Association between the choice of anesthesia and in-hospital outcomes after carotid artery stenting

ObjectiveSeveral prior studies have shown lower risk of myocardial infarction (MI) in carotid artery stenting (CAS) compared with carotid endarterectomy. This is likely because the majority of endarterectomies are performed under general anesthesia (GA), whereas CAS is mainly performed under local anesthesia (LA). Performing CAS under GA may reverse its minimally invasive benefits. The aim of this study was to compare the safety profile of CAS-GA with that of CAS-LA.MethodsA retrospective analysis of the Vascular Quality Initiative database from 2005 to 2017 was performed. Primary outcomes included major adverse cardiac events (MACE), a composite of in-hospital death and MI, and postoperative neurologic events. Multivariable logistic models, and coarsened exact matching were used to evaluate the association between the primary outcomes and anesthesia technique.ResultsOf 12,919 CAS cases performed, 2024 (15.7%) were under GA. Comparing CAS-GA with CAS-LA in the overall cohort, CAS-GA had significantly higher crude rates of in-hospital mortality (2.1% vs 0.5%), MI (1.3% vs 0.7%), composite MACE (3.1% vs 1.2%), and ipsilateral stroke (2.3% vs 1.6%). Patients undergoing CAS-GA also had higher rates of dysrhythmia (3.0% vs 2.2%), acute congestive heart failure (1.6% vs 0.7%) and perioperative hypertension (13.2% vs 9.4%), and were more likely to have a length of hospital stay of more than 4 days (prolonged length of stay) (17.6% vs 8.5%) compared with those undergoing CAS-LA. On multivariable analysis, CAS-GA had a 2.3 times higher odds of in-hospital mortality compared with CAS-LA (OR, 2.52; 95% CI, 1.26-5.03), a 1.9 times the odds of MACE (OR, 1.87; 95% CI, 1.15-3.03), and a 2.3 times the odds of acute congestive heart failure (OR, 2.29; 95% CI, 1.26-4.15; all P < .05). In addition, these patients had a 43% higher odds of developing perioperative hypertension (OR, 1.43; 95% CI, 1.09-1.87; P = .01) and almost 2 times the odds of a prolonged length of stay (OR, 1.82; 95% CI, 1.41-2.35; P < .001). The adjusted odds of stroke, dysrhythmia and reperfusion syndrome were not significantly different between the two groups. Additional analysis using coarsened exact matching showed similar results.ConclusionsIn addition to the established increase risk of perioperative stroke/death with CAS compared with carotid endarterectomy, performing it under GA seems to be associated with increased cardiac complications, length of stay, and consequently hospitalization costs. Pending future data from prospective, randomized, controlled trials to validate our findings, there is evidence to suggest that it may be better to perform CAS under LA, especially in medically high-risk patients.     

Concomitant ipsilateral carotid endarterectomy and stenting is an effective treatment for tandem carotid artery lesions

ObjectiveData regarding the treatment of tandem carotid artery lesions at the bifurcation and ipsilateral, proximal common carotid artery (CCA) are limited. It has been suggested that concomitant treatment with carotid endarterectomy (CEA) and proximal ipsilateral carotid artery stenting confers a high risk of stroke and death. The objective of this study was to evaluate the technique and outcomes of this hybrid procedure at a single institution.MethodsA retrospective chart review was performed including patients who underwent CEA + ipsilateral carotid artery stenting for treatment of atherosclerotic carotid artery disease between December 2007 and April 2017. Primary endpoints were postoperative myocardial infarction, neurologic event, and perioperative mortality.ResultsTwenty-two patients (15 male [68%]) underwent CEA + ipsilateral carotid artery stenting with a mean follow-up of 67 ± 77 months. The mean age was 70.0 ± 6.1 years old, all with a prior smoking history (eight current smokers [64%]). Twelve patients (55%) were treated for symptomatic disease and three had a prior ipsilateral CEA (one also with CAS). Computed tomographic angiography imaging was performed preoperatively in 21 patients (95%). CEA was performed first in 18 patients (82%) followed by ipsilateral carotid artery stenting. CEA was performed with a patch in 20 and eversion endarterectomy in two patients. Ipsilateral CCA was stented in 21 patients (96%) and one innominate was stented in a patient with a right CEA. Additional endovascular interventions were performed in three patients: 1 innominate stent, 1 distal ipsilateral internal carotid artery stent, and 1 right subclavian artery stent. All proximal stents were placed with sheath access through the endarterectomy patch in 12 (55%), CCA in 7 (32%), and through the arteriotomy before patching in 3 (14%). Distal internal carotid artery clamping was performed in 18 (90%, available 20) of patients before ipsilateral carotid artery stenting. All proximal lesions were successfully treated endovascularly with no open conversion. One dissection was created and treated effectively with stenting. One perioperative stroke (4.5%) occurred in a patient treated for symptomatic disease, 1 postoperative myocardial infarction (4.5%), and 2 patients (9.1%) with cranial nerve injuries. There was one patient who expired within 30 days, shortly after discharge for unknown reasons. The mean length of stay was 2.6 ± 2.0 days.ConclusionsIn appropriately selected patients, concomitant CEA and ipsilateral carotid artery stenting can be safely performed in high-risk patients with a low risk of myocardial infarction, neurologic events, and perioperative mortality when careful surgical technique is used, using direct carotid access, and distal carotid clamping for cerebral protection before stenting.     

A comparative analysis of long-term mortality after carotid endarterectomy and carotid stenting

Background

The value of carotid intervention is predicated on long-term survival for patients to derive a stroke prevention benefit. Randomized trials report no significant difference in survival after carotid endarterectomy (CEA) vs carotid artery stenting (CAS), whereas observational studies of “real-world” outcomes note that CEA is associated with a survival advantage. Our objective was to examine long-term mortality after CEA vs CAS using a propensity-matched cohort.

颈动脉内膜剥脱术抑或颈动脉支架术: 颈动脉狭窄手术治疗的金标准之争

脑卒中是当今第三大致死病因,是成年人致残的首要原因。颈动脉狭窄是导致缺血性卒中事件发生的最常见原因。20世纪80～90年代已有多个随机对照试验证实颈动脉内膜剥脱术相比于内科药物治疗对于预防卒中具有明显优势。近年来,随着介入技术和器材的不断进步,血管腔内介入治疗愈发成熟,其安全性及有效性正在为一些大规模的临床随机对照试验所证实,腔内介入治疗颈动脉狭窄正在挑战着外科内膜剥脱术的＂金标准＂地位。     

颈动脉狭窄患者内膜剥脱术与支架植入术1年疗效Meta分析

目的利用Meta分析法探讨颈动脉内膜剥脱术（CEA）与颈动脉支架植入术（CAS）对颈动脉狭窄治疗1年内死亡和卒中、死亡、卒中、重度再狭窄及闭塞事件发生情况并进行评价。方法制定原始文献的纳入标准、排除标准及检索策略,搜索关于CEA及CAS治疗对颈动脉狭窄的对照研究。应用RevMan4.2.2软件对纳入文献进行定量评价。以优势比（OR值）及双侧95%可信区间（CI）作为效应尺度进行分析。结果纳入本研究的文献共6篇,1037例患者接受CAS治疗,1681例接受CEA治疗,将发生死亡和卒中、死亡、卒中事件统计数据合并;累计1586例接受CAS治疗,2196例接受CEA治疗,进行再狭窄及闭塞的统计数据合并。术后1年内CAS与CEA患者死亡和卒中、死亡、卒中事件发生差异无统计学意义,其OR值分别为0.81（95%CI0.56～1.18）、0.75（95%CI0.47～1.19）、0.78（95%CI0.53～1.16）。CAS患者再狭窄率高于CEA患者[OR=1.99（95%CI1.44～2.74）,P〈0.05）。结论对于颈动脉狭窄患者,CEA与CAS的1年死亡和卒中、死亡、卒中事件发生无明显差异,CAS术后重度再狭窄及闭塞率为CEA术的1.99倍。由于在缺乏足够数量的随机对照试验的情况下,纳入部分非随机对照试验的Meta分析,使论证强度受到一定的限制,有待更多大样本高质量随机对照试验对本研究结果进一步验证。     

Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy

ObjectiveCarotid revascularization procedures, carotid artery stenting (CAS) and carotid endarterectomy (CEA), are among the most common vascular interventions performed in the United States, with significant resource utilization. Whereas multiple studies have reported outcomes after these procedures, data regarding 30-day readmission rates after these interventions remain scant.MethodsThe U.S. Nationwide Readmission Database (2010-2014) was queried to identify all patients ≥18 years who were readmitted within 30 days after a hospital discharge for CEA or CAS.ResultsAmong 476,260 patients included, 13.5% underwent CAS and 86.5% underwent CEA. The combined 30-day readmission rate for all carotid revascularization procedures was 9.2% (10.6% after CAS and 9.0% after CEA). After 1:3 propensity matching, CAS was associated with higher risk of readmission compared with CEA (10.4% vs 9.4%). Neurologic complications and cardiac conditions were the two most common causes of readmission after both CAS (29.7% and 23.7%, respectively) and CEA (28.2% and 21.7%, respectively). The 30-day readmission rates were higher in CAS patients across all age groups as well as in those with a low or high baseline burden of comorbidities.ConclusionsIn this large nationwide study, CAS was associated with higher 30-day readmission rates compared with CEA irrespective of age or baseline burden of comorbidities. Neurologic or cardiac adverse events were responsible for >50% of readmissions after CAS and CEA.     

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 impact of anesthetic modality on the outcome of carotid endarterectomy

BACKGROUND: Carotid endarterectomy (CEA) reduces the risk of stroke in patients with high-grade carotid artery stenosis. This study evaluates the clinical outcome of CEA performed under local anesthesia (LA) versus general anesthesia (GA). METHODS: Clinical variables and treatment outcomes were analyzed in 548 CEAs performed under either LA or GA during a 30-month period. Factors associated with morbidity were also analyzed. RESULTS: A total of 263 CEAs under LA and 285 CEA under GA were analyzed. The LA group was associated with a lower incidence of shunt placement, operative time, and perioperative hemodynamic instability compared to the GA group. No differences in neurologic complications or mortality were found between the 2 groups. Hyperlipidemia was a risk factor for postoperative morbidity in both the LA and GA groups, while age greater than 75 years was associated with increased overall morbidity in the GA group but not the LA group. CONCLUSIONS: This study demonstrates that increased age is associated with increased morbidity in CEA under GA, while hyperlipidemia is associated with increased morbidity in CEA regardless of the anesthetic choice.     

颈动脉狭窄血管内支架植入和内膜切除术治疗的临床选择

目的 探讨在不同条件下如何合理选择颈动脉狭窄的治疗方式.方法 回顾性分析经颈动脉血管内支架植入术(CAS)和颈动脉内膜切除术(CEA)治疗的133例颈动脉狭窄患者的临床资料.其中46例患者行CAS,87例行CEA.观察两组患者的住院天数和治疗前后的美国国立卫生研究院卒中评分量表(NIHSS)评分、前向血流,治疗前和治疗后1-24个月狭窄处收缩期血流速度峰值及狭窄程度,以及治疗后死亡、脑卒中或心肌梗死等终点事件的发生率.结果 两组住院天数和治疗后NIHSS评分>20层次时差异有统计学意义(P<0.05);两组治疗前后的前向血流评定差异无统计学意义(P>0.05);多普勒频谱测定两组治疗前后颈动脉狭窄程度有显著性差异(P<0.05);两组治疗后30 d内,终点事件的累计发生率差异有统计学意义(P<0.05);31 d～2年终点事件的累计发生率差异无统计学意义(P>0.05);6个月后再狭窄发生率CAS组高于CEA组.结论 CAS和CEA对颈动脉狭窄的效果无显著差异,狭窄的部位、原因及对侧病变是选择CAS和CEA的重要因素.     

Carotid artery stenting with neuroprotection: assessing the learning curve and treatment outcome

PURPOSE: Carotid artery stenting (CAS) has emerged as an acceptable treatment alternative in high-risk patients with carotid stenosis. The purpose of this study was to assess the effect of the learning curve on treatment complications and the clinical outcomes of CAS. METHODS: Clinical variables and treatment outcomes of 200 consecutive CAS procedures in 182 patients (mean age 72 years) with carotid stenosis > or = 70% during a 40-month period were analyzed. Four sequential groups (groups I, II, III, and IV) of 50 consecutive interventions were compared with regard to technical success, periprocedural complications, and treatment outcomes. RESULTS: Treatment indications and relevant risk factors were similar among the 4 groups. The overall technical success and combined 30-day stroke and death rates were 98% and 2.5%, respectively. An increase in the technical success rate was noted in the latter 3 groups compared with group I (P < .05). Total procedural time and contrast volume were significantly higher in group I compared with the latter 3 groups (P < .05). The intraoperative anticoagulation regimen was changed from intravenous heparin combination to bivalirudin after the first 54 patients, which resulted in decreased bleeding complications in groups III and IV (P = 0.03) compared with the first group. The 30-day stroke and death rate in groups I and II were 8% and 2%, respectively, and was decreased significantly in groups III and IV (0% and 0%, respectively, P < .05). A Cox regression model identified procedural volume (P = .03) as a predictor of decreased complication rate. CONCLUSIONS: CAS with neuroprotection can provide excellent treatment outcomes. Our experience demonstrates a procedure-associated learning curve as evidenced by decreased procedure-related complications, fluoroscopic time, and contrast volume occurring with increased physician experience. Procedural success was also enhanced partly by endovascular device refinement and an improved anticoagulation regimen. Successful CAS outcomes can be achieved once physicians overcome the initial procedure-related learning curve.     

颈动脉内膜剥除术及支架成形术治疗颈动脉狭窄的相关研究

目的：探讨颈动脉内膜切除术及颈动脉支架成形术在治疗颈动脉狭窄中的应用，并对此两种术式的适应证进行讨论。方法：根据狭窄的部位和程度对121例颅外颈动脉狭窄病人采取不同的手术方法；其中104例为颈动脉内膜切除术．17例为颈动脉支架成形术。分析其治疗结果及并发症发生的原因。结果：手术均获成功，但颈动脉内膜切除术术后严重并发症的发生率较支架成形术为低。结论：颈动脉内膜切除术仍然是治疗颅外颈动脉狭窄的主要方法．而颈动脉支架成形术则可应用于颈动脉内膜切除术无法到达的狭窄部位。     

Eversion endarterectomy of the internal carotid artery combined with open endarterectomy of the common carotid artery

The author presents a technique for endarterectomy and reconstruction of the carotid bifurcation in difficult cases when the plaque extends high into the internal carotid artery. The technique combines the aspects of the 2 most commonly performed procedures: carotid endarterectomy after a longitudinal arteriotomy extending from the common carotid artery into the internal carotid artery and eversion endarterectomy in which the plaque is removed from the internal carotid artery sectioned from the common carotid artery and everted. The author suggests applying this technique selectively in patients in whom the atherosclerotic plaque extends very high into the internal carotid artery. The technique offers the advantages of removing the plaque into the common carotid artery under direct vision and leaving the original dimensions and geometry of the internal carotid artery, theoretically decreasing the probability of early thrombosis and recurrent carotid disease. For routine cases, the author prefers and recommends standard carotid bifurcation endarterectomy with patch closure when the size of the arteries is reduced like in women and selected male patients.     

颈动脉狭窄手术及介入治疗的围术期管理

背景 脑卒中是造成人类死亡的主要原因之一.15％～20％的缺血性脑血管病归因于颈动脉狭窄或闭塞,颈动脉内膜剥脱术(carotid endarterectomy,CEA)和颈动脉血管腔内球囊成形及支架植入术(carotid angioplasty and stenting,CAS)对预防缺血事件发生有效,但围手术期卒中、死亡等并发症对围术期管理提出挑战. 目的 对颈动脉狭窄手术及介入治疗围术期管理进行综述. 内容 重点阐述CEA和CAS围术期危险因素控制、术前评估、麻醉方法与管理、术中神经功能监测和脑保护. 趋向 积极谨慎的围术期管理是保证颈动脉狭窄患者围术期脑氧供需平衡、降低围术期并发症的有效措施.     

A comparison of carotid angioplasty with stenting versus endarterectomy with regional anesthesia

Introduction: Percutaneous transluminal angioplasty with stenting (PTAS) has been considered a potential alternative to carotid endarterectomy (CEA) for stroke prevention. Interventionalists have suggested that PTAS carries less anesthetic risk than CEA. The treatment of carotid stenosis with local or regional anesthesia (LRA) allows direct intraprocedural neurologic evaluation and avoids the potential risks of general anesthesia. Methods: We retrospectively analyzed the clinical charts of 377 patients who underwent 414 procedures for the elective treatment of carotid stenosis in 433 cerebral hemispheres with LRA between August 1994 and May 1997. Group I (312 hemispheres) underwent PTAS, and group II (121 hemispheres) underwent CEA. Results: The indications for treatment included the following: asymptomatic severe stenosis (n = 272; 62.8%), transient ischemic attack (TIA; n = 100; 23.1%), and prior stroke (n = 61; 14.1%). The early neurologic results for the patients in group I (n = 268) included 11 TIAs (4.1%), 23 strokes (8.6%), and 3 deaths (1.1%). The early neurologic results for the patients in group II (n = 109) included 2 TIAs (1.8%), one stroke (0.9%), and no deaths. The total stroke and death rates were 9.7% for the patients in group I and 0.9% for the patients in group II (P = .0015). The cardiopulmonary events that led to additional monitoring were evident after 96 procedures in group I (32.8%) and 21 procedures in group II (17.4%; P = .002). Conclusion: PTAS carries a higher neurologic risk and requires more monitoring than CEA in the treatment of patients with carotid artery stenosis with LRA. The proposed benefit for the use of PTAS to avoid general anesthesia cannot be justified when compared with CEA performed with LRA. (J Vasc Surg 1998;28:397-403.)     

Follow-up results of carotid angioplasty with stenting as assessed by duplex ultrasound surveillance

BACKGROUND: Carotid artery stenting (CAS) has become an alternative modality to carotid endarterectomy (CEA) for the treatment of carotid occlusive disease. We report a retrospective review of our institution's experience with CAS versus CEA. METHODS: Postprocedure surveillance duplex, recurrent symptoms, postprocedure strokes, progression of lesions, and rates of re-operation were analyzed in 46 patients who underwent CAS and 48 patients who underwent CEA. The mean length of follow-up evaluation was 13 months. All CAS procedures included neuroprotection devices. RESULTS: Statistically significant differences in progression to critical restenosis (2% vs 2%, P = 1.0), rate of subsequent symptoms or stroke (2% vs 10%, P = .1), or rate of re-interventions were not observed between CAS and CEA groups (2% vs 4%, P = .98). Total mortality (0% vs 2%, P = .33), and the occurrence of major adverse events (2% vs 10%, P = .18) also were not significantly different in the CAS compared with the CEA patients. The average rate of increase in internal carotid velocity at 6 to 12 months (-1% vs 1.1%, P = NS) and 12 to 24 months (-5% vs -6.5%, P = NS) also were equivalent. CONCLUSIONS: Our observed results indicate that CAS may be performed with comparable clinical outcomes and durability of repair comparable with CEA.     

Comparison of nonneurological events in high-risk patients treated by carotid angioplasty versus endarterectomy

OBJECTIVE: To compare results of carotid angioplasty and stenting (CAS) with carotid endarterectomy (CEA) in high cardiac risk patients. METHODS: Patients ineligible for carotid revascularization by North American Symptomatic Carotid Endarterectomy Trial/Asymptomatic Carotid Atherosclerosis Study criteria were treated with CAS (n = 11) or CEA (n = 10). RESULTS: Significant numbers had cardiac (CAS 72%, CEA 60%; P = 0.66) and hypertensive (CAS 82%, CEA 80%; P = 0.64) risk factors. Adverse hemodynamic events were more frequent in the CAS group (CAS 73%, CEA 20%; P = 0.03). Major complications were noted in 1 patient in each group (CAS, myocardial infarction; CEA, death). Postoperative stay was similar (CAS 2.1 +/- 1.4, CEA 1.8 +/- 1.1 days; P = 0.60). However, 4 in the CAS group were readmitted within 1 month (congestive heart failure 2, myocardial infarction 1, rest pain 1), compared with no new events in the CEA group (P = 0.09). CONCLUSIONS: Currently, the use of CAS in patients with cardiac risk factors may not be justifiable.     

Long-term results after carotid endarterectomy for carotid artery stenosis with contralateral occlusion

Patients with one internal carotid artery occlusion and a contralateral stenosis run a significantly higher risk of stroke. We performed endarterectomy of the stenotic carotid in 44 such patients and followed them for mean 54 months (range 1–172 months). Early mortality was 2%. Life-table analysis shows that the incidence of a new stroke was 0.6% per year, the survival rate was 78% after three years, and 70% after five years. We conclude that carotid endarterectomy can be safely performed in patients with contralateral internal carotid artery occlusion and can significantly improve the long-term prognosis of these patients.     

颈动脉内膜切除术和支架植入术的合理选择

颈动脉内膜切除术（CEA）及颈动脉支架植入术（CAS）是目前广泛应用的治疗颅外段颈动脉狭窄的有效手段,由于操作方式、适应人群及围手术期并发症的不同,一直存在关于如何选择治疗方式的争论,笔者就其发展历史和相关临床对照研究结果进行总结。