Perioperative Major Stroke Research Articles

Contralateral occlusion increases the risk of neurological complications associated with carotid endarterectomy.

Objective. To report on the incidence and factors associated with the development of perioperative neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO) and to compare results between those patients and the whole group of patients submitted to CEA at our vascular division from 1997 to 2012. Methods. Our nonrandomized prospective experience including 1639 patients consecutively submitted to CEA was retrospectively reviewed. 136 patients presented a CO contralateral to the treated carotid stenosis. Outcomes considered for analysis were perioperative neurological death rates, major and minor stroke rates, and a combined endpoint of all neurological complications. Results. CO patients more frequently were male, smokers, younger, and symptomatic (P < 0.001), presented with a preoperative brain infarct and associated peripheral arterial disease (P < 0.0001), and presented with higher perioperative major stroke rate than patients without CO (4.4% versus 1.2%, resp., P = 0.009). Factors associated with the highest neurological risk in CO patients were age >74 years and preoperative brain infarct (P = 0.03). The combination of the abovementioned factors significantly increased complication rates in CO patients submitted to CEA. Conclusions. In our experience CO patients were at high risk for postoperative neurological complications particularly when presenting association of advanced age and preoperative brain infarction.

Frequency, Determinants and Prognostic Implications of Infectious Complications After Transcatheter Aortic Valve Implantation

In-hospital infection (IHI) after transcatheter aortic valve implantation (TAVI) has received little attention, although it may have a significant effect on outcomes and costs because of prolonged hospital stay. Therefore, the aim of this study was to determine the incidence, type, predictors, and prognostic effects of IHI after TAVI. This study included 298 consecutive patients from 2 centers who underwent TAVI from November 2005 to November 2011. IHI during the hospital stay was defined on the basis of symptoms and signs assessed by the attending physician in the cardiac care unit or medium care unit in combination with all technical examinations performed to confirm infection. IHI after TAVI was observed in 58 patients (19.5%): urinary tract infections in 25 patients (43.1%), pneumonia in 12 patients (20.7%), and access-site infections in 7 patients (12.1%). In 12 patients (20.7%), the site of infection could not be determined, and 2 patients (3.4%) had multiple infection sites. Multivariate analysis revealed that surgical access through the femoral artery was the most important determinant of infection (odds ratio [OR] 4.18, 95% confidence interval [CI] 1.02 to 17.19), followed by perioperative major stroke (OR 3.21, 95% CI 1.01 to 9.52) and overweight (body mass index ≥25 kg/m²; OR 2.27, 95% CI 1.12 to 4.59). The length of hospital stay in patients with IHIs was 15.0 days (interquartile range 8.0 to 22.0) compared with 7.0 days (interquartile range 4.0 to 10.0) in patients without infections (p <0.0001). Kaplan-Meier estimates of survival at 1 year were 76.6% and 74.4% (log-rank, p = 0.61), respectively. Unadjusted and adjusted OR analysis revealed that IHI did not predict mortality at 30 days (OR 1.27, 95% CI 0.49 to 3.30) or at 1 year (hazard ratio 1.24, 95% CI 0.68 to 2.25). In conclusion, IHI occurred in 19.5% of the patients. Patient-related and, more important, procedure-related variables play a role in the occurrence of infection, indicating that improvements in the execution of TAVI may lead to a reduction of this complication.

Carotid Stenting versus Carotid Endarterectomy: Evidence Basis and Cost Implications

Objective Carotid Angioplasty combined with Stenting (CAS) is increasingly performed because of its presumed benefits. A study was performed to identify key factors that determine the cost-effectiveness as compared to conventional carotid endarterectomy (CEA). Methods The incremental cost-effectiveness of CAS over CEA for different scenarios was estimated using a modeling approach. Treatment costs were based on actual costs of successful procedures whereas costs of complications were taken from the literature. Patient survival was modeled using the endarterectomy patients from the ECST trial. Results Procedural costs of CAS are higher than those of CEA, mainly as a result of the high material costs. Cost-effectiveness of CAS primarily depends on major stroke rates. One percent increase in the peri-operative major stroke rate causes a cost increase of €1 051 and a loss of 0.06 quality adjusted life years. Conclusions At present CAS is at best non-inferior to CEA in terms of clinical outcome. Cost savings due to shorter admission are offset by the high costs associated with catheter-based interventions. At present CAS should be restricted to controlled settings until clinical trials have shown a substantial clinical benefit.

Outcomes of carotid endarterectomy for asymptomatic stenosis in Sweden are improving: Results from a population-based registry

In large randomized trials, carotid endarterectomy (CEA) for asymptomatic stenosis has shown a net benefit compared with best medical treatment. To justify an increased number of procedures for this indication, the perioperative risk of stroke or death must not exceed that of the trials. The aim of this study was to evaluate the outcome in routine clinical practice in Sweden in a population-based study. The Swedish Vascular Registry (Swedvasc) covers all centers performing CEA. Data on all registered CEAs during 1994 to 2003 were analyzed both for the whole time period and for two 5-year periods to study alterations over time. Four validation procedures of the registry were performed. Medical records were reviewed for both a random sample and a target sample (a total of 12% of the CEAs for asymptomatic stenosis). Swedvasc data were cross-matched with the In-Patient-Registry (used for reimbursement) and the Population-registry (death). A total of 6182 CEAs were registered, 671 being for asymptomatic stenosis. In the validation process, no missed registration of major stroke or death was found. Patients with asymptomatic stenosis had, when the whole time-period was analyzed, a perioperative combined stroke or death rate of 2.1%. Outcome improved over time; the combined stroke or death rate decreased from 3.3% (11/330) from 1994 to 1998 to 0.9% (3/341) from 1999 to 2003 (P = .026). During the second time period, no patient with a perioperative major stroke or death was reported. This extensively validated national audit of CEA for patients with asymptomatic carotid artery stenosis showed results well comparable with those of the randomized trials. The results improved over time.

Silent cerebral infarction: risk factor for stroke complicating carotid endarterectomy.

"Silent" cerebral infarction is found in 20% to 30% of patients with significant internal carotid artery (ICA) disease. Our purpose was to determine whether such "silent" cerebral infarction in the operated carotid territory represents a risk factor for stroke during and immediately after carotid endarterectomy. Over 5 years we followed a cohort of 663 patients with symptomatic and asymptomatic ICA stenosis who were consecutively scheduled for surgery. The stenosis was more than 70% in patients with transient ischemic attacks and more than 95% in asymptomatic stenosis patients. All patients underwent preoperative computed tomography to determine the frequency, extent, and location of any "silent" cerebral infarction. Patients were grouped by the absence or presence of infarction in the operated carotid territory. Among the entire cohort, 20 patients had a major perioperative stroke (3.0%). All deaths were stroke-related. No intracranial bleeding occurred. Major stroke occurred in four (0.8%) patients without appropriate "silent" cerebral infarction, compared with 16 (8.8%) with an appropriate "silent" cerebral infarct (p < 0.001). After adjustment for confounding co-variables (e.g., gender, presence of preoperative symptoms, and age), "silent" cerebral infarction was found to be the only independent predictor of perioperative major stroke for symptomatic and asymptomatic stenosis (overall adjusted relative risk 11.5, 95% confidence interval 3.8-34.9, p < 0.0001). Patients with "silent" cerebral infarction seem to be at increased risk of perioperative stroke. Consequently, preoperative cerebral imaging is important for risk classification.

Use of shunts with eversion carotid endarterectomy

Purpose: The purpose of this study was to examine the utility of carotid shunting in the context of eversion endarterectomy. A comparison of patients who underwent carotid endarterectomy by eversion with and without shunts was performed. Methods: Over a 5-year period, 2724 eversion carotid endarterectomies were performed. In most of these operations patients were under cervical block anesthesia. A shunt was used in 112 eversion endarterectomies (4.1%). Cervical block anesthesia was used in 103 patients (92.0%), general anesthesia was used in 5 patients (4.5%), and 4 patients (3.6%) were converted from cervical block to general anesthesia intraoperatively. The indications for shunting were neurologic deterioration in 99 patients (88.4%) who were under cervical block anesthesia, procedures performed in neurologically unstable or otherwise compromised patients who were under general anesthesia, and the operator's discretion in the remaining eight patients. Results: There was a combined stroke/death rate of 2.7% in the shunt group. These three cases included one death from myocardial infarction and one delayed death due to intracerebral hemorrhage after discharge. Shunt insertion was unrelated to the negative outcome in these two cases. One perioperative major stroke in the shunt group was identified. Follow-up averaged 12.3 months (range, 1-53 months). Conclusion: Carotid shunts can be used effectively in the context of eversion endarterectomy. Shunt insertion is not associated with an increased stroke/death rate in these patients. (J Vasc Surg 2000;32:655-62.)

Are We Still Performing Inappropriate Carotid Endarterectomy?

Objectives: the 1998 ECST final report suggests that the decision to operate on patients with greater than 70% symptomatic stenosis should be based on a statistical model incorporating age, sex and degree of stenosis.The aim of this study was to identify patients operated on the basis of the 1991 reports who would not now be offered surgery according to the 1998 ECST recommendations and to determine the surgical morbidity and mortality arising from these ««inappropriate»» CEAs. Methods interrogation of a prospectively gathered database of all CEAs performed for symptomatic stenosis between 1st January 1994 and 1st May 1998. CEAs were classified as ««beneficial»», ««uncertain»» or ««hazardous»» according to the 1998 ECST recommendations. Results: there were 154 males and 72 females (median age (range) was 67 (39–85) and 65 (38–81), respectively). In males 101 (66%) of CEAs were ««beneficial»», 51 (33%) were ««uncertain»» and only two (1%) were ««hazardous»». In women, the corresponding proportions were 13 (18%), 45 (63%) and 14 (19%), respectively. The combined peri-operative major stroke (Rankin 3–5) and death rate was 1.8% (4 patients). Of these, three, one and zero patients were in the ««beneficial»», ««uncertain»» and ««hazardous»» groups.Conclusions : strict adherence to the 1998 ECST recommendations would reduce by 50% the number of CEAs currently performed in this vascular unit and, in general, would restrict CEA to a higher risk group. The validity of the ECST model requires further evaluation.

Prospective audit of carotid endarterectomy in Scotland

Abstract Background Carotid endarterectomy (CEA) is a proven means of stroke prevention provided it is performed in appropriate patients, soon after the index ischaemic event and with low perioperative morbidity and mortality rates. This study investigated how well these conditions are being met in Scotland. Methods This was a prospective study of all 485 CEAs performed in National Health Service hospitals between 1 September 1997 and 31 September 1998. Data collection was by four independent research nurses. Results The median patient age was 67 (interquartile range 61–73) years; 461 patients (95 per cent) were operated on for focal symptoms, 389 of whom had a stenosis of 70 per cent or more. Some 36 per cent of patients were seen by the operating surgeon within 2 weeks of referral and 35 per cent were operated on within 1 month thereafter. The perioperative combined major stroke and death rate was 3 per cent. Operations were performed by 30 surgeons in 13 hospitals. The number of CEAs per surgeon ranged from one to 49, with ten surgeons undertaking fewer than ten operations. The number of CEAs per hospital ranged from four to 99 with only three surgeons undertaking more than 50 operations. The number of CEAs per hospital ranged from four to 99 with three hospitals undertaking 50 or more operations in the study period. Conclusion Despite the ‘diffuse’ nature of vascular surgical services necessitated by the demography and geography of Scotland, CEA is currently being performed with a perioperative major stroke and death rate substantially lower than that reported from randomized controlled trials. However, the overall effectiveness of surgery might be improved by reducing the delays to surgery.

A randomized study on eversion versus standard carotid endarterectomy: Study design and preliminary results: The Everest Trial

Purpose: The EVEREST Trial was designed to determine whether the surgical technique influences the durability and complications of carotid endarterectomy (CEA). The current report focuses on the study design and preliminary results. Methods: EVEREST is a randomized multicenter trial. A total of 1353 patients with carotid stenosis requiring surgical treatment were randomly assigned to received standard (n = 675) or eversion (n = 678) CEA. Primary end points included carotid occlusion, major stroke, death, and restenosis rate. Results: The rate of perioperative major stroke and death (1.3 for each study group) and the incidence of early carotid occlusion (0.6% for eversion vs 0.4% for standard) were similar. No significant differences were found between eversion and standard CEA with respect to incidence of perioperative transient ischemic accident, minor stroke, cranial nerve injuries, neck hematoma, myocardial infarction, or surgical defects as detected with intraoperative quality controls. Clamping time was significantly shorter for eversion CEA compared with patch standard procedures (31.7 ± 15.9 vs 34.5 ± 14.4 minutes, p = 0.02). A shunt was inserted in 11% of patients undergoing eversion CEAs and in 16% of patients undergoing standard procedures. Overall 30-day events occurred in 13.3% of the eversion group and in 11.4% of the standard group ( p = 0.3). At a mean follow-up of 14.9 months (range, 1 to 38 months), 16 (2.4%) restenoses occurred in the eversion group and 28 (4.1%) occurred in the standard group (odds ratio, 0.56; 95% confidence interval, 0.3 to 1.1; p = 0.08). Conclusion: The preliminary results of the EVEREST Trial suggest that eversion CEA is a safe and rapid procedure with low major complication rates. No significant differences in restenosis rates were observed between eversion and standard CEA at the available follow-up. Longer-term results are necessary to assess whether the eversion technique influences the durability of CEA. (J Vasc Surg 1998;27:595-605.)