Variation in surgical and anaesthetic technique and associations with operative risk in the European carotid surgery trial: implications for trials of ancillary techniques

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

BACKGROUND

Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. The shunt may improve the outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2002, 2009, and 2014.

OBJECTIVES

To assess the effect of routine versus selective or no shunting, and to assess the best method for selective shunting on death, stroke, and other complications in people undergoing carotid endarterectomy under general anaesthesia.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched April 2021), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2021, Issue 4), MEDLINE (1966 to April 2021), Embase (1980 to April 2021), and the Science Citation Index Expanded (SCI-EXPANDED) (1980 to April 2021). We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform, and handsearched relevant journals, conference proceedings, and reference lists.

SELECTION CRITERIA

Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy.

DATA COLLECTION AND ANALYSIS

Three independent review authors performed data extraction, selection, and analysis. A pooled Peto odds ratio (OR) and 95% confidence interval (CI) were computed for all outcomes of interest. Best and worse case scenarios were also calculated in case of unavailable data. Two authors independently assessed risk of bias, and quality of evidence using GRADE.

MAIN RESULTS

No new trials were found for this updated review. Thus, six trials involving 1270 participants are included in this latest review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Only three trials comparing routine shunting and no shunting were eligible for meta-analysis. Major findings of this comparison found that the routine shunting had less risk of stroke-related death within 30 days of surgery (best case) than no shunting (Peto odds ratio (OR) 0.13, 95% confidence interval (CI) 0.02 to 0.96, I² not applicable, P = 0.05, low-quality evidence), the routine shunting group had a lower stroke rate within 24 hours of surgery (Peto odds ratio (OR) 0.15, 95% CI 0.03 to 0.78, I² = not applicable, P = 0.02, low-quality evidence), and ipsilateral stroke within 30 days of surgery (best case) (Peto OR 0.41, 95% CI 0.18 to 0.97, I² = 52%, P = 0.04, low-quality evidence) than the no shunting group. No difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring. However, this analysis was inadequately powered to reliably detect the effect. There was no difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited.

AUTHORS' CONCLUSIONS

This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy when performed under general anaesthesia. Large-scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.

Comparison of Results Classical and Eversion Carotid Endarterectomy

INTRODUCTION

Atherosclerosis blood vessels, be it on extra-cranial or intra-cranial circulation, the most common cause of incidents such as cerebro-vascular insult (ICV). Carotid endarterectomy (CEA) is a preventive operation to reduce the risk of stroke and it can be performed by eversion carotid endarterectomy (E-CEA) or a classical carotid endarterectomy (C-CEA). The aim of this study was to investigate the influence of the used techniques in basic perioperative results and the incidence of postoperative complications.

MATERIALS AND METHODS

It was retrospective-prospective study that involved 173 patients, with carotid stenosis, who underwent CEA, in the period of time December 2013 till December 2016. Subjects were divided into two groups in respect of technique: 90 patients were treated with E-CEA and 83 patients were treated with C-CEA.

RESULTS

Between two groups revealed a significant difference in favor of the patients from group E-CEA in the length of the surgery (92.56 ± 29.11 min. vs. 104.04 ± 18.01 min., P = 0.000), the time of clamping the carotid arteries (11.83 ± 1.81 min. vs. 23.69 ± 5:39 min., p = 0.000), the amount of post-operative drainage (25.33 ± 24.67 ml. vs. 36.14 ± 14:32 ml., p = 0.001), time spent in the intensive care unit (± 25.43 vs. 13:51 hours 34.54 ± 35.81 hours, p = 0.000), and the length of stay (4.60 ± 0.90 days vs. 5:42 ± 1.80 days, p = 0.001). In the patients of the group E-CEA, fewer number of individual postoperative complications without statistical significance: ICV (2.2% vs. 4.8%, p = 0.351), cardiac arrhythmia (2.2% vs. 4.8%, p = 0.351), transitory ischaemic attack (TIA) and cognitive disorder (2.2% vs. 7.2%, p = 0.117), mortality (1.1% vs. 1.2%, p = 0.954); and the total number of postoperative complications was significantly less in the same patients (7.77% vs. 18.7%, p = 0.042).

CONCLUSION

The results of this study clearly indicate that operating techniques affects the specified monitored outcomes of vascular treatment of carotid arteries in favor of E-CEA technique. It would be ideally that the conclusions of this study contribute to broader use of E-CEA in treatment of carotid stenosis.

Evolution of Practices in Carotid Surgery: Observational Study in France from 2006 to 2015

BACKGROUND

The principal objective of this study is to determine the evolution of surgical management of stenosis of carotid bifurcation over a period of 10 years in France. The secondary objective is to ascertain the impact of recommendations and of the literature on the evolution of these practices.

METHODS

From the registry of the "Agence Technique de l'Information sur l'Hospitalisation" we collected all the data for carotid surgery procedures carried out in French healthcare establishments between 2006 and 2015. The search was conducted using the common classification of medical procedures for open surgery and endovascular treatment, and diagnosis-related groups corresponding to neurovascular disease. We conducted a descriptive analysis of data year-by-year and analyzed the number of procedures, the evolution of the type of surgery according to the type of establishment, and the mean duration of hospital stays.

RESULTS

During the study period, 165,276 classical procedures (95.8%) and 7319 endovascular procedures (4.2%) of carotid bifurcation were performed. The overall number of procedures was stable over time at a mean of approximately 17,000 procedures per year. Concerning conventional surgery, eversion endarterectomy became the main technique from 2008 onwards, superseding open endarterectomy with patch closure, whereas direct primary closure of the carotid bifurcation has been declining steadily ever since. The use of a shunt declined steadily from 16.3% in 2006 to 13.3% in 2015. Endovascular treatment progressed steadily during the study period from 455 procedures (2.7% of procedures) in 2006 to 943 procedures (5.7%) in 2015. The mean hospital length of stay for patients without associated severe comorbidity was constant for classical surgery (mean of 5.4 days).

CONCLUSION

This observational analysis showed stability in the number of carotid procedures performed during the period and a progressive modification of carotid surgery practices in France, in accordance with the recommendations of learned societies and major publications.

Sex based subgroup differences in randomized controlled trials: empirical evidence from Cochrane meta-analyses

OBJECTIVE

 To evaluate the frequency, validity, and relevance of statistically significant (P<0.05) sex-treatment interactions in randomized controlled trials in Cochrane meta-analyses.

DESIGN

 Meta-epidemiological study.

DATA SOURCES

 Cochrane Database of Systematic Reviews (CDSR) and PubMed.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

 Reviews published in the CDSR with sex-treatment subgroup analyses in the forest plots, using data from randomized controlled trials.

DATA EXTRACTION

 Information on the study design and sex subgroup data were extracted from reviews and forest plots that met inclusion criteria. For each statistically significant sex-treatment interaction, the potential for biological plausibility and clinical significance was considered.

RESULTS

 Among the 41 reviews with relevant data, there were 109 separate treatment-outcome analyses ("topics"). Among the 109 topics, eight (7%) had a statistically significant sex-treatment interaction. The 109 topics included 311 randomized controlled trials (162 with both sexes, 46 with males only, 103 with females only). Of the 162 individual randomized controlled trials that included both sexes, 15 (9%) had a statistically significant sex-treatment interaction. Of four topics where the first published randomized controlled trial had a statistically significant sex-treatment interaction, no meta-analyses that included other randomized controlled trials retained the statistical significance and no meta-analyses showed statistical significance when data from the first published randomized controlled trial were excluded. Of the eight statistically significant sex-treatment interactions from the overall analyses, only three were discussed by the CDSR reviewers for a potential impact on different clinical management for males compared with females. None of these topics had a sex-treatment interaction that influenced treatment recommendations in recent guidelines. UpToDate, an online physician-authored clinical decision support resource, suggested differential management of men and women for one of these sex-treatment interactions.

CONCLUSION

 Statistically significant sex-treatment interactions are only slightly more frequent than what would be expected by chance and there is little evidence of subsequent corroboration or clinical relevance of sex-treatment interactions.

Management of extracranial carotid artery disease

Stroke is the third leading cause of death in developed nations. Up to 88% of strokes are ischemic in nature. Extracranial carotid artery atherosclerotic disease is the third leading cause of ischemic stroke in the general population and the second most common nontraumatic cause among adults younger than 45 years. This article provides comprehensive, evidence-based recommendations for the management of extracranial atherosclerotic disease, including imaging for screening and diagnosis, medical management, and interventional management.

Carotid Endarterectomy: A Review

Background:

Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEAresults.

Investigation:

Brain imaging with CTor MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRAor CTangiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment.

Indications:

Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50 - 69% symptomatic stenosis, and those with asymptomatic stenosis ≥ 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions.

Techniques:

Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. “Eversion” endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis.

Carotid angioplasty and stenting:

Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA.

Auditing:

It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

BACKGROUND

Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. This may improve outcome. This is an update of a Cochrane review originally published in 1996 and previously updated in 2009.

OBJECTIVES

To assess the effect of routine versus selective or no shunting during carotid endarterectomy, and to assess the best method for selecting people for shunting.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched August 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 8), MEDLINE (1966 to August 2013), EMBASE (1980 to August 2013) and Index to Scientific and Technical Proceedings (1980 to August 2013). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in people undergoing carotid endarterectomy.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed the searches and applied the inclusion criteria. For this update, we identified two new relevant randomised controlled trials.

MAIN RESULTS

We included six trials involving 1270 participants in the review: three trials involving 686 participants compared routine shunting with no shunting, one trial involving 200 participants compared routine shunting with selective shunting, one trial involving 253 participants compared selective shunting with and without near-infrared refractory spectroscopy monitoring, and the other trial involving 131 participants compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. In general, reporting of methodology in the included studies was poor. For most studies, the blinding of outcome assessors and the report of prespecified outcomes were unclear. For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. No significant difference was found between the groups in terms of postoperative neurological deficit between selective shunting with and without near-infrared refractory spectroscopy monitoring, However, this analysis was inadequately powered to reliably detect the effect. There was no significant difference between the risk of ipsilateral stroke in participants selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared with pressure assessment alone, although again the data were limited.

AUTHORS' CONCLUSIONS

This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. Large scale randomised trials of routine shunting versus selective shunting are required. No method of monitoring in selective shunting has been shown to produce better outcomes.

The current management of carotid atherosclerotic disease: who, when and how?

Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.

Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy

OBJECTIVE

Patch angioplasty during carotid endarterectomy (CEA) can reduce the risk of perioperative stroke or late carotid artery recurrent stenosis and subsequent ischaemic stroke. We aimed to update our previous systematic review of randomized controlled trials (RCTs) of routine or selective carotid patch angioplasty compared with CEA with primary closure, and of different materials used for carotid patch angioplasty.

METHODS

We identified new RCTs published during 2002-2010 by searching Medline, Embase and the Cochrane Stroke Group Trials Register. We also hand-searched six relevant journals. Pooled estimates of treatment effects combined with our previous review (1966-2001) were calculated on the basis of a weighted estimate of the odds ratio (OR) with the Peto method.

RESULTS

Twenty-three eligible RCTs were identified in both periods. Ten RCTs involving 2,157 operations compared primary closure with routine patch closure. Patch closure significantly reduced the combined risk of perioperative stroke and later stroke during long-term follow-up [OR = 0.49, 95% confidence interval (CI) = 0.27-0.90, p = 0.001; 7 RCTs]. Patching also reduced the risks of perioperative arterial occlusion (OR = 0.18, 95% CI = 0.08-0.41, p < 0.0001; 7 RCTs) and recurrent stenosis during long-term followup (OR = 0.24, 95% CI = 0.17-0.34, p < 0.001; 8 RCTs).

CONCLUSION

Meta-analysis of relatively small RCTs suggests that carotid patch angioplasty reduces the combined perioperative and long-term risk of stroke and the risk of restenosis. More data are needed.

Routine or selective carotid artery shunting for carotid endarterectomy (and different methods of monitoring in selective shunting)

BACKGROUND

Temporary interruption of cerebral blood flow during carotid endarterectomy can be avoided by using a shunt across the clamped section of the carotid artery. This may improve outcome. This is an update of a Cochrane Review originally published in 1996 and previously updated in 2001.

OBJECTIVES

To assess the effect of routine versus selective, or never, shunting during carotid endarterectomy, and to assess the best method for selecting patients for shunting.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched September 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2009), MEDLINE (1966 to November 2008), EMBASE (1980 to November 2008) and Index to Scientific and Technical Proceedings (1980 to November 2008). We handsearched journals and conference proceedings, checked reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials of routine shunting compared with no shunting or selective shunting, and trials that compared different shunting policies in patients undergoing carotid endarterectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the searches and applied the inclusion criteria. We identified one new relevant randomised controlled trial.

MAIN RESULTS

We included four trials in the review: three trials involving 686 patients compared routine shunting with no shunting; the other trial involving 131 patients compared shunting with a combination of electroencephalographic and carotid pressure measurement with shunting by carotid pressure measurement alone. Allocation was adequately concealed in one trial, and one trial was quasi-randomised. Analysis was by intention-to-treat where possible. For routine versus no shunting, there was no significant difference in the rate of all stroke, ipsilateral stroke or death up to 30 days after surgery, although data were limited. There was no significant difference between the risk of ipsilateral stroke in patients selected for shunting with the combination of electroencephalographic and carotid pressure assessment compared to pressure assessment alone, although again the data were limited.

AUTHORS' CONCLUSIONS

This review concluded that the data available were too limited to either support or refute the use of routine or selective shunting in carotid endarterectomy. It was suggested that large scale randomised trials between routine shunting versus selective shunting were required. No one method of monitoring in selective shunting has been shown to produce better outcomes.

Current status of carotid endarterectomy and stenting for symptomatic carotid stenosis

There is still considerable uncertainty about the place of carotid stenting in patients with recently symptomatic carotid bifurcation stenosis. Most reviews of carotid endarterectomy versus carotid stenting concentrate on technical aspects and advances in stenting, but the techniques involved in both carotid endarterectomy and stenting are evolving. In addition to reviewing the results of the various randomised controlled trials of carotid endarterectomy versus stenting for symptomatic carotid stenosis, this review considers recent advances and current best practice for endarterectomy. Ongoing randomized trials will determine whether or not the procedural risk of stroke and death is definitely lower with endarterectomy than with stenting, but the key issue that remains to be determined reliably is how the procedural risks of stenting vary with patient characteristics - perhaps the most important question being not whether endarterectomy is better than stenting or vice versa, but for whom is one technique likely to be better than the other.

Wake-Up Test After Carotid Endarterectomy for Combined Carotid–Coronary Artery Surgery: A Case Series

OBJECTIVE

In combined carotid-coronary artery surgery, it is important to determine patients' neurologic status after carotid endarterectomy (CEA). An initial stroke could be exacerbated by cardiopulmonary bypass required for coronary artery bypass graft (CABG) surgery. Various monitoring methods (eg, electroencephalogram) have been used to reduce neurologic deficits during CEA under general anesthesia. However, none of the methods of determining neurologic status of patients are ideal during the time between the end of CEA and the beginning of CABG surgery. In this study, patient's neurologic status was assessed after CEA with a wake-up test to identify stroke before CABG surgery.

DESIGN

A prospective nonrandomized case series.

SETTING

Single institution, university hospital.

PARTICIPANTS

Forty-four patients with carotid artery stenosis and coronary artery disease underwent combined carotid-coronary artery surgery.

INTERVENTIONS

After CEA, propofol and remifentanil anesthesia was discontinued, the wake-up test was performed, and then anesthesia was reinstituted for CABG surgery.

MEASUREMENTS AND RESULTS

A total of 48 wake-up tests were performed in 43 patients. Two wake-up tests were performed in each of the 5 patients who underwent bilateral CEA. Postoperative stroke were seen in 2 patients. In the first patient, despite a normal wake-up test, the stroke occurred in the cerebral hemisphere contralateral to the CEA, and the patient recovered within 12 days. In the second patient, there was a positive wake-up test after CEA, and he recovered within 3 days. One patient died postoperatively because of ventricular failure.

CONCLUSIONS

Although this is a case series, the authors believe that performing a neurologic examination using a wake-up test may make a contribution and increases the safety of combined surgical procedures in patients with coronary and carotid artery disease.

Carotid endarterectomy, carotid artery shunting and outcome: an historical perspective

PURPOSE OF REVIEW

Carotid endarterectomy is now celebrating its 50th anniversary! Yet, despite millions of these operations having been performed, there is little agreement about the best methods of surgical technique, cerebral protection, anesthetic technique and monitoring methods. In this time of evidence-based medicine, carotid endarterectomy fares badly, with only the indications for the surgery having been subjected to the appropriate methodology of clinical trials and biostatistics for proper evaluation. This review is designed to look back over the history of carotid endarterectomy in order to understand the evolution of current practices.

RECENT FINDINGS

Within the past 5 years, despite the publication of many papers dealing with issues surrounding carotid shunting, no randomized controlled trials evaluating this aspect of carotid artery surgery have appeared. One must probe further into the past to understand how so much can be written yet so little learned!

SUMMARY

Current evidence is not able to support the hypothesis that shunting during carotid artery surgery reduces the risk of perioperative stroke or death or that its use is associated with an increase in perioperative or long-term complications. Routine, selective or no shunting protocols during carotid artery surgery remain a matter of local custom and tradition.

Clinical and operative predictors of outcomes of carotid endarterectomy

OBJECTIVE

The net benefit for patients undergoing carotid endarterectomy is critically dependent on the risk of perioperative stroke and death. Information about risk factors can aid appropriate selection of patients and inform efforts to reduce complication rates. This study identifies the clinical, radiographic, surgical, and anesthesia variables that are independent predictors of deaths and stroke following carotid endarterectomy.

METHODS

A retrospective cohort study of patients undergoing carotid endarterectomy in 1997 and 1998 by 64 surgeons in 6 hospitals was performed (N = 1972). Detailed information on clinical, radiographic, surgical, anesthesia, and medical management variables and deaths or strokes within 30 days of surgery were abstracted from inpatient and outpatient records. Multivariate logistic regression models identified independent clinical characteristics and operative techniques associated with risk-adjusted rates of combined death and nonfatal stroke as well as all strokes.

RESULTS

Death or stroke occurred in 2.28% of patients without carotid symptoms, 2.93% of those with carotid transient ischemic attacks, and 7.11% of those with strokes (P < .0001). Three clinical factors increased the risk-adjusted odds of complications: stroke as the indication for surgery (odds ratio [OR], 2.84; 95% confidence interval [CI] = 1.55-5.20), presence of active coronary artery disease (OR, 3.58; 95% CI = 1.53-8.36), and contralateral carotid stenosis > or =50% (OR, 2.32; 95% CI = 1.33-4.02). Two surgical techniques reduced the risk-adjusted odds of death or stroke: use of local anesthesia (OR, 0.30; 95% CI = 0.16-0.58) and patch closure (OR, 0.43; 95% CI = 0.24-0.76).

CONCLUSIONS

Information about these risk factors may help physicians weigh the risks and benefits of carotid endarterectomy in individual patients. Two operative techniques (use of local anesthesia and patch closure) may lower the risk of death or stroke.

A Systematic Review of the Associations between Age and Sex and the Operative Risks of Carotid Endarterectomy

BACKGROUND

Randomized trials of carotid endarterectomy (CEA) for both symptomatic and asymptomatic carotid stenosis have demonstrated that benefit is decreased in women, due partly to a high operative risk, which is independent of age. However, it is uncertain whether these trial-based observations are generalisable to routine clinical practice.

METHODS

We performed a systematic review of all publications reporting data on the association between age and/or sex and procedural risk of stroke and/or death following CEA from 1980 to 2004.

RESULTS

62 eligible papers reported relevant data. Females had a higher rate of operative stroke and death (25 studies, OR = 1.31, 95% CI = 1.17-1.47, p < 0.001) than males, but no increase in operative mortality (15 studies, OR = 1.05, 95% CI = 0.81-0.86, p = 0.78). Compared with younger patients, operative mortality was increased at > or =75 years (20 studies, OR = 1.36, 95% CI = 1.07-1.68, p = 0.02), at age > or =80 years (15 studies, OR = 1.80, 95% CI = 1.26-2.45, p < 0.001) and in older patients overall (35 studies, OR = 1.50, 95% CI = 1.26-1.78, p < 0.001). In contrast, risk of non-fatal stroke did not increase with age and so the combined perioperative risk was only slightly increased at age > or =75 years (21 studies, OR = 1.18, 95% CI = 0.94-1.44, p = 0.06), at age > or =80 years (10 studies, OR = 1.14, 95% CI = 0.92-1.36, p = 0.34) and in older patients overall (36 studies, OR = 1.17, 95% CI = 1.04-1.31, p = 0.01).

CONCLUSIONS

The effects of age and sex on the operative risk of CEA in published case series are consistent with those observed in the trials. Operative risk of stroke is increased in women and operative mortality is increased in patients aged > or =75 years.

Sequential cohort study of Dacron patch closure following carotid endarterectomy

BACKGROUND

Carotid endarterectomy reduces the risk of stroke and death in patients with severe carotid artery stenosis. This study examined whether the technique used to close the arteriotomy influenced the rate of perioperative transient ischaemic attack (TIA), stroke or death.

METHODS

A cohort of 236 patients undergoing carotid endarterectomy at a single centre was studied; 117 patients had primary closure of the arteriotomy and 119 patients in a sequential series had closure with a Dacron patch. A standard endarterectomy with completion intraoperative duplex imaging and digital subtraction angiography was used throughout.

RESULTS

Patch closure was associated with a significant reduction in the 30-day combined death, stroke and TIA rate: 10.3 per cent for primary closure versus 2.5 per cent for patch closure (P = 0.017). The risk of any cerebral event (stroke or TIA) was also significantly reduced (7.7 versus 1.7 per cent; P = 0.033). Residual stenosis on completion angiography was more common after primary closure (24.6 versus 7.4 per cent; P = 0.003).

CONCLUSION

Dacron patch closure had a higher technical success rate on completion imaging and was associated with a significant reduction in the risk of perioperative stroke, TIA and death.

Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy

BACKGROUND

Patch angioplasty during carotid endarterectomy (CEA) may reduce the risk for perioperative or late carotid artery recurrent stenosis and subsequent ischemic stroke. We performed a systematic review of randomized controlled trials to assess the effect of routine or selective carotid patch angioplasty compared with CEA with primary closure, and the effect of different materials used for carotid patch angioplasty.

METHODS

Randomized trials were included if they compared carotid patch angioplasty with primary closure in any patients undergoing CEA or use of one type of carotid patch with another.

RESULTS

Thirteen eligible randomized trials were identified. Seven trials involving 1281 operations compared primary closure with routine patch closure, and 8 trials with 1480 operations compared different patch materials (2 studies compared both). Patch angioplasty was associated with a reduction in risk for stroke of any type (P = .004), ipsilateral stroke (P = .001), and stroke or death during both the perioperative period (P = .007) and long-term follow-up (P = .004). Patching was also associated with reduced risk for perioperative arterial occlusion (P = .0001) and decreased recurrent stenosis during long-term follow-up (P < .0001). Seven trials that compared different patch types showed no difference in the risk for stroke, death, or arterial recurrent stenosis either perioperatively or at 1-year follow-up. One study of 180 patients (200 arteries) compared collagen-impregnated Dacron (Hemashield) patches with polytetrafluoroethylene patches. There was a significant increase in risk for stroke (P = .02), combined stroke and transient ischemic attack (P = .03), and recurrent stenosis (P = .01) at 30 days, and an increased risk for late recurrent stenosis greater than 50% (P < .001) associated with Dacron compared with polytetrafluoroethylene.

CONCLUSIONS

Carotid patch angioplasty decreases the risk for perioperative death or stroke, and long-term risk for ipsilateral ischemic stroke. More data are required to establish differences between various patch materials.

Carotid revascularization for prevention of stroke: carotid endarterectomy and carotid artery stenting

Carotid endarterectomy (CEA) has been used for the past several decades in patients with carotid occlusive disease. Large randomized controlled trials have documented that CEA is a highly effective stroke preventive among patients with carotid stenosis and recent transient ischemic attack or cerebral infarction. In asymptomatic patients with carotid stenosis, clinical trial data suggest that the degree of stroke prevention from CEA is less than among symptomatic patients. However, otherwise healthy men and women with an asymptomatic carotid stenosis of 60% or greater have a lower risk of future cerebral infarction, including disabling cerebral infarction, if treated with CEA compared with those treated with medical management alone. More recently, carotid artery stenting has been performed Increasingly for patients with carotid occlusive disease. As technology has improved, procedural risks have declined and are approaching those reported for CEA. The benefits and durability of CEA compared with carotid artery stenting are still unclear and are being studied in ongoing randomized controlled trials.

Patch angioplasty versus primary closure for carotid endarterectomy

BACKGROUND

Carotid patch angioplasty (with either a venous or a synthetic patch) may reduce the risk of carotid artery restenosis and subsequent ischaemic stroke.

OBJECTIVES

The objective of this review was to assess the safety and efficacy of routine or selective carotid patch angioplasty compared to carotid endarterectomy with primary closure.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched November 2002). In addition, we searched the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1966 to December 2001), EMBASE (1980 to December 2001) and Index to Scientific and Technical Proceedings (1980 to 2001). We also handsearched eight journals and five conference proceedings. Reference lists were checked and we contacted experts in the field to identify further published and unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing carotid patch angioplasty with primary closure in any patients undergoing carotid endarterectomy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility, trial quality and extracted the data.

MAIN RESULTS

The previous review included six trials involving 794 patients undergoing 882 operations. Since the last review only one study of adequate quality to be included has been reported. This added 399 operations randomised to either primary closure, vein patch or synthetic patch groups resulting in 1127 patients undergoing 1307 operations being available for analysis. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Carotid patch angioplasty was associated with a reduction in the risk of stroke of any type (OR = 0.33, p = 0.004), ipsilateral stroke (OR = 0.31, p = 0.0008), and stroke or death, during the perioperative period (OR = 0.39, p = 0.007) and long term follow-up (OR = 0.59, p = 0.004). It was also associated with a reduced risk of perioperative arterial occlusion (odds ratio 0.15, 95% confidence interval 0.06 to 0.37 p = 0.00004), and decreased restenosis during long-term follow-up in five trials, (odds ratio 0.20, 95% confidence interval 0.13 to 0.29 p < 0.00001). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow-up. Very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation were recorded with either patch or primary closure. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long-term all-cause death rates

REVIEWERS' CONCLUSIONS

Limited evidence suggests that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and restenosis. It would appear to reduce the risk of combined death or stroke and there is a non significant trend towards a reduction in all-cause mortality.

Overview of the principal results and secondary analyses from the European and North American randomised trials of endarterectomy for symptomatic carotid stenosis

OBJECTIVES

Review of the primary results and secondary analyses from the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET).

DESIGN

Review of 48 ECST and NASCET papers.

RESULTS

The simple assumption that all patients with a symptomatic stenosis >70% benefit from CEA is untenable. Approximately 70-75% will not have a stroke if treated medically. The ECST and NASCET have identified subgroups that should have expedited investigation and surgery (male sex, age >75 years, 90-99% stenosis, irregular plaque, hemispheric symptoms, recurrent events for >6 months, contralateral occlusion, multiple co-morbidity). Accordingly development of local protocols for patient selection/exclusion should involve surgeons and physicians and take account of the local operative risk. The ECST and NASCET have also shown that the ubiquitous "string sign" is not associated with a high risk of stroke, and emergency CEA is unnecessary.

CONCLUSIONS

Surgeons must quote their own results and be aware that a high operative risk reduces long-term benefit. Accordingly, in those centres with a higher operative death/stroke rate, some "lower risk" patients should probably be considered for best medical therapy alone. It is hoped that pooling of the ECST and NASCET databases will enable more definitive guidelines to be developed regarding who benefits most from CEA.

Cerebrovascular disease

PURPOSE OF REVIEW

Carotid endarterectomy remains the preferred surgical intervention for the prevention of stroke among patients with extracranial cerebrovascular disease. Subgroup analyses of the results of several multicentre trials have contributed substantially to our understanding of the appropriate selection of patients and the perioperative risk associated with this procedure.

RECENT FINDINGS

This review describes recent advances in our understanding of the appropriate use of carotid endarterectomy, and outlines recent developments and strategies that are likely to influence the perioperative care of these patients.

SUMMARY

As current clinical guidelines for the use of carotid endarterectomy unfold, anaesthesiologists can expect to care more frequently for older patients and those at increased risk of complications. The perioperative management of co-existing diseases, particularly the control of hypertension and the strategies aimed at reducing the risk of cardiac complications, will contribute substantially to reducing perioperative morbidity and mortality.