Postoperative Stroke Research Articles

Incidence Rate of Post Coronary Artery Shunt Complications; Age Dependent!

Numerous complications, such as postoperative arrhythmia and stroke, have been observed following coronary artery bypass graft (CABG) surgery. This study sought to examine the impact of aging on the incidence of post-coronary artery shunt complications. Aging is a physiological process experienced by every living cell, beginning early in development. Age plays a crucial role in determining postoperative complications, including those related to CABG. A retrospective analysis was conducted on 290 patients who underwent CABG at the Mordovian Republic Hospital between 2017 and 2021. The sample was divided into two age-based groups: the first group comprised 126 patients (mean age range: 55.21-60.00), and the second group included 163 patients (mean age range: 66.11-80.00). Statistical analyses employed in this study encompassed descriptive statistics, Chi-square test, T-test, one-way ANOVA test, ROC analysis, and Pearson correlation using Statistica 12 software. Elderly patients in the second group demonstrated a higher incidence of post-CABG arrhythmia (p < 0.012528). Moreover, the second group experienced markedly longer ICU and total hospitalization days following CABG, with p-values of less than 0.000000 and 0.000072, respectively. Notably, elderly individuals in the second group faced an increased risk of developing psychosis after CABG surgery (p < 0.007379). Furthermore, psychosis was found to be significantly associated with longer ICU hospitalization (p < 0.000140). Postoperative stroke occurred more frequently among the elderly (second group) with a p-value of less than 0.037736. Consequently, postoperative stroke was associated with extended ICU hospitalization (p < 0.000747). The usage of internal thoracic arteries (ITAs) was lower among the elderly (second group), with a p-value of less than 0.016145. Regarding correlations, a direct association was observed between age and ICU days, total hospitalization days, and the number of complications, with correlation coefficients (r) of 0.189046, 0.141415, and 0.138565, respectively. Elderly individuals in the second group who undergo CABG face a greater risk of developing psychosis, arrhythmia, prolonged total and ICU hospitalization, and stroke. The presence of arrhythmia, which is commonly observed in patients aged 63 years and older, significantly affects total hospitalization days. The number of complications is influenced by age, cardiopulmonary bypass (CPB) time, aortic cross-clamp time, ICU hospitalization, and total hospitalization duration.

Gender differences in perioperative complications following carotid endarterectomy: A retrospective analysis

Aim: This study aims to examine the distribution of major complications in patients undergoing carotid endarterectomy (CEA) based on gender. The primary objective is to assess the potential effects of gender on perioperative events in hospital. Material and Methods: At Başakşehir Çam and Sakura City Hospital, patients aged 18 and over who underwent CEA between September 2020 and November 2023, were retrospectively analyzed. The patients were categorized into two groups based on their gender. Patient characteristics were obtained from electronic medical records. Postoperative stroke, surgical revision, hematoma, and nerve injury were defined as perioperative events. Results: In this study, the average age of the 225 evaluated patients was found to be 65.8 ± 8.89. There were 73 female patients (32.44%) in Group 1 and 152 male patients (67.56%) in Group 2. Two patients (0.9%) experienced a stroke during the perioperative period. Hematomas were present in 24 patients (10.7%), and nerve damage was also observed in 15 patients (6.7%). Surgical revision due to bleeding was required in thirteen patients (5.8%). Perioperative events were observed in 27 patients. Perioperative events were significantly higher in men than in women (p=0.037). In multivariate logistic regression analysis, male gender was found to be the predictor of perioperative events (odds ratio [OR]: 3.701;95% CI: 1.145-11.963, p=0.029). Conclusion: Our results showed that male gender may be a predictor of perioperative events in patients undergoing carotid endarterectomy. Multicenter and larger study groups may be needed for healthier results.

Efficacy and safety of drug-eluting stents versus bare-metal stents in symptomatic intracranial and vertebral artery stenosis: a meta-analysis

ObjectivesThis study aims to present the first comprehensive meta-analysis assessing the effectiveness and safety of drug-eluting stents (DES) versus bare-metal stents (BMS) in treating intracranial and vertebral artery stenosis.MethodsA comprehensive examination was undertaken to compare the effectiveness and safety of DES and BMS in individuals experiencing symptomatic stenosis in the intracranial and vertebral arteries through an in-depth analysis of clinical research. We conducted an extensive search across multiple databases including PubMed, Embase, Web of Science, and the Cochrane Library up to September 2024. The emphasis of our investigation was on various outcomes including rates of in-stent restenosis, symptomatic occurrences of in-stent restenosis, incidence of stroke, procedural success, mortality rates, complications associated with the procedure, and any adverse events.ResultsOur analysis included 12 studies with a total of 1,243 patients (562 in the DES group and 681 in the BMS group). The findings demonstrated a significantly lower rate of in-stent restenosis in the DES group for both intracranial [odds ratio (OR): 0.23; 95% confidence interval (CI): 0.13 to 0.41; p &amp;lt; 0.00001] and vertebral artery stenosis (OR: 0.38; 95% CI: 0.20 to 0.72; p = 0.003) compared to the BMS group. Additionally, the DES group showed a significantly reduced rate of postoperative strokes in vertebral artery stenosis cases (OR: 0.38; 95% CI: 0.16 to 0.90; p = 0.03), with no significant differences noted in the intracranial artery stenosis comparison (OR: 0.63; 95% CI: 0.20 to 1.95; p = 0.42). The study also revealed no significant disparities in symptomatic in-stent restenosis, procedural success, mortality, adverse effects, and perioperative complications between the two groups across the conditions studied.ConclusionThe comparison indicates that DES significantly reduces the risk of in-stent restenosis and postoperative strokes in patients with vertebral artery stenosis, compared to BMS. For both intracranial and vertebral artery stenosis, DES and BMS exhibit comparable safety profiles.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=439967.

The safety of cell saver washing all shed mediastinal blood before re-transfusing it to the patient.

Cardiotomy suction blood is used in cardiopulmonary bypass (CPB) surgery to maintain blood volume in the CPB system, although it is known to contain micro emboli, cytokines and free plasma hemoglobin. Our aim was to investigate whether cell saver washing the cardiotomy suction blood before re-transfusing it is safe. This is a retrospective study of 1671 elective coronary artery bypass patients, 209 of whom had their pericardial blood processed in a cell saver (Ce-S group). PS matching was performed with patients who had their pericardial blood returned back to the CPB-system by the cardiotomy suction (Ca-S group). Perioperative transfusion requirements, surgical outcome, postoperative lab data and mortality were then compared. There were no differences in baseline characteristics or EuroSCORE between the groups. The number of patients requiring transfusions did not differ, but the patients in the Ca-S group received more platelets (0.34 ± 1.0 vs 0.16 ± 0.7 units, p = .03) than in the Ce-S group. CRP (c-reactive protein) levels at day 2 and 4 were higher in the Ca-S group (174.8 ± 67.2 and 148.9 ± 74.3mg/L vs 160.1 ± 64.6 and 125.9 ± 67.2mg/L, p = .03, p = .002) and so were ASAT (aspartate aminotransferase) levels (0.97 ± 0.8 vs 0.81 ± 0.6μkat/L, p = .03). Mortality, postoperative ventilation time, stroke, mediastinal infections and length of stay in the ICU were the same in both groups. In this retrospective study of patients undergoing elective CABG surgery, washing the cardiotomy suction blood before re-transfusion was not associated with higher risk of allogenic blood transfusion, postoperative stroke, mediastinal infections, or 30- and 365-days mortality. LU EPN 2016/4.

Total arterial revascularization with RIMA-LIMA-Y configuration in patients with left subclavian artery stenosis.

Subclavian artery stenosis (SAS) occurs in 6% of patients undergoing coronary artery bypass grafting (CABG). Complications such as subclavian-coronary steal are common. Revascularization options in such cases remain debatable. In this case series, all patients with angina, had severe triple vessel disease on angiography. All tests including computed tomography (CT) angiography of neck vessels, were done as part of routine workup for CABG. The patients, all males, had a mean age of 66.5 years with three of them having hypertension and diabetes. All were ex-smokers with mean ejection fraction (EF) of 60.1%. CT angiography of neck vessels revealed that two patients had moderate to severe while one had severe left SAS and another had severe proximal left internal mammary artery (LIMA) stenosis. Total arterial revascularization was performed, with an average of 3.5 distal grafts. The LIMA graft was employed in a Y graft configuration, anastomosed to in-situ right internal mammary artery (RIMA). All patients had uneventful postoperative stay and were discharged with a mean hospital stay of 3.8 days. There were no postoperative strokes, myocardial infarction, neurological symptoms, or change in EF. At 6-month follow-up, they were asymptomatic and doing well. The RIMA-LIMA-Y configuration can be a safe, viable option in CABG for patients with left SAS. It is challenging, with re-entry and judicious utilization of the length of LIMA being of paramount importance. The importance of CT angiography of neck vessels to detect SAS cannot be under-emphasized.

An overview of the relationship between inflammation and cognitive function in humans, molecular pathways and the impact of nutraceuticals

Inflammation has been associated with cognitive decline, whether in the peripheral or central nervous systems. The primary mechanism involves the response of microglia, an immune cell in the brain, which generates pro-inflammatory mediators such as cytokines, chemokines, and adhesion molecules. The excessive production of pro-inflammatory mediators may accelerate the damage to neurons, contributing to the development of neurodegenerative diseases such as Alzheimer’s disease, mild cognitive impairment, and vascular dementia, as well as a general decline in cognitive function. Various studies have supported the correlation between elevated pro-inflammatory mediators and a decline in cognitive function, particularly in aging and age-related neurodegenerative diseases. Moreover, this association has also been observed in other inflammatory-related conditions, including post-operative cognitive impairment, diabetes, stroke, obesity, and cancer. However, the interaction between inflammatory processes and cognitive function in humans remains unclear and varies according to different health conditions. Therefore, this review aims to consolidate and evaluate the available evidence from original studies as well as meta-analyses in order to provide a greater understanding of the inflammatory process in connection with cognitive function in humans. Furthermore, relevant biological cellular processes, putative inflammatory biomarkers, and the role of nutraceuticals on the interaction between cognitive performance and inflammatory status are outlined.

Aortic arch replacement in patients with previous repair of acute aortic dissection: a systematic review and meta-analysis.

Despite the popularity of the frozen elephant technique procedure in recent years, evidence is scarce regarding its utilisation for aortic arch replacement following previous acute aortic dissection repair. In this systematic review and meta-analysis, we aimed to analyse clinical outcomes of aortic arch replacement in patients with previous repair of acute aortic dissection. A systematic literature search on PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science until March 2024 was performed for studies on open aortic arch replacement with or without frozen elephant technique procedure in adult patients after previous acute aortic dissection repair. Early and late postoperative mortality were primary, while postoperative complications were outcomes of interest. Additionally, a meta-analysis was performed to pool the early and late postoperative mortality. A total of 574 studies were identified, of which 9 studies including a total of 677 patients met the eligibility criteria. In-hospital or 30-day postoperative mortality and stroke were 0-17.5% and 0-7.7%, respectively. Duration of follow-up across all studies varied from 1.1 to 5.1 years. All-cause late mortality rate ranges from 5.9-30.5%. Aortic reintervention rate was 4.8-38.7%. The pooled early and late mortality rate were 8.7% ([95% CI: 5.7-13%], I2=52%) and 24.9% ([95% CI: 19.5-31.1%], I2=54%), respectively. Current evidence suggest that relatively younger patients with chronic post-dissection aneurysm or residual aortic dissection after acute aortic dissection repair can undergo an aortic arch replacement by a dedicated aortic team with acceptable mortality risk. However, postoperative neurological deficit remains an issue.

Distance from the midline to the aneurysm as simple predictor of ischemic complication with small unruptured middle cerebral artery aneurysm surgery

BackgroundThis study aimed to clarify the risk factors for postoperative cerebral infarction in surgical clipping for prevalent small middle cerebral artery aneurysms (MCA Ans). MethodsThis retrospective study included 246 patients (mean age, 64.8 ± 10.0 years; 25.6% males, 74.4% females) with 258 aneurysms (mean aneurysm size, 5.4 ± 2.4mm) who underwent direct surgery for unruptured MCA Ans at our institution from January 2015 to December 2020. All surgeries were performed under general anesthesia, incorporating indocyanine green videoangiography and transcranial motor-evoked potentials to enhance surgical precision and safety. The occurrence of surgery-related cerebral infarction was evaluated using postoperative CT scans within one week, comparing them with preoperative images. Patients were categorized based on the presence or absence of postoperative stroke and were analyzed for age, sex, past medical history, aneurysm size, number of clips used, and distance from the midline to the aneurysm. ResultsSeventeen patients had postoperative cerebral infarction (6.6%, symptomatic 6, asymptomatic 11). There were no significant differences in terms of age, number of clips, or aneurysm size between the two groups; however, the distance from the midline to the aneurysm was significantly shorter in the stroke group (27.1 ± 4.7mm; p < 0.001), with a cutoff value of 29mm using the receiver operating characteristic curve. ConclusionSurgical clipping for MCA Ans presents a high risk of cerebral infarction for aneurysms located closer to the midline, emphasizing the importance of considering aneurysm location as a risk indication in surgical clipping.

The impact of preoperative four-chamber strain on failure of the maze IV procedure for atrial fibrillation: insights from conventional and speckle-tracking echocardiography

Abstract Background Prior studies have linked decreased left atrial (LA) and left ventricular (LV) function to the failure of both catheter ablation and surgery for atrial fibrillation (AF). Yet, the effects of right atrial (RA) and right ventricular (RV) function on the failure of interventional therapy remain unexplored. This study evaluates four-chamber strain parameters using conventional echocardiography and speckle-tracking analysis to evaluate the contributions of preoperative left heart and right heart function to the failure of surgery for atrial fibrillation. Methods We retrospectively analyzed 821 patients who had surgical AF ablation, using pre- and postoperative data from electronic records to assess AF recurrence and thromboembolic events. Of these, 531 had LA ablation only and 290 had bi-atrial Maze-IV procedures. Four-chamber strain was evaluated via speckle-tracking on preoperative echos with TomTec Arena, excluding low-quality images. Univariate and multivariate logistic regression analyses were conducted to assess the influence of AF duration, LV ejection fraction, age, and gender on post-PAF surgery AF recurrence, thromboembolic events with results shown as odds ratios (ORs) in the table. An OR over 1.00 indicates a higher recurrence risk per variable increment. SAS software was used for all statistical analysis. Results In our cohort with a median age of 67.4±11.0 (46.2% female), unadjusted analyses revealed that increased LA and RA volumes and decreased RV free wall strain were significantly associated with AF recurrence post-surgical ablation. Conversely, each unit decrease in LA and RA peak reservoir strain corresponded to a 6% increase in the risk of AF recurrence, indicating an inverse relationship. Adjusted analyses for LA and RA end diastolic volumes and strain values showed a similar direction of association with AF recurrence, though these were not statistically significant. Similarly, lower LA and RA peak strains and larger atrial volumes were suggestive of an increased risk for postoperative thromboembolic stroke, but did not reach statistical significance, potentially due to the low event rate (1.8% of the cohort). Conclusion Conventional echocardiography offers a practical tool for identifying patients at high risk for AF recurrence and potential thromboembolic events after AF ablation surgery. Our study confirms that reduced preoperative LA, RA and RV strain values and enlarged volumes of LA and RA are strongly associated with AF recurrence following surgical ablation. Additionally, RA strain and volume are as predictive as LA metrics, underscoring their importance in risk stratification. These echocardiographic parameters may also hold value in forecasting the likelihood of postoperative stroke.

Machine Learning Assisted Stroke Prediction in Mechanical Circulatory Support: Predictive Role of Systemic Mitochondrial Dysfunction.

Stroke continues to be a major adverse event in advanced congestive heart failure (CHF) patients after continuous-flow left ventricular assist device (CF-LVAD) implantation. Abnormalities in mitochondrial oxidative phosphorylation (OxPhos) have been critically implicated in the pathogenesis of neurodegenerative diseases and cerebral ischemia. We hypothesize that prior stroke may be associated with systemic mitochondrial OxPhos abnormalities, and impaired more in post-CF-LVAD patients with risk of developing new stroke. We studied 50 CF-LVAD patients (25 with prior stroke, 25 without); OxPhos complex proteins (complex I [C.I]-complex V [C.V]) were measured in blood leukocytes. Both at baseline (pre-CF-LVAD) and postoperatively (post-CF-LVAD), the prior-stroke group had significantly lower C.I, complex II (C.II), complex IV (C.IV), and C.V proteins when compared to the no-prior-stroke group. Oxidative phosphorylation proteins were significantly decreased in prior-stroke group at post-CF-LVAD compared to pre-CF-LVAD. Machine learning Least Absolute Shrinkage and Selection Operator (LASSO) and Random Forest modeling identified six prognostic factors that predicted postoperative stroke with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.93. Oxidative phosphorylation protein reduction appeared to be associated with the new stroke after implantation. Our study found for the first time the existence of mitochondrial dysfunction at the peripheral level in CHF patients with prior ischemic stroke even before CF-LVAD implantation. The changes in OxPhos protein expression could serve as biomarkers in predicting new post-CF-LVAD strokes.

CO2 delivery techniques in mini-sternotomy surgery and neurological events: a multicentric study

BackgroundThe impact of air bubbles into the cerebral circulation after open heart surgery has been a topic of discussion since the introduction of the heart-lung machine. The aim of the study was to evaluate whether the use of a dedicated commercial sponge diffuser is better than a custom-made narrow section cannula or the absence of CO2 in preventing neurological events after aortic valve replacement via J mini-sternotomy.MethodsThree cohorts of J-shaped mini-sternotomy performed at three different centers were prospectively compared: CO2 supplied via sponge diffuser, CO2 supplied via cannula, and no CO2 supply. Propensity matching was used to obtain comparable groups. The primary endpoints were postoperative stroke, transitory ischemic attack, convulsions, and dizziness. Secondary endpoints were 30-day mortality, duration of mechanical ventilation, and intensive care unit length of stay.Results275 patients were enrolled in the study. After propensity matching, the sponge diffuser cohort had a significantly lower duration of mechanical ventilation (P < 0.001) and 30-day mortality (P = 0.05) when compared to the cannula cohort and the no-CO2 cohort, a lower incidence of all neurological events (P = 0.03) and dizziness (P = 0.05) when compare to the no-CO2 cohort, and a lower intensive care unit length of stay when compared to the cannula cohort (P = 0.001).ConclusionsThe sponge diffuser used to deliver the CO2 into the surgical field during aortic valve replacement via J mini-sternotomy has been demonstrated to guarantee better neurological outcomes compared to a custom-made narrow section cannula or the absence of CO2.

Surgical Management of Penetrating Carotid Artery Injury: Preoperative Level of Consciousness Does Matter.

The optimal surgical management of penetrating carotid artery injuries (PCAI) remains controversial. This study aimed to examine the association between operative techniques for PCAI and the incidence of stroke. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program (2016-2021) database. We included patients (≥16 years old) with severe penetrating injuries to the common or internal carotid arteries (CCA/ICA) who underwent one of the following operative procedures: primary suture repair, ligation, and arterial reconstruction with a graft. Multivariate logistic regression analysis with cluster-adjusted robust standard errors was performed to estimate the adjusted odds ratio (AOR) for postoperative stroke stratified by the initial Glasgow Coma Scale (GCS). A total of 429 patients were included (329 underwent primary suture repair, 82 underwent ligation, and 81 underwent arterial reconstruction with a graft). The median age was 31 years (interquartile range [IQR]: 24-43) and median GCS on arrival was 11 (IQR: 3-15). On multivariate analysis after adjusting for potential confounders, ligation of CCA/ICA was significantly associated with increased odds of stroke in patients with initial GCS ≥9 (AOR: 4.40, 95% confidence interval [CI]: 1.16-16.58, p=0.029), whereas there was no significant association in patients with GCS <9 (AOR: 0.77, 95% CI: 0.28-2.11, p=0.37). No significant association was identified between arterial reconstruction with a graft and stroke, irrespective of the initial GCS. The study findings suggest that the preoperative level of consciousness may help in planning operative strategies for PCAI. In patients with an initial GCS ≥ 9, definitive repair of the CCA/ICA, including arterial reconstruction with a graft, should be pursued instead of ligation.

Early injection laryngoplasty for acute unilateral vocal fold paralysis after thoracic aortic surgery

ObjectiveUnilateral vocal fold paralysis (UVFP) following open thoracic aortic surgery increases pulmonary complications and hospital stays. An intervention protocol with early injection laryngoplasty (IL) and swallowing maneuvers was developed for acute UVFP following thoracic aortic surgery. This study aimed to compare the incidence of complications and length of medical care between the non-VFP and the IL-UVFP group managed under this protocol. MethodsPatients who underwent open thoracic aortic surgery from March 2020 to February 2023 were included, excluding those with preoperative VFP or postoperative bilateral VFP. Under the protocol, patients with UVFP and incomplete glottic closure received IL and swallowing maneuvers within one week after diagnosis, while those without a glottic gap started a soft diet along with swallowing maneuvers. Postoperative complications, including reintubation, ICU re-transfer, pneumonia, stroke, delirium, wound infection, and bleeding, as well as hospital and ICU stay, were assessed. ResultsOf the 355 patients included in the study, 51 (14.4%) developed postoperative UVFP, while 304 (85.6%) had normal VF function. In the UVFP group, 42 patients underwent IL, while 9 patients without a glottic gap did not undergo IL. The incidence of complications and length of medical care were analyzed in the non-VFP and the IL-UVFP groups. The IL-UVFP group had a longer median hospital stay compared to the non-VFP group (20.5 vs. 16.0 days), though this difference was not statistically significant (P = .0681). ICU stay (P = .5396) and ICU re-transfer rates (P = 1.00) were also comparable between the groups. There was no significant difference in the incidence of pneumonia between the IL-UVFP group (4.8%) and the non-VFP group (9.5%) (P = .4003). Additionally, no significant differences were observed in the incidence of stroke, delirium, wound infection, or bleeding between the groups. No IL-related complications were reported. ConclusionsThe protocol with early IL appears to help reduce complication rates in acute UVFP patients following thoracic aortic surgery to levels comparable to those in patients without VFP. This protocol could serve as a guideline for otolaryngologists in managing UVFP patients. Level of evidence2b/Individual cohort study.

Results of Carotid Endarterectomy Performed at Different Times During the Acute Period of Ischemic Stroke

AIM OF STUDY. To compare the results of carotid endarterectomy performed at different times (1st, 2nd and 3rd week) of the acute period of ischemic stroke.MATERIAL AND METHODS. In the acute period of ischemic stroke (1–21 days), 92 patients with symptomatic stenosis of the internal carotid artery of 50% or more were operated on using carotid endarterectomy . There were 66 men and 26 women. The average age was 65.7±8.4 years. All patients were divided into three groups depending on the timing of the operation: Group 1, where the operation was performed on the 1st week of stroke (n=48); Group 2, where the operation was performed on the 2nd week after stroke (n=28); Group 3, where carotid endarterectomy was performed on the 3rd week after stroke (n=16). In-hospital endpoints of the study in each group were ipsilateral ischemic stroke, any other stroke (contralateral ischemic or hemorrhagic), myocardial infarction, wound hemorrhagic complications requiring repeated operation and surgical hemostasis, death, and major adverse cardiovascular events (stroke + myocardial infarction + fatal outcome).RESULTS. There were no postoperative ipsilateral ischemic strokes, myocardial infarctions, or deaths in the study group (92 patients). In the overall group of patients (n = 92), the incidence of any postoperative stroke was 2.2% (2 patients): one hemorrhagic stroke on the side of carotid endarterectomy (group 3) and one contralateral ischemic stroke on the first postoperative day in a patient with bilateral critical stenosis of the internal carotid artery (group 1). Postoperative wound hematoma, which required revision and bleeding arrest in the early postoperative period, developed in one (1.1%) patient in Group 1. The overall incidence of major adverse cardiovascular events was 2.2% or 2 patients. In all three groups, a statistically significant and positive effect in regression of the initial neurological deficit was obtained at discharge. In patients operated in the first week after stroke, the neurological deficit at discharge according to the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale was the lowest. In general, 31.3%, 17.9% and 12.5% of patients in groups 1, 2 and 3 were discharged without neurological deficit (0 points according to the NIHSS scale), respectively.CONCLUSIONS. Carotid endarterectomy performed in the acute period of ischemic stroke is a safe surgical intervention in the prevention of recurrent ipsilateral ischemic events. The most positive neurological dynamics and the least neurological deficit at discharge were achieved after operations performed in the first week of ischemic stroke.

Locoregional Versus General Anesthesia in Prolonged Carotid Endarterectomy: A Propensity Score-Matched Study from the American College of Surgeons National Surgical Quality Improvement Program Database from 2011 to 2022

BackgroundCarotid endarterectomy (CEA) is an effective treatment for carotid stenosis. Previous studies yielded conflicting findings regarding postoperative outcomes after CEA when comparing those under general and locoregional anesthesia. However, these findings may be influenced by an inherent selection bias, as general anesthesia is frequently selected for more complex CEA. To counteract this selection bias, this study compared the 30-day outcomes of locoregional and general anesthesia in patients who underwent prolonged CEA. MethodsAdult patients undergoing CEA were identified in ACS-NSQIP targeted database from 2011-2022. Only cases with prolonged operative times (over third quartile) were selected. Patients who had symptomatic and asymptomatic carotid stenosis were examined separately. A 1:3 propensity-score matching was used to address pre-operative differences between patients under locoregional and general anesthesia to assess thirty-day postoperative outcomes. Moreover, factors associated with prolonged CEA were identified by multivariable logistic regression. ResultsAmong symptomatic patients who underwent prolonged CEA, 246 and 4,286 were under locoregional and general anesthesia, respectively. In asymptomatic patients, 388 had locoregional anesthesia and 5,137 had general anesthesia. After propensity-score matching, patients under locoregional and general anesthesia had comparable 30-day mortality (symptomatic: 1.63% vs 0.81%, p=0.28; asymptomatic: 0.77% vs 0.52%, p=0.70) and stroke (symptomatic: 4.88% vs 4.34%, p=0.72; asymptomatic: 1.29% vs 1.46%, p=1.00). All other 30-day outcomes were comparable between groups, except for symptomatic patients under locoregional had shorter operation time (p<0.01) and asymptomatic patients under locoregional had lower cranial nerve injury (2.06% vs 4.90%, p=0.02). High-risk anatomical factors, male sex, younger age, and certain comorbidities were associated with prolonged operative times. ConclusionPatients under both types of anesthesia had mostly comparable 30-day postoperative outcomes, including mortality and stroke, for both symptomatic and asymptomatic patients. Therefore, locoregional and general anesthesia appear to be equally effective in CEA cases characterized by anticipated complexity and, consequently, prolonged operative times.

Moderate hypothermia circulatory arrest as a brain-protective strategy for type A aortic dissection.

Brain-protective strategies for acute type A aortic dissection (TAAD) remain controversial. Moderate hypothermia circulatory arrest (MHCA) without cerebral perfusion is not commonly used. However, we aimed to assess its safety and efficacy in 358 patients who underwent hemiarch replacement with MHCA for acute type A aortic dissection at our institution from August 2012 to August 2022. Clinical outcomes were compared according to circulatory arrest time [≤15 min (S group, n = 52) vs ≥16 min (L group, n = 306)]. The primary outcome was postoperative stroke. The S group had more older patients (72.5 vs 68.8 years; P = 0.04), a greater incidence of carotid artery malperfusion (21% vs 11%; P = 0.043) and a lower body mass index (21.7 vs 23.6 kg/m2; P < 0.01) and hemodynamic instability (3.8% vs 16%; P = 0.02) than the L group. The incidence of postoperative stroke (7.7% vs 12%; P = 0.33) and the rate of 30-day mortality (5.8% vs 6.5%; P = 0.83) did not significantly differ between groups. After adjusting for all potential confounding factors pre- and intraoperatively, there was no significant difference in postoperative outcomes between groups. MHCA alone for TAAD had comparable postoperative outcomes with circulatory arrest times under and over 15 min. However, longer arrest times were associated with a higher risk of stroke.

The Impact of Epiaortic Ultrasound utilization in patients undergoing Coronary Artery Bypass Grafting

To assess whether use of epiaortic ultrasound for assessment of aortic calcification impacts the rate of postoperative stroke following coronary artery bypass grafting (CABG). This was a retrospective study using an institutional database of CABGs performed from 2010 to 2023. All patients undergoing isolated index CABG were included. Patients were dichotomized according to the use of epiaortic ultrasound for intraoperative aortic assessment. Postoperative stroke rates were compared, and multivariable logistic regression for postoperative stroke was performed. Cox regression was performed for the multivariable analysis of mortality. A total of 10,049 patients underwent isolated index CABG. Intraoperative epiaortic ultrasound was utilized in 1,572 (15.6%) of these patients. The STS predicted risk of stroke was 1% and did not differ between the two groups. Postoperative stroke occurred in 13 patients in the epiaortic ultrasound group (0.8%) versus 116 patients in the group in which epiaortic ultrasound was not used (1.4%, p=0.08). On multivariable logistic regression, use of epiaortic ultrasound was not associated with a reduced odds of postoperative stroke (OR 0.62, 95% CI 0.34-1.14, p=0.12). Epiaortic ultrasound use was also not significantly associated with hazards of mortality on Cox regression (HR 1.14, 95% CI: 0.94, 1.38, p=0.12). Postoperative stroke was significantly associated with an increased hazard of death (HR 2.25, 95% CI: 1.61-3.14, p<0.001). Stroke rates after CABG were 0.8% and 1.4% with and without the use of epioartic ultrasound, respectively. The current study did not find an independent association between epiaortic ultrasound use and postoperative stroke.

Direct Implantation of Transcatheter Valve in Mitral Annular Calcification: A Multi-Center Study

BACKGROUNDMitral valve replacement (MVR) in the setting of severe annular calcification (MAC) is associated with high morbidity and mortality. Direct surgical implantation of a transcatheter heart valve (THV) through a trans-atrial approach is a strategy to mitigate surgical risk. This study reports the peri-operative and 1-year outcomes of MVR using a THV in patients with severe circumferential MAC at three Canadian centers. METHODSCharts were reviewed between 1/1/2018 and 30/9/2023 to identify patients with severe circumferential MAC who had undergone direct implantation of a THV. Primary outcomes were 30-day mortality, debilitating stroke, and 1-year mortality. Secondary outcomes included left ventricular outflow tract obstruction (LVOTO), degree of PVL, transvalvular mean pressure gradient, and length of stay. RESULTSTwenty-two patients at the three centres underwent direct implantation of a THV. Nineteen were female with mean age 70.41±9.33 years. A THV was successfully implanted in all patients. There were two deaths at 30-days. Four died from non-cardiac causes at 1-year, and 1 patient had a post-operative stroke. Seventeen (77%) patients had none/trace paravalvular leak, 4 had mild PVL, and one patient had mild-moderate PVL. Mean trans-valvular gradient was 4.42±4.40. There were no cases of LVOTO. CONCLUSIONSDirect deployment of a THV in patients with severe MAC may be a reasonable option. Thirty-day and 1-year mortality rates of 9% and 18%, respectively, suggest that this approach should be reserved for high-risk patients who are not able to undergo conventional strategies.

Outcomes of Carotid Artery Stenting and Endarterectomy in Patients with Prior Contralateral Carotid Revascularization

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are available treatment options for stroke prevention in individuals with severe carotid stenosis. This study aims to compare the early postoperative outcomes in patients who underwent CEA or CAS after prior contralateral carotid revascularization. We conducted a retrospective review of the Society of Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database, identifying patients who had prior carotid artery revascularization followed by a contralateral CEA or CAS between 2017 and 2023. Based on the sequence of the procedures performed, patients were categorized into four groups: 1) patients who had a prior unilateral CEA followed by a contralateral CEA (CEA-CEA); 2) patients who had a prior unilateral CAS followed by a contralateral CEA (CAS-CEA); 3) patients had a prior unilateral CAS followed by a contralateral CAS (CAS-CAS); and 4) patients had a prior unilateral CEA followed by a contralateral CAS (CEA-CAS). Univariate analysis (Pearson χ 2, Wilcoxon rank sum test) and multivariate logistic regression were employed to assess length of stay, rates of in-hospital stroke, myocardial infarction, new-onset arrhythmia, and 30-day mortality. A total of 20,761 patients with a history of prior unilateral carotid revascularization procedures were identified, of which 12,788 underwent contralateral CEA and another 7,973 underwent contralateral CAS. Compared to the CAS-CAS group, patients who underwent CEA followed by contralateral CAS (CEA-CAS group) were associated with higher rates of postoperative in-hospital stroke (1.8% vs. 1%, P = 0.003), new-onset arrhythmia (2% vs. 1.2%, P=0.006), and 30-day mortality (1.3% vs. 0.8%, P = 0.04). On multivariate analysis, preoperative use of statins and beta-blockers was associated with lower odds of in-hospital stroke (OR 0.42; 95% confidence interval [CI] 0.29 - 0.69; P = 0.0002) and new-onset arrhythmia (OR 0.62; 95% CI 0.49 - 0.9; P = 0.01), respectively, after CAS. There were no significant differences in outcomes for CEA-CEA and CAS-CEA groups. Patients with prior CEA undergoing contralateral CAS had higher rates of in-hospital stroke, new-onset arrhythmia, and 30-day mortality. Beta-blockers may reduce postoperative arrhythmia rates in these patients, and established regimens should not be discontinued in the perioperative period; however, further prospective studies are needed to confirm this finding. Optimized medical treatment and appropriate imaging follow-up remain crucial for improvement outcomes.

Correlation Between Intraoperative Near-infrared Spectroscopy Values and Neurologic Outcomes in Patients Undergoing Total Aortic Arch Replacement Using the Frozen Elephant Trunk Technique

ObjectiveTo correlate intraoperative near-infrared-spectroscopy (NIRS) values to neurologic outcome in patients undergoing total aortic arch replacement using the frozen elephant trunk (FET) technique. DesignRetrospective, single centre registry study using a two-way repeated measures ANOVA. SettingBetween 11/2013 and 12/2023, 427 patients were treated for acute and chronic aortic pathologies using FET procedure. ParticipantsOne-hundred sixty-six patients who had complete NIRS data at all predefined timepoints were included and retrospectively divided into two groups: patients with stroke diagnosed by experienced radiologists and clinicians and patients without stroke after FET. MeasurementsBilateral NIRS values were recorded continuously and at seven critical timepoints in each patient a correlation was made between left- and right-sided NIRS values and stroke. Main Results23 patients (13.9%) were diagnosed with a stroke. There was a significantly higher in-hospital mortality in patients with stroke (21.7%) compared to patients without stroke (7.7%) (p = 0.037). Left sided regional cerebral oxygenation (rSO2) did not show any significant difference in patients with stroke versus patients without stroke (p = 0.550). There were differences detected in right sided rSO2 trends (p < 0.001) and the inter-hemisphere NIRS at the specified timepoints (p = 0.009). The interaction Time x Stroke, however, did not show any significant results in all our analyses (p > 0.05). ConclusionNIRS is a reliable tool to monitor intraoperative frontal lobe cerebral oxygen saturation. However, its use to predict postoperative stroke remains limited. Further refinements are needed to develop the technique to a prediction tool.