Standard Carotid Endarterectomy Research Articles

The effect of carotid sinus neurectomy for carotid restenosis: a study protocol for a double-blinded and randomized controlled trial

BackgroundPatients undergoing carotid endarterectomy (CEA) have a high restenosis rate, which increases the risk of stroke, and there is still a lack of effective treatment for restenosis. The cause of stenosis is related to local inflammatory reactions. Some basic studies have shown that the inflammatory response causing arterial stenosis is closely related to the nerve axons distributed in its outer membrane, and that removal of the nerve is effective in reducing the inflammatory response to prevent arterial stenosis. Therefore, we propose to design a randomized controlled trial to study whether disconnecting the carotid sinus nerve during a CEA operation can reduce carotid arterial restenosis.Method/designThis study is a randomized, double-blind, single-center study. We will recruit 276 patients, who will be randomly divided into the experimental group and the control group. Based on the standard CEA operation, the operator will search for the carotid sinus nerve on the surface of the internal carotid artery and will entirely transect it in the experimental group. Both groups will be guided with the same postoperative treatment and will be followed up every 3 months for 3 years after the operation. The main indices observed will be the carotid restenosis rate, incidence and nature of carotid plaque, and carotid blood flow velocity. Other indices will be arrhythmia, blood pressure variability, and biomarkers of atherosclerosis, such as blood lipids, hypersensitive C-reactive protein (hs-CRP), homocysteine, and total bilirubin.DiscussionIt is expected that carotid sinus nerve transection will significantly reduce the occurrence of restenosis after CEA, decrease the incidence of ischemic stroke, and realize the effective primary prevention of stroke.Trial registrationChiCTR2300073652. Registered on July 18, 2023.

Mid-Term Results of an Italian Multicentric Experience with the RoadsaverTM Dual-Layer Carotid Stent System.

Carotid artery stenting (CAS) using first-generation single-layer stents is widely accepted as a good alternative to standard carotid endarterectomy (CEA) but it is associated with worse outcomes in terms of both plaque prolapse and cerebral embolization. To evaluate the perioperative and midterm outcomes of CAS using the new-generation RoadsaverTM dual-layer micromesh-covered carotid stent. Herein, we present the results of an observational, retrospective, multicentric study on non-consecutive patients who underwent the CAS procedure between January 2017 and December 2022 at three Italian, high-volume vascular surgery centers. The inclusion criteria were the patients' eligibility for the CAS procedure in accordance with the current Italian guidelines, and the implantation of a Roadsaver stent. Both symptomatic and asymptomatic patients were included in the study. The patients requiring reintervention for carotid restenosis following CEA were also included. Perioperative data regarding procedural success was defined as the successful implantation of the device in the desired position, less than 30% residual stenosis, and the absence of intraoperative neurological complications. The primary outcome was any adverse cerebrovascular event such as stroke or transient ischemic attack (TIA) during the procedure and/or after discharge. The secondary outcomes were the need for further intervention, and all-cause death following procedure. Three-hundred-fifty-three (353) patients were included in our study; the mean age was 74.3 years. A total of 5.9% of the patients were symptomatic on their operated side, while 7.3% had contralateral carotid occlusion. A cerebral embolic protection device (CPD) was employed in all patients. A total of 13.3% of the patients were operated on for restenosis after CEA Technical success was achieved in 96.9% of the cases with an intraoperative report of six TIAs (1.7%) and six ipsilateral strokes (1.7%). The mean hospital stay was 1.8 days. The thirty-day follow up showed one TIA and one more stroke. At the mean 35-month follow-up time, the primary outcome was present in six patients (1.7%), where four TIAs (1.1%) and two strokes (0.5%) were reported. Restenosis occurred in five patients (1.4%). Death for any cause was reported in 11 patients (3.1%). As most recent, high-quality studies show, the CAS procedure with second-generation devices such as the Roadsaver stent is safe and effective in preventing carotid-related cerebrovascular events in both symptomatic and asymptomatic patients. The intraoperative and postoperative cerebrovascular complication rate in high volume centers is very low, ensuring confidence in its employment for the CAS procedure along with a CPD as a valid alternative to CEA.

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.

Bypass and other modified reconstruction techniques for 'challenging' carotid cases: A comparison with conventional endarterectomy.

Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA. A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis. A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed. Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues.

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.

Thrombosis or vasospasm: The utility of intraoperative neuromonitoring during TCAR.

Transcarotid artery revascularization (TCAR) has become more prevalent as a treatment modality for carotid stenosis. Many centers perform TCAR without any adjunctive neuromonitoring, for example, somatosensory-evoked potential (SSEP) and electroencephalogram (EEG). We present a case of transcarotid artery revascularization (TCAR) performed with concomitant somatosensory-evoked potential (SSEP) and electroencephalogram (EEG) neuromonitoring in the setting of concerning intraoperative angiographic images. TCAR was undertaken for a 58year-old man presenting with symptomatic left carotid stenosis and right ICA occlusion. Based on his comorbidities, pre-existing conditions, and the need for dual antiplatelet therapy, TCAR was offered as an alternative to standard carotid endarterectomy. Intraoperatively, following stent delivery, no flow was appreciated through the carotid stent or distal ICA. Neuromonitoring remained stable and was reassuring for distal ICA spasm with no-reflow phenomenon. The patient tolerated the procedure well and has had no stent-related complications through 10months of follow-up. This case highlights the utility of neuromonitoring with TCAR as an adjunct to intraoperative decision-making in the setting of suspected internal carotid artery (ICA) vasospasm versus thrombosis after stent delivery.

Carotid Bypass with Gore Hybrid Vascular Graft as a Rescue Technique for on Table Failed Carotid Endarterectomy: A Five Years Follow-up

Introduction: Carotid endarterectomy (CEA) remains the gold standard for stenotic lesions involving the carotid bifurcation. Carotid bypass grafting is a suitable alternative technique especially in challenging and on table failed endarterectomy. We report our five years' experience using the Gore Hybrid vascular graft (GHVG) as a rescue technique when standard CEA failed. Methods: Between November 2014 and November 2018 nineteen GHVGs were used in patients undergoing CEA. All patients were scheduled for a routine endarterectomy and patch plasty. Pre-operative detailed duplex imaging was undertaken in all patients to measure the proximal and distal diameter of the internal carotid artery (ICA). The GHVG was used in eleven cases in which the plaque extended beyond the surgical exposure resulting in an unsatisfactory distal end point. Five patients had penetrating atherosclerotic ulcers causing a disruption of the posterior wall. Two cases had a significant wall thinning after the endarterectomy and in one case the bypass option was selected for a post-radiation induced stenosis. All patients were discharged on day 3 on dual antiplatelets and were followed up at 1 , 3, 6 ,12 months with duplex and CT angiogram . After one year the follow up continued regularly every six months using only duplex scan. CT angiogram was requested to monitor a severe restenosis. Kaplan Meir analysis was used for assessing the long term patency. Results: Procedural success was achieved in all cases. All patients made a good post-operative recovery with no perioperative stroke or death. The total operative time and cerebral ischaemic time was reduced because the avoidance of creating two sutured anastomosis. In six patients the external carotid artery (ECA) was re- implanted in an end to side fashion. Four GHVGs occluded during the follow-up at 6, 12,24 and 39 months completely asymptomatic. Five patients developed restenosis without any neurological events at 12, 13,15 20 and 28 months. Two patients underwent a carotid angioplasty and stenting for asymptomatic severe restenosis. The primary patency rate at 50 months was 78.9% Conclusion: The GHVG is a new promising technology in patients with extensive carotid atherosclerotic disease when conventional endarterectomy has failed. Our experience suggests a potential role of this graft in challenging case. Dual antiplatelets and long term follow up are needed to maintain the durability of this graft. Disclosure: Nothing to disclose

Retinal vessel dynamic functionality in the eyes of asymptomatic patients with significant internal carotid artery stenosis.

The goal of this study was to assess the retinal microvascular function in asymptomatic patients with hemodynamically significant internal carotid artery stenosis (ICAS) and to assess the potential efficacy of carotid endarterectomy (CEA) for the improvement of vessel functionality. Retinal vessel caliber and reactions to flicker stimulation were assessed in both eyes of 65 asymptomatic patients with unilateral hemodynamically significant ICAS and 34 healthy subjects. Subsequently, the recruited ICAS patients were referred for standard unilateral CEA procedure. The full ophthalmologic examination of both eyes and vessel analysis were performed 1 day before and 3 months after CEA. The venous responses to flicker stimulation were significantly lower in the EIS (eyes ipsilateral to stenosis) and ECS (eyes contralateral to stenosis) compared with those in the controls (P<0.0001 and P<0.0001, respectively). No changes were identified in retinal vascular flicker responses after CEA in both groups of eyes compared with the baseline values. We observed a decrease in CRVE (central retinal venular equivalent) after the CEA both in eyes ipsilateral (P=0.01) and contralateral (P=0.04) to CEA. Likewise, a decrease in CRAE (central retinal arteriolar equivalent) was identified in the eyes ipsilateral to CEA (P<0.001). This outcome strongly indicates that microvascular dysfunction is long-lasting despite the recovery of the flow in the carotid artery.

Clinical experience of carotid endarterectomy for the treatment of carotid stenosis

Objective To investigate the clinical outcomes and prognosis of carotid endarterectomy (CEA) for moderate to severe carotid stenosis. Method The clinical data of 78 patients with moderate or severe carotid stenosis treated with CEA from March 2015 to December 2017 at Department of Neurosurgery, the First Affiliated Hospital of Zhengzhou University (18 cases) and Department of Neurosurgery, General Hospital of Tianjin Medical University (60 cases) were retrospectively analyzed. There were 72 cases of symptomatic stenosis, 6 cases of asymptomatic stenosis. Among them, there were 66 cases of unilateral stenosis and 12 cases of bilateral stenosis. All patients were treated with standard CEA. There were 72 cases of unilateral CEA and 6 cases of bilateral CEA. A total of 84 CEA operations were performed. Results All operations were performed successfully. The clamping duration was 18.0 to 52.0 minutes, with an average of 28.0±4.2 minutes. During perioperative period, there were 3 new cases of cerebral infarction, including 1 case of massive cerebral infarction and 1 case of transient ischemic attack. The incidence of cerebral ischemic events was 4.8% (4/84). No intracranial hemorrhage or death occurred after operation. All patients were followed up for 6.0 to 38.0 months, with an average of 18.0±3.2 months. There were 4 (4.8%) cases of restenosis (stenosis degree ≥50%) after operation, including 2 cases of cerebral infarction, 1 case of transient ischemic attack and 1 asymptomatic case. Conclusions CEA is an effective treatment for moderate to severe carotid stenosis. Standardized perioperative management and operative procedures could help to reduce postoperative complications and achieve good clinical results. Key words: Endarterectomy, cartoid; Carotid stenosis; Atherosclerosis; Complication

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

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

IP125. Comparative Safety and Durability of Complex/Hybrid Carotid Reconstructions and Standard Carotid Endarterectomy

IP125. Comparative Safety and Durability of Complex/Hybrid Carotid Reconstructions and Standard Carotid Endarterectomy

Carotid endarterectomy for treatment of carotid in-stent restenosis: long-term follow-up results and surgery experiences from one single centre

ObjectiveFew studies have reported the surgical treatment of carotid in-stent restenosis (ISR), more data and longer follow-up are needed. We describe the surgical treatment of ISR by standard carotid endarterectomy...

Do standard carotid artery endarterectomy and primary closure technique cause early restenosis in diabetic patients?

IntroductionWe aimed to investigate carotid restenosis in 2-year follow-up in diabetic and nondiabetic patients who underwent standard carotid endarterectomy with primary carotid closure and determine whether diabetes mellitus is a risk factor for early stenosis for this surgical procedure.Material and methodsWe retrospectively assessed the data of patients who underwent standard carotid endarterectomy with primary carotid closure from the hospital registry and outpatient clinic follow-up between January 2006 and January 2012. The study included 25 diabetics and 25 nondiabetics, in total 50 patients. The control carotid Doppler ultrasonographies and/or computed tomography angiographies of the patients at postoperative 1, 6, 12, and 24 months were examined and a stenosis rate between 70% and 99% was regarded as significant carotid restenosis.ResultsWhen the diabetic and nondiabetic group patients were compared for early carotid restenosis at 2 years, there were 3 (12%) patients in the diabetic group and 4 (16%) patients in the nondiabetic group with restenosis. A statistically significant difference in early carotid restenosis was not observed between the two groups (p > 0.05).ConclusionsStandard carotid endarterectomy and primary closure of the artery is a successfully performed surgical procedure in diabetic patients. We concluded that diabetes mellitus is not a risk factor for early restenosis in the diabetic patient population according to the results of our research.

Clinical results of carotid artery stenting versus carotid endarterectomy

Objective:To review our results of carotid artery stenting (CAS) and carotid endarterectomy (CEA).Methods:We evaluated the medical records of patients undergoing carotid artery revascularization procedure, between 2001 and 2013 in Baskent University Hospital, Ankara, Turkey. Carotid artery stenting or CEA procedures were performed in patients with asymptomatic carotid stenosis (≥70%) or symptomatic stenosis (≥50%). Demographic data, procedural details, and clinical outcomes were recorded. Primary outcome measures were in 30-day stroke/transient ischemic attacks (TIA)/amaurosis fugax or death. Secondary outcome measures were nerve injury, bleeding complications, length of stay in hospital, stroke, restenosis (ICA patency), and all-cause death during long-term follow-up.Results:One hundred ninety-four CEA and 115 CAS procedures were performed for symptomatic and/or asymptomatic carotid artery stenosis. There is no significant differences 30-day mortality and neurologic morbidity between CAS (13%) and CEA procedures (7.7%). Length of stay in hospital were significantly longer in CEA group (p=0.001). In the post-procedural follow up, only in symptomatic patients, restenosis rate was higher in the CEA group (p=.045). The other endpoints did not differ significantly.Conclusions:Endovascular stent treatment of carotid artery atherosclerotic disease is an alternative for vascular surgery, especially for patients that are high risk for standard CEA. The increasing experience, development of cerebral protection systems and new treatment protocols increases CAS feasibility.

Expression of NF-κB, CD68 and CD105 in carotid atherosclerotic plaque.

Atherosclerotic plaque vulnerability is associated with cerebrovascular events in patients with carotid atherosclerosis. The aim of this study was to investigate the expression of inflammatory factors in carotid artherosclerotic plaques in order to explore its clinical significance in patients with carotid stenosis. Forty three patients with carotid stenosis were divided into symptomatic group (n=24) and asymptomatic group (n=19) based on clinical manifestation. All patients were treated with selective standard carotid endarterectomy (CEA); the carotid atherosclerotic plaques were removed surgically and studied pathologically to investigate the expression of nuclear factor-kappa κ (NF-κB), CD68 and CD105. The plaques were grouped into stable and unstable plaques based on thickness of the fibrous cap and the area of lipid-rich core in the plaques. The proportion of unstable plaques were significantly higher in symptomatic group than in asymptomatic group (70.8% vs. 63.2%, P=0.026). Results of immunohistochemisty staining showed that the expression of NF-κB, CD68 and CD105 in unstable plaques was higher than stable plaques (P<0.001). The association of the higher expression of these factors with instability of carotid plaque needs to be clarified in future study.

Mandibular Subluxation as an Adjunct in Very Distal Carotid Arterial Reconstruction: Incidence of Peripheral and Cerebral Neurologic Sequelae in a Single-Center Experience

The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy. Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis. MS-CEA patients were more frequently male (P = 0.03), presented more frequently with symptomatic lesions (P = 0.007), longer lesions (P = 0.01), and had common ICA bypass implantation (P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups (P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P = 0.24). MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA.

Standardized Protocols Enable Early Stroke Recognition and Treatment of Carotid Stenosis

To examine the impact of acute stroke care coordination between vascular surgery and stroke neurology services with primary focus on acute patient stabilization and expeditious carotid endarterectomy (CEA). A standardized acute stroke care protocol was instituted between vascular surgery and stroke neurology services that included expeditious patient evaluation and imaging of brain and carotid computed tomography/magnetic resonance angiography, carotid duplex ultrasound, and/or conventional arteriogram; patient admission to a dedicated stroke unit with 1:1 intensive care staffing and 24-hour available neurointensivist; and treatment of all patients with ipsilateral moderate or severe carotid stenosis via CEA with cervical block (158 [81%]) or general anesthesia (38 [19%]). Patient exclusion from expeditious CEA included stroke in evolution and dense neurological deficit with National Institutes of Health Stroke Scale score >15. All data in this intent-to-treat study were prospectively collected and outcomes evaluated. From 11/2002 to 11/2012, 196 patients were admitted for acute stroke with a mean carotid stenosis of 84% (range, 50%-100%) and underwent CEA with a mean stroke onset to CEA time of 3.4 days (range, 0-7 days), via eversion CEA (185 [94%]) or standard CEA (11 [6%]). During CEA, shunt was placed electively in the majority of patients receiving general anesthesia (41 [21%]) and emergently for neurologic deterioration in patients receiving cervical block (13 [7%]). Six patients had neurologic events; two ipsilateral strokes (1%) and four ipsilateral transient ischemic attacks (2%), which resolved within 24 hours without residual deficits. Ten (5%) patients had myocardial infarctions; there were no deaths. In appropriately selected patients with acute stroke, early CEA is feasible and relatively safe with stroke-death-myocardial infarction complication of 6%. Stroke-death occurs in only 1%, and most complications are of non-fatal cardiac origin. A standardized stroke team protocol inclusive of stroke neurologists and vascular surgeons allows for expeditious and safe CEA in the setting of acute stroke.

Ischemic Stroke Predicts Myocardial Injury After Carotid Endarterectomy for Symptomatic Severe Carotid Artery Stenosis

Myocardial injury following carotid endarterectomy (CEA) is a common cause of morbidity and mortality, and its risk varies depending on the severity and extent of disease. However, when patients with sympotomatic severe carotid stenosis undergo CEA, the frequency and potential predictors of myocardial injury remain unknown. A total of 40 patients (32 men and 8 women) who underwent successful standard CEA were observed. Cardiac troponin I (cTnI) concentrations were assessed before surgery and on postoperative days 1, 2, and 3 in all patients. Myocardial injury was defined as the peak cTnI concentration > 0.04 ng/mL. In all, 42.5% patients had postoperative myocardial injury. Previous ischemic stroke and abnormal ST-segment changes were the preoperative predictors of myocardial injury after CEA, with odds ratios of 4.1 (95% confidence interval, 1.1-16.1; P = .04) and 5.9 (95% confidence interval, 1.3-27.7; P = .04), respectively. Sympotomatic patients with those conditions should receive more attention to myocardial injury, when presented for CEA.

Application analysis between standard and eversion carotid endarterectomy in the treatment of carotid artery

Objective To evaluate the standard and eversion carotid endarterectomy for carotid artery stenosis in clinical application.Methods We analyzed clinical data of 90 sides with 81 patients with carotid endarterectomy,the standard type 25 sides,eversion type 65 sides,analyzing the characteristics of two procedures to assess the value and efficacy of its applications. Results all operations were successful,block time:standard - type 13.4 - 48.6 min,eversion - type 14.5 - 31.2 min.Postoperative patients were reviewed craniocervical CTA,if necessary,review head CT,carotid artery operated side showed normal morphology,the two cases used the standard type occurred after surgery side of infarct,and two cases occurred anastomotic regional plaque formation and restenosis after 11 months; 8 cases of internal carotid artery stenosis and those with hallux valgus bending distortion disappears rear.Conclusions To Standard and eversion carotid endarterectomy can effectively treat carotid artery stenosis to prevent stroke. Two surgical methods have their own characteristics. The appropriate surgical approach should be based on proficiency and patients with lesions,imaging,anatomical. Key words: Carotid; Stenosis; Caortid endarterectom; Standard; Eversion

Routine Shunting is Safe and Reliable for Cerebral Perfusion during Carotid Endarterectomy in Symptomatic Carotid Stenosis

BackgroundThe purpose of this report is to describe the perioperative outcomes of standard carotid endarterectomy (CEA) with general anesthesia, routine shunting, and tissue patching in symptomatic carotid stenoses.Materials and MethodsBetween October 2007 and July 2011, 22 patients with symptomatic carotid stenosis (male/female, 19/3; mean age, 67.2±9.4 years) underwent a combined total of 23 CEAs using a standardized technique. The strict surgical protocol included general anesthesia and standard carotid bifurcation endarterectomy with routine shunting. The 8-French Pruitt-Inahara shunt was used in all the patients.ResultsDuring the ischemic time, the shunts were inserted within 2.5 minutes, and 5 patients (22.7%) revealed ischemic cerebral signals (flat wave) in electroencephalographic monitoring but recovered soon after insertion of the shunt. The mean shunting time for CEA was 59.1±10.3 minutes. There was no perioperative mortality or even minor stroke. All patients woke up in the operating room or the operative care room before being moved to the ward. One patient had difficulty swallowing due to hypoglossal nerve palsy, but had completely recovered by 1 month postsurgery.ConclusionRoutine shunting is suggested to be a safe and reliable method of brain perfusion and protection during CEA in symptomatic carotid stenoses.