Hemodynamic changes and baroreflex sensitivity associated with carotid endarterectomy and carotid artery stenting

Anatomical Variations and Morphometry of Carotid Sinus: A Computed Tomography Study

BACKGROUND

The radiological evaluation of the carotid sinus (CS) anatomy and its morphometry is essentially important for various surgical procedures involving the carotid bifurcation and the CS itself. Despite its tremendous clinical significance, studies dealing with the CS anatomy are seldom reported. Hence, the present study aimed to evaluate the frequencies of the CS positional variants and their morphometry and correlate them with age and body mass index (BMI).

METHODS

In this retrospective cross-sectional study, a total of 754 disease-free carotid arteries were examined using computed tomography angiography scans to determine the CS positional variations (such as types I to III) and its morphometry, including the CS diameter and length. Additionally, the association between these parameters and factors such as sex, age, and body mass index were explored using appropriate statistical tests. The inter-rater agreement of the collected dataset was evaluated using Cohen's Kappa.

RESULTS

The CS type I was observed in 87.67% of the cases, and type II and type III were observed at lower frequencies with 9.02% and 3.32%, respectively. There were statistically significant (p < 0.001) differences observed in the mean diameter and length of the sinus between the sex and the type I CS variations. However, there was no significant and strong correlation between the age and BMI factors with sinus length and sinus diameter. The kappa values for inter-rater agreement ranged from 0.77 to 0.99 for all parameters.

CONCLUSIONS

In type I, the CS length and carotid vessel's diameter is significantly different between the sexes. However, age and BMI do not affect the CS anatomy in radiologically disease-free carotid arteries. Knowledge of the CS variant anatomy is clinically significant as it influences the patients' surgical and physiological outcomes.

Outcomes of Carotid Artery Stenting and Endarterectomy in Patients with Prior Contralateral Carotid Revascularization

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are available treatment options for stroke prevention in individuals with severe carotid stenosis. This study aims to compare the early postoperative outcomes in patients who underwent CEA or CAS after prior contralateral carotid revascularization.

METHODS

We conducted a retrospective review of the Society of Vascular Surgery Vascular Quality Initiative database, identifying patients who had prior carotid artery revascularization followed by a contralateral CEA or CAS between 2017 and 2023. Based on the sequence of the procedures performed, patients were categorized into 4 groups: 1) patients who had a prior unilateral CEA followed by a contralateral CEA; 2) patients who had a prior unilateral CAS followed by a contralateral CEA; 3) patients had a prior unilateral CAS followed by a contralateral CAS; and 4) patients had a prior unilateral CEA followed by a contralateral CAS. Univariate analysis (Pearson χ2, Wilcoxon rank sum test) and multivariate logistic regression were employed to assess length of stay, rates of in-hospital stroke, myocardial infarction, new-onset arrhythmia, and 30-day mortality.

RESULTS

A total of 20,761 patients with a history of prior unilateral carotid revascularization procedures were identified, of which 12,788 underwent contralateral CEA and another 7,973 underwent contralateral CAS. Compared to the prior unilateral CAS followed by a contralateral CAS group, patients who underwent CEA followed by contralateral CAS (prior unilateral CEA followed by a contralateral CAS group) were associated with higher rates of postoperative in-hospital stroke (1.8% vs. 1%, P = 0.003), new-onset arrhythmia (2% vs. 1.2%, P = 0.006), and 30-day mortality (1.3% vs. 0.8%, P = 0.04). On multivariate analysis, preoperative use of statins and beta-blockers was associated with lower odds of in-hospital stroke (odds ratio [OR] 0.42; 95% confidence interval 0.29-0.69; P = 0.0002) and new-onset arrhythmia (OR 0.62; 95% confidence interval 0.49-0.9; P = 0.01), respectively, after CAS. There were no significant differences in outcomes for prior unilateral CEA followed by a contralateral CEA and prior unilateral CEA followed by a contralateral CAS groups.

CONCLUSIONS

Patients with prior CEA undergoing contralateral CAS had higher rates of in-hospital stroke, new-onset arrhythmia, and 30-day mortality. Beta-blockers may reduce postoperative arrhythmia rates in these patients, and established regimens should not be discontinued in the perioperative period; however, further prospective studies are needed to confirm this finding. Optimized medical treatment and appropriate imaging follow-up remain crucial for improvement outcomes.

Efficacy of dexmedetomidine in prevention of carotid artery stenting-induced intraoperative hypotension

There are limited data on the impact of light sedation (LS) on changes in intraoperative hypotension related to carotid artery stenting (CAS). We aimed to investigate intraoperative hypotension and perioperative complications in CAS under LS with intravenous dexmedetomidine (Dex). A retrospective analysis of 140 consecutive patients who underwent CAS at our centre from September 2018 to March 2021 was performed. The primary endpoint was the incidence of intraoperative hypotension associated with CAS, defined as continuous systolic blood pressure < 90 mmHg. The secondary outcomes were perioperative complications, including dysphoria, transient ischaemic attacks (TIA), stroke, myocardial infarction (MI), reperfusion syndrome, and 24-h haemodynamic events after CAS. Eighty-nine patients were treated under LS, and 51 patients were treated under local anaesthesia (LA). Intraoperative haemodynamic instability was observed in 13 of 140 (9.3%) patients; hypotension occurred in 2.2% (2/89) of patients in the LS group, which was significantly lower than the rate in the LA group (2.2% vs. 11.8%, P = 0.027). Dysphoria occurred in 1.1% of the LS cohort and 15.7% of the LA cohort (P < 0.05). TIA was observed in 2.2% of the LS cohort and 15.7% of the LA cohort (P < 0.05), respectively. There were no statistically significant differences in periprocedural stroke, reperfusion syndrome, or 24-h haemodynamic events after CAS between the two groups, and none of the patients exhibited MI. Performing CAS under LS with intravenous Dex was a safe and effective anaesthesia option in terms of inhibiting intraoperative hypotension and could markedly decrease the incidence of dysphoria and TIA.

Comparison of the impact of carotid endarterectomy and stenting on autonomic and baroreflex regulations: a one-year follow-up randomized study

Patients with carotid stenosis can receive indication for either carotid endarterectomy (CEA) or carotid artery stenting (CAS), with both techniques having an impact on the autonomic function and baroreflex control.Seventy carotid stenosis patients randomly assigned to CEA or CAS were enrolled. After exclusion of some recordings, 33 CEA (age 67.79 ± 5.32 yrs, 26 males) and 25 CAS (age 70.32 ± 3.63 yrs, 14 males) were admitted to analysis. Autonomic and baroreflex sensitivity markers were derived from the analysis of heart period and systolic arterial pressure spontaneous variability derived in supine position and during active standing (STAND), before (PRE) the intervention and after a 6 and 12-month follow-up (FU6, FU12).CEA had a preserved response of autonomic and baroreflex control to STAND in PRE and FU6, suggesting an early improvement. CAS had a similar response at PRE but a blunted one at the follow-ups. When directly compared, the two groups had a similar autonomic function, with CAS having a reduced baroreflex control in PRE and lower autonomic function at FU6. All the differences disappeared at the long-term follow-up, showing a similar long term effect of the surgical procedures, suggesting that CEA and CAS induced a similar long-term impairment of autonomic and baroreflex controls.

The efficacy and efficiency of percutaneous lidocaine injection for minimizing the carotid reflex in carotid artery stenting: A single-center retrospective study

OBJECTIVE

To assess whether local anesthetic infiltration could minimize the carotid baroreceptor reflex (CBR) which has an incidence after carotid artery stenting (CAS) that varies from 29% to 51%.

METHODS

This retrospective single-center study included 51 patients (mean age, 70.47 years) who underwent CAS for carotid stenosis. The groups included patients who underwent CAS for asymptomatic ischemic stroke (n=41) or symptomatic disease (n=10). Preprocedural percutaneous lidocaine injections (PPLIs) were administered to 70.6% and 5.9% of patients who underwent elective CAS and emergency CAS, respectively.

RESULTS

Among patients who received PPLIs, the mean degree of stenosis was 80.5% (95% confidence interval [CI]: ±10.74, 51-98%). The mean distance from the common carotid artery bifurcation to the most stenotic lesion (CSD) was 8.3 mm (95% CI: ±0.97, 6.3-10.2 mm); the mean angle between the internal carotid artery and common carotid artery (CCA) trunk (IAG) was 65.6° (95% CI: ±2.39, 61-70°). Among patients who did not receive PPLIs, the mean degree of stenosis was 84.0% (95% CI: ±8.96, 70-99%). The mean CSD was 5.9 mm (95% CI: ±1.83, 1.9-9.9 mm); the mean IAG was 60.4° (95% CI: ±4.41, 51-70°). The procedure time was longer in the PPLI group than in the no PPLI group (28.19 [n=39] vs. 18.88 [n=12] days) (P=0.057); the length of intensive care unit stay was shorter in the PPLI group (20.01 [n=36] vs. 28.10 [n=5] days) (P=0.132).

CONCLUSIONS

Targeted PPLI administration to the carotid bulb decreased aberrant heart rates and blood pressure changes induced by carotid stent deployment and balloon inflation. As CBR sensitivity increases with decreasing distance to the stenotic lesion from the CCA bifurcation, PPLIs may help stabilize patients during procedures for stenotic lesions closer to the CCA.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Redefining postoperative hypertension management in carotid surgery: a comprehensive analysis of blood pressure homeostasis and hyperperfusion syndrome in unilateral vs. bilateral carotid surgeries and implications for clinical practice

Background

This study evaluates the implications of blood pressure homeostasis in bilateral vs. unilateral carotid surgeries, focusing on the incidence of postoperative hypertension, hyperperfusion syndrome, and stroke as primary outcomes. It further delves into the secondary outcomes encompassing major adverse cardiovascular events and all-cause mortality.

Methods

Spanning two decades (2002-2023), this comprehensive retrospective research encompasses 15,369 carotid referrals, out of which 1,230 underwent carotid interventions. A subset of 690 patients received open carotid procedures, with a 10-year follow-up, comprising 599 unilateral and 91 bilateral surgeries. The Society for Vascular Surgery Carotid Reporting Standards underpin our methodological approach for data collection. Both univariate and multivariate analyses were utilized to identify factors associated with postoperative hypertension using the Statistical Package for the Social Sciences (SPSS) Version 22 (SPSS®, IBM® Corp., Armonk, N.Y., USA).

Results

A marked acute elevation in blood pressure was observed in patients undergoing both unilateral and bilateral carotid surgeries (p < 0.001). Smoking (OR: 1.183, p = 0.007), hyperfibrinogenemia (OR: 0.834, p = 0.004), emergency admission (OR: 1.192, p = 0.005), severe ipsilateral carotid stenosis (OR: 1.501, p = 0.022), and prior ipsilateral interventions (OR: 1.722, p = 0.003) emerged as significant factors that correlates with postoperative hypertension in unilateral surgeries. Conversely, in bilateral procedures, gender, emergency admissions (p = 0.012), and plaque morphology (p = 0.035) significantly influenced postoperative hypertension. Notably, 2.2% of bilateral surgery patients developed hyperperfusion syndrome, culminating in hemorrhagic stroke within 30 days. Intriguingly, postoperative stage II hypertension was identified as an independent predictor of neurological deficits post-secondary procedure in bilateral CEA cases (p = 0.004), attributable to hyperperfusion syndrome. However, it did not independently predict myocardial infarction or mortality outcomes. The overall 30-day stroke rate stood at 0.90%. Lowest incidence of post operative hypertension or any complications were observed in eversion carotid endartrertomy.

Conclusion

The study identifies postoperative hypertension as a crucial independent predictor of perioperative stroke following bilateral carotid surgery. Moreover, the study elucidates the significant impact of bilateral CEA on the development of post-operative hyperperfusion syndrome or stroke, as compared to unilateral CEA. Currently almost 90% of our carotid practice is eversion carotid endartrerectomy.

Impact of residual stenosis on clinical outcomes when performing carotid artery stenting without postdilation

OBJECTIVE

Many centers consider postdilation if the final angiography after carotid artery stenting (CAS) shows residual stenosis of >30% to 40%. Postdilation has been demonstrated to potentially increase the risk of developing neurologic events. This study aimed to investigate the safety of CAS without postdilation regardless of the degree of residual stenosis.

METHODS

We retrospectively investigated 191 patients who underwent transfemoral CAS without postdilation intendedly. All cases underwent mild predilation and self-expanding stent implantation. We divided the patients into a residual stenosis of ≥40% group (n = 69 [36.1%]) and a residual stenosis of <40% group (n = 122 [63.9%]) according to their final angiography. We compared the procedural (within 30 days after CAS) and nonprocedural (afterward) adverse cardiovascular events and in-stent restenosis between the two groups. We also investigated the incidence of perioperative hemodynamic depression between the groups and the changes in residual stenosis over the follow-up time.

RESULTS

Patients in the residual stenosis of ≥40% group had a higher preoperative stenosis rate and a greater proportion of severely calcified lesions than those in the <40% group. There was one procedural cardiac death (0.5%), five strokes (2.6%), and four myocardial infarctions (2.1%). A total of 2.9% had stroke or death procedurally in the residual stenosis of ≥40% group and 3.2% in the residual stenosis of <40% group (P > .950). The median nonprocedural follow-up time was 22 months, with a total of six deaths and four strokes. The cumulative 2-year death or stroke rate was 6.2%, with 5.9% in the residual stenosis of ≥40% group versus 6.7% in the residual stenosis of <40% group (P = .507). There were two cases of in-stent restenosis in the residual stenosis of ≥40% group and three in the residual stenosis of <40% group (P = .927). The difference in the peak systolic velocity of the target lesion between groups at 3 months after CAS was no longer present, and residual stenosis stabilized at 10% to 20% at 6 months in both groups. The patients showed an association between increasing hemodynamic depression incidence and residual stenosis in a significantly graded response (P = .021).

CONCLUSIONS

Residual stenosis after carotid stenting without postdilation is not associated with a risk of postoperative adverse events. This study provides evidence for the feasibility of a no postdilation strategy for CAS.

Impact of Non-Pharmacological Interventions on the Mechanisms of Atherosclerosis

Atherosclerosis remains the leading cause of mortality and morbidity worldwide characterized by the deposition of lipids and fibrous elements in the form of atheroma plaques in vascular areas which are hemodynamically overloaded. The global burden of atherosclerotic cardiovascular disease is steadily increasing and is considered the largest known non-infectious pandemic. The management of atherosclerotic cardiovascular disease is increasing the cost of health care worldwide, which is a concern for researchers and physicians and has caused them to strive to find effective long-term strategies to improve the efficiency of treatments by managing conventional risk factors. Primary prevention of atherosclerotic cardiovascular disease is the preferred method to reduce cardiovascular risk. Fasting, a Mediterranean diet, and caloric restriction can be considered useful clinical tools. The protective impact of physical exercise over the cardiovascular system has been studied in recent years with the intention of explaining the mechanisms involved; the increase in heat shock proteins, antioxidant enzymes and regulators of cardiac myocyte proliferation concentration seem to be the molecular and biochemical shifts that are involved. Developing new therapeutic strategies such as vagus nerve stimulation, either to prevent or slow the disease’s onset and progression, will surely have a profound effect on the lives of millions of people.

Incidence of postoperative, major, adverse cardiac events in patients undergoing carotid endarterectomy: A single-center, retrospective study

OBJECTIVE

This study aimed to determine the incidence of postoperative major adverse cardiac events for patients undergoing carotid endarterectomy.

METHODS

This single-center, retrospective study recruited 171 carotid endarterectomy patients between January 1999 and June 2018. Patients who received a carotid endarterectomy in conjunction with other surgery were excluded. The primary outcomes were the incidences of major adverse cardiac events (comprising myocardial infarction, significant arrhythmias, congestive heart failure, and cardiac death) within 7 days, 7-30 days, and > 30 days-1 year, postoperatively. The secondary outcomes were the factors related to major adverse cardiac events and the incidence of postoperative stroke. The patients' charts were reviewed, and direct contact was made with them to obtain information on their status post discharge.

RESULTS

The incidences of major adverse cardiac events within 7 days, 7-30 days, and >30 days-1 year of the carotid endarterectomy were 3.5% of patients (95% confidence interval: 0.008-0.063), 1.2% (95% confidence interval: 0.004-0.028), and 1.8% (95% confidence interval: 0.002-0.037), respectively. The major adverse cardiac events occurring within 7 days were arrhythmia (2.3% of patients), cardiac arrest (1.8%), myocardial infarction (1.2%), and congestive heart failure (1.2%), while the corresponding postoperative stroke rate was 4.7%.

CONCLUSION

The 7-day incidence of major adverse cardiac events after the carotid endarterectomy was 3.5%. The most common major adverse cardiac event during that period was cardiac arrhythmia.

[Baroreceptor failure syndrome after head and neck tumor surgery]

With the continuous updating of head and neck surgery concepts and techniques, more and more head and neck surgeries are developing in the direction of refinement.however, the more complete the surgery, the greater the possibility of subsequent nerve exposure and injury. Even a slight perturbation of the nerve may cause serious complications, such as pressure receptor failure.It is necessary to review the mechanisms and the characteristics of baroreceptor failure syndrome after head and neck tumor surgery.

Predisposing Factors and Management of Hemodynamic Depression Following Carotid Artery Stenting

Carotid artery stenting (CAS) involves dilatation of carotid bulb which can trigger a series of neuronal responses resulting in hemodynamic depression that might influence the outcome of the procedure. This is a frequent but underdiagnosed complication of CAS. Although it is mild, transient and self-limiting in majority of cases, it can result in significant morbidity and mortality if persistent. Neurologists should be aware of the predisposing factors and management of this common complication. In patients who present with stroke following carotid stenting, neurologists should be aware of hypoperfusion secondary to hemodynamic depression as a cause of stroke apart from the stent thrombosis and occlusion.

Recanalization of the Chronically Occluded Internal Carotid Artery: Review of the Literature

Introduction

We reviewed the literature on interventions for patients with medically refractory chronically occluded internal carotid artery (COICA) to assess the risks and/or benefits after recanalization via an endovascular technique (ET) or hybrid surgery (HS, i.e., ET plus carotid endarterectomy).

Methods

A systematic search of the electronic databases was performed. Patients with COICA were classified into 4 different categories according to Hasan et al classification.

Results

Eighteen studies satisfied the inclusion criteria. Only 6 studies involved an HS procedure. We identified 389 patients with COICA who underwent ET or HS; 91% were males. The overall perioperative complication rate was 10.1% (95% confidence interval [CI]: 7.4%-13.1%). For types A and B, the successful recanalization rate was 95.4% (95% CI: 86.5%-100%), with a 13.7% (95% CI: 2.3%-27.4%) complication rate. For type C, the success rate for ET was 45.7% (95% CI: 17.8%-70.7%), with a complication rate of 46.0% (95% CI: 20.0%-71.4%) for ET and for the HS technique 87.6% (95% CI: 80.9%-94.4%), with a complication rate of 14.0% (95% CI: 7.0%-21.8%). For type D, the success rate of recanalization was 29.8% (95% CI: 7.8%-52.8%), with a 29.8% (95% CI: 6.1%-56.3%) complication rate. Successful recanalization resulted in a symmetrical perfusion between both cerebral hemispheres, resolution of penumbra, normalization of the mean transit time, and improvement in Montreal Cognitive Assessment (MoCA) score (ΔMoCA = 9.80 points; P = 0.004).

Conclusions

Type A and B occlusions benefit from ET, especially in the presence of a large penumbra. Type C occlusions can benefit from HS. Unfortunately, we did not identify an intervention to help patients with type D occlusions. A phase 2b randomized controlled trial is needed to confirm these findings.

Efficacy of Acupuncture Combined with Local Anesthesia in Ischemic Stroke Patients with Carotid Artery Stenting: A Prospective Randomized Trial

OBJECTIVE

To evaluate the efficacy of electro-acupuncture (EA) or transcutaneous electrical acupoint stimulation (TEAS) on perioperative cerebral blood flow (CBF) and neurological function in ischemic stroke (IS) patients undergoing carotid artery stenting (CAS).

METHODS

In total, 124 consecutive IS patients were randomly allocated to the EA, TEAS, and sham groups (groups A, T, and S; 41, 42, and 41 cases, respectively) by software-derived random-number sequence. Groups A and T received EA and TEAS, respectively, at the Shuigou (GV 26) and Baihui (GV 20), Hegu (LI4) and Waiguan (TE 5) acupoints. Group S received sham EA. The stimulation was started from 30 min before surgery until the end of the operation. The primary outcome was the CBF at 30 min after surgery, which was measured by transcranial Doppler sonography. The secondary outcomes included hyperperfusion incidence and neurological function. National Institutes of Health Stroke Scale (NIHSS) and General Evaluation Scale (GES) scores were recorded at 1 week, 1 month, and 3 months postoperatively.

RESULTS

Mean CBF velocity at 30 min after surgery in groups A and T was much lower than that in Group S (P < 0.05); the incidence of hyperperfusion in Groups A and T was also lower than that in group S (P <0.05). Acupuncture was an independent factor associated with reduced incidence of hyperperfusion (OR=0.042; 95% CI: 0.002-0.785; =0.034). NIHSS and GES scores improved significantly at 1 week postoperatively in Groups A and T than in Group S (P < 0.05). Relative to Group S, groups A and T exhibited significantly lower incidences of moderate pain, as well as higher incidences of satisfaction with anesthesia, at 1 day postoperatively (P < 0.05).

CONCLUSIONS

EA or TEAS administered in combination with local anesthesia during CAS can inhibit transient increases in CBF, reduce the incidence of postoperative hyperperfusion, and improve neurological function. (Registration No. ChiCTR-IOR-15007447).

Prevention of Back Bleeding During Carotid Endarterectomy: Analysis of Clamping Techniques

OBJECTIVE

Complete control of back bleeding during carotid endarterectomy (CEA) is important. We investigated the causes of back bleeding during CEA and techniques for the control of bleeding.

METHODS

A retrospective review was performed of 214 CEA procedures. We assessed the results of routine preoperative examinations, instruments used for arterial clamping (vessel loop and crude or bulldog clamps), and severity of carotid artery stenosis and arterial wall calcification. The study end point was incomplete control of back bleeding before arteriotomy. Factors associated with back bleeding were identified by univariate analysis. The culprit artery and intraoperative technique used in patients with back bleeding were also determined.

RESULTS

Transient back bleeding occurred in 19 CEA procedures (8.9%). Back bleeding was from the ascending pharyngeal artery in 9 cases, common carotid artery in 8 cases, and external carotid artery in 2 cases. Univariate analysis identified the following factors as being related to incomplete control of back bleeding: moderate carotid artery stenosis (20 mm thick) and use of bulldog clamps.

CONCLUSIONS

Transient back bleeding during CEA was uncommon, with the risk factors being severe carotid calcification and moderate carotid stenosis. Transient back bleeding was managed by clamping an undetected ascending pharyngeal artery or by additional clamping of the common carotid or external carotid artery. The vessel loop and crude were superior to the bulldog clamp for clamping the carotid artery.

Rare Complication of Carotid Stenting: New-Onset Refractory Status Epilepticus: A Study of Five Patients

Introduction:

New-onset refractory status epilepticus (NORSE) is uncommon and almost 50% of cases are cryptogenic. We report the rare development of NORSE following carotid artery stenting (CAS), a procedure which is increasingly being used to treat the carotid stenosis.

Materials and Methods:

Patients who developed NORSE following CAS for the prevention of stroke over a period of 5 years were analyzed retrospectively. The degree of internal carotid artery stenosis (ICA) was estimated as per the NASCET criteria.

Results:

We analyzed five patients (age: 56–83 years). NORSE was reported within 30 min to 14 days post-CAS. Status epilepticus was focal in two patients, generalized in two, and one had nonconvulsive status epilepticus. All patients were treated with multiple antiepileptic drugs. Four patients recovered and survived and one succumbed. Two patients had comorbid hypertension and two had diabetes and hypertension. Four patients had hemiparesis due to the contralateral middle cerebral artery territory infarction and one patient had syncope. Two patients had postinfarction gliosis.

Conclusions:

We report a new cause of NORSE, following CAS. Stroke resulting in gliosis and cerebral hyperperfusion syndrome are the proposed mechanisms.

Baroreceptor Activation Therapy 2 Decades after Vascular Surgery on Both Carotid Arteries in a Patient with Resistant Hypertension: First Case Report in the Literature

Patients with previous surgery of the carotids or significant stenosis are not included in the study populations of baroreceptor activation therapy (BAT). In this case report about a 78-year-old woman with implantation of a BAT system 2 decades after bilateral thromboendarterectomy, control of hypertensive dysregulation could be observed even 20 months after implantation. Successful modulation of the baroreceptors requires intact adventitial tissue near the carotid sinus. In our case with previous longitudinal incision and patch angioplasty, the nerval innervation had been preserved. After careful evaluation, patients with a history of carotid thromboendarterectomy might be considered for BAT.

[Postoperative blood pressure alterations after carotid endarterectomy : Implications of different reconstruction methods]

BACKGROUND

Postoperative blood pressure alterations after carotid endarterectomy (CEA) are associated with an increased risk of morbidity and mortality.

OBJECTIVE

To outline the influence of the two commonly used surgical reconstruction techniques, conventional CEA with patch plasty (C-CEA) and eversion CEA (E-CEA), as well as the innovative carotid sinus-preserving eversion CEA (SP-E-CEA) technique on postoperative hemodynamics, taking the current scientific knowledge into consideration.

METHODS

Assessment of the current clinical and scientific evidence on each operative technique found in the PubMed (NLM) database ranging from 1974 to 2017, excluding case reports.

RESULTS

A total of 34 relevant papers as well as 1 meta-analysis, which scientifically dealt with the described topic were identified. The results of the studies and the meta-analysis showed that E‑CEA correlates with an impairment of local baroreceptor functions as well as with an elevated need for vasodilators in the early postoperative phase, whereas C‑CEA and SP-E-CEA seem to have a more favorable effect on the postoperative blood pressure.

CONCLUSION

The CEA technique influences the postoperative blood pressure regulation, irrespective of the operative technique used. Accordingly, close blood pressure monitoring is recommended at least during the postoperative hospital stay. Further studies are mandatory to evaluate the importance of SP-E-CEA as an alternative to the classical E‑CEA.

Baroreceptor reflex failure: Review of the literature and the potential impact on patients with head and neck cancer

BACKGROUND

Baroreceptor dysfunction and reflex failure may occur after surgery affecting the carotid artery. The implications for patients undergoing treatment for head and neck cancer are not well described.

METHODS

A literature search of PubMed was performed between March 2016 and May 2016. Search terms used individually and in combination included: "baroreflex failure," "carotid sinus sensitivity," "carotid endarterectomy," "carotid body tumor," and "head and neck cancer." Bibliographies of included articles were also reviewed for additional pertinent articles.

RESULTS

There is evidence of baroreceptor failure in certain patients after interventions associated with the carotid artery, including carotid endarterectomy and carotid body tumor excision. Few studies have been performed investigating the potential effect of head and neck surgery treatment, including surgery and/or radiation, on baroreflex function.

CONCLUSION

Head and neck cancer treatment has the potential to cause baroreflex failure, and this is likely an underrecognized and underdiagnosed condition.

Efficacy and safety of stenting for elderly patients with severe and symptomatic carotid artery stenosis: a critical meta-analysis of randomized controlled trials

OBJECTIVE

To investigate both short-term and long-term therapeutic efficacy and safety of carotid artery stenting (CAS) and carotid artery endarterectomy (CEA) for elderly patients with severe and symptomatic carotid artery stenosis.

METHODS

PubMed, EMBASE, Cochrane Library, Clinical Trials Register Centers, and Google Scholar were comprehensively searched. After identifying relevant randomized controlled trials, methodological quality was assessed by using Cochrane tools of bias assessment. Meta-analysis was performed by RevMan software, and subgroup analyses according to different follow-up periods were also conducted.

RESULTS

Sixteen articles of nine randomized controlled trials containing 6,984 patients were included. Compared with CEA, CAS was associated with high risks of stroke during periprocedural 30 days (risk ratio [RR]=1.47, 95% confidence interval [CI]: 1.15-1.88), 48 months (RR=1.37, 95% CI: 1.11-1.70), and >48 months (RR=1.76, 95% CI: 1.34-2.31). There was no significant difference in the aspects of death, disabling stroke, or death at any time between the groups. For other periprocedural complications, CAS decreased the risk of myocardial infarction (RR=0.44, 95% CI: 0.26-0.75), cranial nerve palsy (RR=0.09, 95% CI: 0.04-0.22) and hematoma (RR=0.31, 95% CI: 0.14-0.68) compared with CEA, while it increased the risk of bradycardia or hypotension (RR=8.45, 95% CI 2.91-24.58).

CONCLUSION

Compared with CEA, CAS reduced hematoma, periprocedural myocardial infarction, and cranial nerve palsy, while it was associated with higher risks of both short-term and long-term nondisabling stroke. And they seemed to be equivalent in other outcome measures. As regards to its minimal invasion, it should be applied only in specific patients.