The influence of gender on 30-day adverse clinical outcomes in patients undergoing carotid surgery

BACKGROUND

We aimed to further evaluate sex differences of perioperative and 30-day complications after carotid surgery in patients with both asymptomatic and symptomatic carotid artery stenosis.

METHODS

This was a single-center prospective cohort study including 2013 consecutive patients, who were treated surgically due to extracranial carotid artery stenosis and prospectively followed. Patients who underwent carotid artery stenting and who were treated conservatively were excluded. The primary endpoints for this study were hospital stroke/transitory ischemic attack (TIA) and overall survival rates. Secondary outcomes included all other hospital adverse events, 30-day stroke/TIA, and 30-day mortality rates.

RESULTS

Hospital mortality was higher in female patients with symptomatic carotid stenosis (3% vs. 0.5%, P=0.018). Bleeding requiring re-intervention occurred more often in female patients with both asymptomatic (1.5% vs. 0.4%, P=0.045) and symptomatic carotid stenosis (2.4% vs. 0.2%, P=0.022). 30-day stroke/TIA and mortality rates were higher in female patients with both asymptomatic (stroke/TIA 4.4% vs. 2.5%, P=0.041; mortality 3.3% vs. 1.6%, P=0.046) and symptomatic carotid stenosis (stroke/TIA 8.3% vs. 4.2%, P=0.040; mortality 4.1% vs. 0.7%, P=0.006). After adjusting for all confounding factors, female gender remained an important predicting factor for 30-day stroke/TIA in asymptomatic (OR=1.4, 95%CI 1.0-4.7, P=0.041) and symptomatic patients (OR=1.7, 95%CI 1.1-5.3, P=0.040), as well as for 30-day all-cause mortality in patients with asymptomatic (OR=1.5, 95%CI 1.1-4.1, P=0.030) and symptomatic carotid artery disease (OR=1.2, 95%CI 1.0-5.2, P=0.048).

CONCLUSIONS

Female gender is important predicting factor for stroke/TIA and all-cause mortality, both perioperative and during the first 30 days after carotid surgery.

Long-Term Results of Autologous Bifurcated Carotid Artery Reconstructions

BACKGROUND

Carotid bifurcation revascularization using interposition grafts is rare. While internal carotid artery (ICA) revascularization is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Long-term results of an autologous bifurcated carotid artery reconstruction are discussed.

METHODS

Single-center, retrospective analysis of a consecutive series of patients treated at an academic vascular surgery center.

RESULTS

From December 2006 to November 2019, fifty-one patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (38 males, 75%; median age: 68.7 years; interquartile range [IQR]: 60.2-76.5). Thirty-eight patients were asymptomatic (74.5%). Indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 32, symptomatic: n = 7), carotid aneurysm (n = 11, symptomatic: n = 5), neck tumor with vascular involvement (n = 7), trauma (n = 1). Nonreversed valve depleted saphenous vein y-graft from the groin was used in 49 (94.2%) and reversed cubital vein bifurcation in 3 (5.8%) procedures. The median ICA cross-clamp time was 15 min (IQR: 13-20 min). In four procedures (7.7%), a shunt was inserted because of a significant decrease of cerebral perfusion. In one patient, additional intraoperative stent placement of a proximal common carotid artery (CCA) stenosis was performed. Six patients suffered from ischemic neurological deficits (11.5%), all but 1 recovered with no or moderate symptoms. After a median follow-up of 5.2 years (IQR: 1.1-8.7 years), 7 significant asymptomatic stenoses (13.5%) and 2 occlusions (3.8%, one symptomatic) of the ICA, two significant asymptomatic CCA stenoses (3.8%), five significant stenoses (9.6%) and 7 asymptomatic occlusions (13.5%) of the ECA were observed. This prompted 7 re-redo-interventions in 5 patients. Twenty-eight patients (54.9%) died after a median follow-up of 3.3 years (IQR: 0.5-5.6 years). Two of these patients died due to conditions related to the performed carotid artery reconstruction.

CONCLUSIONS

Autologous bifurcated carotid artery interposition graft provides results comparable to other complex ICA revascularizations. Overall survival in this heterogeneous patient cohort is poor. Due to the high risk of stroke and poor long-term outcome, this procedure should be reserved for symptomatic patients with no other option for revascularization.

Acute Nonruptured Expansion of Extracranial Carotid Artery Aneurysm. An Infrequent Clinical Presentation

The extracranial carotid artery aneurysms are a rare disease, representing a low percentage of peripheral aneurysms (0.4-4%). Their main symptoms are derived from cerebral events and local compression, with rupture being rare. We report the case of a 79-year-old woman who presented with a right Common Carotid Artery aneurysm with pain and local symptoms. The expansion of the aneurysm is documented with images and the surgical treatment consisting of bypass from Common Carotid artery to Internal Carotid artery with Dacron prosthesis and reimplantation of External Carotid artery is described and discussed. To the best of our knowledge, this is the first case of expansion directly documented in the literature.

Biodegrading highly porous elastomeric graft regenerates muscular and innervated carotid artery-Comparative study with vein graft

This study aims to investigate the superiorities of fast degrading elastomeric poly(glycerol sebacate) (PGS)/polycaprolactone (PCL) grafts over autologous vein grafts in the reconstruction of carotid artery, thus providing more suitable vascular grafts for carotid artery replacement. We fabricated small arterial grafts from microporous tubes of PGS reinforced with PCL nanofibers on the outer surface. As control, autologous jugular veins were harvested as vein grafts. Both types of grafts were interpositioned in rat carotid arteries and evaluated at 1 year postoperatively. PGS/PCL grafts remodelled into "neoarteries" (regenerated arteries) with smooth and even vessel wall approximate to native carotid arteries. In contrast, dilated vessel cavity and thickening vessel wall presented in neoarteries remoulded from vein. Histologically, neoarteries from both groups mimic arterial tissue architecture with a confluent endothelium and media and adventita-like layers, whereas PGS/PCL neoarteries presented well-organized muscular component and elastic fibres, which contributed more flexibility and elasticity. Different from vein grafts, PGS/PCL neoarteries acquired reinnervation and displayed apparent vascular function of contraction and relaxation, as was confirmed with responsiveness to various vasoactivators, which suggests that vascular cells within neoarteries express functional phenotypes and potential of autonomic reactivity that carotid arteries owned. To conclude, according to the requirement of strong flexibility, innervation from sympathetic and parasympathetic nerves which can response the carbon dioxide and blood pressure, the muscular remodelling and innervation possessed promising possibility of clinical application.

Autologous Bifurcated Carotid Artery Reconstruction: Technique and 2 Year Follow Up

OBJECTIVE/BACKGROUND

Carotid bifurcation resection with subsequent reconstruction is performed infrequently. While internal carotid artery (ICA) revascularisation is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Indications for and results of an autologous bifurcated carotid artery reconstruction are discussed.

METHODS

This was a single centre retrospective analysis of a consecutive series of patients treated at an academic vascular surgery centre.

RESULTS

From December 2006 to August 2015, 47 patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (36 men; median age 68.3 years [range 41-87 years]; 33 asymptomatic [70%]). The indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 29; symptomatic: n = 12), carotid aneurysm (n = 10), neck tumour with vascular involvement (n = 7), and trauma (n = 1). Groups were not different with regard to vascular risk factors. Non-reversed valve depleted saphenous/accessory saphenous vein from the groin was used in 44 (94%), and reversed valve depleted cubital vein bifurcation graft in three patients (6%). Median ICA cross clamp time was 17 min (range 8-30 min). Five patients suffered from intra-operative ischaemic neurological deficits (11%), of which all were temporary except one. One tumour patient died on post-operative day 1 due to bleeding. Median follow up was 28.3 months (range 0.1-97.4 months). Tumour erosion required graft ligation in one patient 7 months after reconstruction. Five significant stenoses of the ICA (11%), nine (19%) stenoses of the ECA, and two (4%) common carotid artery stenoses, with four (8%) re-redo interventions, were observed. Thirteen patients (28%) died after a median follow up of 6.7 months (range 1.7-56.7 months), all unrelated to the vascular procedure.

CONCLUSION

Autologous bifurcated carotid artery interposition graft avoids the use of prosthetic graft material, the ECA remains patent in 80%, and it provides mid-term results comparable with other redo carotid artery procedures. Therefore, this procedure should be reserved for symptomatic patients with no other revascularisation option.

Polyester vascular patches acquire arterial or venous identity depending on their environment

Polyester is commonly used in vascular surgery for patch angioplasty and grafts. We hypothesized that polyester patches heal by infiltration of arterial or venous progenitor cells depending on the site of implantation. Polyester patches were implanted into the Wistar rat aorta or inferior vena cava and explanted on day 7 or 30. Neointima that formed on polyester patches was thicker in the venous environment compared to the amount that formed on patches in the arterial environment. Venous patches had more cell proliferation and greater numbers of VCAM-positive and CD68-positive cells, whereas arterial patches had greater numbers of vimentin-positive and alpha-actin-positive cells. Although there were similar numbers of endothelial progenitor cells in the neointimal endothelium, cells in the arterial patch were Ephrin-B2- and notch-4-positive while those in the venous patch were Eph-B4- and COUP-TFII-positive. Venous patches treated with an arteriovenous fistula had decreased neointimal thickness; neointimal endothelial cells expressed Ephrin-B2 and notch-4 in addition to Eph-B4 and COUP-TFII. Polyester patches in the venous environment acquire venous identity, whereas patches in the arterial environment acquire arterial identity; patches in the fistula environment acquire dual arterial-venous identity. These data suggest that synthetic patches heal by acquisition of identity of their environment. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 3422-3431, 2017.