Mediastinal hematoma after carotid endarterectomy

A patient with bilateral carotid disease presented with hypotension, unexplained fever, and failing hematocrit after the second of two carotid endarterectomies. Chest roentgenogram revealed marked mediastinal widening, which resolved rapidly with an otherwise benign post-operative course. Mediastinal hematoma is an unusual complication of carotid surgery.     

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。     

Vocal cord paralysis following carotid endarterectomy: The paradox of return of function

In a series of 411 consecutive carotid endarterectomies 29 patients were identified with vocal cord paralysis. All patients were symptomatic, although in many these symptoms were subtle and rapidly resolved. There was a statistically significant predominance of left-sided paralysis. Excluding three patients who died during the initial year of follow-up return of normal voice was noted in 22 patients, but complete return of vocal cord function was present in only 15. Apposition of the contralateral vocal cord against a paralyzed vocal cord allowed for production of normal voice in five patients. Less than 1% of patients remained with symptoms at one year following endarterectomy. We conclude that vocal cord paralysis is a common complication of carotid endarterectomy; the voice becomes an unreliable guide as to its resolution. We recommend laryngoscopic examination of all patients who undergo bilateral carotid endarterectomy.Presented at the Thirteenth Annual Meeting of the New England Society for Vascular Surgery, Dixville Notch, New Hampshire, September 26, 1986.     

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目的　探讨颈动脉内膜切除术 (CEA)治疗颅外颈动脉硬化性狭窄病变中的地位和疗效。方法　对1993年 5月至 2 0 0 3年 10月 5 9例 6 1次颈动脉内膜切除术的临床资料进行回顾性分析。早期 4 6例 4 7次CEA采用颈丛麻醉下通过阻断试验结合返流压力测定选择性应用转流管 ,近期 13例 14次手术在全麻并常规应用转流管下进行。结果　早期手术组颈动脉平均阻断时间 (2 0± 6 )min ,近期手术组颈动脉平均缺血时间 (4 2± 0 7)min ,P <0 0 1。术后 30d内无死亡和脑卒中。术后 2年和 5年神经系统症状发生率分别为 4 7%和 14 8%。结论　本组颈动脉内膜切除术取得满意的近远期疗效。采用全麻合并术中转流可以显著减少同侧脑缺血时间     

Patients at elevated risk of major adverse events following endarterectomy for asymptomatic carotid stenosis

Background

Carotid endarterectomy (CEA) as treatment in patients with asymptomatic carotid stenosis is the subject of much debate.

Methods

The National Surgical Quality Improvement Program database from 2005 to 2012 was queried. Patients undergoing CEA for asymptomatic carotid stenosis were identified. Preoperative risk factors and patient demographics were compared using chi-square analysis and logistic regression to determine their relation with stroke and death.

Results

During an 8-year period, 24,211 CEAs performed for asymptomatic carotid stenosis were identified. Patients with dependent functional status (12.5%), recent myocardial infarction (6.3%), chronic heart failure (5.0%), hypoalbuminemia (4.8%), angina (4.1%), dialysis dependence (3.4%), steroid dependence (3.4%), chronic obstructive pulmonary disease (3.3%), and American Society of Anesthesiologists > 3 (3.2%) had a clinically significant increase in risk of stroke and death. Patients with none of the above risk factors had a stroke and death rate of 1.08%, which was significantly less than the overall stroke and death rate (P < .001).

Conclusions

A high-risk subset of patients undergoing CEA for asymptomatic carotid stenosis can be identified. If patient selection is optimized and perioperative morbidity and mortality are minimized, CEA will continue to play an important role in stroke prevention for those with significant asymptomatic carotid stenosis.     

Risk of prophylactic contralateral carotid endarterectomy

Fifty-eight patients underwent a prophylactic contralateral carotid endarterectomy following an initial endarterectomy for symptomatic (38 patients) or asymptomatic (20 patients) carotid stenosis. No deaths occurred after either operation. Two (3.4%) minor neurologic deficits occurred after the initial operation and two (3.4%) major and two (3.4%) minor deficits occurred after the prophylactic contralateral carotid endarterectomy. Sixteen (28%) of the initial endarterectomies were associated with perioperative hyper- or hypotensive episodes compared to 35 (60%) of the prophylactic contralateral carotid endarterectomies (p<0.001). We did not document an increased risk of surgery in patients undergoing prophylactic contralateral carotid endarterectomy soon after the initial operation. All four neurologic events following a prophylactic contralateral carotid endarterectomy occurred when the operation was performed more than five weeks after the initial endarterectomy. The incidence of perioperative hyper- or hypotension was similar in patients undergoing prophylactic contralateral carotid endarterectomy less than or greater than five weeks after the first operation. Our results suggest that a prophylactic contralateral carotid endarterectomy may be associated with a higher incidence of neurologic complications and hyper- and hypotensive episodes than the initial carotid endarterectomy. Waiting more than five weeks to repair a contralateral asymptomatic carotid stenosis may not enhance the safety of the operation.Presented at the Annual Meeting of the Eastern Vascular Society, Pittsburgh, Pennsylvania, May 5, 1991     

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.     

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.     

颈动脉内膜剥脱术治疗颈动脉狭窄60例临床分析

目的 探讨颈动脉内膜剥脱术治疗颈动脉狭窄的疗效及安全性.方法 回顾性分析新疆维吾尔自治区人民医院血管外科2009年1月-2013年12月行颈动脉内膜剥脱术治疗颈动脉狭窄的60例患者的临床资料.结果 本组无围手术期死亡病例.术后出现脑出血1例,脑梗死2例,轻度伸舌偏移2例.结论 颈动脉内膜剥脱术是一种安全有效的治疗颈动脉狭窄的手术方式.颈动脉内膜剥脱术关键在于严格掌握手术适应证,提高手术技巧和有效防治并发症.     

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.     

Pitfalls during carotid endarterectomy

Summary It is estimated that between 1971 and 1987 the number of carotid endarterectomies has increased from 15,000 to over 85,000 per year. Unless the procedure can be performed safely with a combined morbidity and mortality which is below the yearly risk of stroke (5%) for patients with symptomatic carotid artery disease, one should reconsider this operation as a therapeutic option.We review our experience with 891 carotid endarterectomies performed between January 1979 and June 1987. There were 579 (65%) men and 312 (35%) women of ages from 34 to 82 (median 65); risk factors included diabetes mellitus 213 (14%), hypertension 603 (68%), and smoking 630 (70%). Clinical presentation consisted of transient ischemic attacks 506 (57%), cerebral infarction with minimal neurological residual 252 (28%), stroke in evolution 3 (0.3%) and, asymptomatic stenosis 130 (15%). All patients were operated on under endotracheal anesthesia with transoperative monitoring of intra-arterial pressure, central venous pressure and arterial blood gases. Thiopental (3–5 mg/kg) and lidocaine (1 mg/kg) were given for induction and at 15 minute intervals during carotid cross-clamping. Intraluminal shunts were used in 13 (2%). A conventional (open) endarterectomy was performed in 561 (63%) and a limited endarterectomy (closed) in 330 (37%). Complications included 11 (1%) deaths, 26 (3%) developed a major neurological deficit that persisted, 30 (3%) had perioperative TIA's which resolved completely. Of the patients with preoperative neurological deficits, 33 (4%) recovered. Therefore, at one month after surgery, 854 (96%) were either as well or better than preoperatively. Of 514 (58%) postoperative angiograms, 23 (5%) showed an internal carotid artery occlusion; six of them developed an immediate postoperative cerebral infarction and one of them died, Non-neurologic complications were: cardiac 43 (5%), peripheral nerve 33 (3%), and local wound problems 20 (2%).We believe a carotid endarterectomy can be performed safely when it is done with meticulous attention to detail and consistent surgical technique founded on frequent exposure to the procedure.     

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.     

Outcomes for carotid endarterectomy in nonagenarians

ObjectiveCarotid endarterectomy (CEA) is a well-established procedure with prospective randomized data demonstrating the benefit of stroke prevention. With the aging of the population, there are limited data published for nonagenarians, especially for asymptomatic stenosis. This study investigated 30-day morbidity and mortality as well as late survival in symptomatic and asymptomatic nonagenarians with severe carotid stenosis undergoing CEA.MethodsA retrospective review was conducted of a single vascular surgery group's registry involving multiple hospitals between November 1994 and June 2017 for all primary CEAs of patients ≥90 years old at the time of surgery. The exclusion criterion was redo surgery or bilateral CEAs. Demographic data, sex, symptoms, risk factors, and postoperative complications were analyzed. Survival analysis was conducted using SPSS software (IBM Corp, Armonk, NY) for the specific end point 30-day morbidity or mortality and late survival.ResultsThere were 77 patients (44 male [57%]) who underwent CEA for symptomatic (44 [57%]) and asymptomatic (33 [43%]) internal carotid artery stenosis with a median age of 92 years; 23 women were symptomatic compared with 21 men, and 23 men were asymptomatic compared with 10 women. Symptomatic patients included amaurosis fugax (n = 3), stroke (n = 16), and transient ischemic attack (n = 25). CEAs were performed using the eversion technique under cervical block with selective shunting. The 30-day morbidity included one (2.3%) nonfatal myocardial infarction and one (2.3%) ischemic stroke in the symptomatic group compared with one (3%) patient having a nonfatal myocardial infarction and none with ischemic stroke in the asymptomatic group. One patient of the symptomatic group required return to the operating room for hematoma evacuation. The 30-day mortality was 2.3% in the symptomatic group compared with 6.1% in the asymptomatic group. There was no statistical difference in survival based on sex (P = .444). The symptomatic and asymptomatic groups had similar median survival of 27.7 months and 29.4 months (P = .987), respectively.ConclusionsThe aging population adds increasing difficulty in decision-making for surgical intervention on carotid stenosis. CEA in nonagenarians is associated with reasonably low 30-day rates of ischemic stroke and myocardial infarction in our small study. However, enthusiasm for asymptomatic CEA in this population must be tempered by low survival rates.     

Blood pressure aberrations associated with carotid endarterectomy

This report examines and reviews the frequency, potential causes and management of blood pressure aberrations in 100 consecutive carotid thromboendarterectomies. Reasons for operation and postoperative sequelae included: asymptomatic stenosis, transient ischemic attacks, non-hemispheric symptoms, amaurosis fugax, previous stroke, and evolving stroke. Hypertension (greater than or equal to 100 mmHg diastolic) occurred within 24 hours of operation in 37 instances (37%). Recognized causes included: manifestation of preoperative hypertension (19); carotid sinus denervation or transient mild cerebral edema (16); and massive cerebral edema in the two postoperative strokes of the series. Control of hypertension was most commonly managed by intravenous administration of nitroprusside. Profound immediate hypotension and bradycardia occurred in association with six procedures (6%). Accelerated carotid sinus nerve activity after removal of the noncompliant plaque was the probable cause of this reflex. Management included intravenous administration of parasympatholytic (atropine), and sympathomimetic (epinephrine) drugs. Aberrations of blood pressure, after carotid TEA are common but with proper management do not represent a risk factor for perioperative stroke. Supported in part by NIH Grant # 14192-13, Specialized Center of Research in Hypertension, Vanderbilt University Medical Center.     

Cerebral protection during carotid endarterectomy

BACKGROUND: Perioperative stroke rates with carotid endarterectomy are 3.4% for asymptomatic and 5.2% for symptomatic patients. Several methods are used to limit perioperative stroke. METHODS: A retrospective chart review of consecutive carotid endarterectomies from January 1, 2000 to February, 28, 2003, was performed. Data were collected on patient demographics, operative procedure, intraoperative monitoring, and outcome. Comparative analysis of intraoperative monitoring and outcome was performed. RESULTS: Two hundred twenty-nine patients underwent 251 carotid endarterectomies. In 196 procedures decision to shunt was based on intraoperative monitoring, 129 by electroencephalogram (EEG), and 67 by stump pressures. Sixteen neurologic events occurred perioperatively, one transient ischemic attack and 15 strokes. The EEG group had 12 strokes, with a 38% event rate in procedures with EEG changes without shunting. The stump pressure group had one stroke. Stroke rate for intraoperative EEG monitoring was elevated (P = 0.02). CONCLUSIONS: Intraoperative EEG based decision to shunt may not be as effective as other methods for prevention of perioperative neurologic events. When EEG changes occur, shunting is necessary.     

Morbidity and mortality of carotid endarterectomy

Summary A review of the mortality and morbidity of carotid endarterectomy reported during the last 10 years was made and compared to the risk of carotid stenosis managed by the best medical treatment. For comparison, the patients were classified in asymptomatic patients (grade I), patients with transient ischaemic attacks (grade II), patients with ischaemic neurological deficits operated on acutely (grade III) and into patients with no or incomplete recovery 4–6 weeks after the stroke (grade IV). Based on the results of this literature review, only patients in grade II seem to benefit from carotid endarterectomy.     

A comparison of carotid artery stenting with neuroprotection versus carotid endarterectomy under local anesthesia

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce the risk of stroke in patients with high-grade carotid artery stenosis. Despite the known impact of type of anesthesia on outcome after CEA, none of the current studies comparing CEA with CAS addresses the effect of anesthetic choice on perioperative events. In this study, we compare our results of distally protected CAS versus CEA under local anesthesia. METHODS: Clinical data of 345 patients who underwent 372 procedures for carotid artery occlusive disease over a 36-month were retrospectively collected for this analysis. Distal embolic protection was used in CAS procedures. All procedures, both CEA (n = 221, 59%) and CAS (N = 152, 41%), were performed under local anesthesia. The primary outcome measure was aggregate 30-day major ipsilateral stroke and/or death. Follow-up serial Duplex ultrasound examinations were performed. RESULTS: Both patient cohorts were similar in terms of demographic and risk factors, with the exception of a higher incidence of coronary artery disease in the CAS group (59% versus 30%, P <.05). The 30-day stroke and death rates were 3.2% (CAS) and 3.7% (CEA) (P = not significant). Cranial nerve injury only occurred in the CEA patients (2.3%). Perioperative hemodynamic instability was more common among patients in the CAS group (11.9% versus 4.1%, P <.05). CONCLUSIONS: Percutaneous carotid stenting with neuroprotection provides comparable clinical success to CEA performed under local anesthetic. Further studies are warranted to validate the long-term efficacy of CAS and to elucidate patient selection criteria for endovascular carotid revascularization.