Comparing carotid endarterectomies with or without shunting in symptomatic and asymptomatic patients

Carotid endarterectomy for symptomic and asymptomic stenosis: Report of 65388 cases (Russian register)

AimAnalysis of in-hospital and long-term results of carotid endarterectomy in patients with asymptomatic and symptomatic stenoses.Materials and methodsThe sample was formed by completely including all cases of carotid endarterectomy (n = 65,388) performed during the period from May 1, 2015 to November 1, 2023. Depending on the symptomatic/asymptomatic nature of the stenosis, all patients were divided into two groups: group 1 - n = 39,172 (75.2%) - patients with asymptomatic stenosis; Group 2 - n = 26216 (24.8%) - patients with symptomatic stenosis. The postoperative follow-up period was 53.5 ± 31.4 months.ResultsIn the hospital postoperative period, the groups were comparable in the incidence of death (group 1: n = 164 (0.41%); group 2: n = 124 (0.47%); p = .3), transient ischemic attack (group 1: n = 116 (0.29%); group 2: n = 88 (0.33%); p = .37), myocardial infarction (group 1: n = 32 (0.08%); group 2: n = 19 (0.07%); p = .68), thrombosis of the internal carotid artery (group 1: n = 8 (0.02%); group 2: n = 2 (0.007%); p = 0, 19), bleeding (group 1: n = 58 (0.14%); group 2: n = 33 (0.12%); p = .45). In group 2, ischemic stroke developed statistically more often (group 1: n = 328 (0.83%); group 2: n = 286 (1.09%); p = .001), which led to a higher value of the combined endpoint (group 1: n = 640 (1.63%); group 2: n = 517 (1.97%); p = .001). In the long-term postoperative period, the groups were comparable in cases of death (group 1: n = 65 (0.16%); group 2: n = 41 (0.15%); p = .76) and death from cardiovascular causes (group 1: n = 59 (0.15%); group 2: n = 33 (0.12%); p = .4). A greater number of ischemic strokes were detected in patients of group 2 (group 1: n = 213 (0.54%); group 2: n = 187 (0.71%); p = .006). In group 1, hemodynamically significant restenosis (≥70%) of the internal carotid artery was more often diagnosed (group 1: n = 974 (2.49%); group 2: n = 351 (1.34%); p < .0001) and myocardial infarction (group 1: n = 66 (0.16%); group 2: n = 34 (0.13%); p < .0001). When analyzing stroke-free survival, analysis of Kaplan-Meier curves showed that a statistically larger number of strokes were diagnosed in group 2 (p < .0001).ConclusionDue to the fact that the patients were initially not comparable for a number of indicators, to achieve balance, we applied propensity score matching analysis. Thus, group 1 consisted of 24,381 patients, and group 2 consisted of 17,219 patients. In the hospital postoperative period, statistically significant differences were obtained only in the combined end point, which was greater in group 2 (group 1: n = 465 (1.9%); group 2: n = 382 (2.2%); p = .02). In the long-term follow-up period, after applying propensity score matching, no statistically significant differences were obtained between groups.

Long-term outcomes of carotid endarterectomy with eversion technique in patients with an open circle of Willis: A multicenter registry study

INTRODUCTION

Carotid endarterectomy (CEA) is a surgery aimed at removing atherosclerotic plaque from the carotid artery. There are classical and eversion CEA techniques. The eversion technique is the most popular because it does not require the use of implants. Eversion CEA is also associated with a lower risk of restenosis in the late postoperative period. During the surgery, the carotid artery is clamped and blood flow to the brain comes from the contralateral carotid artery and vertebral arteries. However, if the circle of Willis (COW) is not closed, compensatory mechanisms for protecting the brain are reduced, which can lead to the development of an intraoperative stroke.

PURPOSE

To analysis of in-hospital and long-term CEA outcomes in patients with different types of closed and non-closed COW.

METHODS

This is a multicenter Russian study. In the period from 2010 to 2020. 641 eversion CEA were performed. Depending on the type of structure of the COW, six groups of patients were formed: Type 1 - Closed posterior part (CRS) - in the presence of the posterior communicating (PCOMA) and P1 segment of the posterior cerebral (PCA) arteries; Type 2 - Intermediate type of structure of the posterior part (ISRP) - with hypoplasia of PCOMA or PCA; Type 3 - Open back part (OBP) - in the absence of PCOMA or PCA; Type 4 - Closed anterior part (CFS) - in the presence of the anterior communicating artery (ACOMA) and the A1 segment of the anterior cerebral artery (ACA); Type 5 - Intermediate type of anterior part structure (IFPS) - with ACOMA or ACA hypoplasia; Type 6 - Open Front Section (OFS) - in the absence of ACOMA or ACA. The long-term follow-up period was 107.3 ± 14.6 months. The end points of the study were death, ischemic stroke, transient ischemic attack (TIA), myocardial infarction (MI), ICA thrombosis, hemodynamically significant restenosis of the internal carotid artery, bleeding, and combined endpoint (death + ischemic stroke + TIA + MI).The type of distribution was determined using the Kolmogorov-Smirnov criterion. Group comparisons were performed using the Kruskal-Wallis and Pearson chi-square tests. Differences were assessed as significant at p < .05. According to clinical and demographic characteristics, the majority of patients were male and elderly. In 20% of cases, patients had a history of MI and/or stroke/TIA. Diabetes mellitus was diagnosed in 10%. There were no significant differences between groups in EuroSCOREII.

RESULTS

In the long-term postoperative period, the largest number of deaths occurred in groups 5 and 6 (13 (45.1%) and 12 (30.1%)). The majority of strokes were diagnosed in groups 3 (OBP) and 5 (IFPS) (7 (13.5%) and 9 (17.6%)). The highest value of the combined end point (death + stroke/TIA + MI) was obtained in groups 3 (OBP), 5 (IFPS), and 6 (OFS) (23 (44.2%), 26 (50.1%), and 23 (58.9%)).

CONCLUSION

The eversion technique of carotid endarterectomy for carotid artery stenosis is the most preferred. The greatest number of complications of eversion CEA in the hospital and long-term follow-up periods is observed in patients with OBP, IFPS, and OFS. In the presence of an unstable plaque, a temporary shunt can be used, which will exclude the pharmacological increase in blood pressure and the associated risk of embolization.

Association of Impedance Aggregometry-Measured Platelet Aggregation With Thromboembolic Events in Patients Who Undergo Carotid Endarterectomy: A Pilot Study

OBJECTIVES

The aim of the current study was to assess the relationship among thrombin receptor activator peptide 6 (TRAP test), adenosine-5'-diphosphate (ADP test), arachidonic acid (ASPI test), and stroke/transient ischemic attack (TIA), using the multiple electrode aggregometry (Multiplate) in patients undergoing carotid thromboendarterectomy (CEA).

DESIGN

A retrospective study.

SETTING

Vascular surgery operating rooms of a university hospital.

PARTICIPANTS

One hundred thirty-one out of 474 patients undergoing CEA between November 2020 and October 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A preoperative blood sample of all enrolled patients was analyzed using the Multiplate analyzer. Receiver operating characteristics curves, were generated to test the ability of TRAP, ADP, and ASPI in discriminating perioperative thromboembolic stroke/TIA. A logistic LASSO regression model was used to identify factors independently associated with stroke/TIA. Eight patients experienced a perioperative stroke/TIA. Although all the platelet functional assays showed excellent predictive performance, an ADP value exceeding 72 U showed the highest specificity (87%) and sensitivity (68%) in discriminating patients who had a perioperative thromboembolic stroke/TIA, with a negative predictive value of 99% and a positive predictive value of 15%. After LASSO regression, an ADP >72 U and the need for a shunt during CEA were the only 2 variables independently associated with perioperative stroke/TIA.

CONCLUSION

Because the ADP test was independently associated with perioperative stroke/TIA, the assessment of platelet reactivity using Multiplate may offer potential utility in monitoring patients undergoing CEA.