Rate Of Cranial Nerve Injury Research Articles

Outcomes following carotid revascularization in patients with prior ipsilateral carotid artery stenting in the Vascular Quality Initiative

ObjectiveThe outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive. MethodsUsing Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. ResultsWe identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001). ConclusionsIn asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.

Impact of head and neck radiation on long-term outcomes after carotid revascularization

ObjectiveRadiation-induced carotid artery stenosis (RICS) is a well-described phenomenon seen after head and neck cancer radiation. Previously published literature suggests that, compared with atherosclerotic disease, RICS may result in worse long-term outcomes and early restenosis. This study aims to evaluate the effect of radiation on long-term outcomes after various carotid revascularization techniques using a multi-center registry database. MethodsPatients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry for carotid artery intervention (carotid endarterectomy [CEA]; transfemoral carotid artery stenting [CAS]; transcarotid artery revascularization [TCAR]), who are 65 years or older were included in the study. VQI Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Medicare-linked database was used to obtain long-term procedure-specific outcomes. Primary endpoints were 3-year death, stroke, and reintervention. We performed propensity matching between patients with prior radiation and those without. Kaplan-Meier analysis and a multivariate logistic regression model were used to analyze the outcome variables. ResultsA total of 56,472 patients had undergone carotid revascularization (CEA, n = 48,307; TCAR, n = 4593; CAS, n = 3572), 1244 patients with prior radiation and 54,925 patients without prior radiation. The prior radiation group was more likely to be male (71.9% vs 60.3%; P < .01), to receive a stent (47.5% vs 13.5%; P < .01), and to be on P2Y12 inhibitor (55.2% vs 38.3%; P < .01). Propensity matching was performed on 1223 patients (CEA, n = 655; TCAR, n = 292; CAS, n = 287). There were no significant differences in 30-day outcomes for death, stroke, or major adverse cardiovascular events for all three procedures. The prior radiation group had higher rates of cranial nerve injury (3.7% vs 1.8%; P = .04) and 90-day readmission (23.5% vs 18.3%; P = .01) after CEA. For long-term outcomes, prior radiation significantly increased mortality risk for CEA and CAS (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.38-2.27 and HR, 1.56; 95% CI, 1.02-2.36, respectively). The 3-year risk of stroke for CEA in radiated patients was also significantly higher (HR, 1.47; 95% CI, 1.03-2.09) compared with non-radiated patients. Prior radiation did not significantly affect death and stroke in patients undergoing TCAR. Prior radiation also did not impact the rates of short and long-term reintervention after CEA, CAS, or TCAR. ConclusionsPrior head and neck radiation significantly increases the risk for mortality and stroke for CEA and the risk for mortality after CAS. Long-term outcomes for TCAR are not significantly affected by prior radiation. TCAR may be the preferred treatment modality for patients with radiation-induced carotid stenosis.

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

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

Comparative analysis of outcomes following craniotomy and expanded endoscopic endonasal approach resection of tuberculum sellae meningiomas: a single-institution study.

Traditionally, supratentorial craniotomy has been used to sever tuberculum sellae meningiomas (TSMs), but there has been a remarkably increasing tendency of extended endoscopic endonasal approach (EEEA) used to treat TSMs in the recent decade. Several documents have described the advantages and disadvantages of both approaches, but there is no consensus on whether one is superior to the other. This study aimed to compare surgical outcomes between craniotomy and EEEA for TSMS treated at our institution. From January 2015 to December 2021, a total of 84 cases of TSMs were included in this study. Cases were separated into two groups: the craniotomy group and the EEEA group. Their anamneses and surgical records were reviewed. Demographic data, presenting symptoms, tumor volume, extent of resection, visual outcomes, and follow-up data were tabulated. The Kaplan-Meier curves were constructed for the PFS for both cohorts. Complete data were available for 84 surgeries; 39 cases were treated via craniotomy, and 45 were treated via EEEA. Patient demographic data, pre-operative symptoms, and tumor characteristics were similar between the two cohorts. The extent of resection was similar between the two groups (GTR: 91.11% EEEA vs. 87.18% craniotomy; STR 8.89 vs. 12.82%, p = 0.91). There was no difference in visual outcomes between both groups (92.1 vs. 84.84%, p = 0.46). An increased rate of cranial nerve injury was noted in the craniotomy group (0 vs. 10.25%, p = 0.04). Post-operative CSF leak rate occurred in one patient in the EEEA group. The PFS curves (p = 0.52) and recurrence/progression rates (13.33 vs. 20.51%, p = 0.39) were similar between the two groups. Both EEEA and craniotomy can successfully sever TSMs. The recurrence/progression rate and PFS appear to be similar between the two groups. Although there are no differences in EOR and visual outcomes between the two groups, there was a clear trend in the EEEA group to obtain a better outcome. CSF leakage was common in the EEEA cohort, whereas the rate of cranial nerve injury was found to be higher in the craniotomy cohort. We believe that our data support the conclusion that EEEA surgery is the preferred approach for the removal of TSMs.

Outcomes and role of shunting during carotid endarterectomy for symptomatic patients.

Shunt placement during carotid endarterectomy (CEA) has often been advocated to protect the ischemic penumbra in patients with symptomatic carotid stenosis. In the present study, we assessed the effect of shunt placement during CEA on postoperative stroke risk in symptomatic patients. We queried the American College of Surgeons National Surgical Quality Improvement Program database (2016-2019) for CEA cases with complete CEA procedure-targeted data available. Symptomatic patients were identified as those with a preoperative diagnosis of stroke on presentation (DS), transient ischemic attack, amaurosis fugax, or temporary monocular blindness. The DS patients were further analyzed according to the severity of their stroke using the modified Rankin scale scores. To better assess the effect of shunt placement on the stroke rate, we compared cases of CEA with the patch angioplasty technique stratified by the use of an intraoperative shunt. Patients who had undergone carotid eversion or primary closure were excluded. The baseline demographics and perioperative outcomes were compared using the χ2 and Mann-Whitney U tests. Multivariate analysis was performed to identify the independent risk factors for postoperative stroke and cranial nerve injury. We identified 4652 cases of CEA with patch angioplasty in symptomatic patients, including 1889 with (40.6%) and 2763 without (59.4%) shunt placement. The distribution of age, race, and sex was similar for both procedures. Compared with patients without a shunt, those with a shunt had significantly higher rates of emergency surgery (9.1% vs 7.0%; P= .010), nonelective surgery (40.3% vs 37.2%; P= .035), general anesthesia (97.0% vs 86.3%; P< .001), and bleeding disorders (27.2% vs 22.7%; P< .001). The 30-day incidence of postoperative stroke was similar between the patients with (3.2%) and without (2.6%) shunt placement (P= .219). Additionally, a subgroup analysis failed to show any benefit from shunt placement on the incidence of postoperative stroke, regardless of the preoperative symptoms or neurologic disability. In contrast, shunt placement was associated with an increased rate of cranial nerve injury (4.1% vs 2.4%; P= .001). Multivariate analysis revealed that nonelective surgery (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.36-2.91; P< .001) and DS (vs transient ischemic attack, amaurosis fugax, or temporary monocular blindness; OR, 1.64; 95% CI, 1.12-2.41; P= .012) were predictive of 30-day postoperative stroke. After adjusting for confounders, shunt placement had no effect on stroke risk at 30days but remained an independent risk factor for cranial nerve injury (adjusted OR, 1.87; 95% CI, 1.32-2.64; P< .001). For symptomatic patients undergoing CEA with patch angioplasty, shunt placement was associated with an increased risk of cranial nerve injury without a reduction in postoperative stroke risk.

Microsurgical treatment of carotid body tumors using periadventitial dissection: Analysis of outcomes and prognostic factors in a neurological referral center.

Surgical resection for carotid body tumors (CBTs) is the gold standard of treatment and continues to be a challenging procedure, commonly associated with high vascular injury rates and neurological complications. It is a retrospective case series study between January 2002 and November 2020, with a mean follow-up of 29 months in a single nationwide referral center. Thirty-one patients diagnosed with a carotid body tumor and treated with microsurgical periadventitial resection were included in the study. Patients' demographics, comorbidities, clinical, radiological factors, and tumor grade, evaluated by the Shamblin scale, were obtained. Statistical analysis was performed on all collected data. In this study, we included 31 patients (32 tumors), 80% of the patients were female, and 20% were male, with a mean age of 53 years. One patient presented with bilateral lesions, while 17 tumors were located on the left side. The most frequent symptom was a painless, slow-growing neck mass in 74% of patients. Using the Shamblin classification, 13% of tumors were Grade I, 53% Grade II, and 34% Grade III. In the postoperative period, 3% of patients presented with permanent cranial nerve deficit, while none had vascular injuries or postoperative stroke. A tumor >5 cm increased the risk for nerve lesion by 11 times (OR 12.6, CI 95% 7.4-11.4, P < 0.001). Preoperative embolization followed by periadventitial resection by means of a microsurgical technique is a safe and effective approach to remove CBT, with 3% cranial nerve injury rate and no need for vascular sacrifice or reconstruction.

A systematic review and meta-analysis of carotid artery stenting using the transcervical approach.

Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis. A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded. Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I2=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I2=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I2=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I2=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I2=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I2=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I2=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I2=37.6% and 95% CI: 11.3-16.1, P=0.48, I2=0%, respectively). TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis.

Clinical outcomes of radiation-induced carotid stenosis: A systematic review and meta-analysis

ObjectivesClinical outcomes of radiation-induced carotid stenosis are still unclear. Therefore, a systematic review and meta-analysis is needed to evaluate the short- and long-term outcomes after interventions to treat radiation-induced carotid stenosis. MethodsPubMed, EMBASE, the Cochrane Library and Web of Science were searched from 1 January 2000 for relevant RCTs and observational studies which reported outcomes after carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) for carotid stenosis induced by radiation. Risk of bias were assessed through different scales according to study design. I2 statistic were used to evaluate the heterogeneity, and meta-regression were performed to investigate the source of heterogeneity. Visual inspection of funnel plots was used to judge publication bias. ResultsA total of 26 studies with 1002 patients were included. CEA was performed in 364 patients and CAS in 638 patients. The overall estimated rate of short-term stroke was 0.19% (95% CI: 0–0.90%), and the rate of long-term stroke was 2.68 % (95% CI: 1.19–4.57%). The rate of cranial nerve injury in CEA group was significantly higher than that in CAS group [risk ratio (RR): 6.03, 95% CI: 1.63–22.22, P = .007]. The univariate regression analysis showed that the risk of stroke in CAS group were significantly higher than CEA group in both short- and long-term [incidence rate ratio (IRR): 3.62, 95% CI: 1.21–10.85, P = 0.22; IRR: 2.95, 95% CI: 1.02–8.59, P = .046, respectively]. ConclusionsThis systematic review provided the worldwide profile of outcome of treatment for radiation-induced carotid stenosis, and also found that CEA can yield better results for these patients than CAS. Nonetheless, as large-scale studies have not yet been conducted, and there is a definite need for further studies in the future.

Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy

Anesthesia modalities for carotid endarterectomy continue to vary nationally. We evaluated and compared short-term outcomes after carotid endarterectomy with general anesthesia (GA) and regional anesthesia (RA) in both symptomatic and asymptomatic patients. The 2011-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (PUFs) with merged Vascular Procedure-Targeted PUFs for carotid endarterectomy were queried for patients undergoing carotid endarterectomy. Postoperative complications, mortality, and hospital length of stay in patients undergoing GA or RA were compared. A total of 14,447 patients were evaluated: 12,389 (85.7%) with GA and 2,058 (14.3%) with RA. The use of GA was inversely associated with patients' age (88.0% in patients aged 22-64years vs. 83.4% in patients aged ≥80years, P<0.0001) and with symptomatic presentation (odds ratio [OR]=1.25; 95% confidence interval [CI]: 1.13-1.38). There were no differences between GA and RA for in-hospital mortality, 30-day mortality, or postoperative complications of transient ischemic attack, stroke, bleeding, acute renal failure, or restenosis. However, rates of cranial nerve injury were significantly higher in GA than in RA (2.9% vs. 1.7%, respectively; P<0.002) and confirmed by multivariable analysis (OR=1.68; 95% CI: 1.19-2.39). Total operative time was also longer for GA than for RA (median: 115minutes; Interquartile range (IQR): 89-145 versus median: 93minutes; IQR: 76-119, respectively; P<0.0001). Hospital length of stay was greater in GA than in RA (median: 1day; IQR 1-2 vs. median: 1day; IQR 1-1, respectively; P<0.0001), as were 30-day readmission rates (6.7% vs. 5.4%, respectively; P=0.02). Iatrogenic nerve injury is a feared complication of carotid endarterectomy, especially in elective asymptomatic patients. RA reduces the rate of cranial nerve injury compared with GA. RA is also not inferior to GA for postoperative complications with the benefit of shorter operative times, lengths of hospital stay, and decreased 30-day readmission rates. Consideration should be given to more widespread adoption of this underused anesthesia modality.

Comparison of Hospital Outcomes of Transcarotid Artery Revascularization with Flow Reversal (TCAR) Vs. Carotid Endarterectomy (CEA)

Introduction - TransCarotid Artery Revascularization with flow reversal (TCAR) offers a less invasive option to carotid endarterectomy (CEA) in high risk patients and has the lowest reported overall stroke rate for any prospective trial of carotid artery stenting (CAS). This study compares initial in-hospital outcomes of CEA and TCAR using the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) TCAR Surveillance Project (TSP) done in collaboration with the Centers for Medicare & Medicaid Services (CMS) to create more information for future coverage decisions. Methods - The SVS TSP isdesigned to evaluate the safety and efficacy of TCAR in real world practice, using a contemporary comparison to CEA.Patients enrolled in this project were compared to those undergoing CEA during the same time period (2016-2017). The primary outcome was a composite of in-hospital stroke and death. Average treatment effects were estimated via augmented inverse-probability weighting (AIPW). Additional analysis was performed using multivariable logistic regression as well as various matching techniques such as propensity score matching and coarsened exact matching (CEM).Adjusted analysis accounted for age, gender, race, insurance status, CAD, CHF, CKD, COPD, symptomatic status, restenosis, prior vascular procedures, degree of ipsilateral stenosis and preoperative medication use. Results - A total of 637 patients underwent TCAR compared to 12,049 patients who underwent CEA. Patients undergoing TCAR were older (median age 74 vs.71 years), more likely to be symptomatic (33.6% vs. 27.9%),and had more medical comorbidities such as CAD (47.3% vs.26.6%), CHF (19.8% vs.11.1%), COPD (26.5% vs. 22.3%), CKD (39.9% vs. 33.6%), and prior vascular procedures compared to CEA patients (All p<0.01). The majority of TCAR procedures were done under general anesthesia (79.0% vs.90.3% in CEA, p<0.001). On average, TCAR was 36.7 minutes shorter than CEA (78.0±33.9 vs. 114.7±42.5, p<0.001). On univariate analysis, there were no differences in the rates of in-hospital stroke/death (1.3% vs. 1.7%, p=0.42), overall neurological events (2.0% vs.1.9%, p=0.83), in-hospital MI (0.7% vs.1.1%, p=0.31) and 30-day mortality (0.5% vs. 0.9%, p=0.08) between CEA and TCAR, respectively. Patients undergoing CEA had higher rates of cranial nerve injury (2.8% v.0.8%, p<0.01) and postoperative hypertension (18.3% vs. 11.6%, p<0.001) compared to TCAR patients. On multivariable analysis and using different matching methods, there were no differences in overall stroke, stroke/death or overall neurologic events (Figure 1). The absolute difference in adjusted stroke/death rates between the two groups was 0.3% [95%CI: -1.7%, 1.0%, p=0.64]. Conclusion - Despite a substantially higher medical risk in patients undergoing TCAR, preliminary analysis of the SVS-VQI TCAR Surveillance Project showed similar in-hospital stroke/death rates between TCAR and CEA after multivariable adjustment and rigorous matching. Further studies with larger sample sizes and longer follow will be needed to establish the equivalence of TCAR compared to CEA.

Contemporary outcomes after carotid endarterectomy in high-risk anatomic and physiologic patients

ObjectiveCurrent guidelines state that the acceptable 30-day postoperative stroke/death rate after carotid endarterectomy (CEA) is <3% for asymptomatic patients and <6% for symptomatic patients. The Centers for Medicare and Medicaid Services has identified certain high-risk characteristics used to define patients at highest risk for CEA for whom carotid artery stenting would be reimbursed. We evaluated the impact of the Centers for Medicare and Medicaid Services physiologic and anatomic high-risk criteria on major adverse event rates after CEA in asymptomatic and symptomatic patients. MethodsWe retrospectively reviewed all patients undergoing CEA from 2011 to 2017 in the American College of Surgeons National Surgical Quality Improvement Program vascular targeted database. Patients with high-risk anatomic or physiologic characteristics were identified by a predefined variable and were compared with normal-risk patients. The primary outcome was 30-day stroke/death, stratified by symptom status. ResultsWe identified 25,788 patients undergoing CEA, of whom 60% were treated for asymptomatic carotid disease. Among all patients, high-risk physiology or anatomy was associated with higher rates of 30-day stroke/death compared with normal-risk patients (physiologic risk, 4.6% vs 2.3% [P < .001]; anatomic risk, 3.6% vs 2.3% [P < .001]). Patients who met criteria for high-risk physiology or anatomy also had higher rates of cardiac events (physiologic risk, 3.1% vs 1.6% [P < .001]; anatomic risk, 2.3% vs 1.6% [P < .01]), but only patients with high-risk anatomy had higher rates of cranial nerve injury (physiologic risk, 2.4% vs 2.5% [P = .81]; anatomic risk, 4.3% vs 2.5% [P < .001]). Asymptomatic patients with high-risk physiology or anatomy had higher rates of 30-day stroke/death, especially in the physiologic high-risk group (physiologic risk, 4.7% vs 1.5% [P < .001]; anatomic risk, 2.6% vs 1.5% [P < .01]), compared with normal-risk patients. However, among symptomatic patients, differences in stroke/death were seen only with high-risk anatomic patients and not with high-risk physiologic patients (physiologic risk, 4.6% vs 3.4% [P = .12]; anatomic risk, 4.8% vs 3.4% [P = .01]). ConclusionsAs currently selected, contemporary real-world outcomes after CEA in asymptomatic carotid disease patients meeting high-risk physiologic criteria show an unacceptably high 30-day stroke/death rate, well above the 3% threshold. These results suggest the need for better selection of patients and preoperative optimization before elective CEA.

Validation of training levels in endoscopic endonasal surgery of the skull base.

A five-level training program was first proposed 10 years ago for surgeons learning endoscopic endonasal surgery (EES) of the skull base. Levels were based on the complexity of anatomy, risk of neurovascular injury, intradural dissection, technical difficulty and vascularity of tumors. A three-phase validation concept is proposed: 1) face validity (the classification is related to clinically significant elements), 2) construct validity (the classification predicts the outcome), and 3) inter-team validation (the classification applies to other surgical teams). Consecutive cases over a 1-year time span were retrospectively classified. Primary outcome measures included: complication rates (cranial nerve injury, stroke and vascular injury, cerebrospinal fluid [CSF] leak and infection), estimated blood loss and duration of surgery. Two hundred and nine consecutive cases were analyzed. The distribution of cases for each category was: 63 cases in level II, 70 cases in level III, 66 cases in level IV, and 10 cases in level V. Construct validity demonstrated statistical difference with increasing rate of complications from level II to level III and from level III to level IV; also, specific rates of cranial nerve injury and CSF leak increased between levels III and IV. Face validity identified 162 citations since publication of the original article. Inter-team validation demonstrated no difference between two teams of surgeons. This study provides a three-phase validation of training levels for endoscopic skull base surgery. Adoption of a progressive systematic approach to learning EES from least complex to advanced procedures is expected to minimize the risks while surgical teams gain experience. 3 Laryngoscope, 129:2253-2257, 2019.

A multi-institutional analysis of transcarotid artery revascularization compared to carotid endarterectomy

ObjectiveTranscarotid artery revascularization (TCAR) is a novel approach to carotid intervention that uses a direct carotid cut-down approach coupled with cerebral blood flow reversal to minimize embolic potential. The initial positive data with TCAR indicates that it may be an attractive alternative to trans-femoral carotid artery stenting and possibly carotid endarterectomy (CEA) for high-risk patients. The purpose of this study was to present 30-day and 1-year outcomes after treatment by TCAR and to compare these outcomes against a matched control group undergoing CEA at the same institutions. MethodsA retrospective review of all patients who underwent TCAR at four institutions between 2013 and 2017 was performed to evaluate the use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Inc, Sunnyvale, Calif). TCAR patients had high-risk factors and were either enrolled in prospective trials or treated with a commercially available TCAR device after US Food and Drug Administration approval. Contemporaneous patients undergoing CEA at each institution were also reviewed. Patients were propensity matched in a 1:1 (CEA:TCAR) fashion with respect to preoperative comorbidities. Data were analyzed using statistical models with a P value of less than .05 considered significant. Individual and composite stroke, myocardial infarction, and death at 30 days and 1 year postoperatively were assessed. ResultsConsecutive patients undergoing TCAR or CEA were identified (n = 663) and compared. Patients undergoing the TCAR procedure (n = 292) had higher rates of diabetes (P = .01), hyperlipidemia (P = .02), coronary artery disease (P < .01), and renal insufficiency (P < .01) compared with unmatched CEA patients (n = 371). Stroke rates were similar at 30 days (1.0% TCAR vs 1.1% CEA) and 1 year (2.8% TCAR vs 3.0% CEA) in the unmatched groups. After propensity matching by baseline characteristics including gender, age, symptom status (36.3%, 35.3%) and diabetes, 292 TCAR patients were compared with 292 CEA patients. TCAR patients were more likely to be treated preoperative and postoperatively with clopidogrel (preoperatively, 82.2% vs 39.4% [P < .01]; postoperatively, 98.3% vs 36.0% [P < .01]) and statins (preoperatively, 88.0% vs 75.0% [P < .01]; postoperatively, 97.8% vs 78.8% [P < .01]). Stroke (1.0% TCAR vs 0.3% CEA; P = .62) and death (0.3% TCAR vs 0.7% CEA; P = NS) rates were similar at 30 days and comparable at 1 year (stroke, 2.8% vs 2.2% [P = .79]; death 1.8% vs 4.5% [P = .09]). The composite end point of stroke/death/myocardial infarction at 1 month postoperatively was 2.1% vs 1.7% (P = NS). TCAR was associated with a decreased rate of cranial nerve injury (0.3% vs 3.8%; P = .01). ConclusionsThese early data suggest that patients undergoing TCAR, even those with high-risk comorbidities, achieve broadly similar outcomes compared with patients undergoing CEA while mitigating cranial nerve injury. Further comparative studies are warranted.

Trials and Frontiers in Carotid Endarterectomy and Stenting.

Based on the strength of randomized trials from the 1990s, major societal guidelines recommend carotid endarterectomy (CEA) for severe (≥70%), symptomatic carotid stenosis if an operative stroke/death rate of <6% can be maintained (history and major trials in carotid revascularization are summarized in the online-only Data Supplement).1–4 Though the benefit is less evident, most guidelines also recommend consideration of CEA for 50% to 69% symptomatic stenosis.2–4 There are subtle differences in recommendations regarding carotid artery stenting (CAS) in symptomatic patients. Some guidelines stipulate that CEA should be preferred over CAS in patients with severe (≥70%) symptomatic carotid stenosis,2,5 especially if >70 years old,4 whereas others position CAS as an alternative.1,3 Though the risk of operative stroke/death is higher with CAS, major randomized clinical trials (RCTs) report event rates under the recommended 6% cutoff for both treatment modalities. Regarding asymptomatic disease, CEA is recommended for patients with stenosis ≥60% to 70% in highly selected patients as long as operative stroke/death rates <3% can be maintained.1 A predicted life expectancy of at least 3 to 5 years has also been suggested.2 The 3% threshold has been easily met by CEA cohorts in the CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial; 1.4%)6 and the ACT1 (Asymptomatic Carotid Trial; 1.7%),7 suggesting that an even lower threshold may be appropriate. Controversially, some guidelines have recommended that CAS can be considered in highly selected patients with asymptomatic carotid stenosis ≥60% to 70%,1,4,8 whereas others argue that the evidence remains insufficient.2 The lack of consensus in the management of asymptomatic carotid stenosis is reflective of an ongoing need for high-quality RCT data to guide practice. ### CEA Operative Stroke Risk and High Risk Designation Most clinical trials in carotid revascularization have focused …

Autologous Reconstruction of the Carotid Bifurcation: Should We Just Because We Can?

Autologous Reconstruction of the Carotid Bifurcation: Should We Just Because We Can?

VESS05. In-Hospital Outcomes of Transcarotid Artery Revascularization and Carotid Endarterectomy in the Society for Vascular Surgery Vascular Quality Initiative

Transcarotid artery revascularization (TCAR) offers a less invasive option to carotid endarterectomy (CEA) in high-risk patients and has the lowest reported overall stroke rate for any prospective trial of carotid artery stenting. This study compares initial in-hospital outcomes of CEA and TCAR using the Society for Vascular Surgery (SVS) Vascular Quality Initiative TCAR Surveillance Project done in collaboration with the Centers for Medicare and Medicaid Services to create more information for future coverage decisions. The SVS TCAR Surveillance Project is designed to evaluate the safety and efficacy of TCAR in real-world practice, using a contemporary comparison to CEA. Patients enrolled in this project were compared with those undergoing CEA during the same period (2016-2017). The primary outcome was a composite of in-hospital stroke and death. Average treatment effects were estimated by augmented inverse-probability weighting. Additional analysis was performed using multivariable logistic regression as well as various matching techniques, such as propensity score matching and coarsened exact matching. Adjusted analysis accounted for age, sex, race, insurance status, coronary artery disease, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, symptomatic status, restenosis, prior vascular procedures, degree of ipsilateral stenosis, and preoperative medication use. A total of 637 patients underwent TCAR compared with 12,049 patients who underwent CEA. Patients undergoing TCAR were older, more likely to be symptomatic, and had more medical comorbidities, such as coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and prior vascular procedures, compared with CEA patients (Table). The majority of TCAR procedures were done under local/regional anesthesia (95.3% vs 9.7% in CEA; P < .001). On average, TCAR was 36.7 minutes shorter than CEA (78.0 ± 33.9 vs 114.7 ± 42.5 minutes; P < .001). On univariate analysis, there were no differences in the rates of in-hospital stroke/death (1.3% vs 1.7%; P = .42), overall neurologic events (2.0% vs 1.9%; P = .83), in-hospital myocardial infarction (0.7% vs 1.1%; P = .31), and 30-day mortality (0.5% vs 0.9%; P = .08) between CEA and TCAR, respectively. Patients undergoing CEA had higher rates of cranial nerve injury (2.8% vs 0.8%; P < .01) and postoperative hypertension (18.3% vs 11.6%; P < .001) compared with TCAR patients. On multivariable analysis and using different matching methods, there were no differences in overall stroke, stroke/death, or overall neurologic events (Fig). The absolute difference in adjusted stroke/death rates between the two groups was 0.3% (95% confidence interval, −1.7% to 1.0%; P = .64). Despite a substantially higher medical risk in patients undergoing TCAR, analysis of the preliminary results from the SVS Vascular Quality Initiative TCAR Surveillance Project showed similar in-hospital stroke/death rates between TCAR and CEA after multivariable adjustment and rigorous matching. Further studies with larger sample sizes and longer follow-up will be needed to establish the equivalence of TCAR compared with CEA.TableBaseline and perioperative characteristics of patients undergoing transcarotid artery revascularization (TCAR) vs carotid endarterectomy (CEA) between 2016 and 2017TCAR (n = 637)CEA (n = 12,049)Age, years, median (IQR)74 (66-80)71 (64-77)<.001Female224 (35.2)4680 (38.8).06Race.11 White573 (90.0)11,053 (91.8) Black29 (4.6)530 (4.4) Others35 (5.5)464 (3.9) Hispanic or Latin ethnicity36 (5.7)425 (3.5).01Symptomatic status214 (33.6)3357 (27.9)<.01Coronary artery disease301 (47.3)3201 (26.6)<.001Prior congestive heart failure126 (19.8)1338 (11.1)<.001Hypertension581 (91.2)10,729 (89.1).09COPD169 (26.5)2684 (22.3).01CKD (GFR <60 mL/min)249 (39.9)3946 (33.6)<.01Smoking.08 Prior344 (54.0)5986 (49.7) Current155 (24.3)3040 (25.3)Prior amputation20 (3.1)93 (0.8)<.001Prior ipsilateral CEA or CAS115 (18.1)235 (2.0)<.001Prior contralateral CEA or CAS117 (18.4)1669 (13.9)<.01Preoperative medications Aspirin570 (89.5)10,084 (83.7)<.001 Antiplatelet549 (86.2)3990 (33.1)<.001 Statins561 (88.1)10,036 (83.3)<.01 Anticoagulants85(13.3)1241 (10.3).02Anesthesia technique<.001 Local/regional607 (95.3)1162 (9.7) General30 (4.7)10,877 (90.3)Operative time, minutes, mean (±SD)78.0 (±33.9)114.7 (±42.5)<.001CAS, Carotid artery stenting; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; GFR, glomerular filtration rate; IQR, interquartile range; SD, standard deviation.Values are reported as No. (%) unless otherwise indicated. Open table in a new tab

Radiation-induced carotid stenosis: A personnalized approach

Surgical treatment of radio-induced carotid stenosis (RICS) is challenging and burdened by an elevated risk of local complications. Carotid artery stenting (CAS) may be a suitable alternative. The best approach is yet to be defined. We reviewed the results of both techniques following selection based on better-suitability characteristics (anatomic and clinical). We retrospectively reviewed 38 patients treated for 43 RICS from a group of 1230 patients who had carotid interventions between 2008 and 2015 (5 bilateral). Primary endpoints were morbidity and mortality at 30 days (transient ischemic attack, stroke, myocardial infarction, or death). Secondary endpoints were technical success, wound complications, cranial nerve injury (CNI), restenosis (≥50%) and recurrent symptoms. RICS was symptomatic in 6 patients in the OR group and 3 in the CAS group. Lesions in the OR group were longer (P=0.02) and more calcified (P=0.08). Technical success rate was 100%. Cranial nerve injury rate was 14.2% (3/21). All injuries were completely resolved within several weeks. In the CAS group, technical success rate was 95% (21/22) with the one failure due to a residual stenosis exceeding 30%. Periprocedural stroke rates were 0% and 4.5% in the OR and CAS groups respectively (0/21 vs 1/22, P=0.32). There were no early deaths. Mean follow-up was 19.1 months (3-75). The restenosis rate was 9.5% (2/21) in the OR group and 9% (2/22) in the CAS group. Our results do not support a preferred treatment strategy. The choice of treatment should be considered on an individual basis.

Cranial nerve injury is associated with dual antiplatelet therapy use and cervical hematoma after carotid endarterectomy

To determine predictors of cranial nerve injury (CNI) after carotid endarterectomy (CEA). Consecutive CEAs performed over a 5-year period were enrolled in this study. Outcomes analyzed included 30-day major adverse event rate (composite of stroke, death, and myocardial infarction), death, stroke, disabling stroke, myocardial infarction, cervical hematoma and CNI rate, reoperation, and hospital readmission at 30days. There were 1258 CEAs were included in the study, 1168 (93%) were performed using an eversion technique. Patients with symptoms comprised 27% of the cohort (n= 340). At 30days, there were no deaths, 23 major adverse events (1.8%), 11 strokes (0.9%: nine minor, two major), 12 myocardial infarctions (0.9%), 41 cervical hematomas (3.3%), 9reoperations (0.7%) and 10 hospital readmissions (0.8%). Median duration of stay was 1day (interquartile range, 1-2days). CNI rate at discharge was 2.3% (n= 29). Two patients (9%) had more than one cranial nerve affected. The marginal mandibular branch of the facial nerve was most frequently involved (n= 16; 52%), followed by the hypoglossal (n= 9; 29%), the vagus (n= 4; 13%), and the spinal accessory nerve (n= 2; 6%). Horner's syndrome, consistent with an injury to the cervical sympathetic chain, occurred in 13 patients (1%) who had a true cranial nerve affected as well. The vast majority (94%) of these CNIs and all Horner's syndrome neurapraxias were transient; only the two accessory lesions persisted at their follow-up visit (median, 32months; range, 8-72 months). Significant predictors for CNI included diabetes (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.0-6.2; P= .048), cervical hematoma (OR, 41.7; 95% CI, 13.8-125.4; P< .001), and dual antiplatelet therapy (OR, 4.4; 95% CI, 1.7-11.4; P=.002). CNI is predominantly a transient complication, but is associated significantly with dual antiplatelet therapy use and the occurrence of a postoperative cervical hematoma. Scrupulous attention to hemostasis might reduce the incidence of CNI.

Abstract 119: Can CREST Procedural Results be Reproduced in General Practice in Post CREST Era?: Analysis of National Surgical Quality Improvement Program (NSQIP) Registry

Background: The Carotid revascularization for primary prevention of stroke assessed in CREST trial (year 2010) revealed risk of the composite outcome of stroke, myocardial infarction, or death were almost similar in carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) group. This study analyzed such current clinical practice and outcome (year 2011 to 2013) from multicenter national registry described below. Methods: Cohort of non-high risk patients who underwent targeted CAS or CEA were collected from American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Registry in post CREST era. This registry prospectively collects around more than 300 variables across the nation pertaining to patient characteristics, co-morbid conditions, operative details, and 30-day postoperative outcomes. Frequency analysis of such outcome was performed to assess the re-validation of CREST trial in current clinical practice. Results: In Post CREST NSQIP Registry we identified 142 (CAS) and 7834 (CEA) patients. In Post CREST era (current clinical practice) the rates of any stroke among CEA patients (1.9%, 95% CI 1.57-2.17, CREST Ref 2.3%) (p=0.25) and CAS patients (2.1%, 95% CI 0.54-5.75, CREST Ref 4.1%) (p=0.25) observed in clinical practice were comparable to those observed in CREST trial. The rates of MI/arrhythmia among CEA patients (1.7%, 95% CI 1.47-2.06, CREST Ref 2.3%) (p=0.22) and CAS patients (2.8%, 95% CI 0.89-6.79, CREST Ref 1.1%) (p=0.13) are comparable from CREST trial. The rates of 1 month mortality among CEA patients (0.6%, 95% CI 0.42-0.76, CREST Ref 0.3%) (p=0.27) and CAS patients (0.7%, 95% CI 0.04-3.47, CREST Ref 0.7%) (p=0.92) were also similar. The rate of cranial nerve injury in CEA patients has declined (2.1%, CI 1.83-2.47, CREST Ref 4.7 %) (p&lt;0.0001).The combined primary endpoint for CEA patients (3.7%, 95% CI 3.32-4.17, CREST Ref 4.5%) (p=0.19) and CAS patients (5.6%, 95% CI 2.62-10.7, CREST Ref 5.2%) (p=0.81) was similar to CREST trial. Conclusions: Our results support reproducibility of CREST procedural outcomes for both CEA and CAS in general practice in post-trial period.

Comparison between outcomes of carotid endarterectomy and carotid artery stenting in treating elderly patients

Objective To review the clinical data of elderly patients treated by carotid endarterectomy (CEA) and carotid artery stenting (CAS), and analyze the safety of two kinds of surgery. Methods A total of 691 patients with carotid artery stenosis underwent CEA (121 cases) and CAS (570 cases) respectively. The risk factors, clinical symptoms and postoperative complications in 2 groups of patients were analyzed, and the safety of two kinds of surgery were assessed. Results After 30 d of operation, no significant difference was found between 2 groups in death rate (0.83% vs 1.05%, P = 1.000), stroke rate (4.13% vs 1.93% , P = 0.258) or myocardial infarction rate (0.83% vs 0, P = 0.175). Heart complications and cranial nerve injury rate in CEA group was significantly higher than that in CAS group (8.26% vs 1.05%, P = 0.000; 4.96% vs 0, P = 0.000), while sinus bradycardia or hypotension rate in CEA group was significantly lower than that in CAS group (0 vs 7.54%, P = 0.002). Conclusions Both CEA and CAS are safe for the elderly patients. However, the conditions of elderly patients should be evaluated before operation in order to reduce occurence of complications after operation. doi：10.3969/j.issn.1672-6731.2014.01.006 Video: http://www.cjcnn.org/index.php/cjcnn/pages/view/v14n1a6