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Straus S, Yadavalli SD, Allievi S, Sanders A, Davis RB, Malas MB, Wang GJ, Kashyap VS, Cronenwett J, Motaganahalli RL, Nolan B, Eldrup-Jorgensen J, Schermerhorn M. Seven Years of The Transcarotid Artery Revascularization Surveillance Project, Comparison To Transfemoral Stenting And Endarterectomy. J Vasc Surg 2024:S0741-5214(24)01227-8. [PMID: 38821431 DOI: 10.1016/j.jvs.2024.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/18/2024] [Accepted: 05/21/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE This study utilizes the latest data from the Vascular Quality Initiative (VQI), which now encompasses over 50,000 transcarotid artery revascularization (TCAR) procedures, to offer a sizeable dataset for comparing the effectiveness and safety of TCAR, transfemoral carotid artery stenting (tfCAS), and carotid endarterectomy (CEA). Given this substantial dataset, we are now able to compare outcomes overall and stratified by symptom status across revascularization techniques. METHODS Utilizing VQI data from September 2016 to August 2023, we conducted a risk-adjusted analysis by applying inverse probability of treatment weighting to compare in-hospital outcomes between TCAR vs tfCAS, CEA vs tfCAS, and TCAR vs CEA. Our primary outcome measure was in-hospital stroke/death. Secondary outcomes included myocardial infarction and cranial nerve injury. RESULTS A total of 50,068 patients underwent TCAR, 25,361 patients underwent tfCAS, and 122,737 patients underwent CEA. TCAR patients were older, more likely to have coronary artery disease, chronic kidney disease, and undergo coronary artery bypass grafting/percutaneous coronary intervention as well as prior contralateral CEA/CAS compared to both CEA and tfCAS. TfCAS had higher odds of stroke/death when compared with TCAR (2.9% vs 1.6%, aOR=1.84, 95% CI:1.65-2.06; P<.001) and CEA (2.9% vs 1.3%, aOR=2.21, 95% CI:2.01-2.43; P<.001). CEA had slightly lower odds of stroke/death compared with TCAR (1.3% vs 1.6%, aOR=0.83, 95% CI:0.76-0.91; P<.001). TfCAS had lower odds of cranial nerve injury compared with TCAR (0.0% vs 0.3%, aOR=0.00, 95% CI:0.00-0.00; P<.001) and CEA (0.0% vs 2.3%, aOR=0.00, 95% CI:0.0-0.0; P<.001) as well as lower odds of myocardial infarction compared with CEA (0.4% vs 0.6%, aOR=0.67, 95% CI:0.54-0.84; P<.001). CEA compared with TCAR had higher odds of myocardial infarction (0.6% vs 0.5%, aOR=1.31, 95% CI:1.13-1.54; P<.001) and cranial nerve injury (2.3% vs 0.3%, aOR=9.42, 95% CI:7.78-11.4; P<.001). CONCLUSIONS While tfCAS may be beneficial for select patients, the lower stroke/death rates associated with CEA and TCAR are preferred. When deciding between CEA and TCAR, it's important to weigh additional procedural factors and outcomes such as myocardial infarction and cranial nerve injury, particularly when stroke/death rates are similar. Additionally, evaluating subgroups that may benefit from one procedure over another is essential for informed decision-making and enhanced patient care in the treatment of carotid stenosis.
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Affiliation(s)
- Sabrina Straus
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego (UCSD), San Diego, California
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sara Allievi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew Sanders
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Roger B Davis
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, UC San Diego (UCSD), San Diego, California
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI
| | - Jack Cronenwett
- Section of Vascular Surgery, Dartmouth Medical School, 1 Medical Center Drive, Lebanon, NH
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Brian Nolan
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, ME
| | - Marc Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Manunga J, Pedersen C, Stanberry L, Pai A, Skeik N, Sullivan TM. Impact of Continued Clopidogrel use on Outcomes of Patients undergoing Carotid Endarterectomy. J Vasc Surg 2023:S0741-5214(23)01058-3. [PMID: 37086820 DOI: 10.1016/j.jvs.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVES To evaluate the use of clopidogrel at the time of carotid endarterectomy (CEA) and its association with postoperative complications. METHODS Single institution, retrospective review of a prospective database. RESULTS From 2010 to 2017, CEA was performed in 1066 consecutive patients (median age 73 years, 66% men). The indications for operation included ≥70% asymptomatic stenosis (458, 43%), prior stroke (314, 29%), and transient cerebral or retinal ischemia (294, 28%). At the time of operation, 509 (48%) patients were taking aspirin alone, 441 (41%) were taking clopidogrel (374 in combination with aspirin, 67 as sole therapy), 83 (8%) were on no documented antiplatelet medication, and 33 (3%) were taking warfarin (with therapeutic INR). The likelihood of clopidogrel use at the time of operation was higher for patients with a history of symptomatic carotid disease (p=0.002). Over the study period, clopidogrel use increased from 31.9% in 2010 to, 56.8% in 2017 that corresponds to 11% 95%CI (6, 15) increase annually. Postoperative strokes occurred in 15 patients (overall incidence 1.4%), the majority of which were minor (12/15, 80%). Six strokes occurred in patients taking aspirin alone (6/509, 1.2%), 2 in patients on clopidogrel and aspirin (2/441, 0.5%), 2 in patients taking clopidogrel alone (2/67, 2.9%), 3 in patients on no documented antiplatelet medication (3/83, 3.6%), and 2 in those taking warfarin (one of which was secondary to a fatal intracranial hemorrhage within 30 d of discharge; 2/33, 6.1%). The 30-day mortality rate was 0.03% (3/1066); the risk for the combined endpoint of any stroke, death or myocardial infarction (MI) was 2.3% (25/1066), and the risk for major stroke, death, or MI was 1.2%. There was no apparent association between clopidogrel use and the incidence of postoperative bleeding (p=0.59) or any other postoperative complication (stroke, death, MI, cranial nerve injury, p=0.15). CONCLUSIONS Clopidogrel use in our CEA practice has increased over time and has not been associated with an increased risk of postoperative complications, including bleeding. These data suggest that clopidogrel should not be discontinued prior to CEA, and should be considered as part of 'optimal medical therapy' in patients undergoing CEA.
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Affiliation(s)
- Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital; Minneapolis Heart Institute foundation.
| | - Christopher Pedersen
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital
| | | | - Akila Pai
- Division of Vascular and Endovascular Surgery, The Mount Sinai Hospital
| | - Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital; Minneapolis Heart Institute foundation
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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: 166] [Impact Index Per Article: 166.0] [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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GERMANOVA O, GALATI G, VACHEV A, GERMANOV A, BIONDI-ZOCCAI G. Carotid endarterectomy: the optimal surgical technique from the point of view of cardiologist. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.22.05413-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ribieras AJ, Tabbara M, Rey J, Velazquez OC, Bornak A. Outcomes and role of shunting during carotid endarterectomy for symptomatic patients. J Vasc Surg 2022; 76:1289-1297. [PMID: 35810956 DOI: 10.1016/j.jvs.2022.06.096] [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: 04/19/2022] [Revised: 06/25/2022] [Accepted: 06/30/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Shunt placement during carotid endarterectomy (CEA) is often advocated to protect the ischemic penumbra in patients with symptomatic carotid stenosis. This study assesses the effect of shunt placement on postoperative stroke risk in symptomatic patients undergoing CEA. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program database (2016-2019) for CEA cases with complete CEA procedure-targeted data. Symptomatic patients were identified as having a preoperative diagnosis of stroke on presentation (DS), transient ischemic attack (TIA), amaurosis fugax (AF), or temporary monocular blindness (TMB). DS patients were further analyzed according to the severity of their stroke based on their modified Rankin Scale (mRS). To better assess the effect of shunt placement on stroke rate, we compared cases of CEA with patch angioplasty technique, with and without the use of intraoperative shunt. Patients who underwent carotid eversion or primary closure were excluded. Baseline demographics and perioperative outcomes were compared using Chi-square and Mann-Whitney U test. Multivariate analysis was performed to identify independent risk factors for postoperative stroke and cranial nerve injury. RESULTS We identified 4,652 cases of CEA with patch angioplasty in symptomatic patients, including 1,889 (40.6%) with shunt placement and 2,763 (59.4%) without. Age, race, and sex distributions were similar for both procedures. Compared to patients without shunt, those with shunt had significantly higher rates of emergency (9.1% vs 7.0%, P = .010) and non-elective surgery (40.3% vs 37.2%, P = .035), general anesthesia (97.0% vs 86.3%, P < .001), and bleeding disorders (27.2% vs 22.7%, P < .001). Thirty-day incidence of postoperative stroke was similar between patients who had shunt placement (3.2%) and those who did not (2.6%) (P = .219). Additionally, subgroup analysis failed to show any benefit of shunting on postoperative stroke regardless of preoperative symptoms or neurologic disability. In contrast, shunt placement was associated with increased rate of cranial nerve injury (4.1% vs 2.4%, P = .001). Multivariate analysis revealed that non-elective surgery (OR 1.99, 95% CI 1.36-2.91, P < .001) and DS (vs TIA/AF/TMB) (OR 1.64, 95% CI 1.12-2.41, P = .012) were predictive of 30-day postoperative stroke. After adjusting for confounders, shunt placement had no effect on stroke risk at 30 days but remained an independent risk factor for cranial nerve injury (aOR 1.87, 95% CI 1.32-2.64, P < .001). CONCLUSIONS In symptomatic patients undergoing CEA with patch angioplasty, shunting is associated with increased risk of cranial nerve injury without reduction in postoperative stroke risk.
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Affiliation(s)
- Antoine J Ribieras
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Marwan Tabbara
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Jorge Rey
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Omaida C Velazquez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Arash Bornak
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
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White CJ, Brott TG, Gray WA, Heck D, Jovin T, Lyden SP, Metzger DC, Rosenfield K, Roubin G, Sachar R, Siddiqui A. Carotid Artery Stenting. J Am Coll Cardiol 2022; 80:155-170. [DOI: 10.1016/j.jacc.2022.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022]
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Jaillant N, Thibouw F, Loucou JD, Pouhin A, Kazandjian C, Steinmetz E. A prospective survey of the incidence of cranial and cervical nerve injuries after carotid surgery. Ann Vasc Surg 2022; 87:380-387. [PMID: 35395376 DOI: 10.1016/j.avsg.2022.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/21/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To prospectively evaluate the involvement of the cranial nerves and cervical plexus branches during carotid surgery and to look for risk factors. METHODS All patients (n = 50) undergoing carotid endarterectomy between June 1st and October 31st, 2016 in our center were evaluated prospectively. A complete neurological examination was done before the intervention then daily until hospital discharge, and then at 2 months, 6 months and one year. A nasal endoscopy was systematically performed postoperatively before discharge by an ENT specialist. RESULTS Twenty-six patients (52%) had at least one damaged nerve immediately after surgery. There were 15 cases involving the VII nerve (30%), 12 the C2-C3 branches (24%), 7 the XII nerve (14%), and 2 the X nerve (4%). At 2 months, 6 months, and 1 year, 22%, 16%, and 8% of lesions remained, respectively. We found no independent factor for nerve damage at 6 months or 1 year. In case of dysphonia and/or dysphagia without recurrent nerve paralysis, six hematomas and seven laryngeal edemas were identified under nasal endoscopy and all healed without sequelae. CONCLUSIONS This prospective study showed cranial and cervical nerve injury to be much more frequent than expected in the short term, when assessed by independent ENT and nasal endoscopy exam. Though mainly transient, these lesions can cause post-operative functional discomfort and must be disclosed preoperatively to the patient, in view of the judicialization of health care.
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Affiliation(s)
- Noémie Jaillant
- Division of Vascular Surgery, Reunion University Hospital, Reunion, France.
| | | | - Julien Die Loucou
- Division of Vascular Surgery, Dijon University Hospital, Dijon, France
| | - Alexandre Pouhin
- Division of Vascular Surgery, Dijon University Hospital, Dijon, France
| | | | - Eric Steinmetz
- Division of Vascular Surgery, Dijon University Hospital, Dijon, France
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8
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Panagides V, Kalavrouziotis D, Dumont E, Delarochellière R, Paradis JM, Mesnier J, Mohammadi S, Rodés-Cabau J. Cranial nerve injury during transcarotid transcatheter aortic valve replacement. Int J Cardiol 2022; 353:46-48. [PMID: 35114203 DOI: 10.1016/j.ijcard.2022.01.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND No data exist about cranial nerve injury (CNI) as a potential complication of transcarotid (TC) transcatheter valve replacement (TAVR). METHODS This monocentric study included 318 consecutive patients undergoing TC-TAVR from May 2015 to August 2021. RESULTS CNI occurred in 7 (2.2%) TAVR-TC patients. Five out of the 7 patients (71.4%) had an injury of the laryngeal branch of the vagus nerve, and 2 patients (28.6%) had an injury of the facial nerve. The majority of patients were male (85.7%), with high body mass index (35.6 (IQR: 30.1-37.3) kg/m2). The induced disabilities were clinically important especially for patients with dysphonia. CONCLUSIONS CNI is a potential complication of TC-TAVR likely avoidable by a meticulous surgical technique. Structural heart teams must be aware of this serious setback.
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Affiliation(s)
- Vassili Panagides
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | | | - Eric Dumont
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | | | | | - Jules Mesnier
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | - Siamak Mohammadi
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada.
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Matsumura JS, Hanlon BM, Rosenfield K, Voeks JH, Howard G, Roubin GS, Brott TG. Treatment of carotid stenosis in asymptomatic, non-octogenarian, standard risk patients with stenting versus endarterectomy trials. J Vasc Surg 2021; 75:1276-1283.e1. [PMID: 34695552 DOI: 10.1016/j.jvs.2021.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Asymptomatic carotid stenosis is the most frequent indication for carotid endarterectomy (CEA) in the United States. Published trials and guidelines support CEA indications in selected patients with longer projected survival and when periprocedural complications are low. Transfemoral carotid artery stenting with embolic protection (CAS) is a newer treatment option. The objective of this study was to compare outcomes in asymptomatic, nonoctogenarian patients treated with CAS vs CEA. METHODS Patient-level data was analyzed from 2544 subjects with ≥70% asymptomatic carotid stenosis who were randomized to CAS or CEA in addition to standard medical therapy. One trial enrolled 1091 (548 CAS, 543 CEA) and another enrolled 1453 (1089 CAS, 364 CEA) asymptomatic patients less than 80 years old (upper age eligibility). Independent neurologic assessment and routine cardiac enzyme screening were performed. The prespecified, primary composite endpoint was any stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke within 4 years after randomization. RESULTS There was no significant difference in the primary endpoint between CAS and CEA (5.3% vs 5.1%; hazard ratio, 1.02; 95% confidence interval, 0.7-1.5; P = .91). Periprocedural rates for the components are (CAS vs CEA): any stroke (2.7% vs 1.5%; P = .07), myocardial infarction (0.6% vs 1.7%; P = .01), death (0.1% vs 0.2%; P = .62), and any stroke or death (2.7% vs 1.6%; P = .07). After this period, the rates of ipsilateral stroke were similar (2.3% vs 2.2%; P = .97). CONCLUSIONS In a pooled analysis of two large randomized trials of CAS and CEA in asymptomatic, nonoctogenarian patients, CAS achieves comparable short- and long-term results to CEA.
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Affiliation(s)
- Jon S Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.
| | - Bret M Hanlon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | | | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Ala
| | - Gary S Roubin
- Cardiovascular Associates of the Southeast, Birmingham, Ala
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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11
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Heck D, Jost A. Carotid stenosis, stroke, and carotid artery revascularization. Prog Cardiovasc Dis 2021; 65:49-54. [PMID: 33744381 DOI: 10.1016/j.pcad.2021.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 03/13/2021] [Indexed: 12/28/2022]
Abstract
Atherosclerotic disease of the carotid artery places patients at risk of ischemic stroke and consequently is a target of medical, endovascular and open surgical management. Various imaging modalities are used to characterize anatomy/severity of carotid disease and justify intervention, each having advantages and disadvantages. Carotid revascularization techniques including carotid artery stenting, carotid endarterectomy, and transcarotid artery revascularization vary in invasiveness and are not equally suitable for certain subsets of patients. As such, providing quality care for patients with carotid disease requires a multidisciplinary team of experts in clinical diagnosis, image interpretation, medical management, endovascular intervention, and surgical treatment.
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Affiliation(s)
- Don Heck
- Triad Radiology Associates, Novant Health Forsyth Medical Center, Winston Salem, NC, United States of America.
| | - Alec Jost
- Wake Forest University School of Medicine, Winston Salem, NC, United States of America
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12
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Heck D, Jost A, Howard G. Stenting the carotid artery from radial access using a Simmons guide catheter. J Neurointerv Surg 2021; 14:169-173. [PMID: 33632887 DOI: 10.1136/neurintsurg-2020-017143] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/01/2021] [Accepted: 01/04/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) is a procedure for stroke prevention, usually done from femoral artery access. Reports of CAS using radial artery access have adopted techniques similar to those used for transfemoral CAS. Initial experience with a simpler and lower profile technique for transradial carotid stenting is described here. METHODS Of 55 consecutive elective CAS cases with standard (not bovine) arch anatomy performed during a 15 month time period by the same operator, 20 were selected for transradial treatment using a 6 F Simmons 2 guide catheter. This was a retrospective analysis of those initial 20 patients compared with the 35 patients treated with elective transfemoral CAS. The CAS database was reviewed for clinical indications, technique, procedure and fluoroscopy times, and clinical outcomes. RESULTS All procedures were technically successful (no crossovers). No patient had a decline in National Institutes of Health Stroke Scale score or modified Rankin Scale score within 30 days. Mean (95% CI) procedural times for transradial CAS were slightly higher than transfemoral CAS (29.4 (26.0 to 32.7) vs 23.8 (21.2 to 26.4) min, p=0.0098). Mean (95% CI) fluoroscopy times were also higher for transradial CAS compared with transfemoral CAS (9.6 (8.0 to 11.2) vs 6.4 (5.4 to 7.4), p=0.0006). One patient developed a radial artery pseudoaneurysm which required elective surgical repair. CONCLUSION Transradial carotid stenting using the described lower profile technique provides another effective option in the array of surgical procedures for the treatment of carotid artery stenosis. Relative procedural and fluoroscopy times may initially be longer compared with transfemoral carotid stenting for experienced CAS operators, although absolute differences are small.
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Affiliation(s)
- Don Heck
- Radiology, Triad Radiology Associates, Novant Health Forsyth Medical Center, Winston-Salem, North Carolina, USA
| | - Alec Jost
- Wake Forest School of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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13
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Malas MB, Dakour-Aridi H, Kashyap VS, Eldrup-Jorgensen J, Wang GJ, Motaganahalli RL, Cronenwett JL, Schermerhorn ML. TransCarotid Revascularization with Dynamic Flow reversal versus Carotid Endarterectomy in the Vascular Quality Initiative Surveillance Project. Ann Surg 2020; 276:398-403. [DOI: 10.1097/sla.0000000000004496] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Lukyanchikov VA, Khasauov RK, Kordonskaya OO, Dalibaldyan VA, Senko IV. [Endoscopy-assisted surgical treatment of carotid artery kinking]. Khirurgiia (Mosk) 2020:13-20. [PMID: 32105251 DOI: 10.17116/hirurgia202002113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the results of endoscopy-assisted surgical treatment of patients with 'high' tortuosity of the ICA. MATERIAL AND METHODS Endoscopy-assisted surgical reconstruction of high tortuosity of the ICA was made in 11 patients. All procedures were carried out at the Sklifosofsky Research Institute for Emergency Medicine (Moscow) and Republican clinical hospital of Kabardino-Balkaria (Nalchik) for the period from 01.01.18 to 31.12.18. RESULTS There were no intraoperative and postoperative complications (blood flow velocity increased by 66.2% after surgery). Neurological improvement after surgery was noted in all patients. Partial or complete regression of dizziness was observed in 5 (45.5%) patients. Tinnitus disappeared in 7 (63.6%) patients. CONCLUSION Approach to the distal parts of ICA is traumatic, requires the use of additional techniques and considerable surgical experience. Endoscopic technique is valuable to reduce the risk of injury of soft tissues, neurovascular structures and improve functional outcomes.
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Affiliation(s)
- V A Lukyanchikov
- Sklifosovsky Research Institute for Emergency Medicine of the Moscow Healthcare Department, Moscow, Russia
| | - R Kh Khasauov
- Republican Clinical Hospital of the Ministry of Health of the Kabardino-Balkarian Republic, Nalchik, Russia
| | - O O Kordonskaya
- Sklifosovsky Research Institute for Emergency Medicine of the Moscow Healthcare Department, Moscow, Russia
| | - V A Dalibaldyan
- Republican Clinical Hospital of the Ministry of Health of the Kabardino-Balkarian Republic, Nalchik, Russia; Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of Russia, Moscow, Russia
| | - I V Senko
- Sklifosovsky Research Institute for Emergency Medicine of the Moscow Healthcare Department, Moscow, Russia
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Surgery for posterior fossa meningioma: elevated postoperative cranial nerve morbidity discards aggressive tumor resection policy. Neurosurg Rev 2020; 44:953-959. [PMID: 32107680 DOI: 10.1007/s10143-020-01275-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/28/2020] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Abstract
Radical excision of meningioma is suggested to provide for the best tumor control rates. However, aggressive surgery for meningiomas located at the posterior cranial fossa may lead to elevated postoperative morbidity of adjacent cranial nerves which in turn worsens patients' postoperative quality of life. Therefore, we analyzed our institutional database with regard to new cranial nerve dysfunction as well as postoperative cerebrospinal fluid (CSF) leakage depending on the extent of tumor resection. Between 2009 and 2017, 89 patients were surgically treated for posterior fossa meningioma at the authors' institution. Postoperative new cranial nerve dysfunction as well as CSF leakage were stratified into Simpson grade I resections with excision of the adjacent dura as an aggressive resection regime versus Simpson grade II-IV tumor removal. Simpson grade I resections revealed a significantly higher percentage of new cranial nerve dysfunction immediately after surgery (39%) compared with Simpson grade II (11%, p = 0.01) and Simpson grade II-IV resections (14%, p = 0.02). These observed differences were also present for the 12-month follow-up (27% Simpson grade I, 3% Simpson grade II (p = 0.004), 7% Simpson grades II-IV (p = 0.01)). Postoperative CSF leakage was present in 21% of Simpson grade I and 3% of Simpson grade II resections (p = 0.04). Retreatment rates did not significantly differ between these two groups (6% versus 8% (p = 1.0)). Elevated levels of postoperative new cranial nerve deficits as well as CSF leakage following radical tumor removal strongly suggest a less aggressive resection policy to constitute the surgical modality of choice for posterior cranial fossa meningiomas.
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16
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Anesthesia Type is Associated with Decreased Cranial Nerve Injury in Carotid Endarterectomy. Ann Vasc Surg 2020; 70:318-325. [PMID: 31917229 DOI: 10.1016/j.avsg.2019.12.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/30/2019] [Accepted: 12/19/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Anesthesia modalities for carotid endarterectomy continue to vary nationally. We evaluated and compared short-term outcomes after carotid endarterectomy with general anesthesia (GA) and regional anesthesia (RA) in both symptomatic and asymptomatic patients. METHODS The 2011-2015 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files (PUFs) with merged Vascular Procedure-Targeted PUFs for carotid endarterectomy were queried for patients undergoing carotid endarterectomy. Postoperative complications, mortality, and hospital length of stay in patients undergoing GA or RA were compared. RESULTS A total of 14,447 patients were evaluated: 12,389 (85.7%) with GA and 2,058 (14.3%) with RA. The use of GA was inversely associated with patients' age (88.0% in patients aged 22-64 years vs. 83.4% in patients aged ≥80 years, P < 0.0001) and with symptomatic presentation (odds ratio [OR] = 1.25; 95% confidence interval [CI]: 1.13-1.38). There were no differences between GA and RA for in-hospital mortality, 30-day mortality, or postoperative complications of transient ischemic attack, stroke, bleeding, acute renal failure, or restenosis. However, rates of cranial nerve injury were significantly higher in GA than in RA (2.9% vs. 1.7%, respectively; P < 0.002) and confirmed by multivariable analysis (OR = 1.68; 95% CI: 1.19-2.39). Total operative time was also longer for GA than for RA (median: 115 minutes; Interquartile range (IQR): 89-145 versus median: 93 minutes; IQR: 76-119, respectively; P < 0.0001). Hospital length of stay was greater in GA than in RA (median: 1 day; IQR 1-2 vs. median: 1 day; IQR 1-1, respectively; P < 0.0001), as were 30-day readmission rates (6.7% vs. 5.4%, respectively; P = 0.02). CONCLUSIONS Iatrogenic nerve injury is a feared complication of carotid endarterectomy, especially in elective asymptomatic patients. RA reduces the rate of cranial nerve injury compared with GA. RA is also not inferior to GA for postoperative complications with the benefit of shorter operative times, lengths of hospital stay, and decreased 30-day readmission rates. Consideration should be given to more widespread adoption of this underused anesthesia modality.
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17
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High Mib-1-score correlates with new cranial nerve deficits after surgery for frontal skull base meningioma. Neurosurg Rev 2019; 44:381-387. [PMID: 31834543 DOI: 10.1007/s10143-019-01222-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/01/2019] [Accepted: 12/06/2019] [Indexed: 12/13/2022]
Abstract
Postoperative new cranial nerve deficits comprise severe concomitant morbidity in skull base meningioma surgery. Therefore, long-term cranial nerve integrity represents an important outcome measure. In the current study, we analyzed our institutional database in order to identify risk factors for postoperative new cranial nerve morbidity in the course of frontobasal meningioma surgery. Between 2009 and 2017, 195 patients were surgically treated for frontobasal meningioma at the authors' institution. Postoperative cranial nerve function was assessed immediately after surgery as well as 12 months postoperatively. A univariate and multivariate analysis was performed to identify factors influencing favorable postoperative cranial nerve outcome. Tumors with histological Mib-1-labeling indices > 5% were associated with a significantly higher percentage of new cranial nerve deficits immediately after surgery compared with those with Mib-1-labeling indices ≤ 5% (39% versus 20%, p = 0.029). Elevated Mib-1-labeling indices could be correlated with high CD68-positive macrophage staining (54% for Mib-1 index > 5% versus 19% for Mib-1 index ≤ 5%, p = 0.001). Elevated Mib-1-labeling index correlates with initial new cranial nerve dysfunction after resection of frontal skull base meningioma. With regard to elevated CD68-positive macrophage staining in high Mib-1-positive meningiomas, initial postoperative new cranial nerve morbidity might partly reflect macrophage-based inflammatory immune responses.
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Batchelder AJ, Saratzis A, Ross Naylor A. Editor's Choice - Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2019; 58:479-493. [PMID: 31492510 DOI: 10.1016/j.ejvs.2019.06.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 05/30/2019] [Accepted: 06/05/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this review was to carry out primary and secondary analyses of 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). METHODS A systematic review and meta-analysis of data from 20 RCTs (126 publications) was carried out. RESULTS Compared with CEA, the 30 day death/stroke rate was significantly higher after CAS in seven RCTs involving 3467 asymptomatic patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.02-2.64) and in 10 RCTs involving 5797 symptomatic patients (OR 1.71, 95% CI 1.38-2.11). Excluding procedural risks, late ipsilateral stroke was about 4% at 9 years for both CEA and CAS, i.e., CAS was durable. Reducing procedural death/stroke after CAS may be achieved through better case selection, e.g., performing CEA in (i) symptomatic patients aged > 70 years; (ii) interventions within 14 days of symptom onset; and (iii) situations where stroke risk after CAS is predicted to be higher (segmental/remote plaques, plaque length > 13 mm, heavy burden of white matter lesions [WMLs], where two or more stents might be needed). New WMLs were significantly more common after CAS (52% vs. 17%) and were associated with higher rates of late stroke/transient ischaemic attack (23% vs. 9%), but there was no evidence that new WMLs predisposed towards late cognitive impairment. Restenoses were more common after CAS (10%) but did not increase late ipsilateral stroke. Restenoses (70%-99%) after CEA were associated with a small but significant increase in late ipsilateral stroke (OR 3.87, 95% CI 1.96-7.67; p < .001). CONCLUSIONS CAS confers higher rates of 30 day death/stroke than CEA. After 30 days, ipsilateral stroke is virtually identical for CEA and CAS. Key issues to be resolved include the following: (i) Will newer stent technologies and improved cerebral protection allow CAS to be performed < 14 days after symptom onset with risks similar to CEA? (ii) What is the optimal volume of CAS procedures to maintain competency? (iii) How to deliver better risk factor control and best medical treatment? (iv) Is there a role for CEA/CAS in preventing/reversing cognitive impairment?
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Affiliation(s)
| | | | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
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19
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Ettorre L, Giovannacci L, van den Berg JC. Clinical and surrogate endpoints in future studies on outcome of carotid revascularization. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:325-331. [PMID: 30827085 DOI: 10.23736/s0021-9509.19.10910-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This paper will provide a comparison of classical endpoints like stroke and mortality versus biochemical (non-STEMI) myocardial infarction and DW-MRI new brain lesions and will discuss the importance of cranial nerve lesion in CEA. An overview of possible endpoints of future randomized clinical trials will be given.
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Affiliation(s)
- Ludovica Ettorre
- Service of Vascular Surgery, Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano, Switzerland
| | - Luca Giovannacci
- Service of Vascular Surgery, Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano, Switzerland
| | - Jos C van den Berg
- Service of Interventional Radiology, Centro Vascolare Ticino, Ospedale Regionale di Lugano, sede Civico, Lugano, Switzerland - .,Inselspital, Universitätsspital Bern Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Bern, Switzerland
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20
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Jiang Q, Lin T, Qu L. Predictors of Health-Related Quality of Life for Mental Health Status in Patients After Carotid Endarterectomy. World Neurosurg 2019; 126:e379-e384. [PMID: 30822584 DOI: 10.1016/j.wneu.2019.02.060] [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: 12/18/2018] [Revised: 02/15/2019] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the health-related quality of life (HRQoL) in patients with carotid stenosis and identify the predictive factors that affect the mental health status in patients after carotid endarterectomy (CEA). METHODS A retrospective study was conducted of all patients presenting with carotid stenosis treated with CEA. Clinical data and demographics were collected for logistic regression analysis. The Short-Form General Health Survey Questionnaire (SF-36) and minimum clinically important difference were used to evaluate the mental health status of patients after CEA. RESULTS Between January 2015 and September 2017, a total of 224 patients were enrolled in this study. At baseline, mean SF-36 scores for physical component summary (PCS) (60.1 ± 26.3) and mental component summary (MCS) (59.9 ± 23.1) were significantly lower in patients with carotid disease than the urban population (P < 0.001). After CEA, the SF-36 scores for PCS (62.5 ± 21.7) and MCS (68.4 ± 18.7) were increased. However, only the improvement of MCS achieved minimum clinically important difference. After multiple logistic regression analysis, contralateral stenosis ≥50% (odds ratio [OR] 0.266, 95% confidence interval [CI] 0.141-0.517) and hoarseness (OR 0.160, 95% CI 0.040-0.644) had negative effects on MCS. Dizziness improvement had positive effects on MCS (OR 2.882, 95% CI 1.569-5.298). CONCLUSIONS Contralateral stenosis, dizziness improvement, and hoarseness may be the predictive factors that affect the mental health status in patients after CEA.
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Affiliation(s)
- Qingjun Jiang
- Department of Vascular and Endovascular Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Tao Lin
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lefeng Qu
- Department of Vascular and Endovascular Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China.
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21
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Schneider M, Schuss P, Güresir Á, Wach J, Hamed M, Vatter H, Güresir E. Cranial Nerve Outcomes After Surgery for Frontal Skull Base Meningiomas: The Eternal Quest of the Maximum-Safe Resection with the Lowest Morbidity. World Neurosurg 2019; 125:e790-e796. [PMID: 30738945 DOI: 10.1016/j.wneu.2019.01.171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/16/2019] [Accepted: 01/19/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Maximal aggressive meningioma resection has been suggested to provide the best tumor control rates. However, radical surgery of meningiomas located at the frontal skull base can be accompanied by impairment of adjacent cranial nerve function that negatively affects patients' quality of life. We, therefore, analyzed our institutional database for cases of new cranial nerve deficits and postoperative cerebrospinal fluid (CSF) leakage stratified by the extent of tumor resection. METHODS From February 2009 to April 2017, 195 patients underwent resection of frontal skull base meningioma at our institution. Postoperative new deficits of cranial nerve function and CSF leakage were stratified by the resection into Simpson grade I resection with excision of the dural tail as an aggressive surgical approach and Simpson grade II-V resection. RESULTS Simpson grade I resection was associated with a significantly greater percentage of new cranial nerve deficits immediately after surgery (30%) compared with Simpson grade II (13%; P = 0.007) and Simpson grade II-V (17%; P = 0.035). The differences were greater at the 12-month follow-up point (29% Simpson grade I, 6% Simpson grade II [P < 0.001]; 10% Simpson grade II-V [P = 0.001]). Postoperative CSF leakage occurred in 10.1% of Simpson grade I versus 2.3% of Simpson grade II resections (P = 0.048). The retreatment rates did not differ between these 2 groups (2.5% vs. 3.4%; P = 1.000). CONCLUSIONS We found high levels of new cranial nerve morbidity and CSF leakage after radical removal of frontal skull base meningiomas that included the adjacent dura. Thus, less aggressive surgery for frontobasal meningioma should be preferred.
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Affiliation(s)
- Matthias Schneider
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany.
| | - Patrick Schuss
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Ági Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Johannes Wach
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Motaz Hamed
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
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22
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Karthaus EG, Vahl A, Kuhrij LS, Elsman BHP, Geelkerken RH, Wouters MWJM, Hamming JF, de Borst GJ. The Dutch Audit of Carotid Interventions: Transparency in Quality of Carotid Endarterectomy in Symptomatic Patients in the Netherlands. Eur J Vasc Endovasc Surg 2018; 56:476-485. [PMID: 30077438 DOI: 10.1016/j.ejvs.2018.05.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/31/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Dutch Audit for Carotid Interventions (DACI) registers all patients undergoing interventions for carotid artery stenosis in the Netherlands. This study describes the design of the DACI and results of patients with a symptomatic stenosis undergoing carotid endarterectomy (CEA). It aimed to evaluate variation between hospitals in process of care and (adjusted) outcomes, as well as predictors of major stroke/death after CEA. METHODS All patients with a symptomatic stenosis, who underwent CEA and were registered in the DACI between 2014 and 2016 were included in this cohort. Descriptive analyses of patient characteristics, process of care, and outcomes were performed. Casemix adjusted hospital procedural outcomes as (30 day/in hospital) mortality, stroke/death, and major stroke/death, were compared with the national mean. A multivariable logistic regression model (backward elimination at p > 0.10) was used to identify predictors of major stroke/death. RESULTS A total of 6459 patients, registered by 52 hospitals, were included. The majority (4,832, 75%) were treated <2 weeks after their first hospital consultation, varying from 40% to 93% between hospitals. Mortality, stroke/death, and major stroke/death were, respectively, 1.1%, 3.6%, and 1.8%. Adjusted major stroke/death rates for hospital comparison varied between 0 and 6.5%. Nine hospitals performed significantly better, none performed significantly worse. Predictors of major stroke/death were sex, age, pulmonary disease, presenting neurological symptoms, and peri-operative shunt. CONCLUSION CEA in The Netherlands is associated with an overall low mortality and (major) stroke/death rate. Whereas the indicator time to intervention varied between hospitals, mortality and (major) stroke/death were not significantly distinctive enough to identify worse practices and therefore were unsuitable for hospital comparison in the Dutch setting. Additionally, predictors of major stroke/death at population level could be identified.
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Affiliation(s)
- Eleonora G Karthaus
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands; Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Anco Vahl
- Department of Surgery, OLVG, Amsterdam, The Netherlands; Department of Clinical Epidemiology, OLVG, Amsterdam, The Netherlands
| | - Laurien S Kuhrij
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Robert H Geelkerken
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands; Faculty of Technical Sciences, University of Twente, Enschede, The Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands; Department of Surgery, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Kim JS, Ko JS, Bang S, Kim H, Lee SY. Cervical plexus block. Korean J Anesthesiol 2018; 71:274-288. [PMID: 29969890 PMCID: PMC6078883 DOI: 10.4097/kja.d.18.00143] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/24/2018] [Indexed: 12/14/2022] Open
Abstract
Cervical plexus blocks (CPBs) have been used in various head and neck surgeries to provide adequate anesthesia and/or analgesia; however, the block is performed in a narrow space in the region of the neck that contains many sensitive structures, multiple fascial layers, and complicated innervation. Since the intermediate CPB was introduced in addition to superficial and deep CPBs in 2004, there has been some confusion regarding the nomenclature and definition of CPBs, particularly the intermediate CPB. Additionally, as the role of ultrasound in the head and neck region has expanded, CPBs can be performed more safely and accurately under ultrasound guidance. In this review, the authors will describe the methods, including ultrasound-guided techniques, and clinical applications of conventional deep and superficial CPBs; in addition, the authors will discuss the controversial issues regarding intermediate CPBs, including nomenclature and associated potential adverse effects that may often be neglected, focusing on the anatomy of the cervical fascial layers and cervical plexus. Finally, the authors will attempt to refine the classification of CPB methods based on the target compartments, which can be easily identified under ultrasound guidance, with consideration of the effects of each method of CPB.
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Affiliation(s)
- Jin-Soo Kim
- Department of Anesthesiology and Pain Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Justin Sangwook Ko
- Depatment of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine,, Seoul, Korea
| | - Seunguk Bang
- Depatment of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Sook Young Lee
- Department of Anesthesiology and Pain Medicine, Ajou University College of Medicine, Suwon, Korea
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24
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Jones DW, Brott TG, Schermerhorn ML. Trials and Frontiers in Carotid Endarterectomy and Stenting. Stroke 2018; 49:1776-1783. [PMID: 29866753 DOI: 10.1161/strokeaha.117.019496] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Douglas W Jones
- From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, MA (D.W.J.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.L.S.).
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Fadrná T, Mikšová Z, Herzig R, Langová K, Ličman L, Školoudík D. Factors influencing quality of life in patients followed in the neurosonology laboratory for carotid stenosis. Health Qual Life Outcomes 2018; 16:79. [PMID: 29703211 PMCID: PMC5923016 DOI: 10.1186/s12955-018-0902-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/16/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Quality of life (QoL) is one of the main endpoints in stroke prevention or acute stroke treatment studies. The aim of the current study was to identify risk factors affecting the QoL of patients with carotid stenosis in stroke prevention. METHODS Self-sufficient patients (50-80 years of age) with ≥20% carotid artery stenosis followed in the neurosonology laboratory, and without any severe illnesses within the last 12 months, dementia, or psychiatric disorders were selected for the study after signing informed consent. Patients completed two standardized QoL questionnaires (WHOQoL-BREF and EQ-5D-3 L) and a visual pain scale, provided covariate variables (medication, age, gender, education, and social situation), and the blood pressure and body mass indexes were recorded. Logistic regression (forward stepwise method) was used to identify factors affecting the individual domains of QoL questionnaires. RESULTS Of the 584 consecutive patients, 502 met the inclusion criteria and 344 completely filled both QoL questionnaires (164 men; mean age, 69.7 ± 7.8 years). An independent predictor of worse QoL in all domains was pain. Independent factors decreasing the QoL were lower level of education and blood pressure in the physical health domain, female gender in the psychological domain, and male gender in the social relationships domain. Independent factors decreasing satisfaction with health status were female gender and higher blood pressure. Factors negatively influencing the satisfaction with the QoL were living alone, lower level of education, and higher diastolic blood pressure (WHOQoL-BREF). Factors negatively influencing mobility were age, male gender, living alone, lower level of education, and higher body mass index (EQ-5D-3 L; p < 0.05 in all cases). CONCLUSIONS Pain, blood pressure, body mass index, education, living alone, gender, and age were associated with the QoL in patients with carotid stenosis. TRIAL REGISTRATION ClinicalTrials.gov, NCT02360137 . Registered on 26 January 2015.
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Affiliation(s)
- Táňa Fadrná
- Department of Nursing, Faculty of Health Sciences, Palacký University Olomouc, Olomouc, Czech Republic
| | - Zdeňka Mikšová
- Department of Nursing, Faculty of Health Sciences, Palacký University Olomouc, Olomouc, Czech Republic
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Center, Charles University Faculty of Medicine and University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Kateřina Langová
- Center for Science and Research, Department of Nursing, Faculty of Health Sciences, Palacký University Olomouc, Hněvotínská 3, CZ-775 15, Olomouc, Czech Republic.,Department of Biophysics, Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, Palacký University, Olomouc, Czech Republic
| | - Libor Ličman
- Department of Biophysics, Faculty of Medicine and Dentistry, Institute of Molecular and Translational Medicine, Palacký University, Olomouc, Czech Republic
| | - David Školoudík
- Center for Science and Research, Department of Nursing, Faculty of Health Sciences, Palacký University Olomouc, Hněvotínská 3, CZ-775 15, Olomouc, Czech Republic.
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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: 789] [Impact Index Per Article: 131.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Chabowski M, Grzebien A, Ziomek A, Dorobisz K, Leśniak M, Janczak D. Quality of life after carotid endarterectomy: a review of the literature. Acta Neurol Belg 2017. [PMID: 28639143 PMCID: PMC5670192 DOI: 10.1007/s13760-017-0811-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Strokes are one of the leading causes of death, morbidity, and disability worldwide, mainly among elderly people. It is also the third most common cause of years of life being lost, indicating a high risk of premature mortality. Revascularisation with endarterectomy (CEA) is effective in reducing the risk of death and strokes in patients with carotid artery stenosis, but the effect of invasive treatment on quality of life (QoL) still needs attention. To shed more light on the patients’ perspective on this health condition, we carried out a review of the literature which aimed to analyze the level of health-related QoL among stroke survivors, with special attention to patients who had been treated with CEA. Strokes significantly reduce the level of QoL, which may subsequently be improved in the course of treatment with CEA. Patients experience a reduced level of QoL in the early postoperative period, but at 1 year following CEA, the level of QoL remains stable and is similar to that of chronically ill patients. The domains of QoL which are most affected are physical and emotional functioning, which also serve as markers for decreased QoL in the long term. Older age and comorbidities are predictors of worse QoL. Stroke survivors require proper care both immediately after a stroke happens and during the long-term rehabilitation. Measurement of QoL and of the determining factors that contribute to a reduced level of QoL, as well as focusing on determinants of QoL in stroke survivors may help to reduce patients’ disability and improve their daily functioning in society as well as reducing the cost of health care.
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Affiliation(s)
- Mariusz Chabowski
- Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, 5 Bartla Street, 51-618, Wroclaw, Poland.
- Department of Surgery, 4th Military Teaching Hospital, 5 Weigla Street, 50-981, Wroclaw, Poland.
| | - Anna Grzebien
- Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, 5 Bartla Street, 51-618, Wroclaw, Poland
- Department of General and Vascular Surgery, Research and Development Centre, Voivodship Specialist Hospital in Wroclaw, Wroclaw, Poland
| | - Agnieszka Ziomek
- Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, 5 Bartla Street, 51-618, Wroclaw, Poland
- Department of Surgery, 4th Military Teaching Hospital, 5 Weigla Street, 50-981, Wroclaw, Poland
| | - Karolina Dorobisz
- Department of Otolaryngology, Head and Neck Surgery, Wroclaw Medical University, 213 Borowska Street, 50-556, Wroclaw, Poland
| | - Michał Leśniak
- Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, 5 Bartla Street, 51-618, Wroclaw, Poland
- Department of Surgery, 4th Military Teaching Hospital, 5 Weigla Street, 50-981, Wroclaw, Poland
| | - Dariusz Janczak
- Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, 5 Bartla Street, 51-618, Wroclaw, Poland
- Department of Surgery, 4th Military Teaching Hospital, 5 Weigla Street, 50-981, Wroclaw, Poland
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Gavrilenko AV, Kravchenko AA, Kuklin AV, Fomina VV. [Prediction and risk factors of perioperative neurological complications in patients with internal carotid artery stenosis]. Khirurgiia (Mosk) 2017:109-112. [PMID: 29076494 DOI: 10.17116/hirurgia201710109-112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- A V Gavrilenko
- Vascular Surgery Department of Petrovsky Russian Research Center of Surgery, Moscow, Russia; Sechenov First Moscow State Medical University of Healthcare Ministry of the Russian Federation, Moscow, Russia
| | - A A Kravchenko
- Vascular Surgery Department of Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - A V Kuklin
- Vascular Surgery Department of Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - V V Fomina
- Vascular Surgery Department of Petrovsky Russian Research Center of Surgery, Moscow, Russia
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Langhoff R. Carotid stenosis - basing treatment on individual patients' needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy. VASA 2017; 47:7-16. [PMID: 29064776 DOI: 10.1024/0301-1526/a000668] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Though carotid artery stenosis is a known origin of stroke, risk assessment and treatment modality are not yet satisfactorily established. Guideline updates according to latest evidence are expected shortly. Current clinical weakness concerns in particular the identification of "at-risk" patients. Beside the symptomatic status and the degree of stenosis, further signs of unstable plaque on carotid and cerebral imaging should be considered. Moreover, medical and endovascular therapy are continuously improving. Randomized trials and meta-analyses have shown similar long-term results for protected carotid artery stenting and endarterectomy. However, endovascular revascularization was associated with an increased 30-day rate of minor strokes. Newly developed embolic protection devices could possibly compensate for this disadvantage. Furthermore, high-level optimal medical therapy alone is currently being evaluated comparatively. We assume that a comprehensive evaluation of plaque vulnerability, serious consideration of advanced embolic protection, and more space for optimal medical therapy alone according to latest evidence, will benefit patients with carotid stenosis.
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Affiliation(s)
- Ralf Langhoff
- 1 Department of Angiology, Sankt Gertrauden-Krankenhaus, Berlin, Germany
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Kakkos SK, Kakisis I, Tsolakis IA, Geroulakos G. Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis. J Vasc Surg 2017; 66:607-617. [PMID: 28735954 DOI: 10.1016/j.jvs.2017.04.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/10/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is currently unclear if carotid artery stenting (CAS) is as safe as carotid endarterectomy (CEA) for patients with significant asymptomatic stenosis. The aim of our study was to perform a systematic review and meta-analysis of trials comparing CAS with CEA. METHODS On March 17, 2017, a search for randomized controlled trials was performed in MEDLINE and Scopus databases with no time limits. We performed meta-analyses with Peto odds ratios (ORs) and 95% confidence intervals (CIs). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation method. The primary safety and efficacy outcome measures were stroke or death rate at 30 days and ipsilateral stroke at 1 year (including ipsilateral stroke and death rate at 30 days), respectively. Perioperative stroke, ipsilateral stroke, myocardial infarction (MI), and cranial nerve injury (CNI) were all secondary outcome measures. RESULTS The systematic review of the literature identified nine randomized controlled trials reporting on 3709 patients allocated into CEA (n = 1479) or CAS (n = 2230). Stroke or death rate at 30 days was significantly higher for CAS (64/2176 [2.94%]) compared with CEA (27/1431 [1.89%]; OR, 1.57; 95% CI, 1.01-2.44; P = .044), with low level of heterogeneity beyond chance (I2 = 0%). Also, stroke rate at 30 days was significantly higher for CAS (63/2176 [2.90%]) than for CEA (26/1431 [1.82%]; OR, 1.63; 95% CI, 1.04-2.54; P = .032; I2 = 0%). MI at 30 days was nonsignificantly lower for CAS (12/1815 [0.66%]) compared with CEA (16/1070 [1.50%]; OR, 0.53; 95% CI, 0.24-1.14; P = .105; I2 = 0%); however, CNI at 30 days was significantly lower for CAS (2/1794 [0.11%]) than for CEA (33/1061 [3.21%]; OR, 0.13; 95% CI, 0.07-0.26; P < .00001; I2 = 0%). Regarding the long-term outcome of stroke or death rate at 30 days plus ipsilateral stroke during follow-up, this was significantly higher for CAS (79/2173 [3.64%]) than for CEA (35/1430 [2.45%]; OR, 1.51; 95% CI, 1.02-2.24; P = .04; I2 = 0%). Quality of evidence for all stroke outcomes was graded moderate. CONCLUSIONS Among patients with asymptomatic stenosis undergoing carotid intervention, there is moderate-quality evidence to suggest that CEA had significantly lower 30-day stroke and also stroke or death rates compared with CAS at the cost of higher CNI and nonsignificantly higher MI rates. The long-term efficacy of CEA in ipsilateral stroke prevention, taking into account perioperative stroke and death, was preserved during follow-up. There is an urgent need for high-quality research before a firm recommendation is made that CAS is inferior or not to CEA.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece; Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Ioannis Kakisis
- National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis A Tsolakis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - George Geroulakos
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; National and Kapodistrian University of Athens, Athens, Greece
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Safian RD. Carotid Artery Revascularization: The Known Knowns and the Known Unknowns. J Am Coll Cardiol 2017; 69:2276-2278. [PMID: 28473131 DOI: 10.1016/j.jacc.2017.03.014] [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: 02/27/2017] [Accepted: 03/06/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Robert D Safian
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan.
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Safian RD. Asymptomatic Carotid Artery Stenosis: Revascularization. Prog Cardiovasc Dis 2017; 59:591-600. [PMID: 28478115 DOI: 10.1016/j.pcad.2017.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 04/30/2017] [Indexed: 11/29/2022]
Abstract
In patients with carotid stenosis, the most common cause of stroke is atheroembolization, and the risk is strongly related to stenosis severity and symptomatic status (stroke or transient ischemic attack within 6months). Carotid revascularization by carotid endarterectomy (CEA) or carotid artery stenting (CAS) results in plaque "passivation" by lumen enlargement, plaque removal, or plaque coverage with subsequent endothelialization. While there is considerable circumstantial evidence linking a decrease in the risk of stroke to the use of "optimal medical therapy (OMT)", the components of OMT have not been defined, and such therapy has not been rigorously evaluated in any randomized clinical trial (RCT) compared with revascularization. Studies of other vascular patients suggest that statins decrease the risk of stroke by anti-inflammatory effects, rather than cholesterol reduction. The Carotid Revascularization Endarterectomy versus Stent Trial (CREST-2) is currently randomizing standard-risk patients with asymptomatic severe carotid stenosis to OMT alone versus OMT plus CEA or CAS, but results are not expected until 2020. In the meantime, data from several "landmark" trials of CEA versus aspirin demonstrated 45-65% reduction in the 5-year risk of stroke after CEA. Several RCTs demonstrate superiority of CAS over CEA in high-risk patients (those at high-risk for CEA), and equivalence of CAS and CEA in standard-risk patients (those at acceptable risk for CEA). Compared with CEA, CAS is associated with significantly less periprocedural myocardial infarction, cranial nerve injury, and neurological injury (cranial nerve injury plus stroke); higher risk of minor stroke; and similar risk of long-term stroke. Features that increase the risk of CAS include complex aortic arch and carotid anatomy, and features that increase the risk of CEA include severe underlying cardiopulmonary disease and hostile neck anatomy; age>80years, especially those with baseline cognitive impairment, are at higher risk for stroke after CEA and CAS.
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Affiliation(s)
- Robert D Safian
- Center for Innovation and Research in Cardiovascular Diseases, Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI.
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33
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Carotid Artery Stenting Versus Endarterectomy for Stroke Prevention. J Am Coll Cardiol 2017; 69:2266-2275. [DOI: 10.1016/j.jacc.2017.02.053] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 02/08/2017] [Accepted: 02/28/2017] [Indexed: 11/23/2022]
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34
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de Borst GJ. Commentary on "Cranial Nerve Injury After Carotid Endarterectomy: Incidence, Risk Factors, and Time Trends". Eur J Vasc Endovasc Surg 2017; 53:336. [PMID: 28153553 DOI: 10.1016/j.ejvs.2017.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
Affiliation(s)
- G J de Borst
- Department of Vascular Surgery, UMC Utrecht, Utrecht, The Netherlands.
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35
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Cranial Nerve Injury After Carotid Endarterectomy: Incidence, Risk Factors, and Time Trends. Eur J Vasc Endovasc Surg 2017; 53:320-335. [PMID: 28117240 DOI: 10.1016/j.ejvs.2016.12.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 12/12/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE/BACKGROUND To review the incidence of post-carotid endarterectomy (CEA) cranial nerve injury (CNI), and to evaluate the risk factors associated with increased CNI risk. METHODS The study was a meta-analysis. Pooled rates with 95% confidence intervals (CIs) were calculated for CNIs after primary CEA. Odds ratios (ORs) were calculated for potential risk factors. A fixed-effects model or a random effects model (Mantel-Haenszel method) was used for non-heterogeneous and heterogeneous data, respectively. Meta-regression analysis was performed to examine the influence of publication year upon CNI rate. RESULTS Twenty-six articles, published between 1970 and 2015, were included in the meta-analysis, corresponding to 20,860 CEAs. Meta-analysis revealed that the vagus nerve was the most frequently injured cranial nerve (pooled injury rate 3.99%, 95% CI 2.56-5.70), followed by the hypoglossal nerve (3.79%, 95% CI 2.73-4.99). Fewer than one seventh of these injuries are permanent (vagus nerve: 0.57% [95% CI 0.19-1.10]; hypoglossal nerve: 0.15% [95% CI 0.01-0.39]). A statistically significant influence of publication year on the vagus and hypoglossal nerve injury rate was found, with the injury rate having decreased from about 8% to 2% and 1%, respectively, over the last 35 years. Urgent procedures (OR 1.59, 95% CI 1.21-2.10; p = .001), as well as return to the operating room for a neurological event or bleeding (OR 2.21, 95% CI 1.35-3.61; p = .002) were associated with an increased risk of CNI, whereas no statistically significant association was found between CNIs and the type of anaesthesia, the use of a patch, redo operation, and the use of a shunt. CONCLUSION The vagus nerve appears to be the most frequently injured cranial nerve after CEA, followed by the hypoglossal nerve, with only a small proportion of these injuries being permanent. The CNI rate has significantly decreased over the past 35 years to a point indicating that CNIs should not be considered a major influencing factor in the decision making process between CEA and stenting.
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36
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Sheth KN, Nourollahzadeh E. Neurologic complications of cardiac and vascular surgery. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:573-592. [PMID: 28190436 DOI: 10.1016/b978-0-444-63599-0.00031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This chapter will provide an overview of the major neurologic complications of common cardiac and vascular surgeries, such as coronary artery bypass grafting and carotid endarterectomy. Neurologic complications after cardiac and vascular surgeries can cause significant morbidity and mortality, which can negate the beneficial effects of the intervention. Some of the complications to be discussed include ischemic and hemorrhagic stroke, seizures, delirium, cognitive dysfunction, cerebral hyperperfusion syndrome, cranial nerve injuries, and peripheral neuropathies. The severity of these complications can range from mild to lethal. The etiology of complications can include a variety of mechanisms, which can differ based on the type of cardiac or vascular surgery that is performed. Our knowledge about neuropathology, prevention, and management of surgical complications is growing and will be discussed in this chapter. It is imperative for clinicians to be familiar with these complications in order to narrow the differential diagnosis, start early management, anticipate the natural history, and improve outcomes.
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Affiliation(s)
- K N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.
| | - E Nourollahzadeh
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA
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37
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Hye RJ, Longson S, Brott TG. Reply. J Vasc Surg 2016; 64:1188-9. [PMID: 27666453 DOI: 10.1016/j.jvs.2016.05.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 05/23/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Robert J Hye
- Department of Vascular Surgery, Kaiser Permanente, San Diego, Calif
| | - Sonni Longson
- Department of Vascular Surgery, Kaiser Permanente, San Diego, Calif
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38
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Yip HK, Sung PH, Wu CJ, Yu CM. Carotid stenting and endarterectomy. Int J Cardiol 2016; 214:166-74. [DOI: 10.1016/j.ijcard.2016.03.172] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/20/2016] [Indexed: 01/19/2023]
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39
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Chisci E, Rehring TF, Pigozzi C, Colon S, Borgheresi A, Tramacere L, Ercolini L, Michelagnoli S. Cranial nerve injury is associated with dual antiplatelet therapy use and cervical hematoma after carotid endarterectomy. J Vasc Surg 2016; 64:985-989.e2. [PMID: 27266596 DOI: 10.1016/j.jvs.2016.04.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/05/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine predictors of cranial nerve injury (CNI) after carotid endarterectomy (CEA). METHODS Consecutive CEAs performed over a 5-year period were enrolled in this study. Outcomes analyzed included 30-day major adverse event rate (composite of stroke, death, and myocardial infarction), death, stroke, disabling stroke, myocardial infarction, cervical hematoma and CNI rate, reoperation, and hospital readmission at 30 days. RESULTS There were 1258 CEAs were included in the study, 1168 (93%) were performed using an eversion technique. Patients with symptoms comprised 27% of the cohort (n = 340). At 30 days, there were no deaths, 23 major adverse events (1.8%), 11 strokes (0.9%: nine minor, two major), 12 myocardial infarctions (0.9%), 41 cervical hematomas (3.3%), 9 reoperations (0.7%) and 10 hospital readmissions (0.8%). Median duration of stay was 1 day (interquartile range, 1-2 days). CNI rate at discharge was 2.3% (n = 29). Two patients (9%) had more than one cranial nerve affected. The marginal mandibular branch of the facial nerve was most frequently involved (n = 16; 52%), followed by the hypoglossal (n = 9; 29%), the vagus (n = 4; 13%), and the spinal accessory nerve (n = 2; 6%). Horner's syndrome, consistent with an injury to the cervical sympathetic chain, occurred in 13 patients (1%) who had a true cranial nerve affected as well. The vast majority (94%) of these CNIs and all Horner's syndrome neurapraxias were transient; only the two accessory lesions persisted at their follow-up visit (median, 32 months; range, 8-72 months). Significant predictors for CNI included diabetes (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.0-6.2; P = .048), cervical hematoma (OR, 41.7; 95% CI, 13.8-125.4; P < .001), and dual antiplatelet therapy (OR, 4.4; 95% CI, 1.7-11.4; P = .002). CONCLUSIONS CNI is predominantly a transient complication, but is associated significantly with dual antiplatelet therapy use and the occurrence of a postoperative cervical hematoma. Scrupulous attention to hemostasis might reduce the incidence of CNI.
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Affiliation(s)
- Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy.
| | - Thomas F Rehring
- Vascular and Endovascular Surgery, Colorado Permanente Medical Group, Kaiser Permanente Colorado Region, Denver, Colo
| | - Clara Pigozzi
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Serena Colon
- Department of Medicine, Neurology Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Alessandra Borgheresi
- Department of Medicine, Neurology Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Luciana Tramacere
- Department of Medicine, Neurology Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Leonardo Ercolini
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, "San Giovanni di Dio" Hospital, Florence, Italy
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