Improving the Provision of Carotid Endarterectomy in Line with UK Government Targets Requires More than Just Motivated Surgeons

INTRODUCTION

Carotid endarterectomy confers maximum benefit in symptomatic patients provided it is performed within < 2 weeks of presentation, but few centres achieve this target. The objective of this study was to determine if a surgeon with an interest in carotid endarterectomy could make simple modifications to practice so that carotid endarterectomy was performed within 2 weeks of referral in the majority of patients.

PATIENTS AND METHODS

Audit of 44 symptomatic patients undergoing carotid endarterectomy by one surgeon in 2007 after implementing simple changes in practice (e.g. ad hoc cancellation of non-urgent cases, ad hoc utilisation of cancelled theatre sessions). Outcomes were compared with 36 symptomatic patients undergoing carotid endarterectomy in 2006.

RESULTS

There was only a modest reduction in delay to surgery. In 2006, 11% underwent carotid endarterectomy within 2 weeks of referral increasing to 20% in 2007. By 2007, 48% underwent surgery within 4 weeks compared with 33% in 2006.

CONCLUSIONS

Notwithstanding the additional impact of delays from symptom onset to referral, achieving a 2-week target will require more than motivated surgeons making simple changes to practice. It seems inevitable that vascular units will have to identify 1–2 ‘ring fenced’ theatre sessions per week (but some could go unused) and surgeons will have to accept that they may not always operate on the patients they work-up.     

The Importance of Early Carotid Endarterectomy in Symptomatic Patients

INTRODUCTION

Early carotid endarterectomy (CEA) in symptomatic patients may prevent repeat cerebral events. This study investigates the relationship between waiting time for CEA and the incidence of repeat cerebral events prior to surgery in symptomatic patients.

PATIENTS AND METHODS

A prospective database of consecutive patients undergoing CEA between January 2002 and December 2006 was reviewed. Repeat event rates prior to surgery were calculated using Kaplan–Meier analysis and predictive factors identified using Cox regression analysis.

RESULTS

A total of 118 patients underwent CEA for non-disabling stroke, TIA and amaurosis fugax. Repeat cerebral events occurred in 34 of 118 (29%) patients at a median 51 days (range, 2–360 days) after the first event. The estimated risk of repeat events was 2% at 7 days and 9% at 1 month after first event (Kaplan–Meier survival analysis). Age (HR 1.059; 95% CI 1.014–1.106; P = 0.009] was identified as a predictor of repeat events. Patients underwent surgery at median 97 days (range, 7–621 days) after the first event. Eleven of 60 (18%) patients waiting ≤?97 days for surgery and 23 of 58 (40%) patients waiting >?97 days had repeat events. (P = 0.011, chi-squared test).

CONCLUSIONS

Delays in surgery should be reduced in order to minimise repeat cerebral events in patients with symptomatic carotid stenosis, particularly in the elderly population.     

Risk factors for perioperative ischemic stroke in cardiac surgery

Objective

The purpose of this study was to evaluate the risk factors for ischemic stroke in patients undergoing cardiac surgery.

Methods

From January 2010 to December 2012, 519 consecutive patients undergoing cardiac surgery were analyzed prospectively. The sample was divided into two groups: patients with stroke per and postoperative were allocated in Group GS (n=22) and the other patients in the group CCONTROL (n=497). The following variables were compared between the groups: gender, age, carotid stenosis ≥ 70%, diabetes on insulin, chronic obstructive pulmonary disease, peripheral arteriopathy, unstable angina, kidney function, left ventricular function, acute myocardial infarction, pulmonary arterial hypertension, use of cardiopulmonary bypass. Ischemic stroke was defined as symptoms lasting over 24 hours associated with changes in brain computed tomography scan. The variables were compared using Fisher’s exact test, Chi square, Student’s t-test and logistic regression.

Results

Stroke occurred in 4.2% of patients and the risk factors statistically significant were: carotid stenosis of 70% or more (P=0.03; OR 5.07; IC 95%: 1.35 to 19.02), diabetes on insulin (P=0.04; OR 2.61; IC 95%: 1.10 to 6.21) and peripheral arteriopathy (P=0.03; OR 2.61; 95% CI: 1.08 to 6.28).

Conclusion

Risk factors for ischemic stroke were carotid stenosis of 70% or more, diabetes on insulin and peripheral arteriopathy.     

RACE to protect brains

INTRODUCTION

Rapid-access carotid endarterectomy (RACE) is an evidence-based treatment for symptomatic carotid stenosis. Our vascular centre aims to provide this service within 48 h of symptoms in appropriate patients. This study audits safety and efficacy of the first year of RACE.

SUBJECTS AND METHODS

A clear trust protocol was publicised for the RACE pathway. A prospective database was established for all carotid endarterectomies (CEAs) performed. Outcomes were compared between elective (ECE) and rapid-access operations.

RESULTS

In 1 year, 96 patients received CE; 20 were performed urgently. There were no significant differences in age or gender between ECE and RACE groups. Twenty-three (30%) of ECE were for asymptomatic stenoses; no other significant differences in surgical indication were seen. Of symptomatic ECE, 43% were for completed stroke versus 55% for RACE. Median delay between diagnosis and surgery was 113 days for elective and 2 days for RACE patients. There was one death following ECE (1.3%) and one stroke after RACE (5%), all not significant. Anaesthetic method did not influence outcome. The main reasons for delaying surgery in RACE patients were optimisation of patient fitness and availability of theatre time.

CONCLUSIONS

The RACE pathway dramatically reduces delay without compromising patient safety. In the first year of service, we have treated 50% of suitable patients within 48 h. Further education of patients and colleagues should reduce delay and improve outcomes for symptomatic carotid disease.     

Relationship between ADAMTS4 and carotid atherosclerotic plaque vulnerability in humans

Background

Rupture of atherosclerotic plaques and the resulting thrombosis are vital causes of clinical ischemic events. Recent studies have shown that ADAMTS4 (a disintegrin and metalloproteinase with thrombospondin motifs 4) is a pathogenic factor of plaque vulnerability in mice. However, the relationship between ADAMTS4 and carotid atherosclerotic vulnerable plaques in humans remains unclear.

Carotid endarterectomy in awake patients: safety,tolerability and results

Objective

To analyze the results of 125 carotid endarterectomies under loco-regional anesthesia, with selective use of shunt and bovine pericardium patch.

Methods

One hundred and seventeen patients with stenosis ≥ 70% in the internal carotid artery on duplex-scan + arteriography or magnetic resonance angiography underwent 125 carotid endarterectomies. Intraoperative pharmacological cerebral protection included intravenous administration of alfentanil and dexametasone. Clopidogrel, aspirin and statins were used in all cases. Seventy-seven patients were males (65.8%). Mean age was 70.8 years, ranging from 48 to 88 years. Surgery was performed to treat symptomatic stenosis in 69 arteries (55.2%) and asymptomatic stenosis in 56 arteries (44.8%).

Results

A carotid shunt was used in 3 cases (2.4%) due to signs and symptoms of cerebral ischemia after carotid artery clamping during the operation, and all 3 patients had a good outcome. Bovine pericardium patch was used in 71 arteries ≤ 6 mm in diameter (56.8%). Perioperative mortality was 0.8%: one patient died from a myocardial infarction. Two patients (1.6%) had minor ipsilateral strokes with good recovery, and 2 patients (1.6%) had non-fatal myocardial infarctions with good recovery. The mean follow-up period was 32 months. In the late postoperative period, there was restenosis in only three arteries (2.4%).

Conclusion

Carotid artery endarterectomy can be safely performed in the awake patient, with low morbidity and mortality rates.     

The effect of gender on the early results of coronary artery bypass surgery in the younger patients' group

Introduction

In this retrospective study, we aimed to determine the risk factors for coronary artery bypass surgery in patients under 45 years of age, and evaluate the early postoperative results and the effect of gender.

Methods

A total of 324 patients under 45 years of age who undergone on-pump coronary artery bypass surgery between April 12, 2004 and January 10, 2012 were included to the study. Patients divided into groups as follows: Group 1 consisted of 269 males (mean age 41.3), Group 2 consisted of 55 females (mean age 41.6). Preoperative risk factors, intraoperative and postoperative data and early mortality rates of the groups were compared.

Results

Smoking rate was significantly higher in Group 1. Diabetes mellitus incidence and body mass index were significantly higher in Group 2 (P values P=0.01; P=0.0001; P=0.04 respectively). The aortic cross-clamping and cardiopulmonary bypass time and number of grafts per patient were significantly higher in Group 1 (P values P=0.04; P=0.04; P=0.002 respectively). There were no deaths in either group.

Conclusion

We found that gender has no effect on early mortality rates of the coronary bypass surgery patients under 45 years.     

Indications for intensive care unit care after carotid endarterectomy

Objectives

To describe the complications of carotid endarterectomy and the interventions performed in the intensive care unit (ICU) after carotid endarterectomy. To identify preoperative and recovery room (RR) risk markers for these complications and interventions.

Design

A retrospective case study.

Setting

The ICU of a university hospital.

Patients

One hundred and one patients who required carotid endarterectomy over a 15-month period.

Intervention

Carotid endarterectomy (bilateral procedures in 11 patients).

Outcome Measures

Demographic data including Goldman’s cardiac risk index and the therapeutic intervention scoring system (TISS) score to measure the risk of complications.

Results

Most of interventions conducted in the RR and ICU were to control high blood pressure. In the RR, three patients experienced a neurologic event, one patient was reintubated for vocal cord paralysis and one had electrocardiographic abnormalities. Overall, 5 of the 101 patients had neurologic complications and 2 suffered a myocardial infarction. Two patients died, one as a result of a massive stroke and the other of myocardial infarction with cardiogenic shock. The mean (and standard deviation ) TISS score in the ICU was 12.6 (3.8). Analysis of all events in the RR was not predictive of events in the ICU. However, the absence of major complications in the RR had a negative predictive value of 97%.

Conclusions

The decision to admit patients to the ICU after carotid endarterectomy should be based on major complications occurring in the RR. A low TISS score and low incidence of complications does not warrant routine admission.     

Comparison of outcomes in women and men following carotid interventions in the Washington state's Vascular Interventional Surgical Care and Outcomes Assessment Program

Background

The benefit for carotid endarterectomy (CEA) to prevent a potential stroke has been shown to be less beneficial for women compared with men and the risk of carotid stenting (CAS) is higher in women than men. We hypothesized that a community-based Washington state registry data would also reveal increased morbidity and mortality for women undergoing carotid interventions.

Patch variability following carotid endarterectomy: a survey of Great Britain and Ireland

INTRODUCTION

Evidence suggests a clinical benefit with patch angioplasty after carotid endarterectomy (CEA). The UK National Vascular Database has demonstrated variation in practice but does not record technical details. This study was intended to define indications and technique of patching after CEA.

METHODS

An electronic questionnaire was emailed to all 402 members of the Vascular Society of Great Britain and Ireland. The email could not be received by 23 and 14 did not perform CEA. Some questions allowed multiple answers. Fisher’s exact test was used for statistical analysis.

RESULTS

There were 187 responses (51%). Fifteen members (8%) performed eversion CEA, which obviates patching. Of all the respondents, 121 surgeons (65%) always use a patch. Seventy of these (58%) use the full patch width (median: 8mm, range: 4–10mm). Fourteen (12%) variably trimmed the patch (median: 7.5mm, range: 5–10mm) and 34 (28%) routinely trimmed (median: 6mm, range: 3–20mm). Selective patching, dependent on internal carotid artery diameter, was performed by 48 respondents (26%), 23 of whom specified a median artery threshold diameter of 5mm (range: 3–8mm). General anaesthesia was always or usually used by 83 surgeons (45%), local anaesthesia by 77 (41%) and the remainder followed patient choice. Obligatory patching is performed by 68 of the 83 respondents (82%) who prefer general anaesthesia whereas only 40 of the 77 surgeons (52%) who use local anaesthesia always patch (p<0.0001).

CONCLUSIONS

There is a variable rate of patching after CEA in the UK, which appears dependent on the vessel size and mode of anaesthesia. There are also differences in the patch width adopted.     

Cranial nerve injuries and the retrojugular approach in carotid endarterectomy

INTRODUCTION

This is a retrospective case series analysis to compare the incidence of cranial nerve injuries in carotid endarterectomy by the retrojugular and anteromedial approaches.

PATIENTS AND METHODS

Data were extracted from a prospectively collected database. Ninety-one retrojugular carotid endarterectomies were compared with 145 anteromedial carotid endarterectomies. All were performed under local anaesthesia and used the eversion technique. Data were analysed using the chi-squared test.

RESULTS

Nine (3.8%) cases were complicated by cranial nerve injuries. In four cases, multiple nerves were involved. In total, 13 (5.5%) cranial nerves were injured. The affected nerves were: two (0.8%) marginal mandibular, two (0.8%) laryngeal, three (1.2%) accessory and six (2.5%) hypoglossal. There was no statistically significant difference in total or specific cranial nerve injuries between the two surgical approaches.

CONCLUSIONS

The risk of cranial nerve injuries was similar following either the retrojugular or anteromedial approach. Accessory nerve injuries were only seen in the retrojugular approach but this did not reach statistical significance.     

Effect of using pump on postoperative pleural effusion in the patients that underwent CABG

Objective

The present study investigated effect of using pump on postoperative pleural effusion in patients who underwent coronary artery bypass grafting.

Methods

A total of 256 patients who underwent isolated coronary artery bypass grafting surgery in the Cardiovascular Surgery clinic were enrolled in the study. Jostra-Cobe (Model 043213 105, VLC 865, Sweden) heart-lung machine was used in on-pump coronary artery bypass grafting. Off-pump coronary artery bypass grafting was performed using Octopus and Starfish. Proximal anastomoses to the aorta in both on-pump and off-pump techniques were performed by side clamps. The patients were discharged from the hospital between postoperative day 6 and day 11.

Results

The incidence of postoperative right pleural effusion and bilateral pleural effusion was found to be higher as a count in Group 1 (on-pump) as compared to Group 2 (off-pump). But the difference was not statistically significant [P>0.05 for right pleural effusion (P=0.893), P>0.05 for bilateral pleural effusion (P=0.780)]. Left pleural effusion was encountered to be lower in Group 2 (off-pump). The difference was found to be statistically significant (P<0.05, P=0.006).

Conclusion

Under the light of these results, it can be said that left pleural effusion is less prevalent in the patients that underwent off-pump coronary artery bypass grafting when compared to the patients that underwent on-pump coronary artery bypass grafting.     

Comparison of polyurethane with cyanoacrylate in hemostasis of vascular injury in guinea pigs

Objective

To evaluate the behavior of castor oil-derived polyurethane as a hemostatic agent and tissue response after abdominal aortic injury and to compare it with 2-octyl-cyanoacrylate.

Methods

Twenty-four Guinea Pigs were randomly divided into three groups of eight animals (I, II, and III). The infrarenal abdominal aorta was dissected, clamped proximally and distally to the vascular puncture site. In group I (control), hemostasis was achieved with digital pressure; in group II (polyurethane) castor oil-derived polyurethane was applied, and in group III (cyanoacrylate), 2-octyl-cyanoacrylate was used. Group II was subdivided into IIA and IIB according to the time of preparation of the hemostatic agent.

Results

Mean blood loss in groups IIA, IIB and III was 0.002 grams (g), 0.008 g, and 0.170 g, with standard deviation of 0.005 g, 0.005 g, and 0.424 g, respectively (P=0.069). The drying time for cyanoacrylate averaged 81.5 seconds (s) (standard deviation: 51.5 seconds) and 126.1 s (standard deviation: 23.0 s) for polyurethane B (P=0.046). However, there was a trend (P=0.069) for cyanoacrylate to dry more slowly than polyurethane A (mean: 40.5 s; SD: 8.6 s). Furthermore, polyurethane A had a shorter drying time than polyurethane B (P=0.003), mean IIA of 40.5 s (standard deviation: 8.6 s). In group III, 100% of the animals had mild/severe fibrosis, while in group II only 12.5% showed this degree of fibrosis (P=0.001).

Conclusion

Polyurethane derived from castor oil showed similar hemostatic behavior to octyl-2-cyanoacrylate. There was less perivascular tissue response with polyurethane when compared with cyanoacrylate.     

Randomized controlled trial of pharmacological replacement of melatonin for sleep disruption in individuals with tetraplegia

Objective

To determine the effectiveness of a melatonin agonist for treating sleep disturbances in individuals with tetraplegia.

Design

Placebo-controlled, double-blind, crossover, randomized control trial.

Setting

At home.

Participants

Eight individuals with tetraplegia, having an absence of endogenous melatonin production and the presence of a sleep disorder.

Interventions

Three weeks of 8 mg of ramelteon (melatonin agonist) and 3 weeks of placebo (crossover, randomized order) with 2 weeks of baseline prior to and 2 weeks of washout between active conditions.

Outcome

Change in objective and subjective sleep.

Measures

Wrist actigraphy, post-sleep questionnaire, Stanford sleepiness scale, SF-36.

Results

We observed no consistent changes in either subjective or objective measures of sleep, including subjective sleep latency (P = 0.55, Friedman test), number of awakenings (P = 0.17, Friedman test), subjective total sleep time (P = 0.45, Friedman test), subjective morning alertness (P = 0.35, Friedman test), objective wake after sleep onset (P = 0.70, Friedman test), or objective sleep efficiency (P = 0.78, Friedman test). There were significant increases in both objective total sleep time (P < 0.05, Friedman test), subjective time in bed (P < 0.05, Friedman test), and subjective sleep quality (P < 0.05, Friedman test), although these occurred in both arms. There were no significant changes in any of the nine SF-36 subscale scores (Friedman test, Ps >Bonferroni adjusted α of 0.005).

Conclusion

In this pilot study, we were unable to show effectiveness of pharmacological replacement of melatonin for the treatment of self-reported sleep problems in individuals with tetraplegia.

Trial Registration

ClinicalTrials.gov # {"type":"clinical-trial","attrs":{"text":"NCT00507546","term_id":"NCT00507546"}}NCT00507546.     

Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery

INTRODUCTION

There is no clear guidance as to the management of carotid stenotic disease prior to cardiac surgery. We aimed to review the results of a single centre performing carotid endarterectomy (CEA) under local anaesthesia prior to cardiac surgery.

PATIENTS AND METHODS

All patients referred for cardiac surgery in our tertiary referral unit between January 1998 and August 2008 were identified and data relating to those 100 undergoing CEA prior to cardiac surgery were reviewed. Eighty had coronary artery bypass grafting (CABG) alone, 15 combined valve surgery and CABG and three underwent isolated valve surgery. Two patients died prior to cardiac surgery.

RESULTS

One hundred patients were prospectively identified after screening by clinical features and carotid duplex scanning to require CEA from a total of 11,394. The stroke rate was 1% between CEA and cardiac surgery, 2% following cardiac surgery and 3% in total. Ninety-eight patients proceeded to cardiac surgery (two deaths post-CEA). The cumulative event rate (stroke, myocardial infarct [included in view of the nature of the patients in our cohort] and/or death) was 10.2% following all cardiac surgery (CABG and valve). In 80 patients undergoing CABG only, the cumulative event rate was 7.5% after CABG. Including the two deaths pre-cardiac surgery, the rates were 12% and 8%. The risk of peri-operative stroke and 30-day mortality were reduced to that of patients undergoing cardiac surgery without significant carotid arterial disease, 3% versus 3.3% and 5.1% versus 6.5%, respectively.

CONCLUSIONS

This study demonstrates that a policy of selective screening for significant carotid artery disease in cardiac surgical patients combined with a strategy of CEA under local anaesthesia prior to unselected cardiac surgery (CABG with or without valve surgery) leads to rates of peri-operative CVA, myocardial infarction and death comparable to rates published for CEA prior to isolated CABG surgery. Furthermore, it reduces the risk of peri-operative stroke and 30-day mortality to that observed in patients undergoing cardiac surgery without significant carotid arterial disease.     

The Significance of MMP-9 Over MMP-2 in HCC Invasiveness and Recurrence of Hepatocellular Carcinoma After Curative Resection

Background

The extracellular matrix metalloproteases MMP-9 and MMP-2 are critical for the invasive potential of tumors. However, it is not clear which of the two plays the predominant role in tumor invasion and progression. In the present study, we compared the clinical efficacy of MMP-9 and MMP-2 overexpression for predicting tumor recurrence and survival after surgical resection in HCC patients.

Materials and Methods

MMP-9 and MMP-2 expression in HCC cell lines and in vitro HCC invasion model were detected by quantitative RT-PCR and immunofluorescence. The expression levels of MMP-9 and MMP-2 were assessed by immunohistochemistry in HCC tissue microarrays from HCC patients (study set) who underwent curative resection. The clinicopathological data were retrospectively analyzed. The results were further verified in an independent cohort of 92 HCC patients (validation set).

Results

Univariate analysis demonstrated that high expression of MMP-9 was associated with both time to recurrence (TTR, P = .015) and overall survival (OS, P = .024), whereas high expression of MMP-2 was only correlated with TTR (P = .041). Multivariate analysis confirmed that MMP-9 expression was an independent predictor of TTR and OS. The coindex of MMP-9 and preoperative serum AFP levels was significantly correlated with TTR and OS (P = .036 and P = .040), but the coindex of MMP-2 and AFP did not show prognostic significance for either TTR or OS (P = .067 and P = .053). The prognostic value of MMP-9 overexpression was validated in the independent data set.

Conclusion

MMP-9 is superior to MMP-2 for the prediction of tumor recurrence and survival in HCC patients after surgical resection.

     

Impact of acute cerebral ischemic lesions and their volume on the revascularization outcome of symptomatic carotid stenosis

Background

The influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients.

Predictors of mortality in cardiac surgery: brain natriuretic peptide type B

Objective

We evaluated whether the preoperative serum concentration of brain natriuretic peptide (BNP) is a predictor of in-hospital mortality in patients that underwent cardiac surgery.

Methods

We continuously evaluated 488 patients that underwent cardiac valve surgery or coronary artery bypass grafting (CABG) between January of 2009 and July of 2012. Follow up of these patients were done prospectively for 30 days postoperatively.

Results

Data analysis showed that the overall mortality rate was equal to 9.6%, Receiver Operating Charactheristic (ROC) curve analysis found the optimal cut-off value of BNP equal to 382 pg/mL for overall mortality (AUC=0.73, 95% CI=0.66 to 0.81, P<0.001). Multivariate analysis showed that the value of BNP higher than 382 pg/mL (P=0.033, HR=2.05, 95% CI=1.6 to 3.98) was an independent predictor of overall mortality at 30 days postoperatively.

Conclusion

We concluded that the preoperative serum concentration of BNP is an independent predictor of mortality in patients undergoing valve surgery or coronary artery bypass graft.     

Myocardial regeneration after implantation of porcine small intestinal submucosa in the left ventricle

Introduction

Most cardiomyocytes do not regenerate after myocardial infarction. Porcine small intestinal submucosa has been shown to be effective in tissue repair.

Objective

To evaluate myocardial tissue regeneration and functional effects of SIS implantation in pigs after left ventriculotomy.

Methods

Fifteen pigs were assigned to two groups: porcine small intestinal submucosa (SIS) (N=10) and control (N=5). The SIS group underwent a mini sternotomy, left ventriculotomy and placement of a SIS patch. The control group underwent a sham procedure. Echocardiography was performed before and 60 days after the surgical procedure. Histological analysis was performed with hematoxylin-eosin stain and markers for actin 1A4, anti sarcomeric actin, connexin43 and factor VIII.

Results

Weight gain was similar in both groups. Echocardiography analysis revealed no difference between groups regarding end diastolic and systolic diameters and left ventricular ejection fraction, both pre (P=0.118, P=0.313, P=0.944) and post procedure (P=0.333, P=0.522, P=0.628). Both groups showed an increase in end diastolic (P<0,001 for both) and systolic diameter 60 days after surgery (P=0.005, SIS group and P=0.004, control group). New cardiomyocytes, blood vessels and inflammatory reactions were histologically identified in the SIS group.

Conclusion

SIS implantation in pigs after left ventriculotomy was associated with angiomuscular regeneration and no damage in cardiac function.