Influence of Eversion Endarterectomy and Patch Reconstruction on Postoperative Blood Pressure After Carotid Surgery

Intraoperative intracarotid injection of anesthetics for postoperative blood pressure lability management in carotid endarterectomy: A meta-analysis of randomized controlled trials

Carotid endarterectomy (CEA) is commonly performed to prevent ischemic stroke in patients with significant carotid stenosis but is linked to perioperative blood pressure instability. Intracarotid lidocaine injection has been proposed to improve postoperative hemodynamic stability, but evidence of its efficacy and safety remains mixed. We conducted a meta-analysis of randomized controlled trials (RCTs) assessing the intraoperative intracarotid injection of local anesthetics in CEA, following PRISMA guidelines. Primary outcomes included postoperative blood pressure variability, adverse cardiovascular events, and overall complication rates. Secondary outcomes assessed mortality and incidence of restenosis in the short and long term. Seven RCTs comprising 652 patients were included, with lidocaine as the most commonly used anesthetic. No statistically significant differences were found in postoperative hypotension (OR 1.31, 95% CI 0.62-2.76), hypertension (OR 1.03, 95% CI 0.5-2.15), or mean blood pressure (MD 4.12 mmHg, 95% CI -3.35-11.60). Additionally, postoperative rates of arrhythmias (OR 1.22, 95% CI 0.7-2.12), myocardial infarction (OR 2.03, 95% CI 0.08-54.6), overall complications (OR 1.41, 95% CI 0.74-2.66), and cerebrovascular accidents (OR 2.55, 95% CI 0.61-10.57) did not differ significantly between groups. Intraoperative intracarotid injection of local anesthetic shows no significant benefit for stabilizing postoperative blood pressure in CEA patients. This meta-analysis did not support the hypothesized reduction in carotid sinus sensitivity. However, the small sample size increases the risk of type II error, and long-term outcomes, especially restenosis rates, require further investigation.

Independent Factors Influencing Changes in Baroreceptor Sensitivity after Carotid Endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is a well-established standard therapy for patients with symptomatic or asymptomatic high-grade carotid stenosis. The aim of carotid endarterectomy is to decrease the risk of stroke and avoid relevant functional loss. However, carotid endarterectomy is known to be associated with hemodynamic dysregulation. In this study we compared eversion CEA (E-CEA) and conventional CEA (C-CEA) regarding postoperative blood pressure values as well as preoperative and postoperative baroreceptor sensitivity in the first 7 days after surgery. The aim was to find possible factors influencing changes in baroreceptor sensitivity.

METHODS

Patients (111 patients were enrolled, of which 50 patients received C-CEA and 61 patients E-CEA) were prospectively enrolled in this study. For the measurement of baroreceptor sensitivity, a noninvasive Finometer measuring device from Finapres Medical System B.V. (Amsterdam, The Netherlands) was used. Measurements were performed 1 day before surgery (PRE), directly after surgery (F1), on day 1 (F2), day 2 (F3), and on day 7 (F4) postoperatively.

RESULTS

Postoperative blood pressure values were significantly higher in the E-CEA group on the day of surgery (F1) (P < 0.001) and on day 1 (F2) (P < 0.001). From day 2 (F3, F4) postoperatively, no significant difference was found between the 2 groups. The invasive blood pressure measurement in the postoperative recovery room showed significantly higher systolic blood pressure values in the E-CEA group (P = 0.001). The need of acute antihypertensive therapy was significantly higher in the recovery room in the E-CEA group (P = 0.020). With regard to changes in baroreceptor sensitivity, significantly lower baroreceptor sensitivity (BRS) values were recorded in the E-CEA group at 1 day (F2) postoperatively (P = 0.005). The regression analysis showed that the applied surgical technique and the patient's age were significant factors influencing changes in baroreceptor sensitivity.

CONCLUSIONS

In this study we could confirm higher blood pressure levels after E-CEA in the first 2 days after surgery. Additionally, we identified 22 factors possibly influencing baroreceptor sensitivity: surgical technique and age. Based on the data obtained in this study, hemodynamic dysregulation after CEA (E-CEA, C-CEA) is temporary and short-term. Already after the second postoperative day, there was no significant difference between the E-CEA and E-CEA groups, this effect remained stable after 7 days.

Comparative on the effectiveness and safety of different carotid endarterectomy techniques: a single-center Retrospective Study

BACKGROUND

Carotid endarterectomy (CEA) is a surgical procedure that can reduce the risk of stroke in patients with carotid artery stenosis. However, controversy still exists regarding the optimal surgical technique for CEA.

OBJECTIVE

To compare the safety and effectiveness of different techniques.

METHODS

Data on baseline characteristics as well as perioperative and postoperative complications from patients who underwent CEA at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, were retrospectively collected and analyzed.

RESULTS

A total of 262 CEA patients included in study, with a total of 265 CEA operations. The mean age of 69.95 ± 7.29 (range, 44-89) years. 65 (24.5%) patients underwent cCEA, 94 (35.5%) underwent pCEA, and 106 (40.0%) underwent eCEA. The use of shunt (1.9%) and the mean operation time were lower in eCEA group (P < 0.05). eCEA was also associated with a lower incidence of postoperative hypotension, whereas pCEA was associated with a lower incidence of postoperative hypertension (P < 0.05). There was no significant difference in clinical baseline characteristics, occurrence of perioperative complications, and survival whether restenosis-free, asymptomatic or overall.

CONCLUSIONS

This study found that all three surgical methods are equally safe for the treatment of carotid artery stenosis and are effective in preventing stroke.

Update in Carotid Disease

This review of the literature analyzes publications over the past five years on various problems associated with carotid endarterectomy: 1. Is the eversion or classical technique of surgery with plastic repair of the reconstruction area with a patch more effective? 2. Carotid endarterectomy or carotid angioplasty with stenting is more optimal? 3. When should brain revascularization be performed after the development of ischemic stroke? 4. Should a temporary shunt be used to protect the brain during carotid endarterectomy? 5. How to prevent and treat different types of intraoperative ischemic strokes? 6. What tactics of treatment of patients with combined lesions of the carotid and coronary arteries is more effective? 7. What are the causes and methods of elimination of restenosis of the internal carotid artery known? 8. Is carotid endarterectomy safe in old age?