Surgical Technique for Carotid Endarterectomy: Current Methods and Problems

Neuron-Specific Enolase and S100B as Biomarkers of Ischemic Brain Injury During Surgery

Biochemical markers can be used in addition to neuroimaging techniques to evaluate the extent of ischemic brain injuries and to enable earlier diagnosis and faster intervention following the ischemic event. Among the potential biomarkers of ischemic brain injuries during surgery, neuron-specific enolase (NSE) and S100B are the most frequently studied and were shown to be the most promising. The aim of this review was to summarize the role of NSE and S100B as biomarkers of ischemic brain injuries that occur during selected surgical procedures, predominantly carotid endarterectomy (CEA). Some other invasive interventions that cause ischemic brain injuries, like extracorporeal membrane oxygenation, were also included. We can conclude that these biomarkers can be useful for the evaluation of ischemic brain injuries that occur during various surgical procedures. They can help to determine the most optimal conditions for performing the surgery and therefore improve the procedures to consequently minimize brain damage caused during surgery. Because of a significant delay between sample collection and obtaining the results, they are not suitable for real-time assessment of brain injuries. Some improvement can be expected with the future development of laboratory methods. The association of the changes in NSE and S100B levels during surgery with potential consequences of ischemic brain injury have been described in numerous studies. However, even in a very homogenous group of surgical procedures like CEA, these findings cannot be summarized into a common final conclusion; therefore, the prognostic value of the two markers is not clearly supported at the present time.

Carotid Disease and Management

Carotid artery stenosis is a leading cause of stroke, and 25% of patients experience a recurrent stroke within 5 years. Early detection and treatment are important to reduce the risk of stroke. Optimal medical therapy should be ensured among these patients regardless of symptom status. Carotid artery revascularization with carotid endarterectomy or carotid artery stenting (CAS) should be considered among patients with symptomatic carotid stenosis, or among patients with severe asymptomatic carotid artery stenosis. Refined procedural techniques, improvement in stent design, and use of embolic protection devices have enhanced the efficacy of CAS while reducing the risk of procedural complications.

Novel Fusion Imaging of Muscle, Plaque, Arteries, and Bone Using MR Imaging for Carotid Endarterectomy Patients

BACKGROUND

Indications for carotid endarterectomy (CEA) and reduction of complications require evaluation of the plaque properties and location of the distal end of the plaque. High cervical location can be predicted from the anatomy of the vertebral body and mandibular bones and the locations of the posterior belly of the digastric muscle and stylohyoid muscle. Magnetic resonance (MR) imaging without contrast medium is useful for preoperative evaluation of the plaque, arteries, and bone characterization. However, no method for simultaneous evaluation of the muscle, plaque, arteries, and bone using MR imaging has been established.

METHODS

Five patients with moderate or higher carotid artery stenosis underwent CEA in our institute. Noncontrast MR imaging/MR angiography and computed tomography (CT) angiography were performed before surgery in all cases. The fusion images of the muscle, plaque, arteries, and bone (M-PAB image) acquired from MR imaging/MR angiography, CT angiography, and the intraoperative view were compared.

RESULTS

M-PAB image, CT angiography, and intraoperative view were acquired in all cases with no obvious differences.

CONCLUSIONS

M-PAB imaging using MR imaging without contrast medium is useful for preoperative evaluation of CEA. This method does not require contrast agents and avoids radiation exposure.

Simulating atherosclerotic plaque mechanics using polyvinyl alcohol (PVA) cryogel artery phantoms, ultrasound imaging and inverse finite element analysis

The clinical decision to establish if a patient with carotid disease should undergo surgical intervention is primarily based on the percent stenosis. Whilst this applies for high-grade stenosed vessels (>70%), it falls short for other cases. Due to the heterogeneity of plaque tissue, probing the mechanics of the tissue would likely provide further insights into why some plaques are more prone to rupture. Mechanical characterization of such tissue is nontrivial, however, due to the difficulties in collecting fresh, intact plaque tissue and using physiologically relevant mechanical testing of such material. The use of polyvinyl alcohol (PVA) cryogel is thus highly convenient because of its acoustic properties and tunable mechanical properties.Methods.The aim of this study is to demonstrate the potential of PVA phantoms to simulate atherosclerotic features. In addition, a testing and simulation framework is developed for full PVA vessel material characterization using ring tensile testing and inflation testing combined with non-invasive ultrasound imaging and computational modeling.Results.Strain stiffening behavior was observed in PVA through ring tensile tests, particularly at high (n= 6) freeze-thaw cycles (FTCs). Inflation testing of bi-layered phantoms featuring lipid pool inclusions demonstrated high strains at shoulder regions. The application of an inverse finite element framework successfully recovered boundaries and determined the shear moduli for the PVA wall to lie within the range 27-53 kPa.Conclusion.The imaging-modeling framework presented facilitates the use and characterization of arterial mimicking phantoms to further explore plaque rupture. It also shows translational potential for non-invasive mechanical characterization of atherosclerotic plaques to improve the identification of clinically relevant metrics of plaque vulnerability.

An unexpected variation of occipital and ascending pharyngeal arteries: clinical implications

PURPOSE

The eight typical External Carotid Artery (ECA) branches are the superior thyroid artery, ascending pharyngeal artery, lingual artery, facial artery, occipital artery, posterior auricular artery, maxillary artery, and superficial temporal artery. The Internal Carotid Artery (ICA) has no branches in the cervical region before entering the carotid canal. We identified a variant of the Occipital Artery (OA) and Ascending Pharyngeal Artery (APA) originating in the cervical portion of the ICA and wish to explore the clinical implications this variation may have.

METHODS

Between August and December 2023, 28 formaldehyde donors were dissected in the anatomy course for first-year medical and physician assistant students at the Creighton University School of Medicine, Phoenix campus.

RESULTS

In one donor, dissection of the right common carotid artery (CCA) revealed a variation of the ECA branches. Two branches were found on the proximal portion of the ICA. After tracing the branches cranially, we identified these as the OA and APA. These two arteries typically originate from the ECA. The bifurcation angle was observed to be nearly 180 degrees. This variation was only observed on the right side.

CONCLUSION

As the prevalence of this variation has only been described in one study, reporting at 0.14%, documentation and education of this anatomy aids surgeons and interventional radiologists in head and neck procedures. Exploring the paths of these ectopic arteries promotes informed decision making and risk stratification for carotid endarterectomy, arterial embolization, bypass procedures, and arterial harvesting. Furthermore, performing thorough imaging such as CT angiograms on patients preoperatively provides better foresight to minimize complications.

Comparative Analysis of Somatosensory-Evoked Potentials and Transcranial Doppler Ultrasound for Cerebral Ischemia Detection in Carotid Endarterectomy: Insights from Network Meta-Analysis and Clinical Data

OBJECTIVE

This study aims to compare the diagnostic efficacy of somatosensory-evoked potentials (SEPs) and transcranial Doppler sonography (TCD) for monitoring cerebral tissue ischemia during carotid endarterectomy (CEA) using network meta-analysis and retrospective analysis of clinical data.

METHODS

For the meta-analysis, we conducted a comprehensive search of 4 electronic databases (PubMed, EMBASE, Cochrane, and Web of Science) from inception to September 2023, resulting in the inclusion of 52 relevant articles. Additionally, a retrospective study was conducted at our hospital, involving patients who underwent CEA surgery from July 2019 to July 2021.

RESULTS

The network meta-analysis incorporated 52 articles, with ranking results indicating that SEP demonstrated superior performance in specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy with surface under the cumulative ranking curve values of 99.9%, 93.8%, 96.6%, and 99.9%, respectively. Furthermore, TCD exhibited the highest sensitivity with a surface under the cumulative ranking value of 92.0%. A total of 190 patients meeting inclusion criteria were included in the retrospective study. The area under the curve for SEP's receiver operating characteristic curve was 0.787, compared to TCD's area under the curve of 0.606. SEP demonstrated a sensitivity of 66.67%, with a specificity of 90.76%, PPV of 19.05%, NPV of 98.82%, and accuracy of 90%. For TCD, the diagnostic performance measures included a sensitivity of 50.00%, specificity of 71.19%, PPV of 5.35%, NPV of 97.76%, and accuracy of 70.53%. The Fisher's exact test for sensitivity yielded a result of P = 1.000. The χˆ2 test for specificity resulted in χˆ2 = 22.863, with P < 0.001. Continuous correction χˆ2 tests for PPV and NPV showed χˆ2 = 2.005 (P = 0.157) and χˆ2 = 0.069 (P = 0.793), respectively. Additionally, the χˆ2 test for accuracy showed χˆ2 = 22.742, with P < 0.001.

CONCLUSIONS

During CEA, SEP appears to provide a slightly more reliable indication of the ischemic condition in cerebral tissues compared to TCD.

Heart rate variability as a dynamic marker of surgeons' stress during vascular surgery

BACKGROUND

A surgeon experiences elevated stress levels when operating. Acute stress is linked to cognitive overload, worsening surgical performance. Chronic stress poses a significant risk to a surgeon's health. Identifying intraoperative stress may allow for preventative strategies that reduce surgeons' stress and subsequently improve patient outcomes. The aim of this study was to assess the feasibility of using heart rate variability as a marker of stress during vascular surgery.

METHODS

A total of 11 senior surgeons were evaluated performing three different vascular surgery procedures. Heart rate variability metrics (low-frequency to high-frequency ratio and standard deviation of the normal-normal interval) were determined from single-lead ECG traces at predetermined procedural performance points. State-Trait Anxiety Inventory-6, a validated stress tool, was used to assess surgeon-reported stress. Subjective reports of procedural difficulty were also collected. One-way ANOVA compared heart rate variability at key performance points with baseline. Pearson's coefficient assessed correlation between heart rate variability and subjective stress.

RESULTS

Data were collected for six carotid endarterectomies, six open abdominal aortic aneurysm repairs, and five lower limb bypasses. Heart rate variability metrics indicating markedly greater stress were observed at key performance points across all procedures. Peaks in stress were consistent across different surgeons performing the same procedure. A significant correlation was observed between heart rate variability metrics and subjective State-Trait Anxiety Inventory-6 stress reports (r = 0.768, P =<0.001). The most difficult procedural steps reported corresponded with heart rate variability metrics displaying the greatest stress.

CONCLUSION

Heart rate variability may be a viable approach to assess intraoperative stress and cognitive load during vascular surgery and could be used to evaluate whether a theatre intervention (for example timeout) could reduce stress in areas of surgical difficulty.

Unstable Plaque is a Treatable Cause of Cognitive Decline

While many risk factors are modifiable, there remains a compelling need for novel approaches to prevent cognitive impairment. We propose that unstable carotid plaque causes microemboli that, in turn, cause microinfarcts and other adverse pathophysiological cerebral processes, which individually do not manifest clinically but cumulatively manifest as cognitive decline and ultimately cognitive impairment. Animal models support multiple cerebral microemboli having adverse effects on cognition. By addressing the source for microembolization by endarterectomy or stenting, patients with high-grade atherosclerotic stenosis may have better cognitive outcomes. If our hypothesis is verified, then treatment of carotid plaque at elevated risk of generating cerebral microemboli would be effective in preserving cognition, regardless of whether the stenosis is high-grade or causing cerebral hemispheric hypoperfusion.

The Role of Neurosurgical Techniques in Management of Acute and Chronic Stroke: A Comprehensive Literature Review

Stroke is a medical condition that results from a decreased or completely diminished supply of blood to the brain, and it is considered one of the major causes of morbidity and mortality globally. Stroke is categorized as ischemic and hemorrhagic stroke, both of which demand prompt and particular timely intervention. This extensive review is done to investigate the precise management of acute and chronic manifestations of stroke in relation to neurosurgical interventions, ultimately providing a thorough analysis regarding indications, procedures, outcomes, and complications that are associated with it. In this regard, a pervasive review of literature was carried out, which was primarily sourced from literature databases such as PubMed. This paper particularly outlines a sound relative analysis of anticipating the competence of each neurosurgical technique in use. Endovascular clot retrieval (ECR) has been particularly highlighted, as its effectiveness has been profoundly observed when selected as a treatment option within a time period of 6-24 hours following an ischemic stroke. In less than a time frame of 48 hours, decompressive hemicraniectomy (DH) is usually considered the most suitable treatment for cases of intracranial hypertension resulting from middle cerebral artery (MCA) infarction. Hemorrhages that occur due to ruptured aneurysms are most commonly dealt with clipping and neuroendovascular techniques. Additionally, considering that revascularization surgery is time-sensitive, the results can ultimately vary. Competent results have been linked with stereotactic surgery, which includes deep brain stimulation (DBS) and focused ultrasound ablation (FUSA), which are also famous for being minimally invasive in nature. However, the broader application of these techniques is hindered by the absence of established protocols. This review highlights the importance of timely interventions, advanced equipment, and precise medical protocols to optimize treatment outcomes.

Cerebral autoregulation-directed optimal blood pressure management reduced the risk of delirium in patients with septic shock

Background

When resuscitating patients with septic shock, cerebrovascular reactivity parameters are calculated by monitoring regional cerebral oxygen saturation (rSO2) using near-infrared spectroscopy to determine the optimal blood pressure. Here, we aimed to analyze the impact of cerebral autoregulation-directed optimal blood pressure management on the incidence of delirium and the prognosis of patients with septic shock.

Methods

This prospective randomized controlled clinical study was conducted in the Xiangya Hospital of Central South University, China. Fifty-one patients with septic shock (December 2020-May 2022) were enrolled and randomly allocated to the experimental (n=26) or control group (n=25). Using the ICM+ software, we monitored the dynamic changes in rSO2 and mean arterial pressure (MAP) and calculated the cerebrovascular reactivity parameter tissue oxygen reactivity index to determine the optimal blood pressure to maintain normal cerebral autoregulation function during resuscitation in the experimental group. The control group was treated according to the Surviving Sepsis Campaign Guidelines. Differences in the incidence of delirium and 28-day mortality between the two groups were compared, and the risk factors were analyzed.

Results

The 51 patients, including 39 male and 12 female, had a mean age of (57.0±14.9) years. The incidence of delirium was 40.1% (23/51), and the 28-day mortality rate was 29.4% (15/51). The mean MAP during the first 24 h of intensive care unit (ICU) admission was higher ([84.5±12.2] mmHg vs. [77.4±11.8] mmHg, P=0.040), and the incidence of delirium was lower (30.8% vs. 60.0%, P=0.036) in the experimental group than in the control group. The use of cerebral autoregulation-directed optimal blood pressure (odds ratio [OR]=0.090, 95% confidence interval [CI]: 0.009 to 0.923, P=0.043) and length of ICU stay (OR=1.473, 95% CI: 1.093 to 1.985, P=0.011) were risk factors for delirium during septic shock. Vasoactive drug dose (OR=8.445, 95% CI: 1.26 to 56.576, P=0.028) and partial pressure of oxygen (PaO2) (OR=0.958, 95% CI: 0.921 to 0.996, P=0.032) were the risk factors for 28-day mortality.

Conclusions

The use of cerebral autoregulation-directed optimal blood pressure management during shock resuscitation reduces the incidence of delirium in patients with septic shock.

Trial Registration

ClinicalTrials.gov ldentifer: NCT03879317.

Contemporary open surgical approaches for the management of carotid stenosis: a comprehensive review

This study aims to provide an overview on contemporary open surgical approaches for the management of carotid artery stenosis. A comprehensive literature search was performed to identify and categorize open surgery intervention techniques for the management of carotid artery stenosis, focusing on the benefits and drawbacks of each technique. Five surgical techniques for carotid endarterectomy (CEA) have been described: CEA with primary closure, CEA with patch closure, CEA by eversion technique, CEA by modified eversion technique and CEA by partial eversion. Evidence has reported significantly higher rates of perioperative complications after CEA with primary closure, including 30-days stroke rate and late restenosis. Although more recent techniques have been reported to provide superior outcomes, electing the best surgical technique is still a matter of debate. Also, CEA using a mini-skin incision has been associated to lower risk of cranial/cervical nerve injury and shorter length of hospital stay. The selection of the surgical intervention should be tailored and have into consideration individual patient characteristics, clinical considerations, surgeon preference and surgical team expertise. Further large-scale randomized clinical trials are needed to support more robust decisions on the choice of contemporary open surgical approaches to manage carotid stenosis.

Outcomes of carotid endarterectomy: Insights from a single-center retrospective cohort study

OBJECTIVES

To analyze the outcomes of carotid endarterectomy in individuals with carotid artery stenosis in the context of a tertiary care center.

METHODS

We carried out a retrospective cohort investigation between 2015-2022. Patient data includes demographics, risk factors, preoperative medications, and operative details. The primary outcomes were 30-day postoperative stroke and mortality rates, while the secondary outcome of the study was to assess the morbidity of the procedure.

RESULTS

The mean age of the 54 patients was 66.9±9.88 years, and 57.4% were men. The 30-day stroke rate was 3.7%, and the mortality rate was 1.9%. Most patients did not develop postoperative complications; however, surgical site hematoma was the most common complication encountered (12.9%). Long-term follow-up showed disease regression in 68.5% of patients, with a minority of patients developing ipsilateral restenosis. Admission to an intensive care monitoring unit was the only independent predictor of postoperative complications.

CONCLUSION

This study provided insights into the outcomes of carotid endarterectomy in patients with carotid artery stenosis, emphasizing the importance of careful patient selection and postoperative monitoring. Perioperative risks, including stroke and mortality, were within acceptable limits. Further research incorporating structured and non-structured data for predictive analyses, should explore refining patient profiling and optimizing treatment approaches for different carotid artery stenosis clinical and morphological presentations.

Revitalizing neurosurgical frontiers: The EANS frontiers in neurosurgery committee's strategic framework

Introduction

The field of neurosurgery faces challenges with the increasing involvement of other medical specialties in areas traditionally led by neurosurgeons. This paper examines the implications of this development for neurosurgical practice and patient care, with a focus on specialized areas like pain management, peripheral nerve surgery, and stereotactic radiosurgery.

Research question

To assess the implications of the expanded scope of other specialties for neurosurgical practice and to consider the response of the EANS Frontiers in Neurosurgery Committee to these challenges.

Materials and methods

Analysis of recent trends in neurosurgery, including the shift in various procedures to other specialties, demographic challenges, and the emergence of minimally invasive techniques. This analysis draws on relevant literature and the initiatives of the Frontiers in Neurosurgery Committee.

Results

We explore a possible decrease in neurosurgical involvement in certain areas, which may have implications for patient care and access to specialized neurosurgical interventions. The Frontiers in Neurosurgery Committee's role in addressing these concerns is highlighted, particularly in terms of training, education, research, and networking for neurosurgeons, especially those early in their careers.

Discussion and conclusion

The potential decrease in neurosurgical involvement in certain specialties warrants attention. This paper emphasizes the importance of carefully considered responses by neurosurgical societies, such as the EANS, to ensure neurosurgeons continue to play a vital role in managing neurological diseases. Emphasis on ongoing education, integration of minimally invasive techniques, and multidisciplinary collaboration is essential for maintaining the field's competence and quality in patient care.

Is low carotid bifurcation determined by vertebral level always convenient for surgical approach?

Although high-level carotid bifurcation (HCB) could lead to notable surgical difficulty, the definitive reference point for HCB is unclear. HCB is typically characterized as carotid bifurcation (CB) located higher than the level of the third cervical vertebra (C), however, a major obstacle regarding carotid artery surgical exposure is angle of the mandible (AM). The objective of this study was to investigate CB level, define HCB in relation to AM and vertebral levels, and measure the vertical distance from HCB to ipsilateral AM. Moreover, the percentage of surgically challenged CBs, misclassified as low CBs (LCB) based on vertebral level, was investigated. Patients who underwent neck computed tomography angiography were retrospectively studied. HCBs were classified into two categories: CBs above the C3 and either at or above the ipsilateral AM. Of 172 CBs (86 patients; 57 men, 29 women), CB was mostly found at C3 (44.19%), whereas AM was commonly located at C2 (51.16%). Based on vertebral level and AM, HCBs were detected in 10.47% and 20.35% of CBs, respectively. The association of HCBs determined by either C3 or AM between both sides in each individual was nonsignificant (p>0.05), but HCBs determined by C3 level were predominant in women (OR = 3.58, 95%CI = 1.31-9.80). Considering both C3 and AM, there was 8.72% of HCBs. The remaining 91.28% was classified as LCBs, including 11.63% of CBs located at both C3 and AM which were actually classified as HCBs if determined by AM. In cases of CBs above AM level, the mean vertical distance was as high as 6.56 ±2.41mm.

Comparison of the Clinical Outcome of Carotid Artery Stenting Between Institutions With a Treatment Strategy Based on Risk Factors and Those With First-Line Treatment

PURPOSE

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended based on certain risk factors. The volume of an institution's treatment experience may be associated with good clinical outcomes. There is a dilemma between the treatment strategy based on risk factors and the experience volume. Therefore, we investigated the clinical outcomes of CAS performed at institutions that selected the treatment strategy based on risk factors and those that performed CAS at the first-line treatment.

MATERIALS AND METHODS

Patients who underwent CAS at 5 institutions were included in this retrospective case-control study. We defined CEA/CAS institutions as those that selected the treatment option based on risk factors, and CAS-first institutions as those that performed CAS as the first-line treatment. We investigated cases of ischemic stroke, hemorrhagic stroke, myocardial infarction, and deaths within 30 days of the intervention between the CEA/CAS- and CAS-first institution groups. One-to-one propensity score matching was performed to compare rates of ischemic and hemorrhagic strokes within 30 days of the intervention.

RESULTS

A total of 239 and 302 patients underwent CAS at the CEA/CAS institutions and CAS-first institutions, respectively; ischemic stroke occurred in 12 (5.0%) and 7 patients (2.3%), respectively (p=0.09). No differences in major ischemic strokes (0.8% vs 1.3%; p=0.59), hemorrhagic strokes (0.4% vs 0.3%; p=0.87), or deaths (0.0% vs 0.7%; p=0.21) were observed. Myocardial infarction did not occur in either group. Propensity score analysis showed that ischemic stroke (odds ratio: 1.845, 95% confidence interval: 0.601-5.668, p=0.28) and hemorrhagic stroke (odds ratio: 1.000, 95% confidence interval: 0.0061-16.418, p=1.00) were not significantly associated with either institution group.

CONCLUSIONS

The CAS-specific treatment strategies for CAS can achieve the same level of outcomes as the treatment strategy based on risk factors. The CAS performed based on risk factors in CEA/CAS institutions and the treatment of more than 30 patients/year/institution in CAS-first institutions were associated with good clinical outcomes.

Cadaver investigation of the usefulness of the transstyloid diaphragm approach for high-position plaque carotid endarterectomy

OBJECTIVES

Patients sometimes present with high cervical internal carotid artery (ICA) stenosis. This study demonstrates the usefulness of the transstyloid approach to expose the distal ICA by dissection of the styloid diaphragm covering the distal cervical ICA for carotid endarterectomy (CEA). In particular, the possible exposure length achieved by this approach was investigated using cadaveric heads.

METHODS

The procedure of the transstyloid diaphragm approach was confirmed in 10 cadaveric heads (20 sides). After the carotid triangle was opened, both the posterior belly of the digastric muscle (PBDM) and the stylohyoid muscle could be divided. Then, the carotid sheath was dissected, and the glossopharyngeal nerve was identified crossing over the distal ICA. The revealed length of the ICA was measured with or without dissection of both the PBDM and the stylohyoid muscle. The specimens were dissected under the surgical microscope.

RESULTS

The transstyloid diaphragm approach was achieved successfully in all specimens. The revealed lengths of the ICA with and without dissection of the styloid diaphragm were 53.7 ± 5.9 mm and 38.8 ± 2.9 mm (mean ± standard deviation), respectively. Therefore, the revealed length of the distal ICA was 14.9 ± 4.5 mm greater using the transstyloid diaphragm approach compared to the regular CEA approach.

CONCLUSIONS

More of the ICA can be revealed by dissection of both the PBDM and the stylohyoid muscle. The transstyloid diaphragm approach might be helpful to reveal the distal ICA in cases of high cervical ICA stenosis.

History of Carotid Artery Reconstruction around the World and in Japan

Since ancient times, physicians have been aware of correlations between the carotid artery and consciousness; however, carotid stenosis was only recently identified as the cause of atherothrombotic ischemic stroke. In 1658, Wepfer described the first suggestion of a link between symptoms of cerebral arterial insufficiency and carotid pathology. In 1951, Fisher reported details of the symptoms and pathological findings and emphasized that cervical atheromatous lesions induced cerebral infarction with various symptoms. The beginning of carotid artery surgery was ligation of the carotid artery for neck or head injury, but surgeons were aware that this operation induced cerebral symptoms due to lack of blood supply. Carotid endarterectomy (CEA) was first reported by Eastcott et al. in 1954, and in Japan, Kimoto performed a successful CEA in 1962. In 1979, percutaneous transluminal angioplasty (PTA) was performed for patients with fibromuscular dysplasia, and then, carotid artery stenting (CAS) was first performed in 1989 by Mathias. In Japan, Kuwana et al. were the first to perform carotid PTA, in 1981, whereas Yamashita et al. performed the first CAS in 1997. Yoshimura et al. proposed staged carotid stenting to prevent hyperperfusion syndrome. Some issues in carotid reconstruction are still debated today, which include conventional (standard) CEA versus the eversion technique, CEA versus CAS versus medical therapy, and medical economic problems. In the future, we must continue to develop more effective, safer, and less expensive therapeutic methods to prevent carotid stroke, carrying on the efforts of the ancient peoples who pioneered this research.

Carotid Endarterectomy Versus Stenting for the Treatment of Patients With Carotid Artery Stenosis: An Updated Systematic Review and Meta-Analysis

Carotid endarterectomy (CEA) is a surgical procedure that treats the narrowed carotid arteries, which may be narrowed by atherosclerosis. Stenting is the insertion of a wire mesh scaffold into the narrowed portion of the carotid artery to keep it open by preventing blood from clotting. Using the study done over 10 years back as a point of reference, this study will seek an update on an assessment comparing CEA and stenting in studies carried out between 2015 and to date. The PICOS (population, intervention, control, outcome, and study designs) criteria were used to construct a set of inclusion and exclusion guidelines. This meta-analysis and systematic review used two forms of investigative analysis; both quantitative and qualitative assessments. From the studies, stroke (95% CI: 0.51-0.71, P < 0.001), myocardial infarction (95% CI: 1.49-3.42, P = 0.001), and stroke or death analysis (95% CI: 0.53-0.77, P < 0.001) were noted to be significant. From the analysis, CEA was observed as having better treatment results in terms of stroke events and stroke or death incidences when compared to stenting. Carotid stenting was observed as having lower cases of myocardial infarctions when compared to endarterectomy.

From surgical clamping to endovascular flow arrest/reversal: the concept behind the system

Carotid artery lesions are frequently composed of friable, thrombotic, ulcerated and/or hemorrhagic materials which can embolize during surgical or endovascular interventions. The use of embolic protection devices (EPD) during carotid angioplasty and stenting (CAS) has been proven to be associated with a reduction of the embolic load. Many studies indicate that the clinical results of CAS are comparable with the best surgical series, when EPD are routinely applied. The proximal EPD work by interrupting or reversing the blood flow in the common carotid artery/internal carotid artery (CCA/ICA). Once established the endovascular flow arrest/reversal, these systems have the advantages of promoting a protected crossing of the lesion and blocking both macro-emboli and micro-emboli. Moreover, proximal neuroprotection implies no manipulation of the device in the distal ICA, neither during device deployment nor during device retrieval, and reduces the risk of arterial spasm, dissection, or intimal damage. The choice between transfemoral and transcervical proximal EPD should account for different factors: local availability, operator expertise, and patient characteristics including anatomical features precluding flow arrest/reversal (e.g., incomplete circle of Willis), femoral access (e.g., unfavorable aortic arch anatomy), or transcervical access (e.g., diseased CCA).

The Gupta Perioperative Risk for Myocardial Infarct or Cardiac Arrest (MICA) Calculator as an Intraoperative Neurologic Deficit Predictor in Carotid Endarterectomy

Background: Patients undergoing carotid endarterectomy (CEA) may experiment intraoperative neurologic deficits (IND) during carotid cross-clamping. This work aimed to assess the impact of the Gupta Perioperative Myocardial Infarct or Cardiac Arrest (MICA) risk calculator in the IND. Methods: From January 2012 to April 2021, patients undergoing CEA with regional anaesthesia for carotid stenosis with IND and consecutively control operated patients without IND were selected. A regressive predictive model was created, and a receiver operating characteristic (ROC) curve was applied for comparison. A multivariable dependence analysis was conducted using a classification and regression tree (CRT) algorithm. Results: A total of 97 out of 194 included patients developed IND. Obesity showed aOR = 4.01 (95% CI: 1.66–9.67) and MICA score aOR = 1.21 (1.03–1.43). Higher contralateral stenosis showed aOR = 1.29 (1.08–1.53). The AUROC curve was 0.656. The CRT algorithm differentiated obese patients with a MICA score ≥ 8. Regarding non-obese patients, the model identified the presence of contralateral stenosis ≥ 55% with a MICA ≥ 10. Conclusion: MICA score might play an additional role in stratifying patients for IND in CEA. Obesity was determined as the best discrimination factor, followed by a score ≥ 8. A higher ipsilateral stenosis degree is suggested to have a part in avoiding procedure-related IND. Larger studies might validate the benefit of MICA score regarding the risk of IND.

Surgical access to the distal cervical segment of the internal carotid artery and to a high carotid bifurcation – integrative literature review and protocol proposal

Abstract Several different maneuvers have been described for obtaining access to the distal cervical segment of the internal carotid artery or to a high carotid bifurcation. However there are different approaches to systematization of these techniques. The objective of this study is to review the techniques described and propose a practical protocol to support selection of the most appropriate technique for each case. The review is based on the results of database searches on PubMed Central, the Virtual Health Library (BVSalud), and SciELO for articles on the subject published in English or Portuguese from 1980 to 2021. Among the different maneuvers described, it appears reasonable that the first two steps should be to obtain access at the sternocleidomastoid muscle, followed by section or retraction of the digastric muscle posterior belly. If needed, temporary unilateral mandibular subluxation is an additional resource that is preferable to division of the styloid apparatus process, because of its lesser potential for morbidity. Even wider exposure can be obtained using mandibular osteotomies.

Acesso cirúrgico ao segmento cervical distal da artéria carótida interna e à bifurcação carotídea alta – revisão integrativa da literatura e proposta de protocolo

Several different maneuvers have been described for obtaining access to the distal cervical segment of the internal carotid artery or to a high carotid bifurcation. However there are different approaches to systematization of these techniques. The objective of this study is to review the techniques described and propose a practical protocol to support selection of the most appropriate technique for each case. The review is based on the results of database searches on PubMed Central, the Virtual Health Library (BVSalud), and SciELO for articles on the subject published in English or Portuguese from 1980 to 2021. Among the different maneuvers described, it appears reasonable that the first two steps should be to obtain access at the sternocleidomastoid muscle, followed by section or retraction of the digastric muscle posterior belly. If needed, temporary unilateral mandibular subluxation is an additional resource that is preferable to division of the styloid apparatus process, because of its lesser potential for morbidity. Even wider exposure can be obtained using mandibular osteotomies.

Cerebral and Systemic Stress Parameters in Correlation with Jugulo-Arterial CO2 Gap as a Marker of Cerebral Perfusion during Carotid Endarterectomy

Intraoperative stress is common to patients undergoing carotid endarterectomy (CEA); thus, impaired oxygen and metabolic balance may appear. In this study, we aimed to identify new markers of intraoperative cerebral ischemia, with predictive value on postoperative complications during CEA, performed in regional anesthesia. A total of 54 patients with significant carotid stenosis were recruited and submitted to CEA. Jugular and arterial blood samples were taken four times during operation, to measure the jugulo-arterial carbon dioxide partial pressure difference (P(j-a)CO₂), and cortisol, S100B, L-arginine, and lactate levels. A positive correlation was found between preoperative cortisol levels and all S100B concentrations. In addition, they are positively correlated with P(j-a)CO₂ values. Conversely, postoperative cortisol inversely correlates with P(j-a)CO₂ and postoperative S100B values. A negative correlation was observed between maximum systolic and pulse pressures and P(j-a)CO₂ after carotid clamp and before the release of clamp. Our data suggest that preoperative cortisol, S100B, L-arginine reflect patients' frailty, while these parameters postoperatively are influenced by intraoperative stress and injury. As a novelty, P(j-a)CO₂ might be an emerging indicator of cerebral blood flow during CEA.

Effects of polarity of bipolar sensorimotor direct cortical stimulation on intraoperative motor evoked potentials

OBJECTIVE

The present study investigated the effects of the stimulus polarity and location of motor evoked potential (MEP) to establish a stimulation protocol.

METHODS

Nineteen patients who intraoperatively underwent MEP in bipolar direct cortical stimulation were enrolled in the present study. Somatosensory evoked potentials (SEP) of the contralateral median nerve stimulation were recorded to determine stimulation sites. MEP was performed under two settings in all patients: 1. Anodal bipolar stimulation: an anode on the precentral gyrus and a cathode on the postcentral gyrus, 2. Cathodal bipolar stimulation: a cathode on the precentral gyrus and an anode on the postcentral gyrus. MEP amplitudes and the coefficient of variation (CV) at a stimulation intensity of 25 mA and the thresholds of induced MEP were compared between the two settings.

RESULTS

An electrical stimulation at 25 mA induced a significantly higher amplitude in cathodal bipolar stimulation than in anodal bipolar stimulation. Cathodal bipolar stimulation also showed significantly lower thresholds than anodal stimulation. CV did not significantly differ between the two groups.

CONCLUSIONS

These results indicate that cathodal bipolar stimulation is superior to anodal bipolar stimulation for intraoperative MEP monitoring.

SIGNIFICANCE

MEP in cathodal bipolar cortical stimulation may be used in a safe and useful evaluation method of motor fiber damage that combines sensitivity and specificity.

In vivo endothelialization and neointimal hyperplasia assessment after rabbit carotid endarterectomy with bovine pericardium

Background

Previous studies have reported that the use of a patch in carotid endarterectomy (CEA) surgery can reduce the rate of restenosis and perioperative complications. The goal of this study was to compare the short- and medium-term outcomes of endothelialization and neointimal hyperplasia of patch closure (PC) angioplasty in CEA with direct closure (DC) in a rabbit model. A bovine pericardial patch (BPP) was used in the PC procedures.

Methods

Two carotid arteries were dried by air flow to simulate endarterectomy and selected for PC and DC in each rabbit. Different animals were sacrificed at 1, 2, 3, 4, and 8 weeks after the procedure. The endarterectomized segments were extracted and examined microscopically with histopathological and immunohistochemical analysis, and electron-microscopy measurements.

Results

In all, 19 rabbits were included in this study; 3 rabbits were placed in a 2-week postoperative group and 4 rabbits were placed in the 1-, 3-, 4-, and 8-week postoperative group respectively. Hematoxylin-eosin (HE) staining showed neointima on the PC side at an early stage (1-week postoperatively), and intimal hyperplasia could be seen on both sides. Immunohistochemical analysis showed that Ki-67 was higher on the PC side than on the DC side at an early stage (1,661.5±1,122.9 cells/mm², P=0.060). In the 2-week postoperative group, von Willebrand factor (vWF) was higher on the DC side (−377.0±155.6 cells/mm², P=0.052). Alpha-smooth muscle actin (α-SMA) values were comparable on both sides (P>0.05). Electron microscopy measurements showed that functional endothelial cells exhibited a cobblestone-like morphology and were nicely elongated in the direction of blood flow.

Conclusions

The use of BPP in PC angioplasty during CEA can maintain stability and also provide rapid endothelialization. PC with BPP has comparable ability of efficient endothelialization with DC, but is more likely to have early endothelialization.