Perioperative Stroke Rate Research Articles

Very Urgent Carotid Endarterectomy Does Not Increase the Procedural Risk

The timing of CEA for symptomatic internal carotid artery (ICA) stenosis remains a matter of controversy. Recent registry data showed a significantly increased risk, especially in the very early days after the onset of symptoms. In this study the outcome of CEA in the hyperacute phase has been investigated. The outcome of CEA for symptomatic ICA stenosis between January 2004 and December 2013 has been retrospectively analyzed. Patients were divided into four timing groups: surgery within 0 and 2 days, between 3 and 7 days, 8 and 14 days, and thereafter. The post-operative 30 day stroke and death rates were assessed. A total of 761 symptomatic patients (40.1% with transient ischemic attack [TIA], 21.3% with amaurosis fugax, and 38.6% with ischemic stroke) were included, with an overall peri-operative stroke and death rate of 3.3%. A stroke and death rate of 4.4% (9/206) for surgery within 0 and 2 days, 1.8% (4/219) between 3 and 7 days, 4.4% (6/136) between 8 and 14 days, and 2.5% (5/200) in the period thereafter (p=.25 for the difference between the groups) was observed. The timing of surgery did not influence the peri-operative outcome in a multivariate regression analysis (OR 0.93 [0.63-1.36], p=.71). These data show that very urgent surgery in symptomatic patients can be performed without increased procedural risk. Given the fact that ruptured plaques with neurological symptoms carry the highest risk of a recurrent ischemic event in the first 2 days, treating patients as soon as possible to offer the highest benefit in stroke prevention is recommended.

017 * AORTIC VALVE REPLACEMENT THROUGH AN ANTERIOR RIGHT MINI-THORACOTOMY WITH CENTRAL AORTIC CANNULATION IS SAFE

S 28 EACTS 017 AORTIC VALVE REPLACEMENT THROUGH AN ANTERIOR RIGHT MINI-THORACOTOMY WITH CENTRAL AORTIC CANNULATION IS SAFE D. Hui, M. Bowdish, J. Cleveland, R. Ranjan, R. Sinha, C.J. Baker, M.J. Cunningham, V.A. Starnes Department of Cardiothoracic Surgery, University of Southern California, Los Angeles, United States of America Objectives: Sternotomy is the standard approach to aortic valve replacement. We have adopted an approach of minimally invasive aortic valve replacement (AVR) via a right anterior mini-thoracotomy with central arterial cannulation (MIAVR). We compared perioperative outcomes with this technique to those via sternotomy (SAVR). Methods: A prospective observational study of 492 patients who underwent isolated AVR (294 MIAVR, 198 SAVR) between March 1999 and December 2013. Univariate comparisons between groups were made using t-tests or MannWhitney U (non-normally distributed), and c tests (Fisher’s exact or Pearson) for categorical outcomes; a = 0.05 Results: The groups did not differ in age, BMI, creatinine, sex, diabetes, COPD, atrial fibrillation, history of myocardial infarction, or stroke. MIAVR patients were more likely to have a bicuspid valve (35% vs 18%, P = 0.03). In MIAVR patients, central aortic cannulation was utilized in 92% (n = 273). Venous cannulation was central in 86% (n = 255). Conversion to sternotomy was required in 6 patients (2%). Aortic cross-clamp and cardiopulmonary bypass times were similar. MIAVR patients had shorter ICU (2.8 vs 3.2 days, P < 0.01) and hospital stays (8.2 vs 9.7 days, P < 0.01), shorter time to extubation, reduced transfusions, and fewer wound infections (6.6% vs 1%, P < 0.001). Perioperative stroke (1.7% vs 2.5%) and mortality rates (1% vs 2.5%) were similar [see Table 1]. Table 1: Operative characteristics and postoperative outcomes SAVR (N = 198) MIAVR (N = 294) P-value Continued Table 1: (Continued) SAVR (N = 198) MIAVR (N = 294) P-value Valve size (mm) 23.8 ± 2.4 23.4 ± 1.9 0.13 CPB time (min) 81 ± 32 79 ± 33 0.34 Aortic cross-clamp time (min) 59 ± 26 58 ± 25 0.80 Time to extubation (min) 1074 ± 1730 800 ± 2090 <0.001 Reintubation 6 (3%) 15 (5.1%) 0.36 Intraoperative pRBC (units) 1.9 ± 2.2 1.2 ± 1.6 <0.001 Intraoperative platelets (units) 1.1 ± 1.4 0.6 ± 1.0 <0.001 ICU LOS (days) 3.2 ± 2.9 2.8 ± 3.8 <0.001 Hospital LOS (days) 9.7 ± 5.8 8.2 ± 5.7 <0.001 Postoperative pacemaker 10 (5.1%) 11 (3.7%) 0.50 Postoperative arrhythmia 55 (28.4%) 88 (29.9%) 0.76 Postoperative wound infection 13 (6.6%) 3 (1%) 0.001 Postoperative stroke 5 (2.5%) 5 (1.7%) 4 (1.4%) 0.53 GI bleed 0 (0%) 1 (0.3%) 1.0 Mortality 5 (2.5%) 3 (1%) 0.28 Conclusion: MIAVR via an anterior right mini-thoracotomy with central cannulation results in similar perioperative mortality and stroke rates as compared to standard sternotomy. In addition, the MIAVR technique resulted in earlier extubation, fewer wound infections, reduced intraoperative transfusions, and shorter ICU and hospital stays. As compared to standard sternotomy AVR, our technique of MIAVR with preferential central cannulation appears safe. Interactive CardioVascular and Thoracic Surgery Sunday A bsracts 01 –06

A study of carotid endarterectomy in a Chinese population: Initial experience at a single center

ObjectiveThis retrospective study aimed to evaluate our initial experience with carotid endarterectomy in a Chinese population. MethodsFour hundred and thirty-three patients who underwent carotid endarterectomies at Xuan Wu Hospital Capital Medical University between January 1, 2001, and December 31, 2012, were reviewed. The postoperative 30-day complications were analyzed. Univariate and multivariate logistic regression analyses were used to analyze the factors associated with perioperative stroke and death. ResultsThe overall 30-day complication rates after surgery were 4.08% for death and stroke, 3.63% for cranial nerve injuries, and 3.63% for heart complications. The mean follow-up time was 32.99 months, and only 11 cases required restenosis, including two that were symptomatic (experiencing transient ischemic attacks). In the univariate analysis, a history of cerebral infarction was present preoperatively in 179 patients, of whom 12 (6.70%) had a postoperative stroke or died (P=0.021). Thirty-two patients had a modified Ranking score (mRS)≥3, and six (18.75%) of these patients had a postoperative stroke or died (P<0.001). In the multivariate logistic regression, female gender (OR: 4.669; 95% CI: 1.238–17.602; P=0.023), current smoking habits (OR: 3.826; 95% CI: 1.298–11.277; P=0.015), and an mRS≥3 (OR: 1.540; 95% CI: 3.844–40.909; P<0.001) were independent risk factors for perioperative stroke and death. ConclusionsIn our single-center study, carotid endarterectomies appeared to effectively prevent and treat the carotid artery stenosis that leads to stroke. Female gender, current smoking habits, and neurological deficits (mRS≥3) increased the perioperative stroke and death rates.

Practice patterns of carotid endarterectomy as performed by different surgical specialties at a single institution and the effect on perioperative stroke and cost of preoperative imaging

Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost. This is a retrospective analysis of prospectively collected data of 1000 consecutive CEAs performed at ourinstitution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CTS), and vascular surgeons (VS). VS did 474 CEAs, CTS did 404, and GS did 122. VS tended to operate more often on symptomatic patients than CTS and GS: 40% vs 23% and 31%, respectively (P< .0001). Preoperative workups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and computed tomography angiography in 27%, 35%, and 29%; and DUS and magnetic resonance angiography in 6%, 35%, and 52% for VS, CTS, and GS, respectively (P< .001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (P= .0001) and protamine was used in 0.2%, 19%, and 8% (P< .0001) for VS, CTS, and GS, respectively. VS more often used postoperative drains; however, no association was found between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (P< .0001) for VS, CTS, and GS, respectively. Bovine pericardial patches were used more often by CTS and ACUSEAL (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) patches were used more often by GS (P< .0001). The perioperative stroke/death rates were 1.3% for VS and 3.1% for CTS and GS combined (P= .055); and were 0.7% for VS and 3% for CTS and GS combined for asymptomatic patients (P< .034). Perioperative stroke rates for patients who had preoperative DUS only were 0.9% vs 3.3% for patients who had extra imaging (computed tomography angiography/magnetic resonance angiography; P= .009); and were 0.9% vs 3% for asymptomatic patients (P= .05). When applying hospital billing charges for preoperative imaging workups (cost of DUS only vs DUS and other imaging), the VSpractice pattern would have saved $1180 per CEA over CTS and GS practice patterns; a total savings of $1,180,000 in this series. CEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians who perform CEAs on cost-saving measures may be appropriate.

The effect of carotid stenting on endarterectomy practice – A single institution experience

ObjectivesThe number of operations performed per surgeon is thought to determine the quality of carotid endarterectomy (CEA) surgery. The advent of carotid artery stenting (CAS) threatens to reduce the volume of CEA. This paper assesses CEA and the effects of the introduction of CAS service on outcomes. DesignRetrospective cohort study. MethodsClinical data and results of CEA were reviewed retrospectively for the treatment of carotid stenosis, between January 1988 and December 2010. CEA patients were grouped into those treated before and after the introduction of CAS to our hospital in 2001. Results757 patients underwent a CEA between 1988 and 2010. The perioperative stroke rate prior to the introduction of CAS was 4.9%, and 3.3% after stent introduction in 2001. In this latter period, 85.5% had symptomatic stenosis which suggests that the patients were not low risk. The major adverse event rate (inclusive of death and myocardial infarction) post introduction of CAS from 2001 to 2010 was 4.1%. There was no correlation between post-operative stroke/MAE and procedure volume, despite the trend of decreasing CEA numbers over time. ConclusionThe introduction of carotid artery stenting has led to a decrease in carotid endarterectomy volume. However, outcomes in our high risk patient population are acceptable. Therefore, CEA remains the procedure of choice for carotid artery revascularization.

Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery

Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, “DSA era”; 2007, “ICG era”). The clip repositioning rate for neck residual or parent vessel stenosis did not differ significantly between the two eras. There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective.

Carotid Endarterectomy, Stenting in Elderly Debated

For elderly patients with carotid disease, carotid endarterectomy carries a lower risk of perioperative stroke or transient ischemic attack, the same risk of perioperative myocardial infarction (MI), and a slightly higher risk of death, compared with carotid stenting, according to a meta-analysis. However, the individual elderly patient's vascular anatomy plays a crucial role in determining perioperative risk, as does the person's overall health and clinical profile, said George A. Antoniou, MD, PhD, of the department of vascular surgery, Hellenic Red Cross Hospital, Athens, and his associates. Which treatment is the most appropriate for elderly patients is still much debated. Dr. Antoniou and his colleagues performed a comprehensive review of the medical literature since 1986 and a meta-analysis of 44 articles that directly compared outcomes in elderly patients with those of younger patients after carotid endarterectomy (39 studies) or carotid stenting (18 articles). “Elderly” was defined as older than 80 years in most of these studies. Overall, the meta-analysis included 269,596 endarterectomies in elderly patients against 243,089 in younger patients, and 38,751 carotid stenting procedures in elderly patients against 36,450 in younger patients. For endarterectomy, the rate of perioperative stroke was not significantly different between elderly (0.9%) and younger (1.2%) patients, nor was the rate of transient ischemic attack (1.9% vs. 1.8%, respectively). However, perioperative mortality was significantly higher in elderly (0.5%) than in younger (0.4%) patients. In contrast, for carotid stenting, the rate of perioperative stroke was significantly higher for elderly patients (2.4%) than for younger patients (1.7%), as was the rate of TIA (3.6% vs. 2.1%). But mortality was not significantly different between elderly patients (0.6%) and younger patients (0.7%), the researchers wrote (JAMA Surg. 2013;148[12]:1140–52). Both procedures were associated with an increased rate of perioperative MI in elderly patients, compared with younger patients. These rates were 2.2% in elderly patients, compared with 1.4% in younger patients undergoing endarterectomy; and 2.3% in elderly patients, compared with 1.5% in younger patients undergoing carotid stenting. “It seems that endarterectomy is associated with improved neurologic outcomes compared with carotid stenting in elderly patients, at the expense of increased perioperative mortality,” Dr. Antoniou and his associates said. However, the small increase in mortality seen with endarterectomy – 0.1% – may not be clinically significant. Moreover, neurologic risk is closely tied to vascular anatomy. Elderly patients tend to have more unfavorable anatomy than do younger patients. Unfavorable traits include heavily calcified and tortuous supra-aortic branches, as well as adverse morphology of the aortic arch such as elongation, distortion, and stenosis. Manipulating the stenting instruments through such features may in itself raise the risk of neurologic sequelae. It also makes the procedure more technically difficult, which increases the risk of endothelial trauma, thrombus dislodgement, and thromboembolic events. “In addition, elderly patients with significant extracranial atherosclerotic disease are likely to have a compromised cerebrovascular reserve, which makes them more susceptible to ischemic events from cerebral microembolization,” the researchers said. R. Clement Darling III, MD, said, in a published commentary, that variation in the definition of elderly among the trials is a concern: Some used 70 or even 65 years as the cutoff. “The bottom line is, carotid endarterectomy and carotid stenting seem to work equally well in younger patients, in expert hands. However, in the ‘elderly’ (at any age), endarterectomy has better outcomes with low morbidity, mortality, and stroke rate, and it remains the standard of care,” he said. Dr. Darling is a member of the Vascular Group, Albany, NY. Neither he nor any of the report's authors reported a financial conflict of interest.

Prospective Assessment of the CryoMaze Procedure With Continuous Outpatient Telemetry in 136 Patients

Only 40% of patients with atrial fibrillation (AF) undergoing cardiac surgery are treated with surgical AF correction. We prospectively studied endocardial cryoablation of the Cox-maze III lesion set following prespecified rhythm assessment with outpatient telemetry. Between 2007 and 2011, 136 patients underwent surgical AF correction using an argon-powered cryoablation device. Patients wore continuous electrocardiogram monitoring prior to and at 6, 12, and 24 months after surgery. The average length of monitoring was 6.5±1 days prior to surgery and 11±4 days at each time point after surgery. Patients were assessed for cardiac rhythm, interval cardioversion or ablation procedures, pacemaker placement, and the use of warfarin or antiarrhythmic medications. The primary endpoint of this study was freedom from AF at 1 year. Mean patient age was 66±12 years, 50% (69 of 138) were male and 41% (55 of 134) had persistent AF. CryoMaze was done in conjunction with mitral valve operation in 95% (131 of 138) and other procedures in 41% (56 of 138). Follow-up was 96% complete at 1 year and 90% at 2 years. Freedom from AF was 76% at 1 year. Perioperative mortality and stroke rates were both 1.5% (2 of 138). Perioperative pacemaker implantation was required in 7% (9 of 136). In univariate analysis, younger age, female gender, decreased height and weight, smaller preoperative and postoperative left atrial diameter, intermittent AF, and freedom from AF at discharge were associated with freedom from AF at 1 year. Actuarial 2- and 4-year (Kaplan-Meier) survival were 93% and 80%, respectively. The CryoMaze procedure is safe and is associated with 76% freedom from AF at 1 year.

Impact of Chronic Renal Insufficiency on the Early and Late Clinical Outcomes of Carotid Artery Stenting Using Serum Creatinine vs Glomerular Filtration Rate

This study analyzed the impact of chronic renal insufficiency (CRI) on early and late clinical outcomes of carotid artery stenting (CAS) using serum creatinine and glomerular filtration rate (GFR). There were 313 CAS patients classified into 3 groups: normal (serum creatinine <1.5 mg/dL or GFR ≥ 60 mL/min/1.73 m(2)); moderate CRI, and severe CRI (serum creatinine ≥ 3 or GFR < 30 mL/min/1.73 m(2)). Major adverse events ([MAE] stroke, death, and myocardial infarction) were compared for all groups. Using serum creatinine, perioperative stroke rates for normal, moderate, and severe CRI were: 5%, 0%, and 25%, respectively, (p = 0.05) vs 4.6%, 3.7%, and 11.1%, respectively, (p = 0.44) using GFR. The perioperative MAE rates for symptomatic patients were 9.3% and 0% (p = 0.355) and 2% and 5.9% (p = 0.223) for asymptomatic patients for normal and moderate/severe CRI, respectively, using serum creatinine vs 8.1% and 7.8%, respectively, for symptomatic patients and 2.5% and 3%, respectively, for asymptomatic patients using GFR. At a mean follow-up of 21 months, late MAE rates in normal vs moderate/severe CRI patients were 8.2% and 14%, respectively, (p = 0.247) using serum creatinine vs 6.6% and 13.3%, respectively, (p = 0.05) using GFR. Late MAE rates for symptomatic patients in normal vs moderate/severe CRI were: 8.7% vs 27%, respectively, (p = 0.061) using serum creatinine and 5.7% vs 18.8%, respectively, (p = 0.026) using GFR. Late death rate was 0.55% in normal vs 7.6% (p = 0.002) for moderate/severe CRI. Freedom from MAE at 3 years in symptomatic patients was 81% in normal and 46% in moderate/severe CRI (p = 0.0198). A multivariate Cox regression analysis showed that a GFR of < 60 mL/min/1.73 m(2) had an odds ratio of 1.6 (p = 0.222) of having a MAE after CAS. The GFR was more sensitive in detecting late MAE after CAS. Carotid artery stenting in moderate CRI patients can be done with a satisfactory perioperative outcome; however, late death was significant.

History of Carotid Endarterectomy Then and Now

It seems the first successful carotid endarterectomy (CE) was done by Michael E. DeBakey1 in 1953, although the first published report of CE was by Eastcott et al2 in 1954. During the subsequent 2 decades, the number of these surgeries grew. In 1969, the Joint Study of Extracranial Arterial Occlusion, a methodologically imperfect study, reported that, in 2400 operations performed between 1961 and 1968, there was a surgical mortality of 4.5%, ranging from <2% to 36% among the 24 participating institutions, although there was a steady decline in surgical mortality during the 8 years.3 Fifteen thousand CEs were performed in the United States in 1971, and this grew to 34000 in 1976.4 By 1976, my colleague, David Sherman, and I were becoming troubled with the growth in the number of CEs because we were observing patients experiencing ischemic strokes and deaths in conjunction with these surgeries. We were at Southern Illinois University (SIU) School of Medicine in Springfield, IL, observing the good and the bad results of CE. Our medical colleagues often asked us, “What is the complication rate for carotid endarterectomy in our two hospitals?” We replied, “We don’t know.” The time had come to answer the question. We initiated a retrospective study of 228 consecutive CEs during the arbitrary interval from January 1, 1970, to June 30, 1976, in our two 600-bed community hospitals to determine the perioperative stroke and mortality rate. Our primitive methodology is described in the results publication of the study.5 The combined stroke-mortality rate for our series of patients was 21.1% (48 of 228). Eleven CEs were performed for asymptomatic bruits, and the combined stroke-mortality rate was 18.2% (2 of 11). Fifty-seven CEs were performed for transient ischemic attacks in the symptomatic carotid artery distribution, and the combined stroke …

Long-term results of endovascular repair for distal arch and descending thoracic aortic aneurysms treated by custom-made endografts: usefulness of fenestrated endografts.

We evaluated early and long-term results of atherosclerotic aneurysm repair with custom-made endografts. Eighty-one consecutive patients underwent thoracic endovascular aortic repair with custom-made endografts. Fenestrated grafts were used in 37 patients (45.7%) to maintain blood flow of the neck and a landing zone for as long as possible for distal arch or proximal descending aneurysms. The rates of perioperative mortality, stroke, paraplegia, and primary endoleaks were assessed to evaluate in-hospital safety. The rates of endoleak development, survival, and freedom from aortic-related death were assessed to evaluate long-term efficiency. Twenty-four patients (29.6%) underwent urgent operations, and 38 (46.9%) underwent distal arch or proximal descending aortic aneurysm repair. There was one case (1.2%) of in-hospital mortality and no cases of stroke. Permanent spinal injury occurred in one patient (1.2%). Early and late endoleaks occurred in one and 16 patients, respectively. The actuarial survival rates were 88.9%, 64.9%, and 51.7% at 1, 5, and 10 years, respectively. The actuarial rates of freedom from endoleaks were 90.1%, 81.3%, and 68.6% at 1, 5, and 10 years, respectively. Early results of custom-made endografts were excellent, and fenestrated endografts were safe for distal arch and proximal descending aortic aneurysms.

Carotid Endarterectomy National Trends Over A Decade: Does Sex Matter?

The objective was to evaluate the difference in timing (if any) of in-hospital carotid endarterectomy (CEA) or outcomes of CEA based on sex among men and women hospitalized for carotid artery disease. This was a retrospective cross-sectional study using the Nationwide Inpatient Sample Database. All patients from 2000-2009 who underwent CEA during their hospitalization were examined. International Classification of Diseases, 9th revision codes were used to identify patients who underwent CEA during hospitalization, stratify asymptomatic and symptomatic patients, determine time in days from admission to CEA, and examine in-hospital complications, including perioperative stroke, cardiac events, and death. Statistical analysis was performed with chi-squared and t-tests. Linear and logistic regression models were used to evaluate relationships between sex and outcomes. The main outcome measures were time from admission to surgery, in-hospital mortality, complications, mean duration of stay, and discharge disposition. Two hundred twenty-one thousand two hundred fifty three patients underwent CEA during hospitalization. More than 9% (9.2%) had symptomatic carotid artery disease. Among symptomatic patients, bivariate analysis found that women had a longer mean time from admission to surgery (2.8 vs. 2.6 days; P < 0.001) and a longer duration of hospital stay (6.4 vs. 5.9 days; P < 0.001) than their male counterparts. However, there was no difference between men and women with regard to rates of perioperative stroke, cardiac complications, myocardial infarction, or death. Among asymptomatic patients, women had a longer mean time from admission to surgery (0.53 vs. 0.48 days; P < 0.001) and a trend toward increased perioperative stroke (0.6% vs. 0.5%; P = 0.06), but a lower rate of cardiac complications (1.5% vs. 1.7%; P = 0.01) and in-hospital mortality (0.26% vs. 0.31%; P = 0.05). However, on multivariable analysis adjusting for differences in age, elective status, insurance, race, hospital location, hospital region, and hospital teaching status, there was no sex disparity in time from admission to surgery, regardless of symptomatic status. In addition, asymptomatic women were less likely than men to have a cardiac complication (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) or in-hospital mortality (OR: 0.83; 95% CI: 0.70-0.98). Symptomatic women were also less likely than men to have a cardiac complication (OR: 0.78; 95% CI: 0.63-0.97). In this decade-long national population-based study of hospitalized patients undergoing CEA, women had lower perioperative cardiac morbidity and mortality rates than men. After adjusting for patient, clinical, and hospital factors, there is no discernible difference in timing of CEA based on sex.

Extra-Intracranial Standard Bypass in the Elderly: Perioperative Risk, Bypass Patency and Outcome

Background: Patients with chronic atherosclerotic vessel occlusion and cerebrovascular hemodynamic insufficiency may benefit from extra-intracranial (EC-IC) bypass surgery. Due to demographic changes, an increasing number of elderly patients presents with cerebrovascular hemodynamic insufficiency. So far, little data for EC-IC bypass surgery in elderly patients suffering occlusive cerebrovascular disease are available. We therefore designed a retrospective study to address the question whether EC-IC bypass is a safe and efficient treatment in a patient cohort ≥70 years. Methods: 50 patients underwent EC-IC standard bypass surgery with translocation of the superficial temporal artery to an M2 segment of the medial cerebral artery. Criteria for bypass surgery were presence of symptomatic occlusive cerebrovascular disease of the anterior circulation and proof of a severely restricted or abrogated reserve capacity (detected by H₂O-photon emission tomography or single photon emission computer tomography - before and after forced vessel dilatation by diamox). The incidence of perioperative neurological and surgical complications, bypass patency, bypass function and short-term outcome were retrospectively analyzed. Results: The study cohort consisted of 16 patients ≥70 years (mean = 74.3 years, SE 1.3). It was compared to a cohort of 34 patients <70 years (mean = 61.2 years, SE 1.0). Both groups underwent EC-IC bypass surgery after careful preoperative work-up. Both patient groups did not differ significantly in gender, vascular pathology, previous history of diseases/comorbidity or clinical symptoms. The number of patients which underwent stenting or other endovascular treatments of the internal or common carotid artery prior to EC-IC bypass surgery was significantly higher in the group of patients ≥70 years (37.5 vs. 0%, p < 0.001). Perioperative stroke rate was 0% in both groups and mild morbidity occurred in 18.8 and 14.7%, respectively (p = 0.699). One 84-year-old female patient died due to perioperative endocarditis. Initial bypass patency was 93.8% in patients above the age of 70 years and 97.1% in the younger group (p = 0.542). Secondary occlusion rate was low in both groups (≥70 years: 0% vs. <70 years 3.7%). No new neurologic deficit occurred in patients with a patent bypass during the follow-up period (median 18 ± 13.1 months). Two patients with an initially occluded bypass and one with a secondary bypass occlusion suffered from new neurological symptoms. Conclusions: Our data show comparable safety and efficiency of EC-IC bypass surgery in patients under and above the age of 70 years due to a careful preoperative work-up and a strict indication for bypass surgery.

Long-term outcomes after thoracic aortic surgery: A population-based study

Long-term survival after aortic surgery has remained largely unexplored, despite suggestions of superior durability compared with endovascular techniques. The objective of the present study was to determine the long-term survival after open thoracic aortic surgery and to identify the predictors of mortality. The provincial database was accessed to identify all adult patients who had undergone primary open thoracic aortic surgery in British Columbia since 1993. Kaplan-Meier survival analyses were performed for the entire group and by year of surgery, urgency of surgery, and aortic segment requiring surgery. Multivariate analyses were performed to identify the predictors of mortality. From January 1993 to June 2010, 1960 patients underwent primary open thoracic aortic surgery at 4hospitals in British Columbia. Overall, the 30-day mortality was 9.1%, with a perioperative stroke rate of 5.8%. Long-term survival was 77.7%, 59.6%, and 44.7% at 5, 10, and 15 years, respectively. Subanalyses demonstrated improved long-term survival in the modern era; among patients undergoing elective aortic surgery; and among patients undergoing surgery on the ascending aorta or aortic root (P<.0001). The preoperative characteristics associated with decreased long-term survival included age older than 65 years, acute renal failure, dialysis, cerebrovascular accident, chronic obstructive pulmonary disease, peripheral vascular disease, and descending or thoracoabdominal aorta surgery. Long-term survival after elective thoracic aortic surgery is excellent, with improved outcomes in the modern era. Several preoperative risk factors associated with decreased survival were identified, which could assist in risk stratification and patient selection. Finally, the long-term survival rates identified in the present study should serve as a benchmark to which new aortic interventions should be compared.

The impact of the present on admission indicator on the accuracy of administrative data for carotid endarterectomy and stenting

Administrative data are often hampered by coding errors, absent data, and the difficulty of distinguishing pre-existing conditions from perioperative complications. We evaluated whether the introduction of the present on admission (POA) indicator improved outcome analysis of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) using administrative data. State inpatient databases from California (2005-2008), New York (2008), and New Jersey (2008) were used to identify patients undergoing CAS and CEA. We first analyzed morbidity data without the POA indicator, using International Classification of Diseases, Ninth Revision complication codes (eg, 997.02, iatrogenic cerebrovascular infarction or hemorrhage, postoperative stroke) and diagnosis codes (eg, 433.11, occlusion and stenosis of the carotid artery with cerebral infarction). Then, we applied the POA indicator to both diagnosis and complication codes and calculated the proportion of events that were labeled POA. Symptom status and perioperative stroke rate were compared using these coding approaches. We identified 21,639 patients who underwent CEA and 3688 patients who underwent CAS. Without the POA indicator, the complication code for stroke indicated a postoperative stroke rate of 1.4% for CEA and 2.4% for CAS. After applying the POA indicator, 54% (CEA) and 62% (CAS) of these strokes were labeled POA. These POA strokes were either preoperative or intraoperative events. Proportion of symptomatic patients ranged from 7% to 16% for CEA and from 5% to 22% for CAS. Perioperative stroke rate was the lowest in the POA method (1.1% CEA, 1.8% CAS) compared with two other methods without POA information (1.4% and 9.5% CEA and 2.4% and 16.4% CAS). Kappa indicated a poor (0.2) to fair (0.7) agreement between these approaches. Administrative data has known limitations for assignment of symptom status and nonfatal perioperative outcomes. Given the uncertain timing of POA events as preoperative vs intraoperative and its apparent underestimation of the perioperative stroke rate, the use of administrative data even with the POA indicator for symptom status and non-fatal outcomes after CEA and CAS is hazardous.

Risk factors for ipsi- and contralateral cerebral ischemic lesions after carotid artery stenting with embolic protection

Objective: We aimed to identify factors predictive for new ipsi- and contralateral cerebral ischemic lesions during embolic protected carotid artery stenting (CAS). Background: Carotid endarterectomy and CAS appear to have similar overall perioperative stroke rates, which, however, may differ in specific patient subgroups. Knowledge of the risk factors for cerebral embolic events during CAS may impact treatment decisions for the individual patient, but have not been extensively studied. Aim of the study: To evaluate the risk factors for cerebral embolization after carotid artery stenting with embolic protection. Methods: Out of 837 consecutive patients undergoing CAS with cerebral embolic protection pre- and post-procedural diffusion weighted magnetic resonance imaging (DW-MRI) was performed for evaluation of new cerebral ischemic lesions in 728 patients (86.9%). Multivariate logistic regression analyses were performed to identify factors predictive for embolic events. Results: New ischemic lesions were found in 32.8% of the patients. Age, hypertension, lesion length, lesion excentricity, and aortic arch type III were significantly associated with new ischemic lesions, calcified lesions were negatively associated. In 25% of patients with embolic events lesions were also found in the contralateral hemisphere. Predictive factors for contralateral lesions were age, > 50% stenosis of the contralateral internal carotid artery, and an aortic arch type II, with a trend for aortic arch type III. Conclusions: Age, hypertension, lesion morphology, and aortic arch type were predictive for procedural related cerebral embolic events during embolic protected CAS. Age, significant contralateral carotid stenosis and complex aortic arch type were predictive for contralateral ischemic events. These findings may help to find the optimal treatment decision for the individual patient with carotid artery stenosis.

Anaortic Off-Pump Coronary Artery Bypass Grafting in the Elderly and Very Elderly

Elderly patients undergoing surgical revascularisation may disproportionately benefit from avoiding manipulation of the ascending aorta and cardiopulmonary bypass. In this multi-centre observational study, we sought to determine the 30-day outcomes of anaortic off-pump coronary artery bypass (OPCAB) in an elderly and very-elderly population. Data were prospectively collected for all patients aged >70 years old (y) undergoing anaortic OPCAB at three hospitals between January 2002 and October 2011. Analysis was carried out on two age sub-groups (70-79 y vs. ≥80 y). Multiple logistic regression was used to identify predictors of post-operative 30-day mortality. In total, 1135 patients >70 years underwent anaortic OPCAB - 817 (72%) patients were aged 70-79 y while 318 (28%) were aged ≥80 y. The rate of mortality and morbidity for both groups was low: 30-day mortality (70-79 y: 1.8%; ≥80 y: 2.8%) or permanent stroke (70-79 y: 0.2%; ≥80 y: 0.9%). Chronic lung disease, a history of previous myocardial infarction and left main disease were independent predictors of 30-day mortality. OPCAB is associated with low rates of 30-day mortality and peri-operative stroke in this elderly and very elderly patient cohort. Anaortic OPCAB can provide excellent short-term post-operative outcomes and may give the elderly and very elderly population the opportunity to benefit from surgical coronary revascularisation.

Invited commentary

There has been recent renewed scrutiny into the appropriateness of performing prophylactic interventions on patients with severe asymptomatic carotid artery atherosclerotic plaque to prevent future strokes. Prophylactic carotid endarterectomy (CEA) has been demonstrated in several randomized, prospective trials to provide superior stroke prevention compared with contemporaneous medical therapies in patients with severe carotid artery stenosis. However, ongoing current discussions have focused on the premise that the incidence of ischemic stroke may be decreasing and the hypothesis that improved pharmacologic therapies, such as statin medications, may be responsible for the decreasing stroke rate. If one were a proponent of these hypotheses, it would be natural to conclude that the risk-benefit balance with regard to surgical treatment of asymptomatic severe carotid artery atherosclerosis might have indeed tipped toward the medical therapy side of the seesaw. Nevertheless, stroke remains the fourth leading cause of death in the United States and the leading cause of long-term disability and institutionalization. Stroke represents a major worldwide patient and economic burden. The treatment of stroke, once it has occurred, is generally unsuccessful. Clearly, all physicians would be eager for improved tools to designate those patients at highest risk for stroke as well as for enriched stroke-prevention strategies and methods. With regard to prophylactic carotid endarterectomy (CEA) in asymptomatic patients, knowledge about the patient's long-term survival is critical to properly evaluate whether a patient will derive potential benefit from prophylactic surgical intervention. In this regard, the current study from the Vascular Study Group of New England provides important data for the clinician who evaluates patients with carotid artery disease. A large cohort of asymptomatic patients who underwent CEA was evaluated, and the perioperative stroke and mortality rates were extremely low. More than 80% of the patients who underwent CEA achieved 5-year survival after their surgery. On the basis of randomized, prospective data, this should theoretically be long enough to attain stroke-prevention benefit in appropriately selected asymptomatic patients. A patient should probably not be considered for prophylactic CEA if his or her individual life expectancy is felt to be <3 years. However, 5% of the patient cohort was deemed to be at “high risk” for early death because of comorbid conditions; only 51% of patients in this category would be expected to achieve 5-year survival. In addition, 68% of patients who underwent CEA were deemed “moderate risk,” and only 80% of the patients in this category would be expected to achieve 5-year survival. Clearly, there is room for improvement in patient selection in this regard. The major risk factors for early mortality included advanced age ≥80 years (hazard ratio, 3.94) and dialysis-dependent renal failure (hazard ratio, 3.41); these are not unexpected findings. Unfortunately, the current report is somewhat less successful in discriminating the relative contribution of more “minor” risk factors for death, including congestive heart failure, chronic obstructive pulmonary disease, insulin-dependent diabetes, and the degree of contralateral carotid artery stenosis. Most patients who are evaluated for asymptomatic carotid artery disease will be aged <80 years and not in dialysis-dependent failure; most will also likely have at least one “minor” risk for early mortality, placing them in the “moderate-risk” category according to the risk stratification system derived by the authors. Nevertheless, the current data do provide a valid framework for clinicians to contemplate when choosing appropriate asymptomatic patients for CEA. In addition to considering the degree of stenosis, other anatomic and morphologic characteristics, and the individual patient's risk of perioperative complications after surgery, it is critical for the surgeon to weigh the patient's long-term survival in order to achieve an appropriate stroke-prevention benefit. Certainly, patients deemed at “high risk” for early mortality should probably not be considered for prophylactic CEA, and patients at “moderate risk” need to be carefully considered. Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survivalJournal of Vascular SurgeryVol. 58Issue 1PreviewAlthough carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis. Full-Text PDF Open Archive

Patching plus extended exposure and tacking of the common carotid cuff may reduce the late incidence of recurrent stenosis after carotid endarterectomy

The safety and durability of carotid endarterectomy (CEA) require attention to certain technical details that may evolve over time. The objective of this study was to determine whether routine patch angioplasty and precautions related to the common carotid cuff could reduce the risks for perioperative stroke, internal carotid artery (ICA) thrombosis, or recurrent carotid stenosis. The senior author (N.H.) performed 1959 consecutive isolated CEAs at the Cleveland Clinic from 1976 to 2004. This series can be divided into three distinct eras with respect to patching and management of the proximal common carotid cuff: (1) primary arteriotomy closure with selective patching in only 38 of 653 CEAs (5.8%) from 1976 to 1983 (group 1); (2) routine patching without any special precautions related to the common carotid cuff in 568 CEAs from 1983 to 1990 (group 2); and (3) routine patching with extended exposure and tacking sutures to secure the carotid cuff in 738 CEAs from 1990 to 2004 (group 3). Although vein patching alone seemed to have less risk for perioperative stroke (1.2% vs 2.4%) or ICA thrombosis (0.6% vs 1.8%) than primary closure, these differences did not attain statistical significance. There also were no significant differences in the perioperative stroke and ICA thrombosis rates among the three eras in which changes occurred in patch use and in the management of the carotid cuff. After adjusting for the various lengths of follow-up in the study groups, however, group 3 had a significantly lower risk for recurrent 60% to 99% stenosis or ICA occlusion at >5 years after CEA (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.04-0.22; P < .001). On multivariable analysis, group 3 (OR, 0.23; 95% CI, 0.09-0.60; P = .003) and advancing age (OR, 0.89 per year; 95% CI, 0.85-0.92 per year; P < .001) had less risk for late recurrent stenosis, whereas this risk was higher in women (OR, 2.23; 95% CI, 1.23-4.06; P = .009) and in patients who had undergone previous ipsilateral CEA (OR, 6.02; 95% CI, 1.63-22.2; P = .007). Routine patching plus extended exposure and tacking of the common carotid cuff appear to significantly reduce the long-term incidence of recurrent 60% to 99% stenosis or ICA occlusion after CEA.

Anaesthetic techniques to prevent perioperative stroke

Different techniques and interventions that can be used by an anaesthesiologist to minimize the perioperative stroke risk are summarized. The most important risk factors for perioperative stoke are not modifiable, for example previous stroke or renal failure, but they can be used to identify patients with a high risk for perioperative stroke. The antiplatelet therapy should be continued in patients with a high risk for cardiovascular thrombosis. This might be true even for operations in which bleeding should be strictly avoided such as eye surgery. One of the most recent neuroprotective approaches is the remote ischaemic preconditioning. Perioperative stroke increases morbidity and mortality of patients undergoing surgery and is therefore highly relevant. Neuromonitoring should be used to detect a deterioration of cerebral blood flow and oxygen supply immediately. Statins which are initiated at least 2 weeks before the operation can possibly reduce the perioperative stroke rate. Routinely taken statins should not be terminated and this is also true for β-blockers. The cerebral perfusion pressure should be kept at baseline levels, whereas a mild hypercapnia theoretically could be beneficial. Hypoglycemia has to be avoided while treatment of high blood glucose levels should be started when they exceed 150 mg/dl. The anesthesia for patients with a high risk for stroke has always to be performed by an experienced anaesthesiologist who is able to individualize the therapeutic interventions.