Endarterectomy for asymptomatic carotid artery stenosis under local anaesthesia

Carotid endarterectomy in the asymptomatic elderly: a systematic review of literature

Asymptomatic carotid stenosis (ACS) carries a 4.7% risk of ipsilateral stroke if left untreated. Carotid endarterectomy (CEA) is a surgical intervention that has demonstrated efficacy in reducing stroke risk among symptomatic elderly. However, literature on its efficacy in preventing stroke in patients with ACS remains limited. Our systematic review summarizes evidence on the safety and efficacy of CEA in the asymptomatic elderly.PubMed and Scopus were searched to identify articles that described outcomes after CEA for ACS in patients aged ≥ 65 years old. Articles that did not report outcomes specific to the asymptomatic elderly were excluded. Outcomes of interest were technical success, stroke, death, myocardial infarction and post-operative complications. The Newcastle Ottawa Scale (NOS) was used to perform a qualitative assessment for risk of bias and studies with NOS ≥ 6 were considered high quality. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement.After a title and abstract screen, followed by a full-text review, 7 studies reporting outcomes in 76,404 patients were included. Five studies were retrospective and two were prospective. Among studies that reported criteria for intervention in ACS patients, 2 studies performed CEA for 70% stenosis and one performed CEA for 60% stenosis. One study reported outcomes for all ranges of stenosis (mild: 0-50%, moderate: 50-79% and severe: 80-99%). Clinical outcomes varied among included studies, with rates of death stroke and myocardial infarction ranging from 0.39 to 6.1%, 0.5-1.2% and 0.9-3%, respectively.The decision to perform CEA in patients with ACS is made after outweighing risks and benefits of surgery based on various factors like age, comorbidities and frailty. At present, evidence is largely limited to retrospective studies that utilized nationwide databases. Prospective studies and randomized controlled trials could help characterize the risk of CEA in this cohort.

Changes in Cognition and Hemodynamics 1 Year after Carotid Endarterectomy for Asymptomatic Stenosis

OBJECTIVES

 The impact of a change in hemodynamics on cognitive skills in patients with asymptomatic carotid stenosis (ACS) after carotid endarterectomy (CEA) remains unclear. The aim of this study was to evaluate the results of CEA for ACS at 1 year by assessing the changes in anterior, middle, and posterior cerebral artery blood flow in tandem with changes in cognitive efficiency.

METHODS

 Flow volume in cerebral arteries using quantitative magnetic resonance angiography was measured in a group of 14 males and 5 females before and at 1 year after CEA for ACS. Cognitive efficiency was assessed by Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The values of flow volume were processed using simple ratio (SR) and were used for covariance analyses with changes in cognitive skills after CEA.

RESULTS

 A significant improvement in cognitive efficiency indexes of immediate memory and visuospatial perception at 1 year after CEA for ACS was observed. Simultaneously, a significant deterioration of speech index was noted. During the analysis of association between flow and cognition, the highest correlation could be seen between the middle cerebral artery (MCA) flow and the visuospatial perception. A change in posterior cerebral artery (PCA) flow was associated with an increase in immediate memory index and anterior cerebral artery (ACA) flow change with the speech index.

CONCLUSION

 Convergence of data supporting the association between revascularization and cognitive improvement were added in a small, single-center cohort of ACS patients undergoing CEA. No significant differences in cognition were seen between preoperative findings and at 1 year after CEA. Visuospatial perception improvement was linked to flow change in MCA, immediate memory improvement to flow change in PCA, and speech index change to flow change in ACA. Methodical limitations of this small study preclude formulating larger generalizations. Hemodynamic factors in CEA should be assessed in a larger-scale study.