Reconstruction Of Carotid Artery Research Articles

Long-term results of carotid body tumours surgery and predictive analytics on metastatic disease and recurrence.

The determination of clinico-surgical predictors of carotid body tumour (CBT) metastasizing and/or recurrence. Patients with CBT but without a history of its previous treatment who had received inpatient medical aid at a tertiary surgical centre during the period 2011-2021 were retrospectively reviewed to obtain baseline data. Primary endpoints of the study were CBT metastasizing and/or local recurrence after radical surgery (composite endpoint) and overall survival. Secondary endpoint of the study was primary patency of carotid arteries that had been repaired/reconstructed as a result of CBT removal. Suspected predictors of CBT metastasizing/recurrence were young age of CBT onset, positive family history, multifocal paraganglioma, Shamblin type III CBT, carotid bifurcation and/or internal carotid artery (ICA) reconstruction as a result of CBT excision. To detect CBT metastasizing/recurrence, prospective imaging-based whole-body screening was suggested to patients. Fifty-three patients met the eligibility criteria. The overall survival rate was 100% at a median follow-up time of 68 months (interquartile range [IQR] 27‒104.5 months). The primary patency of repaired carotid arteries (n = 9) was 88.9% at a median follow-up time of 99 months (IQR 15.5‒116.5 months). Thirty-nine patients underwent the prospective whole-body screening. Eight (20.5%) patients were diagnosed with metastatic disease (n = 6) or local recurrence (n = 2). Patients with CBT metastasizing/recurrence were younger at age of CBT onset (p = .011), more frequently had Shamblin type III CBT (p = .004) and the necessity for carotid artery repair/reconstruction (p = .041) than patients without metastasizing/recurrence. These two groups were similar in terms of gender (p = .682), the prevalence of multifocal paraganglioma (p = .167) and positive family history (p = .180). Only the belonging of a CBT to Shamblin type III was defined as a statistically significant predictor of CBT metastasizing/recurrence in both univariable and multivariable binary logistic regression analyses (odds ratio 30; 95% confidence interval: 2.649-339.739; p = .006 and odds ratio 75.409; 95% confidence interval: 1.082-5254.557; p = .046, respectively). Multifocal paraganglioma as a predictor exhibited a strong tendency towards statistical significance (p = .09 and p = .072, respectively). Other suspected predictors didn't reach the level of statistical significance either in univariable (p = .151 for positive family history) or in multivariable (p = .211 for age of CBT onset; p = .734 for carotid artery reconstruction/repair) binary logistic regression analyses. Shamblin type III CBT has high potential for metastasizing and recurrence. Patients with Shamblin type III CBT and/or multifocal paraganglioma should be considered for genetic testing as well as preoperative whole-body radiological imaging and long-term postoperative whole-body imaging-based follow-up.

Application of covered stent implantation combined with radical tumor resection in advanced head and neck squamous cell carcinoma involving the carotid artery: a comparative study with historical literature

Background Studies have shown that carotid artery reconstruction results in the best overall survival (OS) in Advanced Head and Neck Squamous Cell Carcinoma involving the Carotid Artery (AHNSCC-CA). Aims The purpose of this study was to evaluate the efficacy of covered stent implantation combined with radical tumor resection and to compare and analyze the historical literature on conventional carotid artery resection and reconstruction. Materials and methods A total of 68 patients with AHNSCC-CA were included in this study. This study compared the survival, local recurrence, surgical complications, and neurologic complications between the two groups. Results The OS rate at 12 months in the experimental group was 58.5% (median survival time: 15 months, 95% CI: 7.61–22.40). The OS rate at 12 months in the control group was 34.3% (median survival time: 8 months, 95% CI: 3.94–12.06, p = .371). In addition, the differences in the rates of local recurrence, surgical complications and neurological complications between the two groups were statistically insignificant (p = .677, p = .197 and p = .617). Conclusions and significance Compared with conventional carotid artery resection and reconstruction, covered stent implantation combined with radical tumor resection yields similar survival outcomes, but with significantly lower surgical risk and difficulty, and faster postoperative recovery.

Reconstruction of internal carotid artery in the resection of paraganglioma of head and neck

Objective:This study aims to discuss the necessity，surgical method and effect of reconstruction of internal carotid artery （ICA） in the resection of paraganglioma of head and neck. Methods:We retrospectively analyzed the data of the patients who underwent head and neck paraganglioma resection and ICA reconstruction in Peking Union Medical College Hospital from May 2015 to August 2023. The demographic characteristics, preoperative examinations, diagnoses, surgical techniques, and follow-up information were collected. Results:Six patients were enrolled, including four females and two males, with an average age of（39.8±13.0） years. All the patients presented mainly complaining local masses with or without pain. Four cases underwent surgery through Fisch infratemporal fossa approach type A+B, and one through approach type A and one through transcervical approach. Five patients had vascular reconstruction using the great saphenous vein while one patient used an artificial vessel. The average follow-up period was（43.8±31.6） months. One patient had tumor recurrence after 3 years and underwent second surgery to remove the residual tumor, and the other 5 patients had no tumor recurrence. One patient had acute bridging vessel embolism, and the other was found to have occlusion of the bridging vessel at follow-up. Conclusion:Carotid revascularization during resection of paraganglioma of head and neck is an important technique to completely remove the tumor, cure the disease, ensure intracranial blood supply, and reduce cerebrovascular complications. The "pre-reconstruction technique " is an effective method to minimize the duration of brain blood flow interruption, compared to traditional carotid revascularization. Close observation is necessary, along with regular radiological examinations to assess the patency of transplanted vessels, and the residual or recurrent tumors.

Giant cell arteritis as a cause of extracranial internal carotid artery aneurysm: a case report

BackgroundThis report presents the management of patient with extracranial internal carotid artery pseudoaneurysm due to giant cell arteritis.Case presentationLeft internal carotid artery pseudoaneurysm was diagnosed in a 57-year-old Ukrainian woman, which became a direct indication for surgical treatment involving aneurysm resection and internal carotid artery reimplantation. The used reconstruction technique with oblique cutting of internal carotid artery, aneurysm resection, ellipse-form anastomosis formation, and distal intima fixation prevents the dissection, restenosis, and aneurysm of anastomosis in the long-term postoperative period. Histopathological examination revealed the giant cell arteritis of the internal carotid artery.ConclusionThis case emphasizes the importance of open surgical treatment of extracranial carotid artery aneurysms, which allows to perform optimal carotid artery reconstruction and also define the rare etiology of disease.

Efficacy analysis of endovascular treatment for ruptured internal carotid artery pseudoaneurysm hemorrhage in patients with nasopharyngeal carcinoma after radiotherapy.

This study aims to evaluate the efficacy and complications of endovascular treatment for hemorrhage caused by ruptured internal carotid artery pseudoaneurysms following radiotherapy in nasopharyngeal carcinoma (NPC) patients. This study retrospectively analyzed NPC patients who underwent endovascular treatment for ruptured internal carotid artery pseudoaneurysm hemorrhage after radiotherapy at Zhongshan People's Hospital from January 2016 to December 2022. The study aims to assess the postoperative hemostasis rate, postoperative rebleeding rate, complication rate, and 1-year postoperative survival rate. During the study period, 36 patients underwent endovascular treatment, of which 24 patients underwent embolization of the internal carotid artery and 12 patients underwent stenting of the internal carotid artery. The procedure success rate was 100%. The rebleeding rate at 1 year after the procedure was 5.6% (2/36, one patient with stent placement and one patient with coil embolization), and the complication rate was 11.1% (4/36, four patients with coil embolization patients). Two patients developed large-area cerebral infarction after the procedure, and two patients had different degrees of neurological impairment after the procedure. The 1-year survival rate was 91.7% (33/36). Ruptured internal carotid artery pseudoaneurysm hemorrhage after radiotherapy is rare but life-threatening. Endovascular treatment with coil occlusion or stenting reconstruction of the internal carotid artery provides immediate hemostasis and elimination of the pseudoaneurysm with a low rate of recurrence, which may be effective in reducing patient mortality.

Surgical strategy and long-term outcomes of dissected carotid artery with false lumen thrombus in acute type A aortic dissection.

Optimal management of involved common carotid artery (CCA) with false-lumen thrombus remains unclear in aortic dissection patients. We aim to investigate outcomes and compare different surgical strategies. This is a retrospective cohort study and the institutional database of acute type A aortic dissection was reviewed. The patients with CCA involvement and extended false-lumen thrombus were enrolled and grouped according to the management of CCA: extra-thoracic carotid artery replacement (CAR) and reconstruction in situ (RIS). Multivariate logistic regression analysis was used to investigate the effect of management on neurological outcomes. Kaplan-Meier method was used for survival analysis and log-rank test was used to compare the difference on survival rate. From March 2011 to December 2019, 68 patients were enrolled (24 in the CAR group and 44 in the RIS group). The overall operative mortality was 7.4% (5 patients) and 21 patients had the incidence of postoperative neurological deficit was (30.9%). The rates of main postoperative complications were similar between the two groups. Twenty-five (56.8%) patients in the RIS group had residual false-lumen thrombus at discharge. In multivariate analysis, CAR was the only independent protective factor of postoperative neurological deficit [odds ratio (OR) =0.03, 95% confidence interval (CI): 0.0-0.61, P=0.02] and age was the only risk factor (OR =1.34, 95% CI: 1.11-1.62, P=0.002). The median follow-up time was 40 (interquartile range, 24-69) months and some of the patients received imaging follow-up. The overall survival rates at 5 and 10 years were 95.8%, and 95.8% in the CAR group and 84.1%, and 76.4% in the RIS group, with no significant difference (P=0.22). No cerebrovascular accident and reintervention occurred and 20 (90.9%) patients with residual false-lumen thrombus had reabsorption of thrombus during the follow-up period. CAR was a thorough technique and could protect patients from postoperative neurological deficit than RIS. Patients in either group could have a satisfying long-term prognosis after surviving from perioperative period. Most patients had reabsorption of residual false-lumen thrombus after anticoagulant therapy.

Surgical Management Strategies for Carotid Artery Invasion by Head and Neck Cancer: Ligation Versus Reconstruction.

Whether ligation or reconstruction should be performed after radical resection of the tumor and carotid artery in patients with head and neck cancers invading the carotid artery (HNC-CA) has been controversial. This paper provides a review and meta-analysis of the efficacy of these 2modalities. PubMed, Cochrane, Web of Science, Scopus, and Ovid databases were searched through August 2023. Descriptive, graphical, tabular, and quantitative data were extracted. The statistical outcomes (risk difference, RD) were synthesized under a random-effects model. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines. A total of 22 papers and 337 patients met the inclusion criteria for the literature review. Statistical analysis showed that the RD of overall survival (OS) rate at 1-year was 32% (95% confidence interval [CI]: 21%-42%) for ligation and 70% (95% CI: 65%-76%) for reconstruction (P < .05). The RD for OS rate at 2-year was 16% (95% CI: 7%-26%) for ligation and 39% (95% CI: 30%-47%) for reconstruction (P < .05). The RD for disease-free survival rate at 1-year was 27% (95% CI: 17%-38%)for ligation and 60% (95% CI: 51%-70%) for reconstruction (P < .05). There were no statistically significant differences (P > .05) between the 2surgical modalities in terms of locoregional recurrence rate, carotid blowout rate, surgery-related complications rate, neurological complications rate, and perioperative mortality rate. This review demonstrates the significant advantage of carotid artery reconstruction surgery in short-term patient survival, thus making it a recommended option for HNC-CA patients undergoing radical surgery.

Carotid Body Tumor Excision with and without Carotid Artery Reconstruction: Equivalency of 30-Day Outcomes over 12 Years in the American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) Database

Background: Carotid body tumors (CBTs) are rare benign tumors that arise from the chemoreceptor tissue located at the carotid bifurcation that require excision if symptomatic. Depending on the size and location of the tumor, the carotid artery may need to be repaired after resection. This study aims to assess whether CBT excision with artery resection had higher rates of 30-day postoperative outcomes compared with CBT excision without artery resection. Methods: This is a retrospective cohort study. Patients were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry from 2005 to 2017. They were divided into two groups, based on Current Procedural Terminology (CPT®) codes: group A had CBT excision without carotid artery excision (CPT code 60600) and group B with carotid artery excision (CPT code 60605). Patient demographic characteristics, co-morbidities, and 30-days postoperative outcomes were compared between the two groups. Categorical data were analyzed using Pearson’s X2 or Fisher exact tests and presented as proportions (percentages). Continuous data were analyzed using parametric or non-parametric tests as appropriate. Statistical significance was defined as p &lt; 0.05. Statistical analysis was performed using the SPSS statistical software package. Results: A total of 463 patients were identified, 410 (88.4%) in group A and 53 (11.4%) in group B. Overall, there were 291 (62.9%) women. A higher proportion of women underwent CBT excision only, compared to men (91.1% [265/291] vs. 84.3% [145/172], p &lt; 0.0001). Demographics and comorbidities were similar between groups. There was no significant difference in the 30-day postoperative outcomes. The reoperation rate was higher in group B (3.8% vs. 1.5%, p = 0.334), while the readmission rate was higher in group A (3.2% vs. 0% p = 0.269), and both were not significantly different. Overall morbidity and serious morbidity were higher in group B (7.5% vs. 5.9%, p = 0.626) and lower in group A (5.7% vs. 3.9%, p = 0.544), respectively, but were not significantly different. Operative time (mean, SD) was higher in group B (187 ± 107 vs. 138 ± 66 min, p &lt; 0.001). However, the median (IQR) of hospital length of stay (LOS) was similar (2 [1, 4] vs. 2 [1, 3] days, p = 0.134). Conclusions: Overall, no difference was noted in the 30-day postoperative outcome between the two surgical approaches of CBT. However, operative time was longer when artery resection was performed. Further research to determine the factors predicting the need for carotid artery resection among patient gender is needed.

Carotid Artery Reconstruction with an Autologous Bifurcated Saphenous Vein Graft.

We present a new technique for carotid artery reconstruction using a modified bifurcated saphenous vein graft in a patient with a malignant neck tumor. This technique can optimize the size match between the SVG and common carotid artery, as well as the internal and external carotid arteries. Post operative computed tomography performed a year after the operation demonstrated excellent graft alignment and patent carotid arteries.

ALT Free Flap Coverage after Carotid Endarterectomy in the Setting of Severe Radiation Changes

Summary: Carotid endarterectomy with patch angioplasty is commonly performed for severe atherosclerotic disease to reduce stroke risk. After neck radiation, loss of tissue planes; reactive fibrosis of skin; contraction; and rarely, necrosis of skin may occur, leading to severe wound complications and possible exposure of carotid artery reconstruction. Historically, local myocutaneous flaps have been performed to provide soft tissue coverage; however, these procedures may be associated with increased donor site morbidity and can be affected by radiation changes. This report describes the novel use of a fasciocutaneous free flap for durable vascularized soft tissue, and the associated secondary benefit of improved suppleness and range of motion. Additionally, the distant location of the donor site allows for an efficient two-team approach. Here, we describe a patient with severe carotid artery disease with a history of multiple surgical procedures and radiation, which was successfully treated with a carotid endarterectomy and bovine patch angioplasty by vascular surgery and immediate free anterolateral thigh flap coverage by our team.

Deposition of Sevelamer crystals in gastrointestinal tract and lung parenchyma: A rare autopsy finding

Abstract Introduction/Objective Sevelamer carbonate is a non-calcium-based phosphate binder used for the management of hyperphosphatemia in patients with end stage renal disease. The well-known side effects of sevelamer include nausea, vomiting and abdominal pain. However, there are few case reports which described the deposition of sevelamer crystals in the gastrointestinal tract causing mucosal injury, pseudotumor or obstruction. Methods/Case Report We hereby present a case of a 43-year-old decedent female with past medical history of seizures, hypertension, cocaine use, type B aortic dissection status post thoracic endovascular aortic repair, total arch replacement, reconstruction of innominate, carotid, and subclavian artery who presented with hematochezia concerning for possible aorto-esophageal fistula on 10/06/2022 and acute kidney injury. Imaging showed a thrombus in mid-esophagus, blood in trachea and narrowing of the left main stem bronchus. Labs revealed worsening of BUN and creatinine and up trending hyperphosphatemia and therefore sevelamer carbonate via nasogastric route was started on 10/13/22. Unfortunately, the patient’s hospital course was complicated, and she passed away on 11/14/2022. At autopsy, the deceased had gross evidence of acute lung injury with diffuse alveolar hemorrhage, aorta-bronchial ruptured aneurysm defect and aorto-esophageal fistulas. On histopathological examination, the stomach, small and large bowel showed autolysis, necrosis, and numerous rectangular shaped, non-polarizable crystals. The crystals with characteristic morphology of “fish scale” with hues of pink in the center and yellow to orange in the periphery were identified as sevelamer crystals. Interestingly, crystal deposition was also identified in lung parenchyma and rarely in aortic wall and the fistula. Results (if a Case Study enter NA) NA Conclusion As one of the more commonly used resins in end stage kidney disease, gastrointestinal adverse effect of sevelamer carbonate is often underrecognized. Our case report heightens the awareness of the characteristic morphology of this biologically inert agent, sevelamer to those who are unaware of their morphology. This case also highlights the adverse effect of sevelamer in all patients presenting with gastrointestinal symptoms, such as gastrointestinal bleeding and abdominal pain with the use of sevelamer.

153: Favorable Vessel Patency Following Carotid Artery Reconstruction after ECMO in Children with Heart Disease

153: Favorable Vessel Patency Following Carotid Artery Reconstruction after ECMO in Children with Heart Disease

Covered stent graft for treatment of carotid artery stenosis with post-stenotic aneurysm

Several bare metals, self-expanding stents have been approved by the Food and Drug Administration (FDA) to treat carotid stenosis, but no covered stents have been particularly examined or approved for carotid or cerebrovascular applications. Nonetheless, there are a number of potentially useful applications for covered stents in the brachiocephalic, carotid, and even intracranial arteries. As with currently accepted applications for bare metal carotid stents, the use of covered stents in carotid arteries has been reserved for patients who are at high risk for complications with open surgical management of their specific problem. The present case report emphasizes the safety and efficacy of covered stent in complex carotid artery reconstruction entailing stenosis and aneurysmal dilatation and through light on its impact on minimizing the risk of ischemic complications associated with endovascular or surgical carotid sacrifice.

A Systematic Review of Clinical Outcomes After Carotid Artery Ligation Versus Carotid Artery Reconstruction Following Venoarterial Extracorporeal Membrane Oxygenation in Infants and Children

IntroductionIn pediatric and neonatal populations, the carotid artery is commonly cannulated for venoarterial (VA) extracorporeal membrane oxygenation (ECMO). The decision to ligate (carotid artery ligation [CAL]) versus reconstruct (carotid artery reconstruction [CAR]) the artery at decannulation remains controversial as long-term neurologic outcomes remain unknown. The objective of this study was to summarize current literature on clinical outcomes following CAL and CAR after Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO). MethodsPubMed (MEDLINE), Embase, Web of Science, and Cochrane databases were searched using keywords from January 1950 to October 2020. Studies examining clinical outcomes following CAL and CAR for VA-ECMO in patients <18 y of age were included. Prospective and retrospective cohort studies, case series, case-control studies, and case reports were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were performed independently by two reviewers. Assessment of risk of bias was performed. ResultsEighty studies were included and classified into four categories: noncomparative clinical outcomes after CAL (n = 23, 28.8%), noncomparative clinical outcomes after CAR (n = 12, 15.0%), comparative clinical outcomes after CAL and/or CAR (n = 28, 35.0%), and case reports of clinical outcomes after CAL and/or CAR (n = 17, 21.3%). Follow-up ranged from 0 to 11 y. CAR patency rates ranged from 44 to 100%. There was no substantial evidence supporting an association between CAL versus CAR and short-term neurologic outcomes. ConclusionsStudies evaluating outcomes after CAL versus CAR for VA-ECMO are heterogeneous with limited generalizability. Further studies are needed to evaluate long-term consequences of CAL versus CAR, especially as the first survivors of pediatric/neonatal ECMO approach an age of increased risk of carotid stenosis and stroke.

Carotid Artery Resection and Reconstruction due to Benign and Malignant Head and Neck Tumors.

Carotid resection for head and neck cancer is rare, and serious complications may arise since such cancer is frequently detected in advanced stages. The objective is to describe nine cases of carotid artery resection and reconstruction due to tumor invasion. The clinical records of nine patients who underwent carotid resection and reconstruction at our hospital were retrospectively reviewed. Carotid body tumors were evaluated with the aid of a vascular team in case carotid resection was necessary at the time of surgery. CT angiography to determine the status of the circle of Willis was performed in all patients who might undergo carotid resection and reconstruction in case of failure to restore cerebral blood flow and thus reduce possible sequelae due to ligation. Of nine patients, 6 had carotid body tumors, 1 had a thyroid tumor of conglomerate lymph nodes, 1 had a larynx tumor of conglomerate lymph nodes, and 1 had a myofibroblastic tumor. There were no intraoperative cerebrovascular accidents. One patient (11.1%) had a cerebrovascular accident secondary to carotid hematoma in the intermediate postoperative period that required vascular graft removal. One patient (11.1%) died seven days after surgery following an ischemic cerebrovascular accident. Eight patients remain asymptomatic, and 1 patient with recurrence and metastasis. Carotid resection remains a controversial issue in the treatment of advanced head and neck cancer. However, carotid resection and reconstruction are required for disease control, and complications such as thrombosis or vascular accidents may arise. Fortunately, this is a rare condition. We recommend carotid reconstruction for all patients in whom resection is required for tumor control. Ligation should be a last resort, as seen in the management of one of our patients.

History of Carotid Artery Reconstruction around the World and in Japan.

Since ancient times, physicians have been aware of correlations between the carotid artery and consciousness; however, carotid stenosis was only recently identified as the cause of atherothrombotic ischemic stroke. In 1658, Wepfer described the first suggestion of a link between symptoms of cerebral arterial insufficiency and carotid pathology. In 1951, Fisher reported details of the symptoms and pathological findings and emphasized that cervical atheromatous lesions induced cerebral infarction with various symptoms. The beginning of carotid artery surgery was ligation of the carotid artery for neck or head injury, but surgeons were aware that this operation induced cerebral symptoms due to lack of blood supply. Carotid endarterectomy (CEA) was first reported by Eastcott et al. in 1954, and in Japan, Kimoto performed a successful CEA in 1962. In 1979, percutaneous transluminal angioplasty (PTA) was performed for patients with fibromuscular dysplasia, and then, carotid artery stenting (CAS) was first performed in 1989 by Mathias. In Japan, Kuwana et al. were the first to perform carotid PTA, in 1981, whereas Yamashita et al. performed the first CAS in 1997. Yoshimura et al. proposed staged carotid stenting to prevent hyperperfusion syndrome. Some issues in carotid reconstruction are still debated today, which include conventional (standard) CEA versus the eversion technique, CEA versus CAS versus medical therapy, and medical economic problems. In the future, we must continue to develop more effective, safer, and less expensive therapeutic methods to prevent carotid stroke, carrying on the efforts of the ancient peoples who pioneered this research.

A Propensity-Matched Comparison of Ischemic Brain Lesions on Postprocedural MRI in Endovascular versus Open Carotid Artery Reconstruction.

(1) Study purpose: The aim of our prospective single-center, matched case-control study was to compare the number and volume of acute ischemic brain lesions following carotid endarterectomy (CEA) versus carotid artery stenting (CAS) using a propensity-matched design. (2) Methods: Carotid bifurcation plaques were analyzed by using VascuCAP software on CT angiography (CTA) images. The number and volume of acute and chronic ischemic brain lesions were assessed on MRI scans taken 12-48 h after the procedures. Propensity score-based matching was performed at a 1:1 ratio to compare the ischemic lesions on postinterventional MR. (3) Results: A total of 107 patients (CAS, N = 33; CEA, N = 74) were included in the study. There were significant differences in smoking (p = 0.003), total calcification plaque volume (p = 0.004), and lengths of the lesion (p = 0.045) between the CAS and CEA groups. Propensity score matching resulted in 21 matched pairs of patients. Acute ischemic brain lesions were detected in ten patients (47.6%) of the matched CAS group and in three patients (14.2%) in the matched CEA group (p = 0.02). The volume of acute ischemic brain lesions was significantly larger (p = 0.04) in the CAS group than in the CEA group. New ischemic brain lesions were not associated with neurological symptoms in either group. (4) Conclusions: Procedure-related new acute ischemic brain lesions occurred significantly more frequently in the propensity-matched CAS group.

Long-Term Results of Autologous Bifurcated Carotid Artery Reconstructions

Carotid bifurcation revascularization using interposition grafts is rare. While internal carotid artery (ICA) revascularization is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Long-term results of an autologous bifurcated carotid artery reconstruction are discussed. Single centre, retrospective analysis of a consecutive series of patients treated at an academic vascular surgery center. From 12/2006 to 11/2019, fifty-one patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (38 male, 75%; median age: 68.7 years; IQR: 60.2-76.5). Thirty-eight patients were asymptomatic (74.5%). Indication for reconstruction was recurrent carotid stenosis unfavourable for endovascular treatment/redo patchplasty (n=32, symptomatic: n=7), carotid aneurysm (n=11, symptomatic: n=5), neck tumor with vascular involvement (n=7), trauma (n=1). Non-reversed valve depleted saphenous vein y-graft from the groin was used in 49 (94.2%) and reversed cubital vein bifurcation in three (5.8%) procedures. Median ICA cross-clamp time was 15 minutes (IQR: 13-20 minutes). In four procedures (7.7%), a shunt was inserted because of significant decrease of cerebral perfusion. In one patient, additional intraoperative stent placement of a proximal common carotid artery (CCA) stenosis was performed. Six patients suffered from ischemic neurological deficits (11.5%), all but 1 recovered with no or moderate symptoms. After a median follow-up of 5.2 years (IQR: 1.1-8.7 years), 7 significant asymptomatic stenoses (13.5%) and 2 occlusions (3.8%, one symptomatic) of the ICA, two significant asymptomatic CCA stenoses (3.8%), five significant stenoses (9.6%) and seven asymptomatic occlusions (13.5%) of the ECA were observed. This prompted 7 re-redo-interventions in 5 patients. Twenty-eight patients (54.9%) died after a median follow up of 3.3 years (IQR: .5-5.6 years). Two of these patients died due to conditions related to the performed carotid artery reconstruction. Autologous bifurcated carotid artery interposition graft provides results comparable to other complex ICA-revascularizations. Overall survival in this heterogeneous patient cohort is poor. Due to high risk of stroke and poor long-term outcome, this procedure should be reserved for symptomatic patients with no other option for revascularization.

Analysis of clinical prognosis of endoscopic salvage surgery in patients with rT2 recurrent nasopharyngeal carcinoma

Objective: To investigate the feasibility of endoscopic salvage surgery for patients with rT2 recurrent nasopharyngeal carcinoma (rNPC) and to analyze their prognostic factors. Methods: The clinical data of 33 patients with rT2 rNPC who underwent endoscopic extended nasopharyngectomy in Eye & ENT Hospital Affiliated to Fudan University from January 2015 to July 2020 were analyzed, including 29 males (87.9%) and 4 females (12.1%), aging (51.7±10.6) years. The clinicopathological characteristics of these patients were recorded and analyzed, in terms of gender, sex, alcohol and cigarette use, interval between primary treatment to recurrence, adjuvant therapy, lymph node metastasis, internal carotid artery (ICA) invasion, necrosis, margin and reconstruction materials. Kaplan Meier analysis was used to plot the overall survival rate and progression free survival rate curve, Log-rank test was used to analyze the prognostic factors among patients, and multivariate Cox proportional hazards regression was used to determine the independent risk factors of tumor progression free survival. Results: Among 33 patients with rT2 rNPC, the recurrence interval of 24 patients with rNPC after primary radiotherapy was more than 2 years. A total of 25 patients received primary radiotherapy and adjuvant chemotherapy at the same time. There were 6 cases with cervical lymph node metastasis, 12 cases with ICA invasion, 8 cases with positive surgical margin, 7 cases underwent ICA embolization before operation. A total of 18 cases underwent pedicled tissue flap repairment after operation, including 12 pedicled nasal septal mucosa flaps and 6 temporalis muscle flaps. The median follow-up time was 15 months. Five patients died because of disease progression (in 2 cases), post surgical ICA hemorrhage (in 1 case), liver metastasis (in 1 case) and dysphagia (in 1 case). The 1-year, 2-year and 3-year overall survival rates of all patients were 93.9%, 81.8% and 81.8%, respectively. The 1-year, 2-year and 3-year progression free survival rates were 74.7%, 59.7% and 40.9%, respectively. Log-rank statistical analysis showed that the positive surgical margin (P=0.060) and recurrence interval (P=0.151) were possibly related to the prognosis of rT2 rNPC. Multivariate Cox regression analysis showed that the positive surgical margin was an independent risk factor for patients with rT2 rNPC (P=0.034). Nasopharynx hemorrhage occurred in 4 patients, skull base bone necrosis occurred in 2 patients, trismus occurred in 3 patients, and no obvious brain complications occurred in 7 patients with ICA embolization. Conclusion: Endoscopic salvage surgery for rT2 rNPC is a safe and effective surgical option, but the long-term effect still needs long-term follow-up in bulk cases.

Role of mini access during carotid endarterectomy: a prospective observational study.

Data from literature confirmed the non-trivial risk associated with carotid revascularization. The purpose of this study is to evaluate carotid endarterectomy (CEA) via a mini-invasive access (3-6 cm longitudinal) incision as a viable alternative to the traditional access via a cutaneous incision (˃6 cm) in terms of nerve sparing and neck pain/disability for patients. We performed a prospective, observational, cohort study on 796 consecutive patients who underwent CEAs. A number of 730 patients was included in the final analysis. Patients entered in two different cohorts: CEA with 3-6 cm incision was performed in N.=398 (Group A); CEA with>6 cm incision was performed in N.=398 (Group B). Entire data set is available from 382 in group A and 348 in group B. Adverse events were recorded at 30 days, 3 and 6 months after surgery. The primary purpose of this study was to identify the incidence of cranial nerve injuries and related pain (by Northwick Park Neck Pain Questionnaire [NPq]) in both groups. Differences between groups were exploratory, only, and considered significative for P≤0.05. Secondary objectives were: death, major and minor stroke, transient ischemic attack (TIA), myocardial infarction (MI) and main duration of operation. The cumulative incidence of transient deficit of peripheral nerve in group A was 1.7% at 30 days and 19.4% in group B (RR: 0.10, 95% CI 0.07-0.1, P=0.0001) suggesting a possible benefit from mini-skin incision on nerve injuries reduction. Cranial nerve permanent injuries were identified in 0.17% of mini-incision group and 0.23% of standard group. Exploratory comparison did not demonstrate significative differences between the groups (RR: 0.72, 95% CI 0.19-2.71, P=0.63). The median NPq postoperative score was 40% in GROUP A and 79% in GROUP B (exploratory difference 39%, 95% CI 32.22-45.20%, P=0.0001, χ2: 114.007). At 6 months, NPq was 20% and 42%, respectively; exploratory differences were still present. The need to prolong the mini-incision in GROUP A to preserve the surgical outcome was 1.3%, only. According to these results the mini skin incision allows a sufficient vessels exposure for dissection, endarterectomy, reconstruction of carotid artery and shunt positioning, minimizing surgical invasiveness, decreasing the incidence of temporary cervical nerve dysfunction and improving the aesthetic result with significative less pain suffered by the patients. Transverse cervical and great auricular nerves sparing decreased postoperative hypo-paresthesia in the neck, improving patient's satisfaction. These data suggest that this procedure can be considered safe. Exploratory analysis suggested that it could possibly be considered a safety alternative to standard carotid endarterectomy. A randomized controlled trial is ongoing for definitive conclusions.