Patient Satisfaction for Carotid Endarterectomy Performed under Local Anaesthesia

OBJECTIVES: To develop, validate and use a procedure specific questionnaire to evaluate patient experience and satisfaction following carotid endarterectomy (CEA) under either general (GA) or local anaesthesia (LA). METHODS: Twenty post-CEA patients were interviewed. Data were content analysed and recurrent themes used to generate the specific carotid endarterectomy experience questionnaire (CEA-EQ). The CEA-EQ consists of 15 pre-op and 13 postoperative questions. Validity was established by correlation with the FRS Patient Satisfaction with Surgical Services (SSSQ) and State form of the State Trait Anxiety Inventory (STAI-S) in 69 patients (35 LA, 34 GA). Subsequently 88 patients randomised to GA CEA and 88 to LA CEA received the CEA-EQ. A local anaesthetic intraoperative experience questionnaire (LA-EQ) was also developed and given to LA patients only. RESULTS: Validity was confirmed through significant correlations with the STAI-S (r=0.67, p<0.001) and the SSSQ (r=0.44, p<0.001). In the randomised prospective study response rates were greater than 90%. Overall experience and satisfaction with CEA was high. There was no statistically significant difference in anxiety, satisfaction or overall experience between anaesthetic techniques. LA CEA was associated with a significantly better perception of recovery. The majority of LA patients found the procedure acceptable. CONCLUSIONS: The CEA-EQ is a valid tool to assess qualitative aspects of CEA patient care. Overall satisfaction and experience with CEA is good and not related to anaesthetic technique. LA CEA is not associated with any increased anxiety, is tolerated by the majority of patients and is associated with a better perception of recovery.     

Cognitive Function Remains Unchanged After Endarterectomy of Unilateral Internal Carotid Artery Stenosis Under Local Anaesthesia

OBJECTIVE: To assess changes in cognitive function and affective state following carotid endarterectomy (CEA) for high-degree unilateral internal carotid artery stenosis. METHODS: In 33 patients, a CEA was performed under local anaesthesia for a high-grade unilateral stenosis of the internal carotid artery (group A). Twenty-five patients underwent surgery for peripheral arterial occlusive disease under regional anaesthesia served as controls (group B). Patients with neurological deficits due to previous strokes or dementia were excluded. Intelligence level was assessed preoperatively. Cognitive tests were applied preoperatively and postoperatively (3-5 days after surgery) and after 4 months follow-up. Confounding factors, including anxiety and depression, were checked through questionnaires and interviews. RESULTS: No perioperative neurological complication occurred following CEA. Patients in group A showed a significant postoperative deterioration only in one sub-test. There was no significant change in anxiety and depression during follow up. The control group B had no significant changes in cognitive test performance. Anxiety improved significantly postoperatively, but increased again at the end of the study. There was no significant difference between the groups over time. CONCLUSION: Cognitive function does not change following CEA of a unilateral internal carotid stenosis.     

Jugular Venous Neurone Specific Enolase (NSE) Increases Following Carotid Endarterectomy Under General, but Not Local, Anaesthesia

ObjectivesTo determine the prevalence of asymptomatic carotid artery stenosis (ACAS) in patients with peripheral vascular disease (PVD).MethodsLiterature search was carried out through Pubmed, Medline and Cochrane library. Prospective studies published on prevalence of significant carotid stenosis in patients with PVD and used a duplex scan for screenings were included.ResultsNineteen studies with a total of 4573 patients were included. A prevalence of 28% (fixed effect model) and 25% (random effect model) was seen for >50% stenosis, and 14% (in both fixed and random effect models) for 70% stenosis. Significant statistical heterogeneity existed between studies (I² = 82.7%, >50% group) (I² = 77.5%, >70% group). Larger studies revealed a higher prevalence of carotid stenosis.ConclusionHigh prevalence of ACAS exists in patients with PVD. A large multi centre prospective study may help to combat heterogeneity and identify subgroups of PVD patients with higher prevalence.Clinicians who believe in the benefits of carotid endarterectomy for asymptomatic carotid stenosis would gain a greater yield by targeting this group for routine screening rather than a healthy population.     

The Role of Carotid Endarterectomy in the Endovascular Era

OBJECTIVE: Carotid artery angioplasty and stenting (CAS) has been proposed as an alternative to surgery for patients with high-grade symptomatic carotid disease. The purpose of this study was to determine the proportion of patients that were suitable for each type of intervention and to analyse the reasons that precluded stenting. MATERIALS AND METHODS: This was a prospective observational study. All patients considered for intervention for carotid artery disease during an 18-month period were analysed. The management decision was recorded, as were the reasons for unsuitability for stenting. RESULTS: Two hundred and sixty-eight patients' data were analysed, 224 had complete records. Forty-seven patients did not require intervention and received best medical treatment alone. One hundred and seventy-seven patients required intervention, 113 were suitable for stenting and 64 were not. In 51 patients stenting was preferred. Sixty-two patients were suitable for either stent or surgery. Sixty-four patients were unsuitable for stenting. Carotid tortuosity and proximal disease accounted for 70% of this group. CONCLUSIONS: Current enthusiasm for carotid stenting might well be supported by the results of ongoing randomised-controlled clinical trials. However, this study highlights a significant proportion (64/177; 36%) of our patients is presently unsuitable for stenting. The common technical difficulties and limitations of stenting encountered in our unit are related predominantly to carotid anatomy.     

Literature Review of Cranial Nerve Injuries During Carotid Endarterectomy

Objective: In the recent prospective randomised trials on carotid endarterectomy (CEA), the incidence of cranial nerve injuries (CNI) are reported to be higher than in previously published studies. The objective of this study is to review the incidence of post CEA cranial nerve injury and to discover whether it has changed in the last 25 years after many innovations in vascular surgery.

Methods: Generic terms including carotid endarterectomy, cranial nerve injuries, post CEA complications and cranial nerve deficit after neck surgery were used to search a variety of electronic databases. Based on selection criteria, decisions regarding inclusion and exclusion of primary studies were made. The incidence of CNI before and after 1995 was compared.

Results: We found 31 eligible studies from the literature. Patients who underwent CEA through any approach were included in the study. All patients had cranial nerves examined both before and after surgery. The total number of patients who had CEA before 1995 was 3521 with 10.6% CNI (352 patients) and after 1995, 7324 patients underwent CEA with 8.3% CNI (614 patients).Cranial nerves XII, X and VII were most commonly involved (rarely IX and XI). Statistical analysis showed that the incidence of CNI has decreased (X^A2 = 5.89 + 0.74 = 6.63 => p-value = 0.0100). Conclusion: CNI is still a significant postoperative complication of carotid endarterectomy. Despite increasing use of CEA, the incidence of CNI has decreased probably because of increased awareness of the possibility of cranial nerve damage.     

The Case for Urgent Carotid Endarterectomy

The high mortality rate previously reported and the absence of proven advantage of urgent carotid endarterectomy over natural history, has discouraged consideration of this operation. We want to report on two patients with stroke in evolution and fluctuating stroke, who underwent immediate surgery with excellent results. With these cases we aim to demonstrate that selected patients with stroke in evolution or fluctuating stroke due to recent carotid thrombosis have a good prognosis after emergency surgery. We think that in these selected cases endovascular therapy is at this moment a waste of time.     

Carotid Endarterectomy Versus Carotid Stenting: an Updated Review of Randomized Trials and Subgroup Analyses

Atherosclerotic disease of the carotid arteries is responsible for a significant portion of ischemic strokes. Carotid endarterectomy (CEA) is currently the accepted standard of treatment for patients with severe symptomatic carotid stenosis. In the past few years, however, carotid angioplasty and stenting (CAS) has emerged as a potential alternative endovascular treatment strategy for this disorder. In fact, spurred by the positive results of single center studies and small, pivotal randomized trials, some even consider CAS as the treatment modality of choice, especially in presumably surgical high-risk patients. Yet, randomized trials directly comparing CAS with CEA are sparse and have produced conflicting results.

The aim of this article is to review the current trial data on this issue and to define the role of these techniques for the management of two important subgroups of patients.

An updated meta-analysis of seven randomized trials comparing CEA with CAS demonstrates that CAS is associated with a significantly increased risk of any stroke or death within 30 days (OR. 1.41, 95% CI 1.07-1.87, p<0.05). Focusing on patients with a symptomatic carotid stenosis, there was also a significant difference in the odds of treatment-related stroke and death between CAS and CEA (OR, 1.41; CI 1.05 to 1.88, p < 0.05). Data on all disabling strokes and deaths within 30 days was available from five trials. The odds of disabling stroke or death at 30 days were similar in the endovascular and surgical group (OR, 1.33, 95% CI 0.89 to 1.98).

Overall, these data do not justify a blind enthusiasm for CAS and a widespread use of this procedure for the treatment of carotid artery stenosis. On the other hand, a closer inspection of the current literature on elderly patients and those with a contralateral carotid occlusion clearly indicates that CAS and CEA already now have a complementary role. While elderly patients should preferentially be treated with CEA, CAS appears to be the treatment of choice in patients with a symptomatic carotid artery stenosis and a contralateral carotid occlusion in experienced centers.     

A Short Incision for Carotid Endarterectomy Results in Decreased Morbidity

OBJECTIVES: To investigate the effect of a short incision (<5 cm) on the complication rate of the carotid endarterectomy (CEA). DESIGN: A retrospective cohort study. PATIENTS AND METHODS: From January 1994 to December 2005, 874 patients underwent 1048 primary carotid endarterectomy (CEA) procedures. Seven hundred and sixty nine operations were performed through a long neck incision (group A), while 279 were performed through a smaller incision (<5 cm) according to a standard protocol (group B). Preoperative and postoperative cranial nerve assessment was completed on all patients. The main outcome measures were stroke, death, cranial and cervical nerve injuries rates. RESULTS: The 30-day mortality rate was 0.26% in group A and 0.35% in group B (p=.792). The stroke rate was 0.13% and 0% in group A and B respectively (p=.839). The mean length of stay was 2.59 days in group A and 1.67 days in group B (p<.0001). In group A the overall incidence of motor and sensory nerve deficits was 13.5% (104 CEA, 92 patients) but in group B 2.9% (8 CEA, 7 patients, p<.0001, odds ratio [OR] 0.189, 95% confidence interval [CI] 0.091-0.393). CONCLUSIONS: Carotid endarterectomy through a small incision is a feasible and safe approach that provides cosmetic results and fewer nerve complications without compromising the safety of the procedure.     

Stroke From Carotid Endarterectomy: When and How to Reduce Perioperative Stroke Rate?

OBJECTIVES: To analyse four years of CEA with respect to the underlying mechanisms of perioperative stroke and the role of intraoperative monitoring in the prevention of stroke. PATIENTS AND METHODS: From January 1996 through December 1999, 599 CEAs were performed in 404 men and 195 women (mean age: 65 years, range: 39-88). All operations were performed under general anaesthesia using computerised electroencephalography (EEG) and transcranial Doppler (TCD). Any new or any extension of an existing focal cerebral deficit, as well as stroke-related death were registered. Perioperative strokes were classified by time of onset (intraoperative or postoperative), outcome (minor or major stroke), and side (ipsilateral or contralateral). Stroke aetiology was assessed intraoperatively by means of EEG, TCD, completion arteriography or immediate re-exploration, and postoperatively by duplex sonography, computerised tomography (CT) or magnetic resonance imaging (MRI) of the head. RESULTS: Perioperative stroke or death occurred in 20 (3.3%) patients. In four operations stroke was apparent immediately after surgery. Mechanisms of these strokes were ipsilateral carotid artery occlusion (1) and embolisation (3). In 16 patients stroke developed after a symptom-free interval (2-72 h, mean 18 h) due to occlusion of the internal carotid artery on the side of surgery (9). Other mechanisms were: contralateral occlusion of the internal carotid artery (1), postoperative hyperperfusion syndrome (1), intracerebral haemorrhage (1), and contralateral ischaemia due to prolonged clamping (1). In three procedures the cause was unknown. CONCLUSIONS: In our experience most strokes from CEA developed after a symptom-free interval and mainly due to thromboembolism of the operated artery. We suggest the introduction of additional TCD monitoring during the immediate postoperative phase.     

Analysis of Surgical Treatment of Patients with Carotid Artery Stenosis Endarterectomy Versus Stenting

The aim of this paper is to characterize a group of patients with internal carotid artery stenosis and to analyze the outcome of internal carotid artery stenosis treatment. The outcome of treatment of 230 patients with internal carotid artery stenosis hospitalized from 1^st January 2004 to 31^st August 2006 was analyzed. Twenty nine percent of the patients were selected for medical treatment, 70.4% received surgical or endovascular treatment (83.3% of all invasive procedures were endarterectomies, versus 16.7% stenting). The peri-procedural stroke-death rate was 4.9% of patients [3.7% after CEA and 11.1% after CAS (N.S.)]. Statistical analysis disclosed that endarterectomy was associated with a longer in-hospital stay (p < 0.001). In conclusion: Both surgical methods, endarterectomy and stenting are equivalent in safety and present comparable clinical outcomes in selected subgroups of patients (classified to the specific procedure on the basis of the type of atherosclerotic plaque).