Eversion Carotid Endarterectomy Research Articles

Patch angioplasty carotid endarterectomy versus eversion carotid endarterectomy.

To compare carotid endarterectomy patch angioplasty (p-CEA) with eversion carotid endarterectomy (e-CEA) and associated risks of early cardio-cerebrovascular complications. The study was a prospective randomized single-blind trial, monocentric, clinically applicable, descriptive analytical and comparative. From June 2021 to June 2023, 62 consecutive patients with symptomatic and asymptomatic stenosis of the internal carotid artery, admitted to our department and randomized into two groups: carotid endarterectomy with patch angioplasty and eversion carotid endarterectomy. Follow-up for 30 days after surgery. During surgery e-CEA, 70% patients had an arrhythmia, and 24 hours after 66.7%, seven days after 46.7% and month after 13.3%. During surgery p-CEA, 33.3% patients had an arrhythmia, 24 hours later 33.3%, 7 days after 13.3% and 30 days after 13.3% patients. Statistically significant difference observed during surgery (Fishers p=0.004). One day after the surgery rate of patients with arrhythmia that were treated e-CEA has decreased, but it was still higher than after p-CEA (Fishers p=0.010). The frequency and categorization of postoperative cardiac arrhythmias after eversion carotid endarterectomy, the clinical implications of various postoperative heart rhythm disturbances and their long-term effects on patients need to be further investigate through sufficiently powered randomized controlled studies.

Contemporary open surgical approaches for the management of carotid stenosis: a comprehensive review.

This study aims to provide an overview on contemporary open surgical approaches for the management of carotid artery stenosis. A comprehensive literature search was performed to identify and categorize open surgery intervention techniques for the management of carotid artery stenosis, focusing on the benefits and drawbacks of each technique. Five surgical techniques for carotid endarterectomy (CEA) have been described: CEA with primary closure, CEA with patch closure, CEA by eversion technique, CEA by modified eversion technique and CEA by partial eversion. Evidence has reported significantly higher rates of perioperative complications after CEA with primary closure, including 30-days stroke rate and late restenosis. Although more recent techniques have been reported to provide superior outcomes, electing the best surgical technique is still a matter of debate. Also, CEA using a mini-skin incision has been associated to lower risk of cranial/cervical nerve injury and shorter length of hospital stay. The selection of the surgical intervention should be tailored and have into consideration individual patient characteristics, clinical considerations, surgeon preference and surgical team expertise. Further large-scale randomized clinical trials are needed to support more robust decisions on the choice of contemporary open surgical approaches to manage carotid stenosis.

EVERSION CAROTID ENDARTERECTOMY IN A PATIENT WITH COMPLETE BLOCKAGE OF THE CAROTID ARTERIES (CLINICAL CASE)

We present a clinical case that reflects the effectiveness of eversion carotid endarterectomy in a patient with complete blockage of the carotid arteries. A 62 y.o. patient was admitted to the clinic with complaints of dizziness and syncopal events such as “blackouts” when turning his head to the side. Angiography revealed that the right external carotid artery is stenotic up to 85%, the internal one is up to 90%, and the circle of Willis is closed. Endarterectomy was performed from the common carotid, internal carotid and external carotid arteries, with their complete cutting off and subsequent plastic suturing, i.e. formation of a trifurcation anastomosis. As shown in control angiography, the patency of the carotid segment was completely restored, and there was no neurological deficit.

Bailout Distal Internal Carotid Artery Stenting after Carotid Endarterectomy: Indications, Technique, and Outcomes

Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. Six patients were identified during the study period. All were male with an age range of 63 to 82years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2days (range 1-7days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17months. Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.

Immediate and long-term results of eversion carotid endarterectomies

Objective. To study the immediate and long-term results of the new modified technique of eversion carotid endarterectomy (ECEAE). Material and method. The study involved 150 patients with 60–99% stenosis of the internal carotid artery (ICA) who were divided into 2 groups depending on the type of surgical treatment: Group1 (n=61) – patients underwent ECEAE according to the method developed by V.L. Sergeev et al.; Group 2 (n=89) – patients underwent ECEAE according to the method described by R. Kieny. The immediate and long-term results of the two ECEAE methods were evaluated. Results. In the immediate postoperative period, no advantages of any of the ECEAE methods were revealed. In the distant postoperative period, 24 (16.8%) patients died. The incidence of non-fatal ischemic stroke on the operation side was 0% in Group1 and 7,1% in Group 2; the incidence of ICA restenosis formation was 1,7 and 11,7% respectively (p<0,05); 34,6 and 10,4% of patients returned to their labor activity and the complete regression of complaints was achieved in 61,5 and 20,9% respectively. Conclusion. Thus, ECEAE according to the method V.L. Sergeev in the distant postoperative follow-up period showed its safety and efficacy and can be recommended for wider implementation in practical medicine.

Outcomes Following Carotid Endarterectomy with Patch Plasty Versus Eversion Technique: A Comparative Study of 5 Years of Experience

Background: Prompt carotid endarterectomy (CEA) for stroke prevention is still a cornerstone in the treatment of symptomatic carotid stenosis. CEA with patch plasty (CEPP) and eversion CEA (ECE) are two distinct surgical techniques widely used for the above. In this study, we have evaluated and compared the early outcomes of both techniques.

Novel Modified Eversion Carotid Endarterectomy for Patient With Carotid Artery Stenosis

Novel Modified Eversion Carotid Endarterectomy for Patient With Carotid Artery Stenosis

The comparison of the postoperative complications, mortality, and morbidity of the eversion technique and the classical technique in carotid endarterectomy

In the present study, the purpose was to compare the postoperative early and mid-term results of Eversion Carotid Endarterectomy (ECEA) and Classical Carotid Endarterectomy (CCEA) techniques used in the surgical treatment of carotid artery disease. A total of 269 patients who underwent carotid endarterectomy (105 ECEA and 164 CCEA) were included in the study. The 1st, 6th, and 12th-month follow-ups of 266 patients were performed because three patients died in the early postoperative period. All patients were started on acetylsalicylic acid, clopidogrel, and statin treatment in the postoperative period. When the postoperative results were evaluated, it was found that the cross-clamp and operation times of the surgeries performed with the ECEA technique were shorter than the CCEAat statistically significant levels (p=0.0002). Although there statistically significant differences were detected in terms of bleeding/drainage, need for reoperation because of bleeding, and restenosis, ECEA had more positive results than CCEA, and there were no statistically and proportionally significant differences between the two methods in terms of postoperative stroke and mortality. Considering the experience of the surgical team, the use of the ECEA technique has more positive results in terms of operation time and cross-clamp time compared to CCEA. We think that extending the follow-up periods of patients in the postoperative period and conducting multicenter studies with more patients would be more accurate in comparing these two methods.

History of Carotid Artery Reconstruction around the World and in Japan.

Since ancient times, physicians have been aware of correlations between the carotid artery and consciousness; however, carotid stenosis was only recently identified as the cause of atherothrombotic ischemic stroke. In 1658, Wepfer described the first suggestion of a link between symptoms of cerebral arterial insufficiency and carotid pathology. In 1951, Fisher reported details of the symptoms and pathological findings and emphasized that cervical atheromatous lesions induced cerebral infarction with various symptoms. The beginning of carotid artery surgery was ligation of the carotid artery for neck or head injury, but surgeons were aware that this operation induced cerebral symptoms due to lack of blood supply. Carotid endarterectomy (CEA) was first reported by Eastcott et al. in 1954, and in Japan, Kimoto performed a successful CEA in 1962. In 1979, percutaneous transluminal angioplasty (PTA) was performed for patients with fibromuscular dysplasia, and then, carotid artery stenting (CAS) was first performed in 1989 by Mathias. In Japan, Kuwana et al. were the first to perform carotid PTA, in 1981, whereas Yamashita et al. performed the first CAS in 1997. Yoshimura et al. proposed staged carotid stenting to prevent hyperperfusion syndrome. Some issues in carotid reconstruction are still debated today, which include conventional (standard) CEA versus the eversion technique, CEA versus CAS versus medical therapy, and medical economic problems. In the future, we must continue to develop more effective, safer, and less expensive therapeutic methods to prevent carotid stroke, carrying on the efforts of the ancient peoples who pioneered this research.

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

Carotid Artery Remodeling After Modified Eversion Carotid Endarterectomy

Modified eversion carotid endarterectomy (meCEA) is an alternative to classical patch angioplasty or eversion. An meCEA involves everting the carotid plaque through a longitudinal incision over the common carotid artery without transecting the internal carotid artery (ICA). Those who advocate patch angioplasty cite the propensity of luminal narrowing from the procedure or restenosis as a reason to avoid primary repair. We seek to objectively quantify the outcome of the carotid artery after primary repair of the longitudinal incision employed in this technique. We retrospectively reviewed all meCEAs performed at our institution and included those with preoperative and postoperative computerized tomography angiography. Pre- and postoperative centerline measurements, by two independent observers, were obtained at 1 cm and 2 cm proximal to the ICA ostium within the common carotid artery (CCA), the ICA ostium, and 1 cm and 2 cm distally within the ICA. The sum of the diameter changes at each segment was defined as the overall remodeling (OR). Segmental remodeling of the CCA and ICA (ICAR) were defined as the sum of the CCA and ICA changes, respectively. In total, 40 individual carotid arteries treated with meCEA with both pre- and postoperative computerized tomography angiographies (over a range of 0-1183 days) were included. On average, the ICA diameter increased by 5% at its ostium, 12.6% and 9.3% at 1 cm and 2 cm distal to its ostium, respectively. The CCA decreased in diameter, −8% and −3% at 1 cm and 2 cm proximal to the bifurcation, respectively. OR was −0.81 mm for the entire cohort, predominantly driven by remodeling of the CCA (−1.51 mm), whereas ICAR was favorable at +0.48 mm. Interestingly, female patients had more favorable remodeling overall, with less narrowing of the CCA (−0.96 mm vs −1.51 mm in male patients) and positive ICAR compared with preoperative imaging (+1.58 mm vs −0.25 mm in male patients). We found that postoperatively, despite a decreased segmental diameter of the CCA after meCEA, the ICA diameter remains largely intact and also remodels favorably over time. Our findings suggest that meCEA does not yield adverse narrowing of the ICA after primary repair or significant restenosis in this series. Although there may be a gender-related difference in OR, more evaluation is necessary.TablePostendarterectomy percent change in diameter of the common and internal carotid arteries at five locationsOverall cohort (N = 40)% change in diameterCCA 2 cm from bifurcation−3.3CCA 1 cm from bifurcation−8.2Ostial ICA+5.1ICA 1 cm from bifurcation+12.6ICA 2 cm from bifurcation+9.3Male (n = 24) CCA 2 cm from bifurcation−2.8 CCA 1 cm from bifurcation−9.4 Ostial ICA+1.0 ICA 1 cm from bifurcation+1.9 ICA 2 cm from bifurcation+5.5Female (n = 16) CCA 2 cm from bifurcation−4.1 CCA 1 cm from bifurcation−6.4 Ostial ICA+11.3 ICA 1 cm from bifurcation+28.7 ICA 2 cm from bifurcation+14.9CCA, Common carotid artery; ICA, internal carotid artery. Open table in a new tab

Bypass and other modified reconstruction techniques for 'challenging' carotid cases: A comparison with conventional endarterectomy.

Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA. A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis. A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed. Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues.

The Three Most Discussed Questions in Carotid Artery Surgery. Review of Russian and Foreign Studies in the Last Five Years

This literature review analyzes Russian and foreign publications over the past five years on the three most discussed issues related to carotid artery surgery: 1.Which is more effective: eversion carotid endarterectomy or conventional carotid endarterectomy with patch closure? 2. Which is better: carotid endarterectomy (CEE) or carotid angioplasty and stenting (CAS)? 3. How soon after the development of ischemic stroke should cerebral revascularization be performed? The authors of the article came to the following conclusions: 1. According to the majority of large studies and meta-analyses, conventional CEE with patch closure is associated with a higher risk of internal carotid artery restenosis compared to eversion carotid endarterectomy. Single-center trials with small samples of patients do not find statistical differences between the outcomes of applying both surgical techniques. 2. Large multicenter randomized trials are required to address the effectiveness of CEA and CAS in symptomatic and asymptomatic patients. To date, there has been no consensus on this matter. 3. CEE and CAS can be equally effective and safe in the most acute and acute periods of ischemic stroke when performed in the presence of a mild neurological deficit and the ischemic brain lesion not exceeding 2.5 cm in diameter. Nevertheless, the choice of treatment strategy should be made strictly personalized by a multidisciplinary council based on the experience of the institution and current recommendations.

Delirium in cardiac surgery: epidemiology, pathogenesis and prevention highlights (Review)

Symptomatic delirium of the early postoperative period is a qualitative disorder (clouding) of consciousness that is deferred, occurs under mainly vascular, inflammatory and metabolic alterations, manifests by variant behavioral disorders. Three clinical studies were conducted to assess the state of the brain after the most frequent elective cardiac surgery coronary bypass surgery, open-heart valve surgery, open-heart and endovascular aortic valve surgery. 306 patients were included in the listed studies, the controls included the results of the examination of 120 patients who underwent elective eversion carotid endarterectomy and 15 patients who underwent elective abdominal aortic prosthetics. Thus, 441 patients underwent perioperative neurological examination according to a single algorithm. According to the results of the conducted studies, the frequency of symptomatic delirium of the early postoperative period during elective cardiac surgery is 1214%. Symptomatic delirium of the early postoperative period commonly develops 13 days after surgery, the average duration is from 1 to 3 days. Symptomatic delirium of the early postoperative period also increases the likelihood of subsequent development of other clinical types of postoperative cerebral dysfunction perioperative stroke and deferred cognitive impairment. Most of the symptomatic delirium of the early postoperative period risk factors are preoperative and have vascular origin. Combined use of CAM-ICU and RASS scales is recommended for screening diagnostics of symptomatic delirium of the early postoperative period. The increase of the number of cardiac surgeries demonstrates the necessity of the further improvement of perioperative cerebroprotection, the main directions are promptly diagnosis and correction of risk factors, as well as the use of non-pharmacological and pharmacological methods of brain protection, including the original four-component (inosine, nicotinamide, riboflavin, succinic acid) neuroprotector with cytoprotective and antihypoxic effects, as well as meglumine sodium succinate with antihypoxic and anti-inflammatory effects.

Routine versus selective near-infrared spectroscopy-guided shunting during carotid eversion endarterectomy.

The aim of this study was to compare outcomes of routine shunting to near-infrared spectroscopy (NIRS)-guided shunting in patients undergoing eversion endarterectomy (EEA) under general anaesthesia. We retrospectively evaluated data of all patients undergoing EEA of the internal carotid artery (ICA) in our department from January 2011 until January 2019. Included were patients with EEA of the ICA and the patients were divided into 2 groups: selective-shunting group and routine-shunting group. Patients (i) with patch angioplasty during the surgery, (ii) undergoing surgery for restenosis and (ii) stenosis after radiation therapy, (iii) without recorded regional cerebral oxygen saturation trends, (iv) presenting with an emergency treatment indication and (v) operated upon by residents were excluded. In all patients, EEA was performed in general anaesthesia and under NIRS monitoring. One-to-one propensity score matching was used to compare EEA outcomes after routine shunting to NIRS-guided shunting. Primary end points were defined as perioperative stroke and in-hospital mortality after EEA. Routine and NIRS-guided selective shunting were applied in 340 (34.0%) and 661 (66.0%) patients, respectively. A total of 277 pairs were generated via propensity score matching. Fifty-eight (20.1%) from the selective-shunting group were intraoperatively shunted. Concomitant procedures were more frequently performed in the routine-shunting group [170 (61.4%) vs 47 (17.0%), 180 (65%) vs 101 (36.5%), and 60 (21.7%) vs 6 (2.2%), P < 0.001]. The perioperative stroke rate in the routine-shunting group was higher as well [11 (4.0%) vs 3 (1.1%), P = 0.022]. In-hospital death was overall 0.2% (n = 1). Multivariable logistic regression in the matched patient indicated age (odds ratio 1.050, 95% confidence interval 1.002-1.104, P = 0.046) and routine shunting (odds ratio 2.788, confidence interval 1.119-7.428, P = 0.032) as risk factors for perioperative stroke during EEA of the ICA. We found that, during EEA of the ICA, under general anaesthesia, NIRS-guided selective shunting was associated with a lower incidence of perioperative stroke than routine shunting.

Primary versus patching versus eversion as carotid endarterectomy closure.

The type of closure after carotid endarterectomy (CEA), whether with patching primary closure or eversion resulting optimal results, remains somewhat controversial. We conducted a PubMed literature review search comparing CEA with patching versus CEA with primary closure versus eversion CEA over the past four decades with emphasis on randomized controlled trials and systematic/meta-analysis and large single center or multicenter studies. The data showed that routine carotid patching can be recommended over primary closure (level 1 evidence); however, CEA with primary closure can be used for large internal carotid arteries (ICAs)>6 mm. Moreover, selective patching with CEA lacks level 1 evidence support. No significant differences were noted among the various patch materials used (e.g., synthetic patches like dacron, ACUSEAL, PTFE, pericardial patches and vein patches) and in the stroke/death rates between eversion carotid endarterectomy (ECEA) and conventional CEA (CCEA) with patching. In addition, no significant restenosis rates were noted between CEA with patching and ECEA; however, CEA with primary closure had higher late restenosis rates. There is level 1 evidence to support CEA with patching or eversion over primary closure and there is also no significant difference between the use of various patches.

Editor's Choice – Nationwide Outcome Analysis of Primary Carotid Endarterectomy in Symptomatic Patients Depending on Closure Technique and Patch Type

Current European guidelines recommend both eversion carotid endarterectomy (CEA) and conventional CEA with routine patch closure, rather than routine primary closure. Polyester and polytetrafluoroethylene (PTFE) have been used as patch material for a long time. More recently, bovine pericardium has been used; however, there are few studies comparing long term results between bovine pericardium and other patch types. The aim of this study was to investigate the short and long term results after CEA depending on surgical technique and patch material. A registry based study on all primary CEAs (n= 9 205) performed for symptomatic carotid artery stenosis in Sweden from July 2008 to December 2019, cross linked with data from the Swedish stroke registry, Riksstroke, and chart review for evaluation of any events occurring during follow up. The primary endpoint was ipsilateral stroke < 30 days. Secondary endpoints included re-operations due to neck haematoma and < 30 day ipsilateral stroke, > 30 day ipsilateral stroke, all stroke > 30 days, and all cause mortality. 2 495 patients underwent eversion CEA and 6 710 conventional CEA for symptomatic carotid stenosis. The most commonly used patch material was Dacron (n= 3 921), followed by PTFE (n= 588) and bovine pericardium (n= 413). A total of 1 788 patients underwent conventional CEA with primary closure. Two hundred and seventy-three patients (3.0%) had a stroke < 30 days. Primary closure was associated with an increased risk of ipsilateral stroke and stroke or death <30 days: odds ratio 1.7 (95% confidence interval [CI] 1.2 - 2.4, p= .002); and 1.5 (95% CI 1.2 - 2.0), respectively. During follow up (median 4.2 years), 592 patients had any form of stroke and 1 492 died. There was no significant difference in long term risk of ipsilateral stroke, all stroke, or death depending on surgical technique or patch material. There was an increased risk of ipsilateral stroke < 30 days in patients operated on with primary closure compared with eversion CEA and patch angioplasty. There was no difference between primary closure, different patch types, or eversion after the peri-operative phase.

Comparison of eversion carotid endarterectomy under local anesthesia and eversion/conventional carotid endarterectomy under general anesthesia.

Studies searching outcomes of eversion carotid endarterectomy (E-CEA) under local anesthesia are lacking. To evaluate the postoperative outcomes of E-CEA under local anesthesia and compare it with E-CEA/Conventional CEA under general anesthesia in symptomatic or asymptomatic patients. From February 2010 to November 2018 a total of 182 patients (143 males, 39 females; mean age: 69.69 ±9.88 years; range: 47 to 92 years) who underwent eversion CEA or conventional CEA with patchplasty under general or local anesthesia in two tertiary centers were included in this study. Overall in-hospital stay (p = 0.01), postoperative in-hospital stay (p = 0.022) took significantly less time in favor of E-CEA under local anesthesia. Overall, 6 patients developed major stroke (3.2%), among them 4 (2.1%) patients passed away, 7 (3.8%) patients developed cranial nerve injury (the marginal mandibular branch of the facial nerve and hypoglossal nerve), 10 (5.4%) patients developed a hematoma in the postoperative period. No difference was found in terms of postoperative stroke (p = 0.470), postoperative death (p = 0.703), postoperative bleeding rate (p = 0.521) or postoperative cranial nerve injury (p = 0.481) between the groups. The mean operation time, postoperative in-hospital stay, overall in-hospital stay, and need for shunting were lower in patients who underwent E-CEA under local anesthesia. E-CEA under local anesthesia seemed to do better in stroke, death, and bleeding rate, however, this difference was not significant.

POSTOPERATIVE COGNITIVE DISORDERS IN PATIENTS UNDER CAROTID ENDARTERECTOMY

Evaluation of the impact of carotid endarterectomy on the cognitive status of patients remains debatable, since patients with atherosclerotic lesions of the carotid arteries suffer from chronic cerebrovascular insufficiency, and changes in the cognitive status of patients after carotid endarterectomy may be due to factors such as increased blood supply to the brain, microembolism after the start of blood flow, and cerebral ischemia during cross-clamping and also the effect of various anesthesia drugs on the cognitive status in these patients is ambiguous.Purpose. To assess age-related changes in cognitive status in patients with atherosclerotic lesions of the carotid arteries in the postoperative periodMaterial and methods. Neuropsychological testing was performed in 128 patients after eversion carotid endarterectomy, divided into age groups and depending on the methods of anesthesia: Propofol group and Sevoflurane group.Results. In patients under the age of 60 years, there is an improvement in cognitive status in the early and late postoperative period, while in patients of the older age group, there is a slowdown in the progression of cognitive dysfunction in both groups of anesthesia.Conclusion. An important criterion for evaluating the surgical prevention of cerebrovascular accidents is clinical effectiveness, in particular, the impact of operations and anesthesia methods on the cognitive sphere of patients of different ages with pathology of the main arteries of the head, which determines the quality of life not only for patients, but also for relatives.

Prospective Observational Study after Eversion Carotid Endarterectomy with Ultrasound-Guided Deep-Intermediate Cervical Plexus Blockade.

(1) Introduction: The aim was to describe the anesthetic and surgical technique of eversion carotid endarterectomy performed under intermediate-deep cervical block with sedation, and to analyze the intraoperative and postoperative results. (2) Material and Methods: Thirty cases of unilateral eversion carotid endarterectomy (n = 30), performed between 2019–2020 in a tertiary center under intermediate-deep ultrasound-guided cervical plexus block and sedation, were prospectively observed and analyzed. Hemodynamic (blood pressure, heart rate) and neurological (cerebral oximetry) variables were measured in four intraoperative phases: at the beginning of the operation, prior to carotid clamping, after unclamping and at the end of the operation. We assessed acute postoperative pain in a numerical rating scale at 6, 12 and 24 h, early and 30-day complications, and length of stay. (3) Results: Baseline mean arterial pressure values were 100.4 ± 18 mmHg, pre-clamping 95.8 ± 14 mmHg, post-clamping 94.9 ± 11 mmHg, and at the end of the operation 102.4 ± 16 mmHg. Cerebral oximetry values were 61.7 ± 7/62.7 ± 8, 68.5 ± 9.6/69.1 ± 11.7 and 68.1 ± 10/68.1 ± 10 for the left and right hemispheres at baseline, pre- and post-clamping, respectively. The pain assessment showed a score less than or equal to 3. The incidence of residual nerve block, early complications, and major complications in the first 30 days was 40%, 16.7% and 3.3%, respectively. (4) Conclusions: The combination of intermediate-deep cervical plexus block and low-dose sedation is an effective and safe alternative in awake eversion carotid endarterectomy.