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Yagshyyev S, Haney B, Li Y, Papatheodorou N, Zetzmann K, Meyer A, Meyer S, Lang W, Rother U. Independent Factors Influencing Changes in Baroreceptor Sensitivity after Carotid Endarterectomy. Ann Vasc Surg 2024; 108:393-402. [PMID: 39019257 DOI: 10.1016/j.avsg.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/09/2024] [Accepted: 06/11/2024] [Indexed: 07/19/2024]
Abstract
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.
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Affiliation(s)
- Shatlyk Yagshyyev
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Briain Haney
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Yi Li
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Nikolaos Papatheodorou
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Katharina Zetzmann
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, Helios Klinikum Berlin-Buch, Berlin, Germany; Medical School Berlin, Berlin, Germany
| | - Sebastian Meyer
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
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Vukas H, Kadić-Vukas S, Piljić D, Vranić H, Jogunčić A, Đozić E, Kšela J. Patch angioplasty carotid endarterectomy versus eversion carotid endarterectomy. Saudi Med J 2024; 45:685-693. [PMID: 38955440 PMCID: PMC11237269 DOI: 10.15537/smj.2024.45.7.20240245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/10/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVES To compare carotid endarterectomy patch angioplasty (p-CEA) with eversion carotid endarterectomy (e-CEA) and associated risks of early cardio-cerebrovascular complications. METHODS The study was a prospective randomized single-blind trial, monocentric, clinically applicable, descriptive analytical and comparative. From June 2021 to June 2023, 62 consecutive patients with symptomatic and asymptomatic stenosis of the internal carotid artery, admitted to our department and randomized into two groups: carotid endarterectomy with patch angioplasty and eversion carotid endarterectomy. Follow-up for 30 days after surgery. RESULTS During surgery e-CEA, 70% patients had an arrhythmia, and 24 hours after 66.7%, seven days after 46.7% and month after 13.3%. During surgery p-CEA, 33.3% patients had an arrhythmia, 24 hours later 33.3%, 7 days after 13.3% and 30 days after 13.3% patients. Statistically significant difference observed during surgery (Fishers p=0.004). One day after the surgery rate of patients with arrhythmia that were treated e-CEA has decreased, but it was still higher than after p-CEA (Fishers p=0.010). CONCLUSION The frequency and categorization of postoperative cardiac arrhythmias after eversion carotid endarterectomy, the clinical implications of various postoperative heart rhythm disturbances and their long-term effects on patients need to be further investigate through sufficiently powered randomized controlled studies.
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Affiliation(s)
- Haris Vukas
- From the Department of Vascular Surgery (Vukas H), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica; from the of Surgery and Department of Neurology (Vukas H, Varnić, Đozić) Sarajevo School of Science of Technology Medical School; from the Clinic of Cardiovascular Surgery (Piljić), University Clinical Center Tuzla; from the Department of Vascular Surgery (Varnić), General Hospital Sarajevo Abdulah Nakaš; from the Department of Epidemiology (Jogunčić), Public Health Institute of Canton Sarajevo; from the Clinic of Neurology (Đozić), Clinical Center University Sarajevo, Bosnia and Herzegovina; and from the Clinic of Cardiovascular Surgery (Kšela), University Clinical Center Ljubljana, Medical, Faculty Ljubljana, Slovenia.
| | - Samra Kadić-Vukas
- From the Department of Vascular Surgery (Vukas H), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica; from the of Surgery and Department of Neurology (Vukas H, Varnić, Đozić) Sarajevo School of Science of Technology Medical School; from the Clinic of Cardiovascular Surgery (Piljić), University Clinical Center Tuzla; from the Department of Vascular Surgery (Varnić), General Hospital Sarajevo Abdulah Nakaš; from the Department of Epidemiology (Jogunčić), Public Health Institute of Canton Sarajevo; from the Clinic of Neurology (Đozić), Clinical Center University Sarajevo, Bosnia and Herzegovina; and from the Clinic of Cardiovascular Surgery (Kšela), University Clinical Center Ljubljana, Medical, Faculty Ljubljana, Slovenia.
| | - Dragan Piljić
- From the Department of Vascular Surgery (Vukas H), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica; from the of Surgery and Department of Neurology (Vukas H, Varnić, Đozić) Sarajevo School of Science of Technology Medical School; from the Clinic of Cardiovascular Surgery (Piljić), University Clinical Center Tuzla; from the Department of Vascular Surgery (Varnić), General Hospital Sarajevo Abdulah Nakaš; from the Department of Epidemiology (Jogunčić), Public Health Institute of Canton Sarajevo; from the Clinic of Neurology (Đozić), Clinical Center University Sarajevo, Bosnia and Herzegovina; and from the Clinic of Cardiovascular Surgery (Kšela), University Clinical Center Ljubljana, Medical, Faculty Ljubljana, Slovenia.
| | - Haris Vranić
- From the Department of Vascular Surgery (Vukas H), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica; from the of Surgery and Department of Neurology (Vukas H, Varnić, Đozić) Sarajevo School of Science of Technology Medical School; from the Clinic of Cardiovascular Surgery (Piljić), University Clinical Center Tuzla; from the Department of Vascular Surgery (Varnić), General Hospital Sarajevo Abdulah Nakaš; from the Department of Epidemiology (Jogunčić), Public Health Institute of Canton Sarajevo; from the Clinic of Neurology (Đozić), Clinical Center University Sarajevo, Bosnia and Herzegovina; and from the Clinic of Cardiovascular Surgery (Kšela), University Clinical Center Ljubljana, Medical, Faculty Ljubljana, Slovenia.
| | - Anes Jogunčić
- From the Department of Vascular Surgery (Vukas H), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica; from the of Surgery and Department of Neurology (Vukas H, Varnić, Đozić) Sarajevo School of Science of Technology Medical School; from the Clinic of Cardiovascular Surgery (Piljić), University Clinical Center Tuzla; from the Department of Vascular Surgery (Varnić), General Hospital Sarajevo Abdulah Nakaš; from the Department of Epidemiology (Jogunčić), Public Health Institute of Canton Sarajevo; from the Clinic of Neurology (Đozić), Clinical Center University Sarajevo, Bosnia and Herzegovina; and from the Clinic of Cardiovascular Surgery (Kšela), University Clinical Center Ljubljana, Medical, Faculty Ljubljana, Slovenia.
| | - Edina Đozić
- From the Department of Vascular Surgery (Vukas H), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica; from the of Surgery and Department of Neurology (Vukas H, Varnić, Đozić) Sarajevo School of Science of Technology Medical School; from the Clinic of Cardiovascular Surgery (Piljić), University Clinical Center Tuzla; from the Department of Vascular Surgery (Varnić), General Hospital Sarajevo Abdulah Nakaš; from the Department of Epidemiology (Jogunčić), Public Health Institute of Canton Sarajevo; from the Clinic of Neurology (Đozić), Clinical Center University Sarajevo, Bosnia and Herzegovina; and from the Clinic of Cardiovascular Surgery (Kšela), University Clinical Center Ljubljana, Medical, Faculty Ljubljana, Slovenia.
| | - Juš Kšela
- From the Department of Vascular Surgery (Vukas H), from the Department of Neurology (Kadić-Vukas), Cantonal Hospital Zenica; from the of Surgery and Department of Neurology (Vukas H, Varnić, Đozić) Sarajevo School of Science of Technology Medical School; from the Clinic of Cardiovascular Surgery (Piljić), University Clinical Center Tuzla; from the Department of Vascular Surgery (Varnić), General Hospital Sarajevo Abdulah Nakaš; from the Department of Epidemiology (Jogunčić), Public Health Institute of Canton Sarajevo; from the Clinic of Neurology (Đozić), Clinical Center University Sarajevo, Bosnia and Herzegovina; and from the Clinic of Cardiovascular Surgery (Kšela), University Clinical Center Ljubljana, Medical, Faculty Ljubljana, Slovenia.
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Sultan S, Acharya Y, Dulai M, Tawfick W, Hynes N, Wijns W, Soliman O. Redefining postoperative hypertension management in carotid surgery: a comprehensive analysis of blood pressure homeostasis and hyperperfusion syndrome in unilateral vs. bilateral carotid surgeries and implications for clinical practice. Front Surg 2024; 11:1361963. [PMID: 38638141 PMCID: PMC11025470 DOI: 10.3389/fsurg.2024.1361963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
Background This study evaluates the implications of blood pressure homeostasis in bilateral vs. unilateral carotid surgeries, focusing on the incidence of postoperative hypertension, hyperperfusion syndrome, and stroke as primary outcomes. It further delves into the secondary outcomes encompassing major adverse cardiovascular events and all-cause mortality. Methods Spanning two decades (2002-2023), this comprehensive retrospective research encompasses 15,369 carotid referrals, out of which 1,230 underwent carotid interventions. A subset of 690 patients received open carotid procedures, with a 10-year follow-up, comprising 599 unilateral and 91 bilateral surgeries. The Society for Vascular Surgery Carotid Reporting Standards underpin our methodological approach for data collection. Both univariate and multivariate analyses were utilized to identify factors associated with postoperative hypertension using the Statistical Package for the Social Sciences (SPSS) Version 22 (SPSS®, IBM® Corp., Armonk, N.Y., USA). Results A marked acute elevation in blood pressure was observed in patients undergoing both unilateral and bilateral carotid surgeries (p < 0.001). Smoking (OR: 1.183, p = 0.007), hyperfibrinogenemia (OR: 0.834, p = 0.004), emergency admission (OR: 1.192, p = 0.005), severe ipsilateral carotid stenosis (OR: 1.501, p = 0.022), and prior ipsilateral interventions (OR: 1.722, p = 0.003) emerged as significant factors that correlates with postoperative hypertension in unilateral surgeries. Conversely, in bilateral procedures, gender, emergency admissions (p = 0.012), and plaque morphology (p = 0.035) significantly influenced postoperative hypertension. Notably, 2.2% of bilateral surgery patients developed hyperperfusion syndrome, culminating in hemorrhagic stroke within 30 days. Intriguingly, postoperative stage II hypertension was identified as an independent predictor of neurological deficits post-secondary procedure in bilateral CEA cases (p = 0.004), attributable to hyperperfusion syndrome. However, it did not independently predict myocardial infarction or mortality outcomes. The overall 30-day stroke rate stood at 0.90%. Lowest incidence of post operative hypertension or any complications were observed in eversion carotid endartrertomy. Conclusion The study identifies postoperative hypertension as a crucial independent predictor of perioperative stroke following bilateral carotid surgery. Moreover, the study elucidates the significant impact of bilateral CEA on the development of post-operative hyperperfusion syndrome or stroke, as compared to unilateral CEA. Currently almost 90% of our carotid practice is eversion carotid endartrerectomy.
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Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
| | - Yogesh Acharya
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Makinder Dulai
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Wael Tawfick
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, University of Galway, Galway, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - William Wijns
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- The Euro Heart Foundation, Amsterdam, Netherlands
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Douglas N, Leslie K, Darvall JN. Vasopressors to treat postoperative hypotension after adult noncardiac, non-obstetric surgery: a systematic review. Br J Anaesth 2023; 131:813-822. [PMID: 37778937 DOI: 10.1016/j.bja.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/31/2023] [Accepted: 08/08/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Postoperative hypotension is common after major surgery and is associated with patient harm. Vasopressors are commonly used to treat hypotension without clear evidence of benefit. We conducted a systematic review to better understand the use, impact, and rationale for vasopressor administration after noncardiac, non-obstetric surgery in adults. METHODS We conducted a prospectively registered systematic review. Cochrane CENTRAL, EMBASE, MEDBASE, and MEDLINE were searched for RCTs and cohort studies of adult patients receiving vasopressors after noncardiac, non-obstetric surgery. Study quality was critically appraised by two investigators. Findings from the review were synthesised, but formal meta-analysis was not performed because of significant variability in study populations and outcomes. RESULTS A total of 3201 articles were screened, of which seven RCTs, two prospective cohort studies, and 15 retrospective cohort studies were included in the analysis (24 in total). One study was graded as high quality, two as moderate quality, and the remaining 21 as low quality. Sixteen studies relied on clinical assessment alone to decide on therapeutic interventions. Vasodilation was the most common suggested physiological disturbance. The median proportion of patients receiving vasopressors was 42% (interquartile range: 11.5-74.7%). Norepinephrine was the most common vasopressor used. CONCLUSIONS The evidence supporting the use of vasopressors to treat postoperative hypotension is limited. Future research should focus on whether vasodilatation or other physiological disturbance is driving postoperative hypotension to allow rational decision-making.
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Affiliation(s)
- Ned Douglas
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia.
| | - Kate Leslie
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Jai N Darvall
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 233] [Impact Index Per Article: 233.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Lee C, Columbo JA, Stone DH, Creager MA, Henkin S. Preoperative evaluation and perioperative management of patients undergoing major vascular surgery. Vasc Med 2022; 27:496-512. [PMID: 36214163 PMCID: PMC9551317 DOI: 10.1177/1358863x221122552] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
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Affiliation(s)
| | | | | | | | - Stanislav Henkin
- Stanislav Henkin, Heart and Vascular
Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at
Dartmouth, Lebanon, NH 03756, USA.
Twitter: @stanhenkin
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Reslan OM, McPhee JT, Brener BJ, Row HT, Eberhardt RT, Raffetto JD. Peri-Procedural Management of Hemodynamic Instability in Patients Undergoing Carotid Revascularization. Ann Vasc Surg 2022; 85:406-417. [PMID: 35395375 DOI: 10.1016/j.avsg.2022.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
Acute perioperative changes in arterial pressure occur frequently, particularly in patients with cardiovascular disease or those receiving vasoactive medications, or in relation to certain cardiovascular surgical procedures. Hemodynamic Instability (HI) are common in patients undergoing carotid revascularization because of unique patho-physiological and surgical factors. The operation, by necessity, disrupts the afferent pathway of the baroreflex, which can lead to postendarterectomy HI. Poor arterial pressure control is associated with increased morbidity and mortality after carotid revascularization, but good control of arterial pressure is often difficult to achieve in practice. The incidence, implications, and etiology of HI associated with carotid surgery are reviewed, and some recommendations made for its management. Close monitoring and titration of therapy are probably the most important considerations rather than specific choice of agents.
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Affiliation(s)
- Ossama M Reslan
- VA Fargo HCS, Fargo ND, Division of Vascular Surgery, Department of Surgery; University of North Dakota School of Medicine & Health Sciences, Department of Surgery.
| | - James T McPhee
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Boston University School of Medicine, Boston Medical Center
| | - Bruce J Brener
- Newark Beth Israel Medical Center, Division of Vascular Surgery, Department of Surgery
| | - Hunter T Row
- University of North Dakota School of Medicine & Health Sciences, Department of Surgery
| | - Robert T Eberhardt
- Boston University School of Medicine, Boston Medical Center; Division of Cardiovascular Medicine, Department of Medicine
| | - Joseph D Raffetto
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Harvard Medical School, Brigham and Women's Hospital
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Postoperative blood pressure management in patients treated in the ICU after noncardiac surgery. Curr Opin Crit Care 2021; 27:694-700. [PMID: 34757996 DOI: 10.1097/mcc.0000000000000884] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Blood pressure management is a cornerstone of hemodynamic management in patients treated in the ICU after noncardiac surgery. Postoperative blood pressure management is challenging, because blood pressure alterations after surgery can be profound and have numerous causes. RECENT FINDINGS Postoperative blood pressure alterations are common in patients treated in ICUs after noncardiac surgery. There is increasing evidence that hypotension during the initial days after noncardiac surgery is associated with postoperative adverse outcomes including myocardial infarction and death, acute myocardial injury, acute kidney injury, major adverse cardiac or cerebrovascular events, and delirium. Thus, postoperative hypotension could be a modifiable risk factor for postoperative adverse outcomes. However, robust evidence for a causal relationship between postoperative blood pressure and postoperative adverse outcomes is still lacking. SUMMARY Future research on postoperative blood pressure management in patients treated in the ICU after noncardiac surgery needs to assess whether the prevention or treatment of postoperative blood pressure alterations - especially postoperative hypotension - reduces the incidence of postoperative adverse outcomes.
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Meyer A, Gall C, Verdenhalven J, Lang W, Almasi-Sperling V, Behrendt CA, Guenther J, Rother U. Influence of Eversion Endarterectomy and Patch Reconstruction on Postoperative Blood Pressure After Carotid Surgery. Ann Vasc Surg 2021; 78:61-69. [PMID: 34464726 DOI: 10.1016/j.avsg.2021.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/17/2021] [Accepted: 06/12/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Post carotid blood pressure fluctuation and hypertension (PEH) are associated with increased risk for adverse outcome; there is limited evidence on the impact of eversion endarterectomy (E-CEA) versus conventional endarterectomy with patch closure (C-CEA) on postoperative blood pressure course. PATIENTS AND METHODS In this retrospective observational study, 859 consecutive carotid endarterectomy procedures between 2004 and 2014 (C-CEA n = 585 vs. E-CEA n = 274), were evaluated. Pre- and postoperative blood pressure values were recorded from recovery room until third postoperative day and compared between both techniques; influences on the dichotomous target variable "at least one postoperative blood pressure peak", that is need for postoperative vasodilators, were analyzed by a logistic regression model. Influences on postoperative systolic blood pressure were evaluated by a linear mixed effects regression model. RESULTS Preoperative baseline blood pressure was not different between both comparison groups. During postoperative course, significantly increased mean systolic blood pressure values in the E-CEA group from recovery room to second postoperative day (recovery room C-CEA: 129.2 mm Hg vs. E-CEA: 136.5 mm Hg; P < 0.001; first postoperative day C-CEA: 132.4 mm Hg vs. E-CEA: 139.3 mm Hg; P = 0.0002; second postoperative day C-CEA: 138.6 mm Hg vs. E-CEA: 143.1 mm Hg; P = 0.023) were observed. No hyperperfusion syndrome was detected as wells as no difference in postoperative complication rate. Frequency of antihypertensive interventions was also elevated in E-CEA group (C-CEA 22.1 % vs. E-CEA 31.8 %; P = 0.003). E-CEA (OR 1.591, 95% CI [1.146; 2.202]; P = 0.005) and presence of preoperatively elevated systolic readings (OR 1.015, 95%CI [1.006;1.024]; P < 0.001) was also associated with increased need for antihypertensive interventions. CONCLUSION E-CEA was associated with significantly elevated postoperative blood pressure, compared to C-CEA. C-CEA was associated with postoperative blood pressure decrease; however, no difference as to neurologic and surgical complications was detected between both surgical techniques in clinical practice.
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Affiliation(s)
- Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany.
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Julia Verdenhalven
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | | | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Josefine Guenther
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
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10
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Uno M, Takai H, Yagi K, Matsubara S. Surgical Technique for Carotid Endarterectomy: Current Methods and Problems. Neurol Med Chir (Tokyo) 2020; 60:419-428. [PMID: 32801277 PMCID: PMC7490601 DOI: 10.2176/nmc.ra.2020-0111] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Over the last 60 years, many reports have investigated carotid endarterectomy (CEA) and techniques have thus changed and improved. In this paper, we review the recent literature regarding operational maneuvers for CEA and discuss future problems for CEA. Longitudinal skin incision is common, but the transverse incision has been reported to offer minimal invasiveness and better cosmetic effects for CEA. Most surgeons currently use microscopy for dissection of the artery and plaque. Although no monitoring technique during CEA has been proven superior, multiple monitors offer better sensitivity for predicting postoperative neurological deficit. To date, data are lacking regarding whether routine shunt or selective shunt is better. Individual surgeons thus need to select the method with which they are more comfortable. Many surgical techniques have been reported to obtain distal control of the internal carotid artery in patients with high cervical carotid bifurcation or high plaque, and minimally invasive techniques should be considered. Multiple studies have shown that patch angioplasty reduces the risks of stroke and restenosis compared with primary closure, but few surgeons in Japan have been performing patch angioplasty. Most surgeons thus experience only a small volume of CEAs in Japan, so training programs and development of in vivo training models are important.
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Affiliation(s)
- Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School
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Carotid endarterectomy with concomitant distal endovascular intervention is associated with increased rates of stroke and death. J Vasc Surg 2020; 73:960-967.e1. [PMID: 32707384 DOI: 10.1016/j.jvs.2020.07.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/08/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) with concomitant distal endovascular intervention (CEA+D) is infrequently necessary but has often been used as a salvage maneuver when complications occur during CEA. The present study aimed to determine whether preoperative risk factors associated with CEA requiring CEA+D exist and to evaluate the outcomes compared with isolated CEA. METHODS The Vascular Quality Initiative CEA registry was used to identify patients who had undergone CEA or CEA+D for asymptomatic or symptomatic carotid stenosis from 2013 to 2019. Data regarding distal intervention included whether angioplasty or stenting of the distal internal carotid artery (ICA) and/or bifurcation had been required. However, information regarding the indication or whether the intervention had been planned was not included. The χ2 test and analysis of variance were used to evaluate the categorical and continuous perioperative variables. Variables with P < .20 on univariate analysis were included in the multivariable analysis to assess for preoperative predictors of the need for CEA+D and the association with perioperative stroke. RESULTS From 2013 to 2019, 327 CEA+D cases were identified and compared with 105,192 isolated CEA cases. The CEA+D patients were more likely to have undergone previous ipsilateral CEA (CEA, 1.8%; CEA+D, 4.9%; P < .01) and contralateral ICA occlusion (CEA, 4.6%; CEA+D, 11.0%; P < .01) but were less likely to have had ipsilateral stenosis ≥70% (CEA, 88.3%; CEA+D, 80.6%; P < .01). The preoperative factors associated with the need for CEA+D on multivariable analysis included previous peripheral vascular intervention, American Society of Anesthesiologists class ≥4, contralateral ICA occlusion, low-volume surgeon, and previous ipsilateral CEA. CEA+D was associated with significantly increased rates of stroke in both asymptomatic (CEA+D, 3.9%; CEA, 0.9%; P < .01) and symptomatic (CEA+D, 9.4%; CEA, 1.9%; P < .01) patients. CEA+D was associated with decreased rates of 30-day survival in both asymptomatic (CEA+D, 98.3%; CEA, 99.4%; P = .02) and symptomatic (CEA+D, 94.8%; CEA, 99.1%; P < .01) cohorts. On multivariable analysis, CEA+D remained significantly associated with stroke (odds ratio, 3.17; 95% confidence interval, 1.80-5.60; P < .01). Other factors significantly associated with perioperative stroke included procedure length >135 minutes, diabetes, hypertension, shunt for indication, symptomatic status, previous ipsilateral CEA, contralateral ICA occlusion, urgent or emergent procedure, intravenous medications for hemodynamic instability, and re-exploration at the initial operation. CONCLUSIONS Although markers of more significant cardiovascular disease burden were associated with the use of CEA+D, their power to predict CEA+D use was limited. In cases in which CEA+D was used, CEA+D was associated with significantly greater rates of perioperative stroke and mortality compared with isolated CEA for both asymptomatic and symptomatic patients, which could be useful for framing the expected outcomes after these procedures.
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Tan J, Wang Q, Shi W, Liang K, Yu B, Mao Q. A Machine Learning Approach for Predicting Early Phase Postoperative Hypertension in Patients Undergoing Carotid Endarterectomy. Ann Vasc Surg 2020; 71:121-131. [PMID: 32653616 DOI: 10.1016/j.avsg.2020.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/27/2020] [Accepted: 07/04/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study aimed to establish and validate a machine learning-based model for the prediction of early phase postoperative hypertension (EPOH) requiring the administration of intravenous vasodilators after carotid endarterectomy (CEA). METHODS Perioperative data from consecutive CEA procedures performed from January 2013 to August 2019 were retrospectively collected. EPOH was defined in post-CEA patients as hypertension involving a systolic blood pressure above 160 mm Hg and requiring the administration of any intravenous vasodilator medications in the first 24 hr after a return to the vascular ward. Gradient boosted regression trees were used to construct the predictive model, and the featured importance scores were generated by using each feature's contribution to each tree in the model. To evaluate the model performance, the area under the receiver operating characteristic curve was used as the main metric. Four-fold stratified cross-validation was performed on the data set, and the average performance of the 4 folds was reported as the final model performance. RESULTS A total of 406 CEA operations were performed under general anesthesia. Fifty-three patients (13.1%) met the definition of EPOH. There was no significant difference in the percentage of postoperative stroke/death between patients with and without EPOH during the hospital stay. Patients with EPOH exhibited a higher incidence of postoperative cerebral hyperperfusion syndrome (7.5% vs. 0, P < 0.001), as well as a higher incidence of cerebral hemorrhage (3.8% vs. 0, P < 0.001). The gradient boosted regression trees prediction model achieved an average AUC of 0.77 (95% CI 0.62 to 0.92). When the sensitivity was fixed near 0.90, the model achieved an average specificity of 0.52 (95% CI 0.28 to 0.75). CONCLUSIONS We have built the first-ever machine learning-based prediction model for EPOH after CEA. The validation result from our single-center database was very promising. This novel prediction model has the potential to help vascular surgeons identify high-risk patients and reduce related complications more efficiently.
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Affiliation(s)
- Jinyun Tan
- Department of Vascular Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Qi Wang
- Department of Vascular Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Weihao Shi
- Department of Vascular Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Kun Liang
- Department of Vascular Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Bo Yu
- Department of Vascular Surgery, Pudong Hospital, Fudan University, Shanghai, China.
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Lee S, Conway AM, Nguyen Tranh N, Anand G, Leung TM, Fatakhova O, Giangola G, Carroccio A. Risk Factors for Postoperative Hypotension and Hypertension following Carotid Endarterectomy. Ann Vasc Surg 2020; 69:182-189. [PMID: 32502683 DOI: 10.1016/j.avsg.2020.05.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/06/2020] [Accepted: 05/20/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients undergoing carotid endarterectomy (CEA) often experience postoperative hemodynamic changes that require intravenous medications for hypo- and hypertension. Prior studies have found these changes to be associated with increased risks of 30-day mortality, stroke, myocardial infarction (MI), and length of stay (LOS). Our aim is to investigate preoperative risk factors associated with the need for postoperative intravenous medications for blood pressure control. METHODS A retrospective review of an internally maintained prospective database of patients undergoing carotid interventions between January 2014 and March 2019 was performed. Demographic data, clinical history, and perioperative data were recorded. Carotid artery stents and reinterventions were excluded. Our primary end points were the need to intervene with intravenous medication for either postoperative hypotension [systolic blood pressure (SBP) <100 mm Hg] or postoperative hypertension (SBP >160 mm Hg). RESULTS A total of 221 patients were included in the study after excluding those with a prior ipsilateral CEA or carotid artery stent. The mean age was 72.3 (±8.9) years, 157 (71%) patients were male, and 78 (35.3%) were Caucasian. Following CEA, 151 (68.3%) patients were normotensive, while 33 (14.9%) and 37 (16.7%) required medication for hypotension and hypertension, respectively. A univariate logistic regression identified 5 variables as being associated with postoperative blood pressure including race, history of MI, prior percutaneous transluminal coronary angioplasty (PTCA), statin use, and angiotensin-converting enzyme-inhibitor/angiotensin-receptor blocker (ARB) use. A stepwise regression selection found race, prior MI, and statin use to be associated with our primary end points. The hypertensive group was more likely to have a history of MI compared to the hypotensive and normotensive groups (40.5% vs. 27.3% vs. 18.5%, P = 0.02), PTCA (43.2% vs. 39.4% vs. 23.8%, P = 0.03), and statin use (94.6% vs. 93.9% vs. 78.8%, P = 0.01). Mean LOS was also the highest for the hypertensive group, followed by hypotensive and normotensive patients [2.0 (±1.6) vs. 1.8 (±2.4) vs. 1.3 (±0.8), P = 0.002]. Multivariable logistic regression demonstrated that non-Caucasian patients [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.26-5.86, P = 0.01] and those with a history of MI (OR 2.98, 95% CI 1.33-6.67) were more likely to have postoperative hypertension compared to patients who were Caucasian or had no history of MI. CONCLUSIONS Postoperative hypertension is associated with non-Caucasian race and a history of MI. Given the potential implications for adverse perioperative outcomes including MI, mortality, and LOS, it is important to continue to elucidate potential risk factors in order to further tailor the perioperative management of patients undergoing CEA.
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Affiliation(s)
- Samuel Lee
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
| | - Allan M Conway
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Nhan Nguyen Tranh
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Gautam Anand
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Tung Ming Leung
- Department of Biostatistics, Feinstein Institute for Medical Research, Manhasset, NY
| | - Olga Fatakhova
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Gary Giangola
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alfio Carroccio
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
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Ross EG, Mell MW. Evaluation of regional variations in length of stay after elective, uncomplicated carotid endarterectomy in North America. J Vasc Surg 2020; 71:536-544.e7. [PMID: 31280981 PMCID: PMC8269949 DOI: 10.1016/j.jvs.2019.02.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 02/25/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate factors affecting regional variation in length of stay (LOS) after elective, uncomplicated carotid endarterectomy (CEA). METHODS Data were obtained from the Vascular Quality Initiative database and included patients with complete data who received elective CEA without complications between 2012 and 2017 across 18 regions in North America and 294 centers. The main outcome measure was LOS >1 day after surgery (LOS >1 postoperative day [POD]). Using least absolute shrinkage and selection operator regression, multivariable modeling, and mixed-effects general linear modeling, we evaluated whether regional variations in LOS were independent of demographic, clinical, or center-related factors and to what extent these factors accounted for postoperative variation in LOS. RESULTS A total of 36,004 patients were included. Mean postprocedure LOS was 1.6 ± 6.6 days. Overall, 24% of patients had an LOS >1 POD. After adjustment for important demographic, clinical, and center-related factors, the region in which a patient was treated independently and significantly affected LOS after elective, uncomplicated CEA. Region and center of treatment accounted for 18% of LOS variation. Demographic, clinical, and surgical factors accounted for another 32% of variation in LOS. Of these factors, postoperative discharge to a facility other than home (odds ratio [OR], 6.3; confidence interval [CI], 5.2-7.6), use of intravenous (IV) vasoactive agents (OR, 3.2; CI, 3-3.4), intraoperative drain placement (OR, 1.4; CI, 1.3-1.55), and female sex (OR, 1.4; CI, 1.3-1.5) were associated with longer LOS. Factors associated with LOS ≤1 POD included preoperative aspirin (OR, 0.88; CI, 0.8-0.96) and statin use (OR, 0.9; CI, 0.83-0.98), high surgeon volume (highest quartile: OR, 0.68; CI, 0.5-0.87), and completion evaluation after CEA (eg, Doppler, ultrasound; OR, 0.87; CI, 0.8-0.95). We also found that use of IV vasoactive medications varied significantly across regions, independent of demographic and clinical factors. CONCLUSIONS Significant regional variation in LOS exists after elective, uncomplicated CEA even after controlling for a wide range of important factors, indicating that there remain unmeasured causes of longer LOS in some regions. Even so, modification of certain clinical practices may reduce overall LOS. Regional differences in use of IV vasoactive medications not driven by clinical factors warrant further analysis, given the strong association with longer LOS.
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Affiliation(s)
- Elsie Gyang Ross
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Matthew W Mell
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif.
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Eslami MH, Saadeddin Z, Farber A, Fish L, Avgerinos ED, Makaroun MS. External validation of the Vascular Study Group of New England carotid endarterectomy risk predictive model using an independent U.S. national surgical database. J Vasc Surg 2019; 71:1954-1963. [PMID: 31676184 DOI: 10.1016/j.jvs.2019.04.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 04/11/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Previously, we described a Vascular Study Group of New England (VSGNE) risk predictive model to predict composite adverse outcomes (postoperative death, stroke, myocardial infarction, or discharge to extended care facilities) after carotid endarterectomy (CEA). The goal of this study was to externally validate this model using an independent database. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) CEA-targeted database (2010-2014) was used to externally validate the risk predictor model of adverse outcomes after CEA previously created using the VSGNE carotid database. Emergent cases and those in which CEA was combined with another operation were excluded. Cases in which a discharge destination cannot be determined were also excluded. To assess the predictive power of our VSGNE prediction score within this sample, a receiver operating characteristic curve was constructed. Risk scores for each NSQIP patient were also computed using beta weights from the VSGNE CEA model. To further assess the construct validity of our VSGNE prediction score, the observed proportion of adverse outcomes was examined at each level of our prediction scale and within five roughly equally sized risk groups formed on the basis of our VSGNE prediction scores. RESULTS In this database, 10,889 cases met our inclusion criteria and were used in this analysis. The overall rate of adverse outcomes in this cohort was 8.5%. External validation of the VSGNE model on this sample showed moderately good predictive ability (area under the curve = 0.745). Patients in progressively higher risk groups, based on their VSGNE model scores, exhibited progressively higher rates of observed adverse outcomes, as predicted. CONCLUSIONS The VSGNE CEA risk predictive model was externally validated on an NSQIP CEA-targeted sample and showed a fairly accurate global predictive ability for adverse outcomes after CEA. Although this model has a good population concordance, the lack of cut point indicates that individual risk prediction requires more evaluation. Further studies should be geared toward identification of variables that make this risk predictive model more robust.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Larry Fish
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Pi J, Sun Y, Zhang Z, Wan C. Combined anesthesia shows better curative effect and less perioperative neuroendocrine disorder than general anesthesia in early stage NSCLC patients. J Int Med Res 2019; 47:4743-4752. [PMID: 31510831 PMCID: PMC6833388 DOI: 10.1177/0300060519862102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objectives We aimed to compare the effects of general anesthesia with combined epidural and general anesthesia in patients with early-stage non-small cell lung carcinoma (NSCLC). Methods Patients scheduled to undergo tumor resection with adjuvant chemoradiotherapy were eligible. Patients in the control group received general anesthesia during surgery, and those in the observation group received combined epidural and general anesthesia. The hemodynamic factors mean arterial pressure (MAP), heart rate, end-tidal carbon dioxide, and oxygen saturation were measured. Serum levels of pro-inflammatory cytokines interleukin (IL)-1, IL-8, high-sensitivity C-reactive protein (hs-CRP), and tumor necrosis factor (TNF)-α as well as β-endorphin were measured by enzyme-linked immunosorbent assay. Serum malondialdehyde (MDA) was measured using the thiobarbituric acid method. Results The incidence of specific adverse events was reduced and overall and disease-free survival were improved in the observation group compared with the control group. MAP was generally lower in the observation group compared with the control group, as were the serum levels of IL-1, IL-8, hs-CRP, TNF-α, and MDA. Conclusions Compared with general anesthesia, combined epidural and general anesthesia may inhibit the occurrence of short-term adverse events and improve long-term outcomes by inhibiting inflammatory responses in patients with early-stage NSCLC after tumor resection.
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Affiliation(s)
- Jingbo Pi
- Department of Anesthesia, Second People's Hospital of Banan District, Chongqing, China
| | - Yi Sun
- Department of Oncology, People's Hospital of Guizhou Province, Guiyang, Guizhou Province, China
| | - Zhenghong Zhang
- Department of Thoracic Surgery, Second People's Hospital of Banan District, Chongqing, China
| | - Chengfu Wan
- Department of Anesthesia, Second People's Hospital of Banan District, Chongqing, China
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Ngo HTN, Nemeth B, Wever JJ, Veger HTC, Mairuhu ATA, de Laat KF, Statius van Eps RG. Clinical outcomes of postcarotid endarterectomy hypertension. J Vasc Surg 2019; 71:553-559. [PMID: 31280977 DOI: 10.1016/j.jvs.2019.04.477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/11/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study was to determine the clinical relevance of postcarotid endarterectomy hypertension (PEH) by investigating the effect of PEH on hospital length of stay (LOS) and by investigating short-term and long-term complications of PEH. In addition, risk factors for PEH were determined. METHODS A single-center retrospective cohort study was performed. Demographic, preoperative, intraoperative, and postoperative outcomes of 192 patients undergoing carotid endarterectomy were evaluated. Outcomes were compared between patients with PEH and patients without PEH. PEH was defined as an acute systolic blood pressure (SBP) rise >170 mm Hg or persistent SBP >150 mm Hg on the ward and leading to the consultation of an internist. The overall survival and event-free survival were compared using a Kaplan-Meier analysis and a Cox regression analysis. A multivariate logistic regression analysis was performed to determine risk factors for PEH. RESULTS PEH developed in 44 of 192 patients (25%). Preoperative hypertension (SBP >150 mm Hg) was determined to be a risk factor for PEH (odds ratio, 3.3; 95% confidence interval [CI], 1.6-6.9). Hospital LOS was prolonged in patients with PEH compared with patients without PEH (median LOS of 5 days vs 3 days, respectively; P < .001). No difference in the occurrence of ischemic neurologic events or rebleeding during hospitalization was observed (P = .58 and P = .72, respectively). Cardiovascular and ischemic neurologic events during follow-up did not occur more often in patients with PEH than in patients without PEH (P = .46). There was no difference in mortality between the PEH and non-PEH groups (hazard ratio, 1.6; 95% CI, 0.6-4.3). The same applies to the event-free survival (hazard ratio, 0.77; 95% CI, 0.4-1.7). Combined event-free survival for stroke and myocardial infarction was 92% (95% CI, 87%-97%) at 2 years for patients without PEH and 86% (95% CI, 74%-98%) at 2 years for patients with PEH (P = .25). Event-free survival for mortality was 90% (95% CI, 85%-96%) at 2 years for patients without PEH and 94% (95% CI, 86%-100%) at 2 years for patients with PEH (P = .36). CONCLUSIONS Patients with PEH had a significant increase in hospital LOS. However, adverse short-term and long-term events did not occur more often in patients with PEH. High preoperative SBP was identified as a risk factor for PEH; no other demographic and clinical variables were associated with PEH.
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Affiliation(s)
- Hà T N Ngo
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan J Wever
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hugo T C Veger
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Albert T A Mairuhu
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Karlijn F de Laat
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Neurology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Randolph G Statius van Eps
- HAGA Heart and Vascular Center, Haga Teaching Hospital, The Hague, The Netherlands; Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands.
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Deşer SB, Yucel SM, Demirag MK, Kolbakir F, Keceligil HT. Relationship of Inter-Arm Systolic Blood Pressure Difference with Subclavian Artery Stenosis and Vertebral Artery Stenosis in Patients Undergoing Carotid Endarterectomy. Braz J Cardiovasc Surg 2019; 34:136-141. [PMID: 30916122 PMCID: PMC6436778 DOI: 10.21470/1678-9741-2018-0257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/07/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction The aim of this study was to examine the association of inter-arm systolic
blood pressure difference (IASBPD) with carotid artery stenosis, subclavian
artery stenosis and vertebral artery stenosis in patients who underwent
carotid endarterectomy. Methods A total of 141 patients (29 females, 112 males; mean age 71.2±10.4
years; range 47 to 92 years) who underwent carotid endarterectomy between
September 2010 and December 2017 were retrospectively evaluated. We
classified patients into four groups according to the IASBPD ˂ 10 mmHg,
≥ 10 mm Hg, ≥ 20 mmHg and ≥ 30 mmHg. The stenosis of
both subclavian and vertebral arteries was considered as ≥ 50%. Results Of the 141 patients, 44 (31.2%) had ≥ 10 mmHg, 29 (20.5%) had ≥
20 mmHg and 4 (2.8%) had ≥ 30 mmHg of IASBPD. 26 patients (18.4%)
were diagnosed with significant subclavian artery stenosis and 18 (69.2%) of
them had more than 20 mmHg of IASBPD. Of the 29 patients with IASBPD
≥ 20 mmHg, 19 patients (65.5%) had a significant subclavian artery
stenosis. We found a significant correlation between preoperative symptoms
and subclavian artery stenosis (P=0.018) and overall
perioperative stroke was seen more frequently in patients with subclavian
artery stenosis (P=0.041). A significant positive
correlation was observed between vertebral artery stenosis and subclavian
artery stenosis (P=0.01). Conclusion Patients who were diagnosed with both subclavian artery stenosis and IASBPD
(≥ 20 mmHg) had a higher risk of postoperative stroke and death, had
higher total cholesterol, LDL-C, blood creatinine level, and were more
symptomatic.
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Affiliation(s)
- Serkan Burç Deşer
- Department of Cardiovascular Surgery, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Semih Murat Yucel
- Department of Cardiovascular Surgery, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Mustafa Kemal Demirag
- Department of Cardiovascular Surgery, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Fersat Kolbakir
- Department of Cardiovascular Surgery, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hasan Tahsin Keceligil
- Department of Cardiovascular Surgery, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Shigematsu K, Iwashita K, Mimata R, Owaki R, Totoki T, Gohara A, Okawa J, Higashi M, Yamaura K. Preoperative Left Ventricular Diastolic Dysfunction Is Associated with Pulmonary Edema after Carotid Endarterectomy. Neurol Med Chir (Tokyo) 2019; 59:299-304. [PMID: 31105129 PMCID: PMC6694021 DOI: 10.2176/nmc.oa.2019-0028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This retrospective study was aimed to investigate the association between preoperative left ventricular (LV) cardiac function and the incidence of postoperative pulmonary edema (PE) in patients undergoing carotid endarterectomy (CEA). Most patients undergoing CEA for carotid artery stenosis have concomitant heart diseases, leading to hemodynamic instability that can cause postoperative cardiac complications such as cardiac heart failure. LV diastolic function has recently been recognized as an independent predictor of adverse cardiac events in patients undergoing cardiovascular surgery. We analyzed clinical data from the anesthetic and medical records of 149 consecutive patients who underwent CEA at our university hospital between March 2012 and March 2018. LV systolic and diastolic function were evaluated by ejection fraction and the ratio of LV early diastolic filling velocity to the peak velocity of mitral medial annulus (E/e′). Postoperative PE was diagnosed based on chest X-ray and arterial gas analysis by two independent physicians. Postoperative PE was developed in four patients (2.8%). Patients with postoperative PE were not related to preoperative low ventricular ejection fraction, but had a significantly higher E/e′ ratio than those without PE (P = 0.01). Furthermore, there was an increasing trend of PE according to the E/e′ category. Preoperative LV diastolic function evaluated by E/e′ was associated with the development of postoperative PE in patients who underwent CEA. The results suggest that the evaluation of LV diastolic dysfunction could be possibly useful to predict PE in patients undergoing CEA.
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Affiliation(s)
- Kenji Shigematsu
- Department of Anesthesiology, Fukuoka University School of Medicine
| | - Kouhei Iwashita
- Department of Anesthesiology, Fukuoka University School of Medicine
| | - Ryosuke Mimata
- Department of Anesthesiology, Fukuoka University School of Medicine
| | - Ryoko Owaki
- Department of Anesthesiology, Fukuoka University School of Medicine
| | - Takaaki Totoki
- Department of Anesthesiology, Fukuoka University School of Medicine
| | - Akira Gohara
- Department of Anesthesiology, Fukuoka University School of Medicine
| | - Jingo Okawa
- Department of Anesthesiology, Fukuoka University School of Medicine
| | - Midoriko Higashi
- Department of Anesthesiology, Fukuoka University School of Medicine
| | - Ken Yamaura
- Department of Anesthesiology, Fukuoka University School of Medicine
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Meng L, Yu W, Wang T, Zhang L, Heerdt PM, Gelb AW. Blood Pressure Targets in Perioperative Care. Hypertension 2018; 72:806-817. [DOI: 10.1161/hypertensionaha.118.11688] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lingzhong Meng
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, China (W.Y.)
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (T.W.)
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan Province, China (L.Z.)
| | - Paul M. Heerdt
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Adrian W. Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (A.W.G.)
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Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M. Editor's Choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:3-81. [PMID: 28851594 DOI: 10.1016/j.ejvs.2017.06.021] [Citation(s) in RCA: 803] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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22
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[Postoperative blood pressure alterations after carotid endarterectomy : Implications of different reconstruction methods]. Chirurg 2017; 89:123-130. [PMID: 28842735 DOI: 10.1007/s00104-017-0502-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Postoperative blood pressure alterations after carotid endarterectomy (CEA) are associated with an increased risk of morbidity and mortality. OBJECTIVE To outline the influence of the two commonly used surgical reconstruction techniques, conventional CEA with patch plasty (C-CEA) and eversion CEA (E-CEA), as well as the innovative carotid sinus-preserving eversion CEA (SP-E-CEA) technique on postoperative hemodynamics, taking the current scientific knowledge into consideration. METHODS Assessment of the current clinical and scientific evidence on each operative technique found in the PubMed (NLM) database ranging from 1974 to 2017, excluding case reports. RESULTS A total of 34 relevant papers as well as 1 meta-analysis, which scientifically dealt with the described topic were identified. The results of the studies and the meta-analysis showed that E‑CEA correlates with an impairment of local baroreceptor functions as well as with an elevated need for vasodilators in the early postoperative phase, whereas C‑CEA and SP-E-CEA seem to have a more favorable effect on the postoperative blood pressure. CONCLUSION The CEA technique influences the postoperative blood pressure regulation, irrespective of the operative technique used. Accordingly, close blood pressure monitoring is recommended at least during the postoperative hospital stay. Further studies are mandatory to evaluate the importance of SP-E-CEA as an alternative to the classical E‑CEA.
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Galyfos G, Sianou A, Filis K. Cerebral hyperperfusion syndrome and intracranial hemorrhage after carotid endarterectomy or carotid stenting: A meta-analysis. J Neurol Sci 2017; 381:74-82. [PMID: 28991720 DOI: 10.1016/j.jns.2017.08.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/03/2017] [Accepted: 08/15/2017] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Cerebral hyperperfusion syndrome (CHS) and intracranial hemorrhage (ICH) after carotid revascularization have been associated with significant morbidity and mortality, although pooled data comparing these outcomes between open and endovascular treatment are lacking. Aim of this meta-analysis is to compare CHS and ICH risk between carotid endarterectomy (CEA) and carotid angioplasty with stenting (CAS). METHODS A systematic literature review was conducted conforming to established criteria, in order to identify eligible articles published prior to February 2017. Eligible studies compared CHS and/or ICH between patients undergoing CEA and CAS. Other outcomes evaluated in this review included stroke and death due to ICH. Outcome risks are presented as odds ratios (OR) and 95% confidence intervals (CI). RESULTS Overall, 6 studies (5 studies reporting on CHS and 4 studies reporting on ICH) included 236,537 procedures (218,144 CEA; 18,393 CAS) in total. CEA was associated with a higher risk for CHS compared to CAS (pooled OR=1.432 [95% CI=1.078-1901]; P=0.015), although this difference was generated mainly from older studies (prior to 2012). However, no difference was found regarding ICH risk between the two methods (pooled OR=0.544 [95% CI=0.111-2.658]; P=0.452). Regarding stroke incidence, no difference was found between the two methods as well, although this resulted mainly from studies with a higher volume of CAS procedures (pooled OR=0.964 [95% CI=0.741-1.252]; P=0.833). Finally, death rate was significantly higher among patients with ICH compared to patients without ICH (pooled OR=386.977 [95% CI=246.746-606.906]; P<0.0001). Pooled data were not adequate to calculate potential risk factors for CHS/ICH after CEA compared to CAS. CONCLUSIONS CEA seems to be associated with a higher risk for CHS compared to CAS, although this difference was generated mainly from older studies. However, there seems to be no difference regarding ICH risk between the two methods, with ICH being associated with a significantly higher risk for death.
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Affiliation(s)
- George Galyfos
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece.
| | - Argiri Sianou
- Department of Microbiology, University of Athens Medical School, Areteion Hospital, Athens, Greece
| | - Konstantinos Filis
- First Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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Jiménez-Díaz J, Higuera-Sobrino F, González-Marín MA, Camacho-Pedrero A. Síndrome del seno carotídeo tras endarterectomía carotídea. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:241-244. [DOI: 10.1016/j.acmx.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 07/13/2016] [Accepted: 07/21/2016] [Indexed: 11/27/2022] Open
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Chen T, Crozier JA. Carotid endarterectomy: What difference does a clinical protocol make? JOURNAL OF VASCULAR NURSING 2017; 34:100-5. [PMID: 27568317 DOI: 10.1016/j.jvn.2016.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/20/2016] [Accepted: 05/25/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND The initial eight hours after carotid endarterectomy (CEA) are crucial to patient outcome as many potential complications can occur during this period. Hypotension is one of the most common issues observed after patients have returned to the surgical ward. Postoperative management of patients undergoing CEA varies between facilities, with reported direct intensive care unit or surgical high dependence unit admission. Patients that underwent a CEA procedure at the study hospital were monitored in the Recovery Unit for a minimum of four hours before being transferred to the surgical ward. Episodes of hypotension, on return to the surgical ward, were one of the main issues identified. This observation resulted in revision of the CEA management policy with collaboration from all specialties involved in the care of patients undergoing a CEA. The aim of this study was to compare whether there was any difference in short-term clinical outcomes between preupdate and postupdate of the carotid management policy in a tertiary referral hospital in New South Wales. METHODOLOGY Retrospective review of health care records was undertaken for the following two time intervals: prepolicy change from July 2008 to June 2009; postpolicy change from June 2011 to May 2012. Hypotension was defined as a systolic blood pressure less than 90 mm Hg. State SE 12.1 was used for data analysis. RESULTS After assessing for potential confounding factors-such as postoperative heart rate, risk factors, gender, and age-patients from the postpolicy change group were less likely to receive vasoactive medications to manage blood pressure deviation (OR, 0.33; 95% CI, 0.12-0.91; P = 0.026), the odds of receiving vasoactive medications was 0.33 times lower than that of the pre-policy change group patients, and is 95% confident that the true association lies between 0.12 and 0.91 in the underlying population. Over 90% of intensive care unit admission was avoided in patients from the postpolicy change group with estimated cost saving of $807 Australian dollars per patient. CONCLUSIONS The study hospital postoperative carotid surgery management policy has driven practice change with an extended Recovery Unit observation. This is a cost effective and safer management method. The Clinical Nurse Consultant was essential for clinical policy development, implementation, and evaluation.
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Affiliation(s)
- Tanghua Chen
- Department of Vascular Surgery, Liverpool Hospital, Sydney, Australia.
| | - John A Crozier
- Department of Vascular Surgery, Liverpool Hospital, Sydney, Australia
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Pothof AB, Soden PA, Fokkema M, Zettervall SL, Deery SE, Bodewes TCF, de Borst GJ, Schermerhorn ML. The impact of contralateral carotid artery stenosis on outcomes after carotid endarterectomy. J Vasc Surg 2017; 66:1727-1734.e2. [PMID: 28655552 DOI: 10.1016/j.jvs.2017.04.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/01/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patients with contralateral carotid occlusion (CCO) have been excluded from randomized clinical trials because of a deemed high risk for adverse neurologic outcomes with carotid endarterectomy (CEA). Evidence for this rationale is limited and conflicting. Therefore, we aimed to compare outcomes after CEA between patients with and without CCO and varying degrees of contralateral carotid stenosis (CCS). METHODS We identified patients undergoing CEA from 2003 to 2015 in the Vascular Study Group of New England (VSGNE) registry. Patients were stratified by preoperative symptom status and presence of CCO. Multivariable analysis was used to account for differences in demographics and comorbidities. Our primary outcome was 30-day stroke/death risk. RESULTS Of 15,487 patients we identified who underwent CEA, 10,377 (67%) were asymptomatic. CCO was present in 914 patients, of whom 681 (75%) were asymptomatic. Overall, the 30-day stroke/death was 2.0% for symptomatic patients (CCO: 2.6%) and 1.1% for asymptomatic patients (CCO: 2.3%). After adjustment, including symptom status, CCO was associated with higher 30-day stroke/death (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.3; P = .001), any in-hospital stroke (OR, 2.8; 95% CI, 1.7-4.6; P < .001), in-hospital ipsilateral stroke (OR, 2.2; 95% CI, 1.2-4.0; P = .02), in-hospital contralateral stroke (OR, 5.1; 95% CI, 2.2-11.4; P < .001), and prolonged length of stay (OR, 1.6; 95% CI, 1.3-1.9; P < .001). CCS of 80% to 99% was only associated with a prolonged length of stay (OR, 1.3; 95% CI, 1.1-1.6; P = .01), not with in-hospital stroke. Neither CCO nor CCS was associated with 30-day mortality. CONCLUSIONS Although CCO increases the risk of 30-day stroke/death, in-hospital strokes, and prolonged length of stay after CEA, the 30-day stroke/death rates in symptomatic and asymptomatic patients with CCO remain within the recommended thresholds set by the 14 societies' guideline document. Thus, CCO should not qualify as a high-risk criterion for CEA. Moreover, there is no evidence that patients with CCO have lower stroke/death rates after carotid artery stenting than after CEA. We believe that CEA remains a valid and safe option for patients with CCO and that CCO should not be applied as a criterion to promote carotid artery stenting per se.
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Affiliation(s)
- Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Margriet Fokkema
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Diastolic Blood Pressure is a Risk Factor for Peri-procedural Stroke Following Carotid Endarterectomy in Asymptomatic Patients. Eur J Vasc Endovasc Surg 2017; 53:626-631. [PMID: 28318997 PMCID: PMC5423873 DOI: 10.1016/j.ejvs.2017.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/01/2017] [Indexed: 01/19/2023]
Abstract
Objective/Background Carotid endarterectomy (CEA) prevents future stroke, but this benefit depends on detection and control of high peri-operative risk factors. In symptomatic patients, diastolic hypertension has been causally related to procedural stroke following CEA. The aim was to identify risk factors causing peri-procedural stroke in asymptomatic patients and to relate these to timing of surgery and mechanism of stroke. Methods In the first Asymptomatic Carotid Surgery Trial (ACST-1), 3,120 patients with severe asymptomatic carotid stenosis were randomly assigned to CEA plus medical therapy or to medical therapy alone. In 1,425 patients having their allocated surgery, baseline patient characteristics were analysed to identify factors associated with peri-procedural (< 30 days) stroke or death. Multivariate analysis was performed on risk factors with a p value < .3 from univariate analysis. Event timing and mechanism of stroke were analysed using chi-square tests. Results A total of 36 strokes (27 ischaemic, four haemorrhagic, five unknown type) and six other deaths occurred during the peri-procedural period, resulting in a stroke/death rate of 2.9% (42/1,425). Diastolic blood pressure at randomisation was the only significant risk factor in univariate analysis (odds ratio [OR] 1.34 per 10 mmHg, 95% confidence interval [CI] 1.04–1.72; p = .02) and this remained so in multivariate analysis when corrected for sex, age, lipid lowering therapy, and prior infarcts or symptoms (OR 1.34, 95% CI 1.05–1.72; p = .02). In patients with diastolic hypertension (> 90 mmHg) most strokes occurred during the procedure (67% vs. 20%; p = .02). Conclusion In ACST-1, diastolic blood pressure was the only independent risk factor associated with peri-procedural stroke or death. While the underlying mechanisms of the association between lower diastolic blood pressure and peri-procedural risk remain unclear, good pre-operative control of blood pressure may improve procedural outcome of carotid surgery in asymptomatic patients.
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Demirel S, Goossen K, Bruijnen H, Probst P, Böckler D. Systematic review and meta-analysis of postcarotid endarterectomy hypertension after eversion versus conventional carotid endarterectomy. J Vasc Surg 2017; 65:868-882. [DOI: 10.1016/j.jvs.2016.10.087] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
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Huibers A, Hendrikse J, Brown M, Pegge S, Arnold M, Moll F, Kapelle L, de Borst G. Upper Extremity Blood Pressure Difference in Patients Undergoing Carotid Revascularisation. Eur J Vasc Endovasc Surg 2017; 53:153-157. [DOI: 10.1016/j.ejvs.2016.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
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Wang GJ, Beck AW, DeMartino RR, Goodney PP, Rockman CB, Fairman RM. Insight into the cerebral hyperperfusion syndrome following carotid endarterectomy from the national Vascular Quality Initiative. J Vasc Surg 2016; 65:381-389.e2. [PMID: 27707618 DOI: 10.1016/j.jvs.2016.07.122] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/24/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral hyperperfusion syndrome (CHS), characterized by severe ipsilateral headache, seizures, and intracranial hemorrhage, is a rare, poorly understood complication that can be fatal following carotid endarterectomy (CEA). The purpose of the study was to determine the factors associated with CHS as captured in the Vascular Quality Initiative. METHODS Analysis was conducted on 51,001 procedures captured from the CEA module of the Vascular Quality Initiative from 2003 to 2015. Preoperative, operative, and postoperative variables were considered for inclusion in logistic regression analyses to determine possible associations with CHS. The relative contribution of each variable to the overall model was determined using dominance analysis. RESULTS The mean age was 70.2 ± 9.4 years; there were 39.6% female patients, 93.1% of white race, with 29.6% of CEAs being performed for symptomatic status. The overall rate of CHS was 0.18% (n = 94), with 55.1% occurring in asymptomatic and 44.9% occurring in symptomatic patients with an associated mortality rate of 38.2%. Multivariable analysis including preoperative variables showed that female gender (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.09-2.51; P = .019), <1 month major ipsilateral stroke (OR, 5.36; 95% CI, 2.35-12.22; P < .001), coronary artery disease (OR, 1.77; 95% CI, 1.15-2.71; P = .009), and contralateral stenosis ≥70% (OR, 1.54; 95% CI, 1.00-2.36; P = .050) were independently associated with CHS and that <1 month major stroke was the most important contributor to the model. With the additional inclusion of operative and postoperative variables, female gender (OR, 1.75; 95% CI, 1.14-2.67; P = .010), <1 month ipsilateral major stroke (OR, 3.20; 95% CI, 1.32-7.74; P = .010), urgency (OR, 2.25; 95% CI, 1.38-3.67; P = .001), re-exploration (OR, 2.98; 95% CI, 1.27-6.97; P = .012), postoperative hypertension (OR, 4.09; 95% CI, 2.65-6.32; P < .001), postoperative hypotension (OR, 3.21; 95% CI, 1.97-5.24; P < .001), dysrhythmias (OR, 3.23; 95% CI, 1.64-6.38; P = .001), and postoperative myocardial infarction (OR, 2.84; 95% CI, 1.21-6.67; P = .017) were significantly associated with CHS, with postoperative blood pressure lability and cardiac complications having the strongest associations with CHS. CONCLUSIONS The risk of CHS was highest in female patients and in those with a recent major stroke, coronary artery disease, and contralateral stenosis ≥70%. In addition, in adjusting for operative and postoperative variables, CHS was most significantly associated with postoperative blood pressure lability and cardiac complications. These data lend insight into a high-risk population for this devastating complication.
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Affiliation(s)
- Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
| | - Adam W Beck
- Division of Vascular Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | | | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchock Medical Center, Lebanon, NH
| | - Caron B Rockman
- Division of Vascular Surgery, NYU Langone Medical Center, New York, NY
| | - Ronald M Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
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Predictors of poor outcome after carotid intervention. J Vasc Surg 2016; 64:663-70. [DOI: 10.1016/j.jvs.2016.03.428] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 03/14/2016] [Indexed: 01/10/2023]
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Mehaffey JH, LaPar DJ, Tracci MC, Cherry KJ, Kern JA, Kron I, Upchurch GR. Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy. Ann Vasc Surg 2016; 39:195-203. [PMID: 27554691 DOI: 10.1016/j.avsg.2016.05.126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 04/11/2016] [Accepted: 05/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day. RESULTS Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05). CONCLUSIONS Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.
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Affiliation(s)
- James H Mehaffey
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
| | - Damien J LaPar
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Margret C Tracci
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Kenneth J Cherry
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Irving Kron
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Gilbert R Upchurch
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
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Temporary Transvenous Pacemaker Implantation during Carotid Endarterectomy in Patients with Trifascicular Block. Ann Vasc Surg 2016; 34:206-11. [DOI: 10.1016/j.avsg.2015.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/14/2015] [Accepted: 12/15/2015] [Indexed: 12/25/2022]
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Leblanc I, Chterev V, Rekik M, Boura B, Costanzo A, Bourel P, Combes M, Philip I. Safety and efficiency of ultrasound-guided intermediate cervical plexus block for carotid surgery. Anaesth Crit Care Pain Med 2016; 35:109-14. [DOI: 10.1016/j.accpm.2015.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/15/2015] [Accepted: 08/11/2015] [Indexed: 11/16/2022]
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Eslami MH, Rybin D, Doros G, Farber A. An externally validated robust risk predictive model of adverse outcomes after carotid endarterectomy. J Vasc Surg 2016; 63:345-54. [DOI: 10.1016/j.jvs.2015.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 09/14/2015] [Indexed: 01/12/2023]
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Steely AM, Callas PW, Bertges DJ. Renin-angiotensin-aldosterone-system inhibition is safe in the preoperative period surrounding carotid endarterectomy. J Vasc Surg 2015; 63:715-21. [PMID: 26603543 DOI: 10.1016/j.jvs.2015.09.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/28/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Discontinuation of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) medications before surgery has been suggested because of the potentially deleterious effects of hypotension. We investigated the effect of preoperative ACEI and/or ARB use on early outcomes after carotid endarterectomy (CEA). METHODS We examined 3752 consecutive CEA patients within the Vascular Study Group of New England from September 2012 to September 2014 and compared outcomes for patients treated (n = 1772) or not treated (n = 1980) with ACEI and/or ARB preoperatively. Outcomes included perioperative need for intravenous vasoactive medication (IVBPmed) for hypotension or hypertension (HTN), major adverse cardiac events (MACEs), and the combined outcome of stroke or death. Adjusted analysis was performed using multivariable logistic regression of the crude cohort and by constructing a propensity score matched cohort (n = 1441). RESULTS ACEI and/or ARB users were more likely to be male (64% vs 59%; P = .001), with a higher prevalence of diabetes (41% vs 28%; P < .0001), HTN (97% vs 82%; P < .0001), coronary artery disease (31% vs 25%; P = .0001), congestive heart failure (10% vs 8%; P = .02), and asymptomatic carotid disease (59% vs 54%; P = .004). Patients who received ACEI and/or ARB preoperatively were more likely to be treated with aspirin (92% vs 88%; P = .0002) and statins (89% vs 85%; P = .001) preoperatively. In the unadjusted analysis, no significant differences were identified in hypotension that required IVBPmed (12% vs 11%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.9-1.4; P = .22), MACE (3% vs 2%; OR, 1.3; 95% CI, 0.8-1.9; P = .32), or stroke or death (3% vs 3%; OR, 1.0; 95% CI, 0.7-1.6; P = .89) for preoperative ACEI and/or ARB treated and nontreated patients, respectively. Preoperative ACEI and/or ARB usage was, however, associated with HTN that required IVBPmed (13% vs 10%; OR, 1.3; 95% CI, 1.1-1.6; P = .01). Analysis of the propensity score matched cohort revealed no significant differences in hypotension that required IVBPmed (12% vs 12%; OR, 1.0; 95% CI, 0.8-1.3; P = .86), MACE (3% vs 2%; OR, 1.1; 95% CI, 0.7-1.8; P = .62; ), or stroke or death (3% vs 3%; OR, 1.0; 95% CI, 0.7-1.6; P = .91) for patients treated or not treated with preoperative ACEI and/or ARB, respectively. ACEI and/or ARB remained associated with HTN that required IVBPmed (13% vs 10%; OR, 1.3; 95% CI, 1.0-1.7; P = .02). Results were similar after adjustment using logistic regression. The incidence of hospital length of stay >1 day was similar between ACEI and/or ARB treated and not treated patients (29% vs 32%; OR, 0.9; 95% CI, 0.8-1.1; P = .21). CONCLUSIONS Preoperative ACEI and/or ARB use was associated with marginally increased use of IVBPmed for HTN but not for hypotension and was not associated with increased MACE, stroke, or death. On the basis of these metrics, the use of preoperative ACEI and/or ARB appears safe before CEA.
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Affiliation(s)
- Andrea M Steely
- Division of Vascular Surgery, The University of Vermont Medical Center, Burlington, Vt
| | - Peter W Callas
- Division of Vascular Surgery, The University of Vermont Medical Center, Burlington, Vt
| | - Daniel J Bertges
- Division of Vascular Surgery, The University of Vermont Medical Center, Burlington, Vt.
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Zdrehuş C. Anaesthesia for carotid endarterectomy - general or loco-regional? Rom J Anaesth Intensive Care 2015; 22:17-24. [PMID: 28913451 PMCID: PMC5505327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Carotid endarterectomy has been widely used for the surgical treatment of carotid stenosis, and may be performed under either general or loco-regional anaesthesia. The greatest risks of carotid endarterectomy are the neurologic complications and the myocardial infarction. Anaesthetic and surgical techniques are constantly under scrutiny to try to reduce the relatively high incidence of morbidity and mortality of an operation which in itself is only preventative. Loco-regional anaesthesia is an alternative to general anaesthesia which has attracted considerable attention amid claims of a reduction in operative morbidity and mortality. This review describes the problems and some solutions for providing loco-regional or general anaesthesia for carotid endarterectomy.
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Affiliation(s)
- Claudiu Zdrehuş
- Adress for correspondence: Claudiu Zdrehuş, MD, PhD, Disciplina ATI I, Univ. de Medicină şi Farmacie, „Iuliu Haţieganu”, Cluj-Napoca, Str. Croitorilor 19–21, 400162 Cluj-Napoca, România, E-mail:
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Hobika G, Porhomayon J, Kocz R, Matson B, Paladino M. Prolonged Hypotension Following Innominate and Left Common Carotid Artery Bypass. J Cardiothorac Vasc Anesth 2015; 30:154-7. [PMID: 25813224 DOI: 10.1053/j.jvca.2014.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Geoffrey Hobika
- Department of Anesthesiology, VA Western New York Healthcare System, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Jahan Porhomayon
- Department of Anesthesiology, VA Western New York Healthcare System, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY.
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Abstract
Summary Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid cross-clamping; haemodynamic control is predictable; and hospital stay is consistently shorter compared with general anaesthesia (GA). Despite these purported benefits, mortality and stroke rates associated with CEA remain around 5% for both regional anaesthesia and GA. Regional anaesthetic techniques for CEA have improved with improved methods of location of peripheral nerves including nerve stimulators and ultrasound together with a modification in the classification of cervical plexus blocks. There have also been improvements in local anaesthetic, sedative, and arterial pressure-controlling drugs in patients undergoing CEA, together with advances in the management of patients who develop neurological deficit after carotid cross-clamping. In the UK, published national guidelines now require the time between the patient's presenting neurological event and definitive treatment to 1 week or less. This has implications for the ability of vascular centres to provide specialized vascular anaesthetists familiar with regional anaesthetic techniques for CEA. Providing effective regional anaesthesia for CEA is an important component in the armamentarium of techniques for the vascular anaesthetist in 2014.
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Affiliation(s)
- M D Stoneham
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
| | - D Stamou
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
| | - J Mason
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
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