Perioperative Ischemic Events Research Articles

Outcomes of Transcarotid Artery Revascularization (TCAR) in Octogenarians and Older

Retrospective, single-center review between May 31, 2018, and February 12, 2020. Almost half (43/97) of transcarotid artery revascularizations (TCARs) at this institution for symptomatic and asymptomatic disease were performed in patients ≥80 years old. Technical success was achieved in all cases without any major complications after 30 days, such as perioperative stroke, myocardial infarction, cranial nerve injury, or mortality. Although there were no significant differences in procedure time, flow reversal time, or fluoroscopy time of patients younger or older than 80 years, median length of stay was significantly longer for octogenarians (2 days vs 1 day). TCAR can be successfully performed in both symptomatic and asymptomatic high-risk elderly patients with a very low incidence of perioperative cerebral ischemic event, myocardial infarction, or death.

Outcomes of Transcarotid Artery Revascularization (TCAR) in Octogenarians and Older

Carotid revascularization, both endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS), are associated with an increased risk of adverse outcomes in patients aged ≥80years. Transcarotid artery revascularization (TCAR) is a technique that combines surgical principles of neuroprotection with less invasive endovascular techniques to treat severe carotid stenosis. Data from a recent registry study comparing TCAR with that of CEA and TFCAS demonstrated no significant difference in outcomes between TCAR and CEA in patients aged ≥80years, and a significant reduction in stroke and composite outcomes between TCAR and TFCAS in patients aged ≥80years. To add to these studies, a more in-depth analysis of demographic, procedural, and outcome factors is warranted for elderly patients aged ≥80years undergoing TCAR. At our center, with a large volume of elderly patients based on local demographics, we expect there will be no significant effect of age on outcome measures between patients aged <80 years and those aged ≥80years. Data were collected retrospectively for patients undergoing TCAR for symptomatic (≥50%) or asymptomatic (≥80%) extracranial carotid artery stenosis. Primary endpoints were the incidence of ipsilateral cerebrovascular ischemic event (stroke or transient ischemic attack), myocardial infarction (MI), cranial nerve injury, and death through 30days after the procedure. Secondary endpoints were postoperative length of hospital stay (LOS), procedure time, carotid artery clamp/flow reversal time, and fluoroscopy time. Subgroup analyses were performed to examine the effect of inpatient/outpatient status, carotid symptomatology, and type of anesthesia on secondary outcomes. Ninety-seven TCAR procedures were performed at our institution during the study period, of which 43 (44%) were on patients aged ≥80years. Technical success was achieved in all cases, with no incidence of cerebrovascular ischemic event, MI, cranial nerve injury, or mortality through 30days after procedure. In patients aged ≥80years, the mean procedure time was 47±12min, clamp/flow reversal time was 4.7±1.1min, fluoroscopy time was 4.1±1.6min, and median LOS was 2.0±1.0days. Procedure time, clamp/flow reversal time, and fluoroscopy time were not significantly different between the age groups. However, there was a significant difference in the LOS, with patients aged <80years demonstrating a median LOS of 1.0±0.0days (P = <0.001). Our experience with TCAR confirms that it can be performed successfully in both symptomatic and asymptomatic high-risk elderly patients, with our series finding no incidence of perioperative cerebral ischemic event, MI, or death.

Treatment of patients with a cerebral arterial aneurysm and stenosis of the internal carotid artery

The purpose of this study was to analyse the world literature dedicated to the problem concerning treatment of a combination of internal carotid artery stenosis at the extracranial level and an arterial aneurysm of the brain, as well as to demonstrate own results of surgical treatment of patients presenting with this concomitant pathology of the carotid basin. From 2013 to 2019, a clinical course of combined pathology of the basin of the internal carotid artery (an intracranial aneurysm and stenosis of the internal carotid artery at the extracranial level) was revealed in 35 of 1638 examined patients. There were ten men and 25 women, with a mean age of 66±7 years. In all the 35 patients, intracranial aneurysms appeared to be asymptomatic and were revealed during diagnosis of an atherosclerotic lesion of the internal carotid artery. Fifteen (43%) of the 35 patients were operated on. A two-stage surgical approach was used in 2 patients with ipsilateral location of the cerebral aneurysm and stenosis of the internal carotid artery: the first stage consisted in clipping of the arterial aneurysm, with stage 2 being carotid endarterectomy. A vascular stage alone (carotid endarterectomy or stenting of the internal carotid artery) was carried out in 9 patients, with a neurosurgical stage alone (clipping of the aneurysm) in 4 patients. The incidence of internal carotid artery stenosis with an arterial cerebral aneurysm, according to our findings, amounted to 2.1%. In the group of surgical treatment, in 1 case (6.7%) after stenting of the symptomatic stenosis of the internal carotid artery a female patient with an ipsilateral asymptomatic aneurysm of the middle cerebral artery intraoperatively developed 'minor' ischaemic stroke. Neither perioperative aneurysmal ruptures nor lethal outcomes were observed in the group of patients subjected to surgical interventions. An individual tactical approach to patients presenting with a combination of a cerebral aneurysm and internal carotid artery stenosis at the extracranial level made it possible at this stage of the work to avoid both intracranial haemorrhagic complications and lethal outcomes. The frequency of perioperative ischaemic cerebral events amounted to 6.7%. Further collection of the clinical material is needed to work out an optimal surgical policy in a combined lesion of the extra- and intracranial basin of the internal carotid artery.

Rationale and design of perioperative myocardial ischemia: a protocol for troponin monitoring, prognostic thresholds, economic analysis and further insights into pathophysiology for non-cardiac surgery patients

Introduction: Worldwide, near 200 million adults undergo major non cardiac surgery each year, and 10 million of them are estimated to suffer a myocardial injury after non-cardiac surgery (MINS), defined as an elevated high sensitive troponin T (hs-cTnT) in the first 3 days after surgery. Troponin levels need to be monitored in order to diagnose MINS, high sensitive cardiac Troponin T (hs-cTnT) assays being currently the most frequently used. Perioperative hs-cTnT screening could lead to care decisions that can potentially improve clinical outcomes. However, many of the clinical and economic implications of perioperative hs-cTnT monitoring remain unclear, and need to be elucidated. Methods and analysis: Prospective cohort that will include patients with high cardiovascular risk undergoing major non-cardiac surgery, expected to require at least an overnight hospital admission. Three determinations of hs-cTnT in each patient (before surgery, at 48, and 72 hours after surgery) will be obtained. We will determine the incidence and prognosis of MINS, and calculate prognostically relevant thresholds for pre- and post-operative hs-cTnT. We will also conduct a cost-effectiveness analysis of hs-cTnT screening, compared with usual care. Finally, using computed tomography angiography (CTA) and cardiac magnetic resonance imaging (MRI), we aim to elucidate further the pathophysiology of MINS. Ethics and dissemination: Our center had Ethics approval before including patients. Written informed consent is required for all patients before inclusion. The study will evaluate the feasibility and impact of implementing an hs-cTnT monitoring program at a tertiary hospital, as well as its cost-effectiveness, determine pre and postoperative thresholds of hs-cTnT and finally, evaluate potential mechanisms involved in perioperative ischemic events. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organizations, and taking published results to real practice.

Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety.

To review the efficacy and safety of perioperative administration of intravenous (IV) antiplatelet agents as a substitute for oral P2Y12 inhibitors and to provide clinicians guidance on optimal and cost-effective use of these medications. A MEDLINE literature search (1950 to November 2018) was performed using the key search terms abciximab, bridging, cangrelor, cardiac surgery, coronary artery bypass surgery, eptifibatide, intravenous antiplatelet agent, and tirofiban. Additional references were identified from a review of literature citations. In all, 18 original research reports and case reports/series were included in the review. Prevention of postoperative bleeding is critical to decrease morbidity and mortality after cardiac surgery. IV antiplatelet medications have short half-lives and are frequently used to substitute for oral P2Y12 inhibitors to allow platelet function recovery before procedures. Functional recovery of platelets is delayed after abciximab discontinuation and increases postoperative bleeding risk. Eptifibatide and tirofiban have similar pharmacokinetic/pharmacodynamic properties and comparable efficacy and safety in the setting of perioperative bridging. Cangrelor may be considered in patients with renal insufficiency as decreased clearance of eptifibatide or tirofiban may increase the risk of postoperative bleeding. Relevance to Patient Care and Clinical Practice: Comparative studies of IV antiplatelet medications have not been published. Appropriate use of IV antiplatelet medications can prevent perioperative ischemic events and bleeding. Eptifibatide, tirofiban, and cangrelor are preferred over abciximab as a perioperative bridge. The choice of agent should be tailored to clinical characteristics of the patient and institutional acquisition costs.

Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado

BackgroundPerioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. MethodsPatients older than 60 years, ASA II–III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient‐controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST‐segment Holter monitoring. ResultsThirty‐one patients (intravenous patient‐controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient‐controlled analgesia group. This difference was not statistically significant (p=0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient‐controlled analgesia group) or in terms of pain scores. ConclusionsUsing continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Perioperative lumbar plexus block and cardiac ischemia in patients with hip fracture: randomized clinical trial

BackgroundPerioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject. MethodsPatients older than 60 years, ASA II–III, with risk factors for or known coronary artery disease were enrolled in this randomized controlled study. Patients were randomized to conventional analgesia using opioid intravenous patient-controlled analgesia or continuous lumbar plexus block analgesia, both started preoperatively and maintained until postoperative day three. Continuous electrocardiogram monitoring with ST segment analysis was recorded. Serial cardiac enzymes and pain scores were registered during the entire period. We measured the incidence of ischemic events per subject registered by a continuous ST-segment Holter monitoring. ResultsThirty-one patients (intravenous patient-controlled analgesia 14, lumbar plexus 17) were enrolled. There were no major cardiac events during the observation period. The number of ischemic events recorded by subject during the observation period was 6 in the lumbar plexus group and 3 in the intravenous patient-controlled analgesia group. This difference was not statistically significant (p=0.618). There were no statistically significant differences in the number of cases with increased perioperative troponin values (3 cases in the lumbar plexus group and 1 case in the intravenous patient-controlled analgesia group) or in terms of pain scores. ConclusionsUsing continuous perineural analgesia, compared with conventional systemic analgesia, does not modify the incidence of perioperative cardiac ischemic events of elderly patients with hip fracture.

Quantitative analysis and predictors of embolic filter debris load during carotid artery stenting in asymptomatic patients

ObjectiveThe objective of this study was to perform a quantitative analysis and to identify predictors of embolic filter debris (EFD) load during carotid artery stenting (CAS) in asymptomatic patients. MethodsAll patients with asymptomatic carotid stenosis >70% undergoing CAS between 2008 and 2016 were included in a prospective database. A distal filter protection device was used in all patients. At the end of the procedure, the filter was fixed in formalin and then analyzed with a stereomicroscope. Morphometric analysis was performed with Image-Pro Plus software (Media Cybernetics, Rockville, Md). The total area of the filter membrane and the area covered by particulate material were quantified. The quantity of membrane occupied by debris was expressed as percentage of covered surface area. Anatomic and clinical variables were evaluated for their association with EFD load using multiple logistic regression. ResultsAmong the 278 patients undergoing CAS, an open-cell stent was implanted in 211 patients (76%); 67 patients (24%) received a closed-cell stent. Overall technical success and clinical success were both 99%; no perioperative death was reported. Stroke rate was 1.8% (major, n = 1 [0.4%]; minor, n = 4 [1.4%]); transient ischemic attacks occurred in 5% of cases (n = 14). The quantitative analysis of the filter revealed that EFD was present in 74% of cases (n = 207). The mean EFD load was 10% of the filter surface (median, 1; range, 0-80); it was <10% in 203 patients (73%), between 11% and 20% in 39 patients (14%), between 21% and 30% in 14 patients (5%), and >31% in 22 (8%). Patients with any type of ischemic neurologic event after CAS (stroke and transient ischemic attack) had a significantly higher mean EFD load compared with uneventful cases (26.7% ± 19.0% vs 8.5% ± 13.5%; P < .001). The observational frequency distribution analysis identified the presence of >12.5% EFD load as the optimal cutoff for the association with clinically relevant perioperative ischemic events (sensitivity, 78%; specificity, 77%; area under the curve, 0.81). The multivariate analysis demonstrated that age >75 years (odds ratio [OR], 2.56; P = .003), pre-existing ipsilateral ischemic cerebral lesions (OR, 2.09; P = .047), hypoechogenic plaque on the preoperative duplex ultrasound examination (OR, 6.05; P < .001), and plaque length >15 mm (OR, 1.79; P = .049) were independent predictors of EFD load >12.5%. ConclusionsThe majority of asymptomatic carotid stenoses treated with CAS have detectable embolic debris in the protecting filter. Age >75 years, pre-existing ipsilateral cerebral ischemic lesions, hypoechogenic plaque, and plaque length >15 mm should be taken into consideration as independent predictors of clinically relevant embolic debris during the procedure.

VESS03. Quantitative Analysis and Predictors of Embolic Filter Debris Load During Carotid Artery Stenting in Asymptomatic Patients

This study was conducted to perform a quantitative analysis and to identify predictors of embolic filter debris (EFD) load during carotid artery stenting (CAS) in asymptomatic patients. All patients with asymptomatic carotid stenosis ≥70% undergoing CAS between 2008 and 2016 were included in a prospective database. A distal filter protection was used in all patients. At the end of the procedure, the filter was fixed in formalin and then analyzed with a stereomicroscope. Morphometric analysis was performed with Image-Pro Plus software (Media Cybernetics). The total area of the filter membrane and the area covered by particulate material were quantified. The percentage of membrane occupied by debris was expressed as the percentage of covered surface area. Anatomic and clinical variables were evaluated for their association with EFD load using multiple logistic regression. Among the 278 patients undergoing CAS, an open-cell stent was implanted in 214 patients (78%), and 62 patients (22%) received a closed-cell stent. Overall technical and clinical success were both 99%. No perioperative death was reported. Stroke rate was 1% (major: n = 1 [0.4%]; minor: n = 2 [0.7%]), and transient ischemic attacks (TIA) occurred in 5.7% (n = 16). The quantitative analysis of the filters revealed that EFD was present in 74% (n = 207). The mean EFD load was 10% ± 14% of the filter surface (median, 1%; range, 0%-80%), and was ≤10% in 132 patients (47.5%), between 11% and 20% in 39 (14%), between 21% and 30% in 14 (4%), and ≥31% in 22 (8%). Patients with any type of ischemic neurologic event after CAS (stroke and TIA) had a significantly higher mean EFD load compared with uneventful cases (26.7% ± 19% vs 8.5% ± 13.5%; P < .001). The observational frequency distribution (Fig) identified the presence of >12.5% EFD load as the optimal cutoff for the association with clinically relevant perioperative ischemic events (sensitivity, 78%; specificity, 77%; area under the curve, 0.81). The multivariate analysis demonstrated that age >75 years (odds ratio [OR], 2.56; P = .003), pre-existing ipsilateral ischemic cerebra lesions (OR, 2.09; P = .04), hypoechogenic plaque at the preoperative duplex ultrasound study (OR, 6.05; P < .001), and plaque length >15 mm (OR, 1.79; P = .04) were independent predictors of EFD load >12.5%. Most patients with asymptomatic carotid stenosis treated with CAS have detectable embolic debris in the protecting filter. Age >75 years, pre-existing ipsilateral cerebral ischemic lesions, hypoechogenic plaque, and plaque length >15 mm, should be taken in consideration as independent predictors of clinically relevant embolic debris during the procedure.

Innovations in Endovascular Treatment Strategies for Large Carotid Cavernous Aneurysms—The Safety and Efficacy of a Flow Diverter

The efficacy for the treatment of large carotid cavernous aneurysms (CCAs) was compared between conventional endovascular treatments, stent-assisted coiling (SAC), parent artery occlusion (PAO), and the flow diverter (FD). Between January 2001 and December 2015, 49 patients with large, broad-necked, unruptured CCA underwent endovascular treatment at our institution. We performed PAO in 22 patients, SAC in 18 patients, and FD in 9 patients. Safety and efficacy were assessed in all patients by periodic clinical and radiological examinations during a 6-month follow-up. All 22 aneurysms treated with PAO disappeared immediately after treatment, but in the SAC-treated group, complete occlusion was obtained in only 5 of the 18 patients. All aneurysms in the FD group resulted in body filling. Perioperative ipsilateral temporary ischemic events occurred in 6 cases (PAO 4, SAC 2, FD 0). Delayed deterioration or new onset of cranial nerve symptoms was observed in 10 cases (PAO 3, SAC 3, FD 4), almost all of which recovered within 3 months. During the 6-month follow-up, all aneurysms treated with PAO showed a decrease in size without recanalization. In the SAC group, 12 aneurysms showed neck remnants, and marked recanalization occurred in 4 cases. Six of the 9 aneurysms in the FD group were completely occluded. The FD provided excellent final results despite transient worsening of symptoms. Although further long-term follow-up is essential, from a cost-effective and time-saving viewpoint, FD is a relatively safe and reliable method for the treatment of large CCAs.

Evaluation of the hemostatic potential at coronary artery bypass surgery during long-term aspirin therapy

To estimate thrombin generation test parameters in patients with coronary heart disease during coronary artery bypass surgery under extracorporeal circulation after transfusion of donor platelet concentrates during long-term therapy with acetylsalicylic acid (ASA). A total of 148 patients with coronary heart disease who had undergone elective primary coronary artery bypass surgery under extracorporeal circulation during preserved therapy with ASA (75-100 mg/day) were examined. According to donor platelet concentrate transfusion, all the patients were divided into 2 groups: 1) 76 patients undergoing donor platelet transfusion and 2) 72 without this procedure. A control group consisted of 20 apparently healthy individuals. At the pre-, intra-, and early postoperative stages, the investigators evaluated the following thrombin generation test parameters: lag time (min); peak thrombin concentration (nM/l); time to peak (min); the area under the thrombin generation curve (nM), and thrombin generation rate (nM/min). During long-term ASA therapy, the patients were found to have an activated endogenous thrombin potential in the pre- and intraoperative periods, as evidenced by the high peak concentration of thrombin and the increased rate of its generation. At the same time, the time of prothrombinase complex activation and that of thrombin generation were longer than those in the control group. In the early postoperative period, the patients who had not been transfused with platelet concentrates with a further increase in the temporal parameters, showed a decreased hemostatic potential, reaching the control level, whereas donor platelet transfusion stimulated endogenous thrombin generation: the time to initiate clotting and that to reach the peak were shorter; in this case, the thrombin generation rate and concentrations increased, but the preoperative level was not reached. No perioperative (hemorrhagic or thrombotic ischemic) events were noted in the examined groups. The hemostatic potential was preserved in patients receiving long-term therapy for ASA. Taking into account laboratory and clinical findings, platelet concentrate transfusions are unnecessary for preventive purposes. The appropriateness of donor platelet transfusion should be strictly individually approached with regard to the laboratory parameters of the thrombin generation test, by minimizing the risk of perioperative ischemic and hemorrhagic events in each specific patient.

Effects of preoperative statin use on perioperative outcomes of carotid endarterectomy.

ObjectivesSeveral studies have shown the beneficial role of statins in reducing the risk of major perioperative complications and death associated with noncardiac vascular surgery, but few have focused on their effects in the event of carotid endarterectomy (CEA). This study analyzes the effects of preoperative statin use on perioperative outcomes in patients undergoing CEA.Materials and MethodsData from all consecutive patients who underwent primary CEA for symptomatic and asymptomatic carotid disease between 2002 and 2014 at a single institution were prospectively stored in a vascular surgery registry, recording risk factors, medication, and indication for surgery. Endpoints of the study were perioperative (30‐day) stroke and death.ResultsOverall, 784 patients were on statins (825 CEAs, Group I), while 494 were not (545 CEAs, Group II). There were two perioperative strokes in Group I (0.24%) and four in Group II (0.73%; p = .22), and no deaths. The only nonfatal cardiac complication occurred in Group II (0.18%, p = .39). A neurologist assessed patients at 1, 6, and 12 months after CEA, and every 2 years thereafter. Follow‐up (range: 0.1–13 years; mean, 6.3 ± 3.7 years) was obtained for 1,239 patients (1,326 CEAs). Because 165 patients (166 CEAs) crossed over from Group II to Group I during the follow‐up time, long‐term data were stratified by postoperative statin treatment rather than by preoperative statin use. The 5‐ and 10‐year restenosis/occlusion and survival rates did not differ significantly between the two groups.ConclusionsTaking statins prior to CEA did not seem to affect the risk of major perioperative ischemic events and death, most likely due to the extremely low overall incidence of perioperative complications.

Coronary stenting and surgery: perioperative management of antiplatelet therapy in patients undergoing surgery after coronary stent implantation

The management of antiplatelet therapy in patients with coronary stents undergoing surgery is a growing clinical problem and often represents a matter of debate between cardiologists and surgeons. It has been estimated that about 4-8% of patients undergoing coronary stenting need to undergo surgery within the next year. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. In addition, surgery confers an additional risk of perioperative cardiac ischemic events, being high in these patients because of the pro-inflammatory and pro-thrombotic effects of surgery. Current international guidelines recommend to postpone non-urgent surgery for at least 6 weeks after bare metal stent implantation and for 6-12 months after drug-eluting stent implantation. However, these recommendations provide little support with regard to managing antiplatelet therapy in the perioperative phase in case of urgent operations and/or high hemorrhagic risk. Furthermore, ischemic and hemorrhagic risk is not defined in detail on the basis of clinical and procedural characteristics. Finally, guidelines shared with cardiologists and surgeons are lacking. The present consensus document provides practical recommendations on the management of antiplatelet therapy in the perioperative period in patients with coronary stents undergoing surgery. Cardiologists and surgeons contributed equally to its creation. An ischemic risk stratification has been provided on the basis of clinical and procedural data. All surgical interventions have been defined on the basis of the hemorrhagic risk. A consensus on the most appropriate antiplatelet regimen in the perioperative phase has been reached on the basis of the ischemic and hemorrhagic risk. Dual antiplatelet therapy should not be withdrawn for surgery at low bleeding risk, whereas aspirin should be continued perioperatively in the majority of surgical operations. In the event of interventions at high risk for both bleeding and ischemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be considered.

Efficacy and Safety of Vorapaxar in Non-ST-Segment Elevation Acute Coronary Syndrome Patients Undergoing Noncardiac Surgery.

BackgroundPerioperative antiplatelet agents potentially increase bleeding after non–ST‐segment elevation (NSTE) acute coronary syndromes (ACS). The protease‐activated receptor 1 antagonist vorapaxar reduced cardiovascular events and was associated with increased bleeding versus placebo in NSTE ACS, but its efficacy and safety in noncardiac surgery (NCS) remain unknown. We aimed to evaluate ischemic, bleeding, and long‐term outcomes of vorapaxar in NCS after NSTE ACS.Methods and ResultsIn the TRACER trial, 2202 (17.0%) patients underwent major or minor NCS after NSTE ACS over 1.5 years (median); continuing study treatment perioperatively was recommended. The primary ischemic end point for this analysis was cardiovascular death, myocardial infarction, stent thrombosis, or urgent revascularization within 30 days of NCS. Safety outcomes included 30‐day NCS bleeding and GUSTO moderate/severe bleeding. Overall, 1171 vorapaxar and 1031 placebo patients underwent NCS. Preoperative aspirin and thienopyridine use was 96.8% versus 97.7% (P=0.235) and 89.1% versus 86.1% (P=0.036) for vorapaxar versus placebo, respectively. Within 30 days of NCS, no differences were observed in the primary ischemic end point between vorapaxar and placebo groups (3.4% versus 3.9%; adjusted odds ratio 0.81, 95% CI 0.50 to 1.33, P=0.41). Similarly, no differences in NCS bleeding (3.9% versus 3.4%; adjusted odds ratio 1.41, 95% CI 0.87 to 2.31, P=0.17) or GUSTO moderate/severe bleeding (4.2% versus 3.7%; adjusted odds ratio 1.15, 95% CI, 0.72 to 1.83, P=0.55) were observed. In a 30‐day landmarked analysis, NCS patients had a higher long‐term risk of the ischemic end point (adjusted hazard ratio 1.62, 95% CI 1.33 to 1.97, P<0.001) and GUSTO moderate/severe bleeding (adjusted hazard ratio 5.63, 95% CI 3.98 to 7.97, P<0.001) versus patients who did not undergo NCS, independent of study treatment.Conclusion NCS after NSTE ACS is common and associated with more ischemic outcomes and bleeding. Vorapaxar after NSTE ACS was not associated with increased perioperative ischemic or bleeding events in patients undergoing NCS.

Occipital pial synangiosis

Indirect revascularization techniques for posterior circulation moyamoya are infrequently described in the literature given the relative rarity of the disease process, particularly in the best candidates for indirect approaches-children. We present a detailed, illustrated video demonstration of the occipital pial synangiosis procedure performed in a 5-year-old child. The specific advantages of the pial synangiosis technique-suturing the donor vessel to the pia and a wide arachnoidal opening-can be successfully applied to posterior circulation indirect revascularization. • Perioperative hydration and aspirin limit the risk of perioperative stroke. • Pain control and maintained normocapnea limit the risk of perioperative ischemic events. • The posterior auricular artery may be an alternative donor vessel. • The donor vessel is dissected from distal to proximal; forceps protect it during skin incision. • The donor vessel is dissected along a generous length to minimize tension. • Coagulation of the dura is limited as meningeal vessels may serve as synergistic collaterals. • A wide arachnoidal opening facilitates the ingrowth of collateral vessels. • Suturing the donor vessel to the pia ensures it remains well apposed to the brain surface. • The dura is left open to encourage ingrowth of collateral vessels and limit tension on the donor vessel. • EEG monitoring is a crucial adjunct.

Carotid artery stenting in nonagenarians: are there benefits in surgically treating this high risk population?

BackgroundCarotid angioplasty and stenting (CAS) is considered desirable treatment for patients at high risk for carotid endarterectomy. Despite a growing elderly population, scant data exist on CAS in nonagenarians. Nonagenarians...

Surgical Outcomes and Predictors of Stroke in a North American White and African American Moyamoya Population

The majority of moyamoya surgical series have been confined to Asian and pediatric populations. Few have studied demographics, risk factors, and outcomes in adult North American populations. To examine outcomes after revascularization for moyamoya in white and African American adults and to assess for predictors of recurrent stroke. A retrospective review of 75 non-Asian patients undergoing 110 procedures at the Mayo Clinic was performed. Demographics, known moyamoya associations, cerebrovascular risk factors, and autoimmune diseases were recorded. Primary outcomes for vascular events were assessed with Kaplan-Meier analysis. Fisher exact methods were used to evaluate for associations with recurrent events. Mean age was 42 years, and mean follow-up was 47 months. Seventy-one of the 75 patients were white. The majority had bilateral disease (n = 49). Perioperative ischemic events occurred in 5 patients (4.5%). The 5- and 10-year event rates were 5.8% and 9.9%. Significant associations were found with a history of thyroid disease (P = .05) and recurrent stroke. A trend was also found between hypertension and autoimmune disease with recurrent stroke. Outcomes were favorable with revascularization in this subset with moyamoya. A significant association between a history of thyroid disease and recurrent stroke was found. Additionally, high prevalences of autoimmune disease, hypertension, and thyroid disease were found in our cohort, suggesting that they may play a role in the pathophysiology and progression of moyamoya disease in this population. A new classification for moyamoya is proposed based on these data.

Understanding risk factors for perioperative ischemic events with carotid stenting: is patient age over 80 years or is unfavorable arch anatomy to blame?

ObjectiveSeveral studies have reported increased perioperative risk after carotid artery stenting (CAS) for patients ≥80 years of age; however, most have not considered unfavorable anatomic features noted more frequently in...

Endovascular Abdominal Aortic Aneurysm Repair under General Anesthesia Does Not Decrease Perioperative Myocardial Ischemic Events Compared with Open Repair

Objectives: Endovascular abdominal aortic aneurysm repair (EVAR) is a common procedure for abdominal aortic aneurysm (AAA), based on minimal invasiveness compared with open surgical repair (OSR). However, general anesthesia can cause considerable perturbations in patients with AAA undergoing operative repair. The aim of this study was to compare the incidence of myocardial ischemic events in association with hemodynamic changes during EVAR and OSR under general anesthesia. Methods: We retrospectively reviewed the anesthetic and medical records of patients who underwent elective abdominal aortic aneurysm repair. ST segment changes on electrocardiography and hemodynamic changes were reviewed by the attending physicians. Results: Among 120 patients, EVAR and OSR were performed in 81 and 39 patients, respectively. There were no significant differences in preoperative morbidity between the two groups. The amount of estimated blood loss was significantly lower in EVAR than OSR. The incidence of ST segment changes in the two groups (EVAR: 16%, OSR: 23%) was not statistically different. ST segment changes occurred mainly postoperatively at resolution of anesthesia in EVAR, compared with intraoperatively in OSR. ST segment changes were mostly accompanied by tachycardia in EVAR patients, whereas they were associated with hypotension in OSR. Conclusion: Our results demonstrated a comparable incidence of perioperative ST segment changes under general anesthesia in EVAR and OSR. Patients who undergo EVAR and develop tachycardia are at risk of myocardial ischemia at resolution of anesthesia.

Recommendations for Management of Antiplatelet Therapy in Patients Undergoing Elective Noncardiac Surgery After Coronary Stent Implantation

Patients commonly undergo noncardiac surgical procedures after implantation of a coronary stent. In the case where surgery cannot be deferred until completing the minimum duration of dual antiplatelet therapy, the Brigham and Women's Hospital Cardiac Catheterization Laboratory recommends using a glycoprotein IIb/IIIa bridging protocol to minimize the risk of perioperative ischemic events. We discuss our algorithm for managing antiplatelet agents, including the newer agents, prasugrel and ticagrelor, in patients undergoing noncardiac surgery after coronary stenting and present our glycoprotein IIb/IIIa bridging strategy along with a review of the relevant pharmacodynamic and clinical evidence.