Results Of Carotid Endarterectomy Research Articles

Association Between Hospital Policy on Local Versus General Anesthesia, and Outcomes of Carotid Endarterectomy

BACKGROUND Carotid endarterectomy (CEA) is an established procedure for the treatment of extracranial internal carotid artery stenosis. However, the type of anesthesia during elective CEA is still under debate. This study analyzes the association between the hospital policy on local anesthesia (LA) versus general anesthesia, and the outcome of elective CEA in German hospitals. METHODS This retrospective analysis is based on the nationwide German statutory carotid quality assurance database for the years 2012 to 2016. Research was funded by Germany's Federal Joint Committee Innovation Fund (funding reference number 01VSF19016). Emergency CEA and carotid stenting procedures were excluded from the analysis. A total of 119 800 patients remained in the analysis. Hospitals were classified on a yearly basis as routine general anesthesia (<10% LA), selective LA (10%–90% LA), or routine LA centers (>90% LA). The primary outcome event was the combined in‐hospital rate of stroke or death. Secondary outcome events were in‐hospital stroke, major stroke or death, death, myocardial infarction, and major adverse cardiovascular events. Univariate and multivariable regression analyses were performed to analyze associations between the primary outcome event and the hospital policy on LA versus general anesthesia as well as clinical or procedural variables. RESULTS Patient characteristics did not differ significantly between the groups (age, degree of stenosis, and rate of symptomatic patients). Raw primary outcome event rates were 1.9%, 2.1%, and 1.6% in routine general anesthesia, selective LA, and routine LA centers, respectively. Multivariable analysis revealed a significant lower rate of the primary outcome event for CEA operated under LA (adjusted odds ratio, 0.47 [95% CI, 0.33–0.67]; P <0.001). Stratified multivariable analysis revealed that the beneficial effect of LA was only present in routine LA centers. CONCLUSION LA is associated with a lower risk of in‐hospital stroke or death after CEA in centers that use LA routinely.

Comparing the Surgical Outcomes of Carotid Endarterectomy: Assessing the Impact of Consultant versus Trainee Cases on Patient Care and Surgical Training

ObjectiveThis study assesses the impact of having a surgical trainee performing a carotid endarterectomy procedure on the post-operative rates of stroke and death. DesignObservational Retrospective study MethodsConsecutive patients, who underwent carotid endarterectomy between 01/05/2016 and 31/7/2022, were entered into a retrospectively collected database. Patients were stratified into two categories – consultant-led cases and trainees-led cases. Primary outcomes were 30- day stroke rate, and 30-day morbimortality. A sub analysis was performed after grouping the patients in whether there was a neurological event in the previous six months – symptomatic or asymptomatic. Results/ConclusionsTrainees-led cases had significantly longer clamping times and higher rates of stroke in asymptomatic patients compared with consultant-led cases. Patient’s safety should be our top priority. Any practice leading to a significantly increased rate of post-operative stroke must be discontinued. Training protocols and adequate supervision must ensure that trainees possess the necessary skills and knowledge to safely and effectively perform carotid endarterectomy (CEA) procedures, thereby prioritizing patient safety.

Improvement of rest pain in a patient with symptomatic peripheral artery disease as an unexpected outcome of carotid endarterectomy: A case report

Improvement of rest pain in a patient with symptomatic peripheral artery disease as an unexpected outcome of carotid endarterectomy: A case report

Carotid endarterectomy outcomes according to anesthesia method: General anesthesia or regional anesthesia?

Aim: Surgical strategies in carotid endarterectomy (CEA) vary according to the method of anesthesia, neurological monitoring, shunt use, and closure methods, and the gold standard method has not yet been determined. In this study, we aimed to analyze the superiority and feasibility of CEA under general anesthesia and regional anesthesia. Material and Methods: Demographic characteristics, operative information and follow-up results of 237 patients who underwent CEA between January 2015 and June 2020, 165 patients under regional anesthesia (RA: Group 1) and 72 under general anesthesia (GA: Group 2), were retrospectively analyzed. In Group 1, carotid shunt was placed in patients with a negative awake test (n: 21, 12.7%) and in Group 2 carotid shunt was placed in all cases. Results: There was no statistically significant difference in postoperative stroke, transient ischemic attack (TIA) and cardiovascular mortality (p: 0.48; p: 0.30; p: 0.63, respectively). Although the operation and clamp time were shorter in Group 1, no significant difference was observed (97.93±11.02 min, 101.46±9.49 min p: 0.23; 19.60±5.62 min, 25.62±7.47 min p: 0.24, respectively). The duration of intensive care unit (ICU) stay was shorter and statistically significant in Group 1. (p: 0.003). There was no significant difference for restenosis rates (p: 0.34). Conclusion: There was no significant increase in postoperative complications in the RA group compared to the GA group despite shunting according to the awake test. Also, patients who underwent RA stayed in ICU for a shorter period of time. CEA can be performed under both GA and RA with similar complication rates.

Determinants of Pre- and Post-Procedural Neurological Assessment, and Outcome of Carotid Endarterectomy or Stenting.

Background: The German-Austrian guideline on the treatment of carotid stenosis recommends specialist neurological assessment (NA) before and after carotid endarterectomy (CEA) or carotid artery stenting (CAS). This study analyzes the determinants of NA and the association of NA with the perioperative rate of stroke or death. Materials and Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the nationwide German statutory quality assurance carotid database. Patients were classified as asymptomatic (group A), elective symptomatic (group B), and others (group C: emergency (C1), simultaneous operation (C2), and other indications (C3)). The primary outcome event (POE) of this study was any in-hospital stroke or death. Adjusted odds ratios for pre- and post-NA and the POE were calculated using multivariable regression analyses. Results: We analyzed 228,133 patients (54% asymptomatic, 68% male, mean age 72 years) undergoing CEA or CAS between 2012 and 2018. Age and sex were not associated with the likelihood of pre-NA or post-NA. The multivariable regression analysis showed an inverse association between pre-NA and POE (adjusted odds ratio (aOR) 0.47; 95% CI 0.44-0.51, p < 0.001), and a direct association of post-NA and POE (aOR 4.39; 95% CI 4.04-4.78, p < 0.001). Conclusions: Pre- and postinterventional specialist NA is strongly associated with the risk of any in-hospital stroke or death after CEA or CAS in Germany. A relevant confounding by indication or reversed causation cannot be ruled out. Nevertheless, to improve the quality assurance of treatment, the NA recommended in the guideline should be carried out consistently.

Optimizing Treatment of Significant Carotid Artery Stenosis in Times of Logistic Restraints as a Result of COVID-19 Pandemic

BackgroundCOVID-19 confronted medical care with many challenges. During the pandemic, several resources were limited resulting in renouncing or postponing medical care like carotid endarterectomy (CEA) for patients with significant carotid artery stenosis. Although according to international guidelines CEA is the first choice, carotid artery stenting (CAS) could potentially be a reasonable alternative especially during logistical restraints. PurposeTo evaluate outcomes of CAS versus CEA before, during and after the COVID-19 pandemic. Our hypothesis was that a CAS first approach yielded comparable outcomes compared to a CEA first approach. MethodsRetrospective analysis of consecutive patients with significant carotid artery stenosis treated with CEA or CAS between September 2018 and March 2023. Each consecutive period of 1.5 year marked a new (treatment) period: pre-COVID (CEA first strategy), during COVID (CAS first strategy) and post COVID (patient tailored approach). Primary outcome was the composite endpoint of stroke, TIA or death within 30 days. Secondary outcome consisted of the rate of technical success, cerebral hyperperfusion syndrome, myocardial infarction or other cardiac complications needing intervention, bleeding of the surgical site needing intervention, nerve palsy, unintended IC admission, pseudoaneurysm, restenosis or occlusion. ResultsA total of 318 patients were included. Out of 137 patients treated with CEA, 55, 36 and 46 were treated pre-COVID, during COVID and post-COVID, respectively. Out of 181 CAS procedures, 38, 59 and 84, respectively, were performed in each time period. Primary outcome occurred in 5.5%, 0% and 2.2% in the CEA group and 0%, 1.7% and 3.6% in the CAS group (p = .27; p = 1.00; p = 1.00, respectively). Overall technical success was 100% for CEA and 99.4% for CAS (p = 1.00). Rate of restenosis was the only secondary outcome measure which was significantly better after CAS compared to CEA in the pre- and post-COVID period (CEA vs CAS, 12.7% vs 7.9% and 23.9% vs 4.8% with a p-value of .03 and .03, respectively). Hospital presentation to treatment interval did not differ significantly during the pandemic. ConclusionOutcomes were comparable between CAS versus CEA in patients with significant carotid artery stenosis before, during and after the COVID-19 pandemic. CAS showed better results in terms of other complications (i.e., restenosis rate) in the pre- and post-COVID period compared to CEA. Our results may support a CAS first approach when no relevant contra-indications exist without exposing the patient to complications associated with an open surgical approach. Discussion in a multidisciplinary team is advised.

In Patients with Heart Failure Undergoing Carotid Endarterectomy, Locoregional Anesthesia is Not Associated with Decreased Mortality, Stroke, or Myocardial Infarction Compared to General Anesthesia

ObjectiveWhile existing literature reports no benefit of locoregional anesthesia (LRA) over general anesthesia (GA) in patients undergoing carotid endarterectomy (CEA), the effect of LRA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this population. MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005-2022 and the procedural targeted ACS-NSQIP database for CEA between 2011-2022, all patients receiving CEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer’s exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. Mortality, stroke, myocardial infarction (MI), and major adverse cardiac events (MACE) were compared between patients receiving general anesthesia (GA) and locoregional anesthesia (LRA) using univariate analysis. ResultsA total of 3,040 patients (2,733 undergoing GA, 307 undergoing LRA) with a diagnosis of CHF undergoing CEA were identified. No difference in mortality (GA 3.1% vs LRA 4.6%, p=0.162), MI (GA 3.0% vs LRA 2.3%, p=0.478), stroke (2.4% vs 2.6%, p=0.805) or MACE (GA 7.4% vs LRA 8.1%, p=0.654) was observed. LRA patients had a significantly lower hospital stay compared to GA patients (1 day [IQR 1-3] vs 2 days [IQR 1-4], p<0.001). Shunt was more commonly used in patients receiving GA (32.9% vs 12.5%, p<0.001) compared to LRA. ConclusionWhile utilizing LRA compared to GA during carotid endarterectomy in patients with CHF is associated with a shorter hospital stay and less intraoperative shunting, the choice of anesthesia did not impact the outcomes of mortality, MI or stroke. Further research is needed to determine the effect of LRA on the outcomes of CEA among patients with different stages of heart failure.

Association Between Ambulatory Status and Outcomes of Carotid Endarterectomy

Association Between Ambulatory Status and Outcomes of Carotid Endarterectomy

30-day Outcomes of Carotid Endarterectomy in Patients With Chronic Obstructive Pulmonary Disease

30-day Outcomes of Carotid Endarterectomy in Patients With Chronic Obstructive Pulmonary Disease

Association between hospital ownership and patient selection, management, and outcomes after carotid endarterectomy or carotid artery stenting

BackgroundThis study analyses the association between hospital ownership and patient selection, treatment, and outcome of carotid endarterectomy (CEA) or carotid artery stenting (CAS).MethodsThe analysis is based on the Bavarian subset of the nationwide German statutory quality assurance database. All patients receiving CEA or CAS for carotid artery stenosis between 2014 and 2018 were included. Hospitals were subdivided into four groups: university hospitals, public hospitals, hospitals owned by charitable organizations, and private hospitals. The primary outcome was any stroke or death until discharge from hospital. Research was funded by Germany’s Federal Joint Committee Innovation Fund (01VSF19016 ISAR-IQ).ResultsIn total, 22,446 patients were included. The majority of patients were treated in public hospitals (62%), followed by private hospitals (17%), university hospitals (16%), and hospitals under charitable ownership (6%). Two thirds of patients were male (68%), and the median age was 72 years. CAS was most often applied in university hospitals (25%) and most rarely used in private hospitals (9%). Compared to university hospitals, patients in private hospitals were more likely asymptomatic (65% vs. 49%). In asymptomatic patients, the risk of stroke or death was 1.3% in university hospitals, 1.5% in public hospitals, 1.0% in hospitals of charitable owners, and 1.2% in private hospitals. In symptomatic patients, these figures were 3.0%, 2.5%, 3.4%, and 1.2% respectively. Univariate analysis revealed no statistically significant differences between hospital groups. In the multivariable analysis, compared to university hospitals, the odds ratio of stroke or death in asymptomatic patients treated by CEA was significantly lower in charitable hospitals (OR 0.19 [95%-CI 0.07–0.56, p = 0.002]) and private hospitals (OR 0.47 [95%-CI 0.23–0.98, p = 0.043]). In symptomatic patients (elective treatment, CEA), patients treated in private or public hospitals showed a significantly lower odds ratio compared to university hospitals (0.36 [95%-CI 0.17–0.72, p = 0.004] and 0.65 [95%-CI 0.42-1.00, p = 0.048], respectively).ConclusionsHospital ownership was related to patient selection and treatment, but not generally to outcomes. The lower risk of stroke or death in the subgroup of electively treated patients in private hospitals might be due to the right timing, the choice of treatment modality or actually to better structural and process quality.

Outcomes of carotid endarterectomy: Insights from a single-center retrospective cohort study.

To analyze the outcomes of carotid endarterectomy in individuals with carotid artery stenosis in the context of a tertiary care center. We carried out a retrospective cohort investigation between 2015-2022. Patient data includes demographics, risk factors, preoperative medications, and operative details. The primary outcomes were 30-day postoperative stroke and mortality rates, while the secondary outcome of the study was to assess the morbidity of the procedure. The mean age of the 54 patients was 66.9±9.88 years, and 57.4% were men. The 30-day stroke rate was 3.7%, and the mortality rate was 1.9%. Most patients did not develop postoperative complications; however, surgical site hematoma was the most common complication encountered (12.9%). Long-term follow-up showed disease regression in 68.5% of patients, with a minority of patients developing ipsilateral restenosis. Admission to an intensive care monitoring unit was the only independent predictor of postoperative complications. This study provided insights into the outcomes of carotid endarterectomy in patients with carotid artery stenosis, emphasizing the importance of careful patient selection and postoperative monitoring. Perioperative risks, including stroke and mortality, were within acceptable limits. Further research incorporating structured and non-structured data for predictive analyses, should explore refining patient profiling and optimizing treatment approaches for different carotid artery stenosis clinical and morphological presentations.

Thirty-day outcomes of carotid endarterectomy versus carotid artery stenting in asymptomatic and symptomatic patients: a propensity score-matched analysis.

Technological and surgical approaches to carotid artery stenting (CAS) have evolved. Modern randomised controlled trials comparing CAS and carotid endarterectomy (CEA) are limited, and information about updated post-intervention outcomes are mostly from retrospective, small studies. This study aims to compare the 30-day outcomes of stroke, transient ischaemic attack (TIA), acute myocardial infarction (AMI) and death with propensity-matched groups of CEA and CAS in asymptomatic and symptomatic patients over a recent study period of new CAS technologies and approaches. A retrospective, observational, multicentre analysis was conducted including consecutive symptomatic and asymptomatic patients treated with either primary CEA or CAS for internal carotid artery stenosis, between 2015 and 2022. Patients were propensity score-matched based on comorbidities and assessed according to symptom status. Primary endpoints include composite ipsilateral stroke, TIA, AMI and death within 30 days. Secondary endpoints include technical success and length of hospital stay. From a cohort of 1,110 patients, propensity matching produced 269 distinct treatment pairs (n=538). Most patients were asymptomatic (n=456, 85%). All 6 strokes were minor (CEA=2; CAS=4) and registered among asymptomatic patients. One AMI (CEA) and 1 patient death (CAS) were reported among symptomatic patients. Composite stroke/AMI/death were not significantly different between both types of symptom status and both revascularisation techniques (p=0.44 and p=1, respectively). Technical success was 100%. The length of hospital stay was significantly shorter in asymptomatic patients treated with CAS compared to those treated with CEA (p=0.05), but no difference was registered among symptomatic patients (p=0.32). Propensity-matched analysis suggests that CAS has similar postprocedural outcomes for stroke, AMI and death at 30 days compared to CEA.

Intraoperative Completion Studies and their Associations with Carotid Endarterectomy Outcomes.

This study aimed at assessing outcomes after carotid endarterectomy (CEA) in dependence of center policy with respect to imaging intraoperative completion study (ICSi) usage. Although randomized controlled studies are missing, a beneficial effect was shown for ICSi techniques (i.e., angiography and intraoperative duplex ultrasound) after CEA. This secondary data analysis is based on the German statutory quality assurance database. Research was funded by Germany's Federal Joint Committee Innovation Fund (G-BA Innovationsfonds, 01VSF19016 ISAR-IQ). According to their ICSi policy, hospitals were categorized as routine ICSi (>90%), selective ICSi (10-90%), or sporadic ICSi (<10%) centers. Primary study outcome was in-hospital stroke or death. Multivariable regression analyses were performed. Between 2012 and 2016, a total of 119,800 patients underwent CEA. In-hospital stroke or death rates were lower in routine ICSicenters (1.7%) compared to selective (2.1%) and sporadic ICSicenters (2.0%). The multivariable regression analysis showed, that in routine ICSicenters, ICSi use was associated with lower rates of stroke or death (aOR 0.64; 95% CI 0.44-0.93). In selective ICSicenters, ICSi was not associated with the occurrence of either of the assessed outcomes. In sporadic ICSicenters, ICSi was associated with higher rates of stroke or death (aOR 1.91; 95% CI 1.26-2.91). Lowest in-hospital stroke or death rates are achieved in routine ICSicenters. While ICSi is associated with a lower perioperative risk in routine ICSicenters, it might act as a surrogate marker for worse outcomes due to intraoperative irregularities in sporadic ICSicenters. Routine use of ICSi is advisable.

The 5-Factor Modified Frailty Index is a Concise and Effective Predictor of 30-Day Adverse Outcomes in Carotid Endarterectomy

IntroductionFrailty is a clinically identifiable condition characterized by heightened vulnerability. The 5-item Modified Frailty Index provides a concise calculation of frailty that has proven effective in predicting adverse perioperative outcomes across a variety of surgical disciplines. However, there is a paucity of research examining the validity of 11-item Modified Frailty Index (mFI-5) in carotid endarterectomy (CEA). This study aimed to investigate the association between mFI-5 and 30-day outcomes of CEA. MethodsPatients underwent CEA were identified from American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2021. Patients with age<18 were excluded. Patients were stratified into four cohorts based on their mFI-5 scores: 0, 1, 2, or 3+. Multivariable logistic regression was used to compare 30-day perioperative outcomes adjusting for preoperative variables with P value<0.1. ResultsCompared to controls (mFI-5 = 0), patients mFI-5 = 1 had higher risk of stroke (adjusted odds ratio [aOR] = 1.333, P = 0.02), unplanned operation (aOR = 1.38, P < 0.01), and length of stay (LOS) > 7 days (aOR = 0.814, P < 0.01). Patients with mFI-5 = 2 had higher stroke (aOR = 1.719, P < 0.01), major adverse cardiovascular events (MACE) (aOR = 1.315, P = 0.01), sepsis (aOR = 2.243, P = 0.01), discharge not to home (aOR = 1.200, P < 0.01), 30-day readmission (aOR = 1.405, P < 0.01). Compared with controls, patients with mFI-5≥3 had higher mortality (aOR = 1.997 P = 0.02), MACE (aOR = 1.445, P = 0.03), cardiac complications (aOR = 1.901, P < 0.01), pulmonary events (aOR = 2.196, P < 0.01), sepsis (aOR = 3.65, P < 0.01), restenosis (aOR = 2.606, P = 0.02), unplanned operation (aOR = 1.69, P < 0.01), LOS>7 days (aOR = 1.425, P < 0.01), discharge not to home (aOR = 2.127, P < 0.01), and 30-day readmission (aOR = 2.427, P < 0.01). ConclusionsThe mFI-5 is associated with 30-day mortality and complications including stroke, MACE, cardiac complications, pulmonary complications, sepsis, and restenosis. Additionally, elevated mFI-5 scores correlate with an increased likelihood of unplanned operations, extended LOS, discharge to facilities other than home, and 30-day readmissions, all of which could negatively impact long-term prognosis. Therefore, mFI-5 can serve as a concise yet effective metric of frailty in patients undergoing CEA.

Clinical outcomes of transcarotid artery revascularization vs carotid endarterectomy from a large single-center experience

BackgroundTranscarotid artery revascularization (TCAR) has been practiced as an alternative for both carotid endarterectomy (CEA) and transfemoral carotid artery stenting, specifically in high-risk patients. More recently, the Centers for Medicare and Medicaid Services expanded coverage for TCAR in standard surgical risk patients if done within the Society for Vascular Surgery Vascular Quality Initiative TCAR surveillance project. A few registry studies (primarily from the Society for Vascular Surgery Vascular Quality Initiative) compared the early and up to 1-year outcomes of TCAR vs CEA or transfemoral carotid artery stenting. There is no large single-center study that reported late clinical outcomes. The present study compares intermediate clinical outcomes of TCAR vs CEA. MethodsThis study retrospectively analyzed collected data from TCAR surveillance project patients enrolled in our institution and compare it with CEA patients done by the same providers at the same time period. The primary outcome was combined perioperative stroke/death and late stroke/death. Secondary outcomes included combined stroke, death, and myocardial infarction, cranial nerve injury (CNI), and bleeding. Propensity matching was done to analyze outcome. Kaplan-Meier analysis was used to estimate freedom from stroke, stroke/death, and ≥50% and ≥80% restenosis. ResultsWe analyzed 646 procedures (637 patients) (404 CEA, 242 TCAR). There was no significant difference in the indications for carotid intervention. However, TCAR patients had more high-risk criteria, including hypertension, coronary artery disease, congestive heart failure, and renal failure. There was no significant differences between CEA vs TCAR in 30-day perioperative stroke (1% vs 2%), stroke/death rate (1% vs 3%; P = .0849), or major hematomas (2% vs 2%). The rate of CNI was significantly different (5% for CEA vs 1% for TCAR; P = .0138). At late follow-up (2 years), the rate of stroke was 1% vs 4% (P = .0273), stroke/death 8% vs 15% (P = .008), ≥80 % restenosis 0.5% vs 3% (P = .0139) for CEA patients vs TCAR patients, respectively. After matching 242 CEAs and 242 TCARs, the perioperative stroke rate was 1% for CEA vs 2% for TCAR (P = .5037), the stroke/death rate was 2% vs 3% (P = .2423), and the CNI rate was 3% vs 1% (P = .127). At late follow-up, rates of stroke were 1% for CEA vs 4% for TCAR (P = .0615) and stroke/death were 8% vs 15% (P = .0345). The rate of ≥80% restenosis was 0.9% for CEA vs 3% for TCAR (P = .099). The rates of freedom from stroke at 6, 12, 18, and 24 months for CEA vs TCAR were 99%, 99%, 99%, and 99% vs 97%, 95%, 93% and 93%, respectively (P = .0806); stroke/death were 94%, 90%, 87%, and 86% vs 93%, 87%, 76%, and 75%, respectively (P = .0529); and ≥80% restenosis were 100%, 99%, 98%, and 98% vs 97%, 95%, 93%, and 93%, respectively (P = .1132). ConclusionsIn a propensity-matched analysis, both CEA and TCAR have similar perioperative clinical outcomes. However, CEA was superior to TCAR for the rates of late stroke/death and had a somewhat lower rate of ≥80% restenosis at 2 years, but this difference was not statistically significant.

Carotid artery revascularization using second generation stents versus surgery: a meta-analysis of clinical outcomes.

Meta-analyses and emerging randomized data indicate that second-generation ('mesh') carotid stents (SGS) may improve outcomes versus conventional (single-layer) stents but clinically-relevant differences in individual SGS-type performance have been identified. No comparisons exist for SGS versus carotid endarterectomy (CEA). Thirty-day death (D), stroke (S), myocardial infarction (M), and 12-month ipsilateral stroke and restenosis in SGS studies were meta-analyzed (random effect model) against CEA outcomes. Eligible studies were identified through PubMed/EMBASE/COCHRANE. Forest plots were formed for absolute adverse evet risk in individual studies and for relative outcomes with each SGS deign versus contemporary CEA outcomes as reference. Meta-regression was performed to identify potential modifiers of treatment modality effect. Data were extracted from 103,642 patients in 25 studies (14 SGS-treated, 41% symptomatic; nine randomized controlled trial (RCT)-CEA-treated, 37% symptomatic; and two Vascular Quality Initiative (VQI)-CEA-treated, 23% symptomatic). Casper/Roadsaver and CGuard significantly reduced DSM versus RCT-CEA (-2.70% and -2.95%, P<0.001 for both) and versus VQI-CEA (-1.11% and -1.36%, P<0.001 for both). Gore stent 30-day DSM was similar to RCT-CEA (P=0.581) but increased against VQI-CEA (+2.38%, P=0.033). At 12 months, Casper/Roadsaver ipsilateral stroke rate was lower than RCT-CEA (-0.75%, P=0.026) and similar to VQI-CEA (P=0.584). Restenosis with Casper/Roadsaver was +4.18% vs. RCT-CEA and +4.83% vs. VQI-CEA (P=0.005, P<0.001). CGuard 12-month ipsilateral stroke rate was similar to VQI-CEA (P=0.850) and reduced versus RCT-CEA (-0.63%, P=0.030); restenosis was reduced respectively by -0.26% and -0.63% (P=0.033, P<0.001). Twelve-month Gore stent outcomes were overall inferior to surgery. Meta-analytic integration of available clinical data indicates: 1) reduction in stroke but increased restenosis rate with Casper/Roadsaver, and 2) reduction in both stroke and restenosis with CGuard MicroNET-covered stent against contemporary CEA outcomes at 30 days and 12 months used as a reference. This may inform clinical practice in anticipation of large-scale randomized trials powered for low clinical event rates (PROSPERO-CRD42022339789).

Outcomes of carotid endarterectomy in octogenarians compared to their younger counterparts: a retrospective observational study.

This study was performed to analyze the association between age and outcomes of carotid endarterectomy (CEA) by comparing postoperative outcomes between octogenarians and younger patients. From November 1994 to December 2022, 1,585 internal carotid arteries of 1,434 patients were enrolled. Patients were stratified into 2 groups: octogenarians (≥80 years old) and non-octogenarians (<80 years old). Primary endpoints were early (≤30 days) outcomes of ipsilateral stroke, any stroke, myocardial infarction, death, and major adverse cardiovascular events (MACE). We also compared overall any stroke and death between the 2 groups. One of 132 octogenarians (0.8%) and 17 of 1,453 non-octogenarians (1.1%) experienced ipsilateral stroke within 30 days. Thirty-day MACE occurred in 4 of 132 octogenarians (3%) and 44 of 1,453 non-octogenarians (3%). There were no significant differences in any early (≤30 days) outcomes. Symptomatic status was associated with increased 30-day MACE (odds ratio [OR], 2.610; 95% confidence interval [CI], 1.450-4.696; P = 0.003) and 30-day any stroke (OR, 3.999; 95% CI, 1.627-9.828; P = 0.003). Symptomatic status was also associated with overall any stroke (hazard ratio [HR], 2.885; 95% CI, 1.865-4.463; P < 0.001), but age of ≥80 years was not associated with 30-day MACE, 30-day any stroke, or overall stroke. Age of ≥80 years was only associated with overall survival (HR, 2.644; 95% CI, 1.967-3.555; P < 0.001). CEA would be a safe and effective treatment for octogenarians with low 30-day complications and long-term stroke rates, comparable with that of younger counterparts. Advanced age is not a contraindication for CEA.

Outcome of carotid endarterectomy in patients with symptomatic carotid near occlusion with partial collapse

Background Symptomatic carotid near occlusion with partial collapse (CNOPC) of the distal internal carotid artery (ICA) is an uncommon condition. Guidelines for its treatment have recommended conservative management, although surgery may be indicated for many patients. In this work, our goal was to examine the postoperative outcomes of CNOPC patients who had undergone carotid endarterectomy (CEA) for symptomatic disease. Methods Symptomatic CNOPC patients were identified in this single-center retrospective study from January 2019 to February 2022. Patients’ demographics, comorbidities, and CEA indications were gathered. At 30 days and 1 year after surgery, postoperative complications including stroke and death, hospital stay, and operational details were evaluated. Results In the 3-year study period, 128 CEAs were done, and 21 (16.4%) patients had CNOPC. Males were 15 (71.4%) with no sex difference in comorbidities except a significantly higher IHD in men, P less than 0.01. The mean ipsilateral to contralateral distal ICA luminal narrowing ratio was 34.1%. All patients had carotid patches. General anesthesia was associated with more shunt usage, P less than 0.05. High carotid bifurcation lengthened CEA time (P&lt;0.05), but neither anesthetic type, nor the use of a shunt or patch did. At 30-day post CEA, there was only 1 (4.7%) recorded cerebrovascular event (CVA), no mortality, and no carotid restenosis or occlusion was found. At 1-year, no new CVA were reported but 1 (4.7%) fatality was recorded. Conclusion Carotid endarterectomy for patients with carotid near occlusion and partial distal collapse is safe and may be considered despite marginally higher procedural risks than patients with low-to-moderate risk anatomy.

Clinical Significance of Carotid Endarterectomy and Carotid Artery Stenting in Older Patients Over 80.

As the average life expectancy increases, neurosurgeons are likely to encounter patients aged 80 years and above with carotid stenosis; however, whether old age affects clinical post-treatment outcomes of carotid endarterectomy (CEA) or carotid artery stenting (CAS) remains inconclusive. Thus, this study aimed to evaluate the outcomes following CEA or CAS in patients aged 80 years and above. This study included older over 80 years (n = 34) and younger patients (<80 years; n = 222) who underwent CEA or CAS between 2012 and 2022. All of them were followed up for a mean of 55 months. All-cause mortality, the incidence of vascular events, ability to perform daily activities, and nursing home admission rates were assessed. During follow-up periods, 34 patients (13.3%) died due to coronary artery disease, malignancy, and pneumonia, and the incidence was significantly higher in the elderly group than in the younger group (P = 0.03; HR, 3.01; 95% CI, 1.53-5.56). The incidence of vascular events did not differ between the older group (29.5%) and the younger group (26.9%, P = 0.58); however, the incidence was significantly higher in patients with high-intensity plaques than in those without that (P = 0.008; HR, 2.83, 95%CI, 1.27-4.87). The decline in the ability to perform daily activities and increased nursing home admission rates were high in elderly patients (P < 0.01). Although the mortality rate was higher in the elderly group, subsequent vascular events were comparable to that in the younger group. The results suggest that CEA and CAS are safe and useful treatments for carotid stenosis in older patients, especially to prevent ipsilateral ischemic stroke.

Indications and Outcome of Carotid Endarterectomy (CEA): A Single Centre Experience.

Background Stroke is a prevalent ailment that impacts a substantial number of individuals globally, resulting in both physical impairment and mortality. One of its major causes is carotid artery stenosis. The symptoms and degree of stenosis are key indications for carotid endarterectomy (CEA).In this study, we highlight the indications and outcomes of carotid endarterectomy in our center. Methods This is a descriptive, retrospective, observational study. Data of patients who underwent CEA at Glan Clwyd Hospital from January 2018 to January 2023 was retrieved. The study sample consisted of patients diagnosed with symptomatic carotid artery stenosis who had CEAat Glan Clwyd Hospital. The data was analyzed using statistical software SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Results A total of 150 patients were enrolled in the study. A majority of the patients were male, accounting for 69.3% (n = 104), and had a mean age of 71.1 ± 9.9 standard deviation. A majority of the patients were smokers (48.7%) and had additional medical conditions, including hypertension (34%), ischemic heart disease (17.3%), chronic obstructive pulmonary disease (73.3%), and diabetes (46.7%). Nevertheless, the remaining comorbidities were less common. The outcome of the CEA among the patients was cardiac event 3.3% (n = 5); transient ischemic attack (TIA) 3.3% (n = 5); stroke 0.6% (n = 1); hemorrhage 2.6% (n = 4); surgical site infection 2% (n = 3); perioperative mortality 1.3% (n = 2); and cranial nerve injury 1.3% (n = 2). However, no complications were reported in most of the patients, 85.6% (n = 128). Conclusion An endarterectomy is quite advantageous for treating symptomatic stenosis. The findings can be applied to patients who arephysically suitable for surgery. The efficacy of endarterectomy is contingent upon not only the severity of carotid stenosis but also various other parameters, such as the time elapsed between the presenting event and the surgical intervention, as well as the patient's overall medical condition. However, the CEA is the gold standard in surgical management for symptomatic carotid disease.