Guideline on carotid surgery for stroke prevention: updates from the Italian Society of Vascular and Endovascular Surgery. A trend towards personalized medicine

BACKGROUND

This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association.

METHODS

GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations.

RESULTS

The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]).

CONCLUSIONS

This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

Anesthetic management of carotid endarterectomy: an update from Italian guidelines

BACKGROUND AND AIMS

In order to systematically review the latest evidence on anesthesia, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure management for carotid endarterectomy. The present review is based on a single chapter of the Italian Health Institute Guidelines for diagnosis and treatment of extracranial carotid stenosis and stroke prevention.

METHODS AND RESULTS

A systematic article review focused on the previously cited topics published between January 2016 and October 2020 has been performed; we looked for both primary and secondary studies in the extensive archive of Medline/PubMed and Cochrane library databases. We selected 14 systematic reviews and meta-analyses, 13 randomized controlled trials, 8 observational studies, and 1 narrative review. Based on this analysis, syntheses of the available evidence were shared and recommendations were indicated complying with the GRADE-SIGN version methodology.

CONCLUSIONS

From this up-to-date analysis, it has emerged that any type of anesthesia and neurological monitoring method is related to a better outcome after carotid endarterectomy. In addition, insufficient evidence was found to justify reversal or no-reversal of heparin at the end of surgery. Furthermore, despite a low evidence level, a suggestion for blood pressure monitoring in the postoperative period was formulated.

Sudden Rupture of Abdominal Aortic Aneurysm in COVID19 Patients

Purpose:

The purpose of the paper is to report the clinical outcomes of 4 patients with ruptured abdominal aortic aneurysm (AAA) during (3 patients) or immediately after (1 patient) moderate-severe SARS-CoV-2 infection. We discuss COVID-19-related mechanisms which could impact AAA rupture.

Patients and Methods:

During the period of the pandemic (March 2020—May 2021), we performed surgery in 18 patients with ruptured AAA. Four patients were affected by moderate or severe SARS-CoV-2 infection (in 3 patients the rupture occurred during the infection and in 1 patient 3. months after discharge from the hospital). Two patients underwent open repair and 2 endovascular surgery.

Results:

No postoperative mortality and no major complication occurred. Rapid growth of the AAA in comparison with a previous Duplex scan was evident in all 4 patients.

Conclusions:

Family doctors and vascular surgeons should be aware about the possibility of AAA degeneration in patients with moderate-severe COVID19 infection. The risk is increased by steroid therapy which is essential in more advanced stages of the infection. In this clinical setting, endovascular repair is a valid choice.

Reduced Vascular Practice and Increased Cardiovascular Mortality for COVID-19-Negative Patients

BACKGROUND

The aim of our study was to compare COVID-19- and not-COVID-19-related mortality rates in two Italian regions during the pandemic period when the same isolation rules and therapeutic approaches were introduced for all hospitals in Italy. Risk factors for not-COVID-19-related deaths during the pandemic were analyzed; we tried to assess a possible correlation between reducing hospital visits and "deferrable" vascular operations and the increased cardiovascular mortality not related to COVID-19 infection.

METHODS

We analyzed COVID-19- and not-COVID-19-related mortality rates in two Italian regions in the period January 2020-January 2021. We compared mortality rates during the pandemic period with those of the previous five years. We tried to determine the factors involved in increased mortality rates during the pandemic period.

RESULTS

Despite the same isolation rules for people and the same therapeutic approaches for hospitals, mortality rates did not increase in the region Lazio, where the pandemic was not severe. In the region Lombardy, the mortality rate was doubled in comparison with the previous years, and 50% of the increase was related to not-COVID-19 deaths.

CONCLUSIONS

The increase in mortality rates for not-COVID-19-related deaths in the region Lombardy was connected to the generalized turmoil in the acute phase of an overwhelming pandemic, including diffuse stress, inadequate communications, reluctance to ask for medical help unless symptoms were severe, and unexpected inadequate number of health workers, hospital beds, and intensive care unit beds. Reduced hospital visits may have had a fundamental role.

Intraoperative Cerebral Monitoring During Carotid Surgery: A Narrative Review

BACKGROUND

Intra-operative neurological monitoring (IONM) during carotid endarterectomy (CEA) aims to reduce neurological morbidity of surgery.

OBJECTIVE

This narrative review analyses the role and results of different methods of IONM.

METHODS

review articles on PUBMED and Cochrane Library, by searching key words related to IONM and CEA, from 2000 up to date.

RESULTS

regional anesthesia in some centers represents the "gold standard". The most often used alternative techniques are: stump pressure, electroencephalogram, somatosensory evoked potentials, transcranical doppler ultrasound, near infrared spectroscopy and routine shunting. Every technique shows limitations. Regional anesthesia can make difficult prompt intubation when needed. Stump pressure shows a wide operative range. Electroencephalogram is unable to detect ischemia in sub-cortical regions of the brain. Somatosensory evoked potentials certainly demonstrate the presence of cerebral ischemia, but are no more specific or sensitive than the electroencephalogram. Transcranical doppler monitoring is undoubtedly operator-dependent and suffers from the limitations that the probe has to be placed relatively near to the surgical site and may impede the operator, especially if it needs constant adjustments; moreover, an acoustic window may not be found in 10% -20% of the subjects. Near infrared spectroscopy appears to have a high negative predictive value for cerebral ischemia, but has a poor positive predictive value and low specificity, because predominantly estimates venous oxygenation as this makes up about 80% of cerebral blood volume. The data on the use of Routine Shunting (RS) from RCTs are limited.

CONCLUSIONS

currently, with no clear consensus on monitoring technique, choice should be guided by local expertise and complication rates. With reflection, best practice may dictate that a standard technique is selected as suggested above and this remains the default position for individual practice. Nevertheless, current techniques for monitoring cerebral perfusion during CEA are associated with false negative and false positive resulting in inappropriate shunt insertion.

Abdominal Aorta Angiosarcoma after Endovascular Aneurysm Repair

Primary tumors originating within the wall of the arteries are rare and they frequently manifest late, making effective treatment a challenge. We describe here a case of Abdominal Aorta AngioSarcoma masqueraded as an infected EndoVascular Aortic Repair. The knowledge of this pathology from vascular surgeons and radiologist is crucial, because a prompt diagnosis and treatment can improve the prognosis.

Re-organization of the Vascular Surgery Department During the Acute Phase of the COVID19 Outbreak: Lessons Learned and Future Perspectives

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection represents a serious threat to public health because it leads to a wide spectrum of clinical manifestations. The region Lombardia (Italy) has suffered from severe problems during the acute phase of the outbreak in Italy (March–April 2020). The aim of our analysis is to report the experience of the Department of Vascular Surgery of Pavia, including the learned lessons and future perspectives, considering that the COVID-19 outbreak is in its acute phase in other continents.

Material and methods

Single-center, retrospective, observational study based on extracted data from the medical records of all consecutive COVID-19 patients observed in our Vascular Department between March 1st and April 30th, 2020. We reviewed the records for demographic information, comorbidities, laboratory tests, and anticoagulation treatment at the time of hospital admission.

Results

We observed an important reduction in elective and urgent interventions compared to the same period of the previous year; in parallel, we observed an increase in the diagnosis of deep vein thrombosis (DVT) in hospitalized patients, especially with severe infection. In our department, four infections were reported among health workers.

Conclusions

The impact of the COVID19 pandemic on health-care delivery has been massive. A wave of vascular-related complications is expected. Regular SARS-CoV-2 screening, adequate protection, and quick reorganization of health-care resources are still needed.

Acute arterial and deep venous thromboembolism in COVID-19 patients: Risk factors and personalized therapy

BACKGROUND

The Lombardy region suffered severely during the acute phase of the coronavirus disease 2019 outbreak in Italy (Mar-Apr 2020) with 16,000 diagnosed coronavirus disease 2019-related deaths (49% of the total coronavirus disease 2019-related deaths in Italy). In the area surrounding Pavia during the critical stage of the outbreak (Mar-Apr 2020), 1,225 of the documented 4,200 deaths were related to coronavirus disease 2019 infection, with a mortality rate of 181/100,000 inhabitants and an increase in deaths of 138% compared with the same period during previous years. Our aim was to report the experience of the Department of Vascular Surgery of Pavia (Lombardy, Italy), including the lessons learned and future perspectives regarding the management of coronavirus disease 2019 patients who developed severe acute ischemia with impending lower limb loss or deep vein thrombosis.

MATERIALS AND METHODS

We carried out a retrospective data collection of coronavirus disease 2019 patients with severe acute ischemia of the lower limbs or deep vein thrombosis, which we observed in our department during the period March 1, 2020, to April 30, 2020. Primary outcomes of the analysis were postoperative mortality for all patients and amputation rates only in those coronavirus disease 2019 patients suffering from acute lower limb ischemia. Secondary outcomes were the prevalence of the disease among admitted coronavirus disease 2019 patients, and any possible correlation among inflammatory parameters, thrombolytic status, and the presence of acute ischemia or deep vein thrombosis.

RESULTS

We observed 38 patients (28 male) with severe coronavirus disease 2019 infection (6 with lower limb arterial thrombosis and 32 with deep vein thrombosis). The median patient age was 64 years (range 30-94 y). In the arterial group, 3 had thrombosis on plaque and 3 on healthy arteries ("simple" arterial thrombosis). All underwent operative or hybrid (open/endo) revascularization; 1 patient died from major organ failure and 1 patient underwent major amputation. In the deep vein thrombosis group, 9 (28%) patients died from major organ failure, despite aggressive medical therapy. In patients with simple arterial thrombosis and those with deep vein thrombosis, we observed a decrease in inflammatory parameters (C-reactive protein) and in D-dimer and fibrinogen after aggressive therapy (P <.001).

CONCLUSION

Our study confirms that critically ill, coronavirus disease 2019 patients who develop arterial and deep vein thrombosis have a high risk of mortality, but, if treated properly, there is an improvement in overall survival, especially in patients of 60 years of age or younger.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and the Upper Limb Deep Vein Thrombosis Risk

Little or nothing is known about the correlation between the upper limb deep vein thrombosis (UL-DVT) and severe acute respiratory syndrome coronavirus 2 (SARS–CoV-2). We describe the increased risk of UL-DVT in 3 patients with SARS–CoV-2 who require continuous positive airway pressure with a hood and the need for early adequate antithrombotic prophylaxis.

Near Infrared Spectroscopy Monitoring During Carotid Endarterectomy: Which Threshold Value is Critical?

OBJECTIVES

Retrospectively to verify which decreasing percentage in regional oxygen saturation (rSO(2)) identified patients with good collateralisation during carotid artery cross clamp.

MATERIALS AND METHODS

During 594 endarterectomies under general anaesthesia the decreasing percentage from preclamp value to value detected in the first 2 min after clamping the CCA and/or ICA was calculated in real time. No temporary shunt was placed in any case. ROC analysis was performed to determine the optimal cut-off for rSO(2) decrease to identify the occurrence of neurological complications.

RESULTS

A cut-off of 11.7% was identified as optimal. Sensitivity and specificity were 75% (95% CI 71-78) and 77% (95% CI 74-80), respectively. The cut-off of 20% had a lower sensitivity (30%) and a higher specificity (98%) to identify patients with complications, with positive and negative predictive value of 37 and 98%, respectively.

CONCLUSIONS

The study suggest that a relative decrease in rSO(2) of <20% from preclamp to early cross clamp value has a high negative predictive value, i.e. if rSO(2) does non decrease more than 20%, ischemia by hypoperfusion is unlikely and a shunt should not be necessary. Moreover, a relative decrease >20% may not always indicate intraoperative neurological complications.

Essential thrombocythemia and acute leukemia

A case of leukemic evolution from essential thrombocythemia (ET) is described. The patient developed acute myeloid leukemia (AML) six months after diagnosis while receiving hydroxyurea (HU). He died in four days in spite of treatment with low-dose cytarabine (ARA-C).