, p = 0.02) were significantly related to WMLs, whereas the presence of bilateral stenosis showed a trend toward significance (OR 2.25, 95% CI 0.93–5.45, p = 0.074). No relation was found between plaque morphology and MWMLL, periventricular, or deep WMLs.Conclusion: We have shown a slight correlation between the length of stenosis and the presence of WMLs which might be due to microembolisation originating from the carotid plaque. However, the presence of bilateral ICAS seems also to be related to WMLs which may point to common underlying vascular risk factors contributing to the occurrence of WML.

Does severe contralateral carotid artery stenosis affect the outcomes of carotid endarterectomy?

This study aims to evaluate the effect of contralateral internal carotid artery stenosis on postoperative stroke and mortality rate and blood pressure alterations following carotid artery endarterectomy. Between January 2009 and April 2017, a total of 152 carotid artery endarterectomy operations in 141 consecutive patients (30 females, 111 males; mean age 70.0±10.2 years; range, 48 to 92 years) with internal carotid artery stenosis were retrospectively analyzed. The patients were divided into two groups as those with contralateral internal carotid artery stenosis <70% (n=95) and contralateral internal carotid artery stenosis ?70% (n=26). Stroke and mortality rates in the early postoperative period (within the first 30 days), postoperative blood pressure alterations at six and 24 hours, non-neurological outcomes, and baseline demographic characteristics were analyzed and compared between the groups. Both groups showed similar results in terms of the demographic characteristics. There was no statistically significant difference in the postoperative blood pressure alterations at six (p=0.917) and 24 hours (p=0.6), stroke rate (7.6% vs. 3.1%, p=0.282), mortality rate (3.8% vs. 2.1%, p=0.519), non-neurological complications (15.3% vs. 11.4%, p=0.736), and length of hospital stay (p>0.05) between the groups. The patients with contralateral severe internal carotid artery stenosis were younger (p=0.005). The present study shows that the presence of a contralateral severe internal carotid artery stenosis does not increase the risk of postoperative stroke and mortality rates and blood pressure alterations. Therefore, carotid artery endarterectomy can be performed with acceptable complication rates in patients with contralateral severe internal carotid artery stenosis with strict perioperative hemodynamic monitoring.

Incomplete circle of Willis is associated with a higher incidence of neurologic events during carotid eversion endarterectomy without shunting

ObjectiveA complete circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of an incomplete CoW with isolated middle cerebral artery (iMCA) on immediate neurologic events (INEs) after CEA. MethodsWe prospectively collected the clinical data and outcomes of 902 patients who underwent CEA under general anesthesia between 2013 and 2015. All patients had preoperative computed tomography angiography of the extracranial and intracranial cerebral circulation. Indications were asymptomatic (52%) and symptomatic (48%) carotid artery disease. Patients who had CEA with shunt (n = 35) and those with inadequate intracranial imaging to assess CoW were excluded (n = 322) only. Computed tomography angiography images were reviewed retrospectively and independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation and each segment of the CoW, which was classified as normal, hypoplastic (diameter < 0.8 mm) or absent. The ipsilateral MCA was considered isolated if there was an absence of the anterior and posterior communicating branches from the contralateral carotid or posterior circulations. INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. ResultsOf the 545 included patients (331 males; mean age, 69 ± 8 years), 12 (2.2%) had a stroke in the postoperative period. There were 20 INEs (8 strokes and 12 TIAs). A complete CoW was rare; it was only detected in 19 patients (3.5%) and an iMCA was found in 34 patients (6.3%). When at least one collateral circulation was complete (in 330 patients), we observed only four INEs (1.2%). Of the 34 patients with an iMCA, 8 (24%) had INE (6 TIAs and 2 strokes). Overall, iMCA was an independent predictor of INEs (odds ratio, 11.12; 95% confidence interval, 3.57-35.87; P < .001). With logistic regression, the model included hypertension, smoking, diabetes, hyperlipidemia, carotid clamping time (minutes), contralateral significant internal carotid artery stenosis of greater than 90%, ipsilateral significant internal carotid artery stenosis of greater than 90%, preoperative symptoms in 6 months, and iMCA; above iMCA only symptomatic patients had significant risk (odds ratio, 3.34; 95% confidence interval, 1.19-9.73; P = .02), whereas all other parameters were not significant. ConclusionsAn iMCA carries more than a 10-fold higher the risk of INEs after CEA with cross-clamping without shunt protection. In these patients, routine shunting is recommended to prevent INEs.

Flip-Flop Phenomenon: Swallowing-Induced Arterial Displacement as an Indicator of Carotid Artery Disease

Background and purpose: The dynamic displacement of the carotid arteries with interference of the hyoid bone during swallowing, named as “flip-flop” phenomenon (FFP), may be associated with ischemic stroke. However, the extent to which FFP is prevalent in carotid artery disease remains unknown. We aimed to investigate its exact prevalence to explore the relationship between FFP and carotid artery disease. Methods: We examined 202 consecutive patients who were affected by neurological diseases including cerebrovascular diseases. Using carotid ultrasound, we evaluated carotid intima-media thickness, internal carotid artery stenosis (ICS), and FFP during swallowing with neck rotation. Results: FFP was observed in 39 of the 202 patients (19.3%). Patients with FFP showed significantly higher prevalence of ICS than those without FFP (12/39 [30.8] vs. 21/163 [12.9%]; p = 0.007). Among those with ICS (n = 33; 36 vessels), FFP was associated with symptomatic ICS more frequently than with asymptomatic ICS (6/11 [54.5] vs. 5/25 [20.0%]; p = 0.038). Among those with unilateral FFP (n = 37), the prevalence of ipsilateral ICS was higher than that of contralateral ICS (9/37 [24.3] vs. 2/37 [5.4%]; p = 0.035). Conclusions: FFP accompanies the swallowing movement in some neurological patients, and more frequently in patients with ICS. FFP may thus be a novel indicator of stroke.

In-hospital outcomes of carotid endarterectomy depending on severity of contralateral lesion

To compare in-hospital outcomes of carotid endarterectomy (CEE) in patients with different lesion of contralateral internal carotid artery (ICA). There were 730 CEE procedures in patients with bilateral ICA lesion for the period 2011-2016. All patients were divided into 4 groups depending on contralateral ICA stenosis grade: group 1 - stenosis up to 60% (42.6%, n=311); group 2 - 60-90% (18.7%, n=137); group 3 - 90-99% (25.9%, n=189); group 4 - occlusion (12.7%, n=93). Endpoints were unfavorable cardiovascular events including death, myocardial infarction (MI), stroke/TIA, significant hemorrhage by BARC scale (Bleeding Academic Research Consortium). In-hospital mortality and incidence of MI, stroke/TIA were similar in all groups. However, there were no cardiovascular complications in patients with critical contralateral stenosis or occlusion. Bleeding followed by redo surgery was the most frequent complication. Overall incidence of adverse cardiovascular events did not exceed 1.23%. There was no correlation between contralateral ICA stenosis and incidence of in-hospital adverse events including death, MI, stroke/TIA. Currently, technique of CEE is well developed that is associated with low incidence of postoperative complications.

Very Early CEA Without Shunting for Stroke—The Preferred Therapy

There has been an evolution toward early carotid endarterectomy (CEA) after stroke, but there remains a reluctance to perform CEA earlier than 2 weeks. There has also historically been a bias toward shunting for previous stroke. This study analyzed the results of early CEA (<2 weeks) for stroke patients without shunting over a 12-year period to determine whether CEA earlier than 2 weeks after stroke was safe and whether a strategy of no shunting absent neuromonitoring changes was justified. A retrospective review of all CEA performed by a single surgeon over a 12-year period was performed. All patients with stroke were included except modified Rankin scale 6. The decision to shunt was based only on defined changes in continuous electroencephalography/somatosensory evoked potentials dynamics reflecting ischemia intraoperatively. Patient demographics, including age, degree of internal carotid artery (ICA) stenosis, preoperative neurologic symptoms, and medications were reviewed. Thirty-day outcomes were tabulated, including stroke, transient ischemic attack, death, and other major complications. A total of 432 patients (100 men [62.5%]) with a mean age of 69.4 years (range, 44-91 years) underwent 451 CEAs. There were 220 CEAs (49%) for symptomatic disease; of these, 183 had a documented stroke. CEA was performed within 72 hours in 162 stroke patients (88%) and within 5 days in the remaining 21 patients. Of the stroke cohort, mean pre-CEA modified Rankin scale was 3.8. One patient of this cohort had a new stroke (contralateral). The 72-hour perioperative stroke rate for the whole CEA group was 0.66% (3 of 451). The 30-day stroke, transient ischemic attack, and death rates were 5 (1.1%), 0 (0%), and 5 (1.1%), respectively. There was one intraoperative stroke, and the remainder of the four strokes occurred within 30 days. Early CEA for stroke (ie, <72 hours) can be performed safely without the need for shunting and does not increase postoperative stroke, morbidity, or mortality. Electroencephalography and somatosensory evoked potentials monitoring dramatically reduces the need to place a shunt during CEA. Recent stroke, contralateral ICA occlusion, or contralateral high-grade ICA stenosis are not an indication for intraoperative shunting. CEA for stroke is best done early, with no additional increase in perioperative stroke, thus shielding the patient from the early risk of recurrent stroke.

Relationships between 2-Year Survival, Costs, and Outcomes following Carotid Endarterectomy in Asymptomatic Patients in the Vascular Quality Initiative

Carotid endarterectomy (CEA) for asymptomatic patients with limited life expectancy may not be beneficial or cost-effective. The purpose of this study was to examine relationships among survival, outcomes, and costs within 2 years following CEA among asymptomatic patients. Prospectively collected data from 3097 patients undergoing CEA for asymptomatic disease from Vascular Quality Initiative VQI registry were linked to Medicare. Models were used to identify predictors of 2-year mortality following CEA. Patients were classified as low, medium, or high risk of death based on this model. Next, we examined costs related to cerebrovascular care, occurrence of stroke, rehospitalization, and reintervention within 2years following CEA across risk strata. Overall, 2-year mortality was 6.7%. Age, diabetes, smoking, congestive heart failure (CHF), chronic obstructive pulmonary disease, renal insufficiency, absence of statin use, and contralateral internal carotid artery (ICA) stenosis were independently associated with a higher risk of death following CEA. In-hospital costs averaged $7500 among patients defined as low risk for death, and exceeded $10,800 among high risk patients. Although long-term costs related to cerebrovascular disease were 2 times higher in patients deemed high risk for death compared with low risk patents ($17,800 vs. $8800, P=0.001), high risk of death was not independently associated with a high probability of high cost. Predictors of high cost at 2 years were severe contralateral ICA stenosis, dialysis dependence, and American Society for Anesthesia Class 4. Both statin use and CHF were protective of high cost. Greater than 90% of patients undergoing CEA live long enough to realize the benefits of their procedure. Moreover, the long-term costs are supported by the effectiveness of this procedure at all levels of patient risk.