Carotid endarterectomy for symptomatic carotid artery near-occlusion / 中华普通外科杂志

Objective:To investigate the effect of carotid endarterectomy(CEA) in the treatment of symptomatic carotid artery near-occlusion(CNO).Methods:Clinical symptoms, imaging examination, treatment and prognosis of 122 symptomatic CNO patients admitted to China-Japan Friendship Hospital from Jan 2014 to Jan 2020 undergoing CEA were retrospectively analyzed. Patients were divided into two groups based on the collapse condition,full collapse group(54 cases) and non-full collapse group(68 cases).Results:The difference was insignificant between the two groups at the 30-day and 12-month occurrence rate of primary endpoints(1.85% vs. 4.41%, P=0.629;7.41% vs. 4.41%, P=0.698).Postoperative re-stenosis occurred in one case in the non-full collapse group 8 months after CEA. Conclusions:CEA can achieve good curative effect for patients with CNO with recurrent symptoms, irrelevant to the existence of distal full collapse. The shunt can prevent intraoperative hypoperfusion and postoperative hyperperfusion.

Evidence-based and therapeutic technical progress of carotid stenosis / 国际外科学杂志

Stroke is the leading cause of death among urban and rural residents in China. About 25% to 30% of ischemia stroke is related to atherosclerotic carotid stenosis. The main treatments for carotid stenosis include carotid endarterectomy, carotid artery stenting and best medical therapy. In recent years, clinical trial evidence on the treatment of carotid artery stenosis continues to emerge, in which a series of new arguments and consensus have emerged. In addition, with the innovation of surgical techniques and the reform of intracavitary instruments, new surgical techniques and surgical equipment have been extended. This article summarizes the latest evidence-based and technical progress in the treatment of carotid artery stenosis in recent years, in order to provide theoretical guidance for the clinical practice of carotid artery stenosis.

Predictors of restenosis after carotid endarterectomy and carotid artery stenting / 国际脑血管病杂志

Carotid artery stenosis is an important cause of ischemic stroke. Carotid endarterectomy and carotid artery stenting are the effective methods for treating carotid artery stenosis, but postoperative restenosis remains a challenge. The pathogenesis of postoperative restenosis is currently not fully understood. However, multiple factors, including biomarkers, imaging features, and surgical related factors, have been proven to be associated with postoperative restenosis and can predict the occurrence of postoperative restenosis. This article reviews the predictors of restenosis after carotid endarterectomy and carotid artery stenting.

Outcomes of Arteriotomy Closure Technique for Carotid Endarterectomy: Bovine Pericardial Patch Closure versus Primary Closure

ABSTRACT Introduction: The aim of our study was to compare the primary closure (PRC) and patch angioplasty closure (PAC) of carotid artery following carotid endarterectomy (CEA). Methods: Data of patients who underwent CEA in the period from January 2005 to June 2020 were reviewed through files. Demographic characteristics, information about the operation, and postoperative follow-up outcomes of the patients were compared. Results: Of the 144 CEA cases included in the study, PRC and PAC were applied to 62 (43.7%) and 82 (56.3%) patients, respectively, for the carotid artery closure. Duration of surgery and carotid artery clamping time were not different between the PRC and PAC groups (106.73±17.13 minutes vs. 110.48±20.67 minutes, P=0.635; 24.25±11.56 minutes vs. 25.19±8.99 minutes, P=0.351, respectively). Postoperative respiratory impairment was more common in the PRC group (P=0.012); however, nerve injuries (P=0.254), surgical wound hematomas (P=0.605), surgical site infections (P=0.679), and mortality (P=0.812) were not significantly different between the groups. During the mean patient follow-up time of 26.13±19.32 months, restenosis was more common in the PRC group than in the PAC group (n=26, 41.9% vs. n=4, 4.9%, respectively; P=0.003). Frequencies of stroke (n=4, 2.8% vs. n=2, 2.4%, respectively; P=0.679), transient ischemic attacks (n=2, 1.4% vs. n=0, 0%, respectively; P=0.431), and mortality (n=4, 6.5% vs. n=4, 4.9%, respectively; P=0.580) were not significantly different between the PRC and PAC groups. Conclusion: We are of the opinion that the PAC method is effective and safe for carotid artery closure in patients undergoing CEA.

Determinants of success in treating acute ischemic cerebral and ocular ischemia through carotid revascularization. An observational study of a case series / Determinantes do sucesso no tratamento da isquemia cerebral e ocular aguda por meio da revascularização carotídea. Um estudo observacional de uma série de casos

ABSTRACT Objective: stroke etiology is ischemia in 85%, and in circa 25% of these, the source is the extracranial carotid. Recurrence is frequent and usually more severe. Carotid revascularization prevents new ischemic strokes. The sooner the treatment is undertaken, complete recovery chances are greater with less recurrences. But, historically, intervention in the acute setting was catastrophic. Objective: Identify determinants of success when carotid revascularization after a recent cerebral ischemic event is performed. Materials and Methods: A cohort of 50 subjects underwent carotid revascularization after ischemic symptoms, within a period of 71 months. The currently diagnostic tools were used, and the symptoms stratified by the Rankin scale. The extension of the cerebral lesion and the source location the source of the event was analyzed. Results: indications were based on the Rankin Scale (R0: 35.4%; R1: 45.8%; R2:18.8% and R3: zero), on the location of the source and the absence of ischemic areas greater than 15mm. An early surgical approach was adopted in all patients. Extreme care was applied to control arterial pressure. At discharge, no additional deficits were observed. Conclusions: carotid revascularization after ischemic events can be achieved without additional morbidity and no recurrences, using the most appropriate therapy in the shortest time, in patients with Rankin Scale up to 2, absence of intracranial hemorrhage and single or multiple ischemic intracerebral areas, with 15mm or less in their greater dimension.

RESUMO Introdução: isquemia é a etiologia do acidente vascular cerebral em 85% dos casos e em cerca de 25% destes, a fonte é a carótida extracraniana. Recorrência é frequente e usualmente mais grave que a inicial. A revascularização carotídea previne novos acidentes. Quanto mais cedo for realizado o tratamento, maiores as chances de recuperação e menor o risco de recorrência. Mas, historicamente, os resultados das intervenções precoces eram catastróficos. Objetivos: identificar determinantes de sucesso da revascularização carotídea após um evento isquêmico cerebral recente. Materiais e Métodos: uma coorte de 50 pacientes foi submetida à revascularização carotídea após sintomas isquêmicos, em um período de 71 meses. Foram empregados os métodos de investigação atuais e os sintomas estratificados pela Escala de Rankin. A extensão das lesões cerebrais e a fonte do evento foram estudados e analisados. Resultados: as indicações foram baseadas na escala de Rankin (R0: 35.4%; R1: 45.8%; R2: 18.8% e R3: zero), na localização da fonte e na ausência de áreas isquêmicas com menos de 15mm. Uma abordagem cirúrgica precoce foi empregada em todos os pacientes. Cuidados extremos com a pressão arterial foram aplicados. Na alta hospitalar, nenhum déficit adicional foi observado. Conclusões: a revascularização carotídea após eventos isquêmicos pode ser realizada sem morbidade adicional ou recorrências, empregando a terapêutica mais apropriada no período de tempo mais curto, em pacientes classificados como Rankin até 2, na ausência de hemorragia intracraniana e com áreas isquêmicas intracerebrais únicas ou múltiplas, com menos de 15mm em sua maior dimensão.

Carotid artery revascularization strategy in synchronous carotid and coronary artery revascularization / 中华普通外科杂志

Objective:To evaluate the efficacy of different carotid artery revascularization strategy in sychronous carotid and coronary artery revascularization.Methods:The clinical data of 53 patients receiving simultaneous carotid and coronary artery revascularization in China-Japan Friendship Hospital from Jan 2014 to Dec 2019 was retrospectively analyzed. The clinical characteristics, imaging examination, treatment and prognosis were collected and reviewed. Patients were divided into CEA group (42 cases) and CAS group (11 cases) according to the carotid artery revascularization method.Results:The mean operative time and blood loss of CEA group were (288.81±43.28) min and (419.05±127.33) ml, respectively. The mean operative time and blood loss of CAS group were (251.82±23.16) min and (318.18±98.16) ml, respectively. The difference of operative time and blood loss between the 2 groups were not significant (all P>0.05). Four minor strokes, 4 transient ischemic attacks (TIA), 2 pulmonary infections and 4 recurrent laryngeal nerve injury were observed in CEA group. Two TIA and 1 re-thoracotomy for hemostasis occurred in CAS group. Conclusions:Both carotid endarterectomy and carotid stenting can achieve good clinical result in synchronous carotid and coronary artery revascularization procedure. The selection of proper carotid artery revascularization method should base on the lesion characteristic and surgeon's experience.

Comparison of carotid endarterectomy vs. carotid stent implantation in the treatment of carotid stenosis / 中华普通外科杂志

Objective:To compare carotid endarterectomy (CEA) and carotid artery stenting (CAS) in perioperative, medium and long term prognosis of patients with carotid artery stenosis.Methods:A retrospective analysis was performed on 1 329 cases of carotid artery stenosis treated at Department of Vascular Surgery, Beijing Anzhen Hospital from Jan 2011 to Aug 2020, as all cases being divided into CAS group and CEA group.Results:There were significant differences in age ( t=0.098, P=0.023) and drinking habits ( χ2=8.055, P=0.005) between the two groups. There were more unstable plaques in CEA group ( χ2=4.392, P=0.038), and more bilateral lesions in CAS group ( χ2=9.673, P=0.038). In perioperative period, there were more mannitol use in CEA group ( χ2=78.614, P<0.001), more incision/puncture site complications ( χ2=5.158, P=0.035), lung infection ( χ2=6.355, P=0.013), cerebral hyperperfusion syndrome (CHS) ( χ2=5.158, P=0.035) and extracranial nerve injury ( χ2=23.760, P<0.001) in CEA group than in CAS group, and more acute renal failure in CAS group ( χ2=10.393, P=0.001). There was no significant difference in survival rate and ischemic stroke, myocardial infarction, cerebral hemorrhage and renal insufficiency between the two groups (all P>0.05). The mean survival time of CAS group was 53.195 months (95% CI: 52.040-54.350), and 54.492 months (95% CI: 53.790-55.195) in CEA group ( P=0.051). Conclusions:Patients in CEA group had more unstable plaque and a lower perioperative stroke rate. CEA group had higher risk of CHS,while CAS was with lower postoperative lung infection rate and less wound local complications. There was no significant difference in long-term survival between the two groups.

Effect of nimodipine on postoperative cognitive function in elderly patients undergoing carotid endarterectomy / 中华麻醉学杂志

Objective:To evaluate the effect of nimodipine on postoperative cognitive function in elderly patients undergoing carotid endarterectomy.Methods:Eighty-two American Society of Anesthesiologists physical status Ⅱ or Ⅲ patients of both sexes, aged 65-80 yr, scheduled for elective carotid endarterectomy under general anesthesia, were divided into 2 groups ( n=41 each) using a random number table method: control group (group C) and nimodipine group (group N). Nimodipine 7.5 μg·kg -1·h -1 was intravenously infused starting from the beginning of surgery until the end of surgery in group N, while the equal volume of normal saline was given in group C. Before infusing nimodipine (T 1), before placing the the shunt (T 2), at 10 min after placing the the shunt (T 3) and at 10 min after releasing carotid artery (T 4), blood samples were taken from the radial artery and jugular bulb for blood gas analysis.Jugular venous blood oxygen content, arterio-jugular difference of oxygen content, and cerebral oxygen extraction ratio were calculated.The concentrations of S100β protein in serum of the jugular bulb were measured by enzyme-linked immunosorbent assay.Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) Scale (Chinese version) at 1 day before surgery and 1, 3 and 7 days after surgery, and the occurrence of cognitive dysfunction (MoCA score<26) was recorded within 7 days after operation. Results:Compared with group C, MoCA scores were significantly increased at each time point after surgery, and the incidence of cognitive dysfunction was decreased (27% vs.17%), and the jugular venous blood oxygen content was increased, and arterio-jugular difference of oxygen content, cerebral oxygen extraction ratio, and concentrations of serum S100β protein were decreased at T 2-4 in group N ( P<0.05). Conclusions:Nimodipine can improve the cognitive function after carotid endarterectomy, which may be related to the improvement in intraoperative cerebral oxygen metabolism and reduction of brain injury in elderly patients.

Disminución de complicaciones neurológicas peri-operatorias en pacientes con endarterectomía carotídea bajo anestesia regional / Decrease of perioperative neurological complications in patients with carotid endarterectomy under regional anesthesia

INTRODUCCIÓN: La endarterectomía carotídea es el estándar de oro para disminuir la incidencia de evento cerebral isquémico en pacientes con enfermedad ateroesclerótica carotídea sintomática o severa. Sin embargo, durante el procedimiento se requiere la interrupción de flujo sanguíneo cerebral por la carótida interna, lo que puede conllevar una inadecuada perfusión cerebral y un evento cerebrovascular perioperatorio. OBJETIVO: Determinar la incidencia de eventos cerebrovasculares perioperatorios, mortalidad y complicaciones, así como la estancia hospitalaria, en pacientes llevados a endarterectomía carotídea en el Hospital de San José, en Bogotá, Colombia. Además, se comparará el beneficio del uso de anestesia local, en comparación con anestesia general, en los pacientes llevados a este procedimiento quirúrgico, para disminuir el riesgo de eventos cerebrovasculares. METODOLOGÍA: Estudio de cohorte retrospectiva de pacientes llevados a endarterectomía carotídea entre noviembre del 2006 y noviembre del 2017. RESULTADOS: 32 pacientes fueron llevados a endarterectomía carotídea, de los cuales 12 (37,5 %) fueron bajo anestesia general y 20 (62,5 %) bajo anestesia regional. La incidencia de ECV global fue del 15,6 %. Requirieron shunt 12 pacientes (37,5 %), con una incidencia de infarto cerebral en pacientes en los que se usó shunt del 33,3 %, en comparación con el 5 % en los que no se usó. La mortalidad global y las complicaciones fueron de 3,1 % y la mediana de días de estancia hospitalaria en los pacientes de anestesia general fue de cuatro días (RIQ = 3,5-8,5), en contraste con los 2,5 días (RIQ = 2-7,5) en pacientes de anestesia regional. CONCLUSIONES: Según la experiencia obtenida en el Hospital de San José, existe una menor incidencia de ECV perioperatorio, menor tasa de mortalidad, una estancia hospitalaria y en UCI en los pacientes llevados a endarterectomía carotídea bajo anestesia regional.

SUMMARY INTRODUCTION: Carotid endarterectomy is the gold standard for reducing the incidence of ischemic stroke in patients with symptomatic or severe carotid atherosclerosis. However, the procedure requires the interruption of cerebral blood flow by the internal carotid, this can result in inadequate cerebral perfusion and a perioperative cerebrovascular event. OBJECTIVE: To determine the incidence of peri-operative cerebrovascular events, mortality and complications, as well as hospital stay, in patients undergoing carotid endarterectomy at the Hospital de San José de Bogotá. We also compared the benefit of using local anesthesia vs general anesthesia in patients taken to this surgical procedure to reduce the risk of cerebrovascular events METHODOLOGY: Study of a retrospective cohort of patients undergoing carotid endarterectomy between November 2006 and November 2017. RESULTS: 32 patients were taken to a carotid endarterectomy of which 12 (37.5 %) were under general anesthesia and 20 (62.5 %) were under regional anesthesia, the incidence of global CVD was 15.6 %. Twelve patients (37.5 %) required a shunt with an incidence of cerebral stroke in patients in whom a shunt of 33.3 % was used. 5 % in those that were not used. Overall mortality and complications were 3.1 % and median hospital stay in patients under general anesthesia for 4 days (RIQ: 3.5-8.5) versus regional anesthesia 2.5 days (RIQ: 2-7.5). CONCLUSIONS: According to the experience in the hospital of San José de Bogotá, there is a lower incidence of cerebrovascular events, in the perioperative period, a lower mortality rate, a hospital stay and in the lower intensive care unit in patients undergoing carotid endarterectomy under regional anesthesia.

Clinical study of carotid endarterectomy and carotid artery stenting in treating carotid artery stenosis in the elderly / 中华老年医学杂志

Objective To investigate the clinical efficacy and safety of carotid endarterectomy (CEA)and carotid artery stenting(CAS)for the treatment of carotid artery stenosis in the elderly.Methods Clinical data of 116 elderly patients aged over 65 years with carotid artery stenosis were retrospectively analyzed.Of 116 patients,73 patients underwent CAS(the CAS group) and 32 received CEA(the CEA group).The success rate,30-day perioperative complications and follow-up results were compared between the two groups.Results There was no significant difference in the success rate (96.8％ vs.100.0％,P ＞ 0.05),30-day perioperative complications,such as bradycardia (6.25％ vs.4.5％,x2 =0.228,P=0.663),acute myocardial infarction(0.0 vs.1.4％,x2 =0.432,P=0.511),transient hypotension(6.3％ vs.8.1％,x2 =0.114,P =0.735),ischemic stroke(6.3％ vs.6.8％,x2 =0.009,P =0.923),and cerebral hyperperfusion syndrome (18.8 ％ vs.10.8％,x2 =0.009,P =0.923),between the CEA and CAS groups.The incidence of persistent hypotension was lower in the CEA group than in the CAS group(3.1％ vs.17.6％,x2 =4.398,P=0.036).No significant difference was found in carotid artery restenosis(moderate:6.3％ vs.8.1％,x2 =0.114,P =0.735;severe:3.1 ％ vs.2.7％,x2=0.014,P=0.905)and ipsilateral stroke(3.1％ vs.5.4％,x2 =0.279,P=0.598)between the CEA and CAS groups at one-year fellow-up.Conclusions Both CEA and CAS have good effieacies in treating carotid artery stenosis in the elderly,while the incidence of persistent hypotension is higher with CAS than with CEA.

The effect of neovascularization in carotid plaque on clinical manifestations / 中华普通外科杂志

Objective To explore the effect of angiogenesis in carotid atherosclerotic plaque.Methods From Jan 2016 to Aug 2016,Carotid artery plaque was abtained in 52 cases after carotid endarterectomy at the Department of Cardiovascular Surgery of China-Japan Friendship Hospital.Patients were divided into symptomatic group and asymptomatic group.Specimens were stained with HE and Movat,and the density,size,distribution and morphology of neovascularization were counted.Results The density of neovascularization in the symptomatic group and the asymptomatic group were 5.27 ± 0.46 and 2.30 ±0.29,respectively (P ＜ 0.001),the average cross-sectional area of neovascularization in the symptomatic group was (2.26±0.21) mm2 and (1.00 ±0.48) mm2 in the asymptomatic group (P=0.02).In the distribution,the symptomatic group and the asymptomatic group were 3.37 ± 0.46/ mm2,1.32 ±0.16/mm2 in basal part,3.71 ±0.42/mm2,1.56 ±0.20/mm2 in the shoulder part,3.48 ±0.44/mm2,1.55 ± 0.21/ mm2 in the fibrous cap,respectively (P ＜ 0.001).Conclusion The density and cross-sectional area of neovascularization in the symptomatic group were larger than those in the asymptomatic group,irregular branching vessels were dominant.

Risk-Benefit Assessment of Carotid Revascularization / Avaliação do Risco-Benefício da Revascularização Carotídea

Abstract Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.

Resumo A doença aterosclerótica carotídea grave é responsável por 14% de todos os acidentes vasculares cerebrais (AVC), que refletem em uma alta taxa de morbimortalidade. Nos últimos anos, os avanços no tratamento clínico das doenças cardiovasculares geraram um decréscimo importante na mortalidade por estas causas. Revisar principais estudos que dizem respeito à revascularização carotídea avaliando a relação entre risco e beneficio deste procedimento. Os dados encontrados indicam que o procedimento só deve ser realizado se houver um risco periprocedimento menor que 6% em pacientes sintomáticos para que haja beneficio líquido na intervenção carotídea. O tratamento clínico reduziu significativamente o benefício líquido da revascularização na prevenção de AVC em pacientes assintomáticos. Registros que refletem a prática diária demonstram que a angioplastia carotídea esta associada a um risco periprocedimento mais elevado. O volume anual de procedimentos por operador e a idade dos pacientes têm uma importante influência nas taxas de AVC e morte pós angioplastia. Pacientes sintomáticos têm uma maior incidência de AVC e morte após procedimento. A revascularização tem o maior benefício nas primeiras semanas do evento. Existem discrepâncias na literatura científica com relação à revascularização carotídea e/ou tratamento clínico, tanto na prevenção primária quanto secundária de pacientes com lesão carotídea. A identificação do paciente que realmente será beneficiado é um processo dinâmico sujeito a constante revisão.

Preoperative ultrasonographic parameters in symptomatic carotid artery stenosis patients with different curative effects of stenting / 中华老年心脑血管病杂志

Objective To study the preoperative ultrasonographic parameters and their relationship with age in symptomatic CAS patients with different curative effects of stenting.Methods Fiftyseven symptomatic CAS patients admitted to our hospital for stenting were divided into young age group (n=7),middle age group (n=25),old age group (n=25) according to their age,and into very good curative effect group (n=18),good curative effect group (n=33) and no curative effect group (n=6) according to their postoperative NIHSS score.The carotid ultrasonographic parameters in different groups were compared and analyzed within 3 days before operation.Results A significant difference was found in the ratio of UPT,maximal ER of plaques,PV of stenosis,PI,resistance index (RI),carotid artery stiffness index (SI),distensibility coefficient (Dc) and compliance coefficient (Cc) in different curative effect groups (P＜0.01).The carotid artery SI was significantly higher in old age group than in young age group and middle age group (P＜0.01).A linear regression equation was established between carotid stiffness and age (y=0.075x-1.537,R2 =0.448,F=44.727,P =0.000).Conclusion The ratio of UPT,maximal ER of plaques,PV of stenosis,PI,RI,carotid artery SI,Dc and Cc are different in patients with different curative effects of stenting,and a linear relationship is found between carotid artery SI and age of patients.

Diagnosis and treatment of free floating thrombus in carotid artery / 中华普通外科杂志

Objective To evaluate diagnostic method and treatment strategy for free floating thrombus in carotid artery.Methods From Ju12016 to Oct 2017,7 patients with free floating thrombus in carotid artery was diagnosed at our department.The medical history,symptoms,diagnosis,treatment strategy and prognosis of those patients were analyzed retrospectively.Results Among 7 patients,4 were symptomatic;4 patients were concomitant with severe carotid artery stenosis and 3 with mild to moderate stenosis.3 received carotid endarterectomy and patch angioplasty.4 received carotid artery stenting with distal cerebral protection divice.There was no perioperative and 30-day stroke,myocardial infarction,death or hyperperfusion syndrome occurred.The 12-month follow up showed no restenosis,no free floating thrombus recurrence and no ischemic cerebrovascular event.Conclusion Free floating filling defect in carotid artery is a typical sign for unstable plaque.Both carotid endarterectomy and carotid artery stenting can be used for the treatment of free floating thrombus.

Emergent headache after carotid endarterectomy / 中华普通外科杂志

Objective To determine the incidence and clinical features of headache after carotid endarterectomy (CEA).Methods A retrospective analysis was made on the data of patients undergoing CEA in the Department of Vascular Surgery,Peking Union Medical College Hospital from Jan 2014 to Jan 2015.There were 119 males and 24 females,including 97 cases of symptomatic carotid stenosis and 110 cases of severe carotid stenosis.Results The incidence of newly emergent headache after surgery was 44％ (63/143).The earliest time of headache was 30 minutes after surgery and the latest was 6 days after surgery.95％ of headache occurred within 48 hours after surgery (60/63).79.4％ (50/63) of the headache lay ipsilaterally with CEA,and bilateral headache accounted for 20.6％ (13/63).Severe headache accounted for 4.8％ (3/63),all were ipsilaterally frontal and temporal headache,complicating central nervous system symptoms.Conclusions After CEA headache is a common clinical symptom.Most were mild to moderate and unilateral,which can be relieved spontaneously.Cerebral hemodynamics need to be further examined to differentiate the different pathological states of severe headache on the operative side after CEA because of the high risk of developing hyperperfusion syndrome or cerebral infarction.History of TIA or stroke is the risk factor of post-CEA headache.

Application and efficacy of induced hypertension and hypotension in carotid endarterectomy / 中华普通外科杂志

Objective To evaluate the safety and efficacy of induced hypotension and hypotension in carotid endarterectomy (CEA).Methods Data of 1 486 patients who underwent CEA in multicenters from Aug 2012 to Aug 2018 were retrospectively analyzed.After screening,a total of 1 448 patients met the inclusion criteria.Induced hypertension and hypotension was used in all thees patients.Results 87.8％ of the patients were with severe carotid stenosis.The average operative time was (51.8 ± 6.1) min,and the internal carotid artery clamping time was (11.4 ± 3.1) min.After induced hypertension,the stump pressure were higher than that before,of which 1 438 (99.3％) were greater than 50 mmHg.Monitoring of EEG oxygen saturation showed that the value of ipsilateral rSO2 was significantly lower than that of the contralateral [(56％ ± 3％) vs.(64％ ± 4％),P ＜ 0.05] before induced hypertension.After induced hypertension and clamp removal,the value of ipsilateral rSO2 was lower than that of the contralateral,but there was not significant difference (all P ＞ 0.05).Perioperative cerebral infarction occurred in 2 cases,ipsilateral cerebral hemorrhage in 1 case,contralateral cerebral hemorrhage in 1 case and myocardial infarction in 2 cases.Connclusion The technique of induced hypotension and hypotension play a temporary role in brain protection for patients undergoing CEA.This study demonstrated the safety and effectiveness of induced hypertension and hypotension technique.

Comparision of perioperative cerebrovascular events through different surgical approaches for severe bilateral carotid artery stenosis / 中华普通外科杂志

Objective To explore the feasibility and safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in patients with severe bilateral carotid stenosis.Methods From Jul 2003 to Sep 2017,unilateral CEA or CAS were performed in 1 046 patients,213 of which were with severe bilateral carotid stenosis.These 213 patients were divided into CEA group and CAS group according to procedures taken.The perioperative outcomes of 213 patients were analyzed retrospectively.Results The incidence of typical cerebral ischemia symptoms of CEA group was higher than that in CAS group (25.3％ vs.13.3％,P =0.029).The incidence of perioperative death or stroke in CEA group was 5.63％ (4/71),which had no significant difference with that in CAS group (2.82％,4/142) (P =0.524).Conclusion Based on adequate preoperative assessment and reasonable surgical selection,CEA and CAS are both safe and feasible for the unilateral lesion during one-stage operation for patients with severe bilateral carotid stenosis

Estenose de carótida extracraniana: revisão baseada em evidências / Extracranial carotid stenosis: evidence based review

RESUMO A doença vascular cerebral extracraniana é uma das mais importantes causas de morte e de incapacidade em todo o mundo e seu tratamento se baseia em estratégias clínica e cirúrgica, sendo que esta última pode ser feita pelas técnicas convencional ou endovascular. O manejo da estenose da bifurcação carotídea visa principalmente a prevenir o acidente vascular cerebral e tem sido objeto de extensa investigação. O papel do tratamento clínico tem sido re-enfatizado, mas a endarterectomia de carótida permanece como o tratamento de primeira linha para pacientes sintomáticos com estenose de 50% a 99% e, para pacientes assintomáticos, com estenose de 60% a 99%. A angioplastia com stent é reservada para pacientes sintomáticos, com estenose de 50% a 99% e com risco elevado para a cirurgia aberta, por motivos anatômicos ou clínicos. Atualmente, o procedimento endovascular não é recomendado para pacientes assintomáticos que tenham condições de serem submetidos ao tratamento cirúrgico convencional. O Brasil apresenta tendência semelhante à de outros países da América do Norte e Europa, observando a manutenção da endarterectomia como a principal indicação para o tratamento da estenose carotídea e reservando o procedimento endovascular para casos em que há contraindicações para a primeira intervenção. Todavia, temos de melhorar os nossos resultados, reduzindo as complicações, notadamente a taxa de mortalidade geral.

ABSTRACT Extracranial cerebrovascular disease is one of the most important causes of death and disability worldwide and its treatment is based on clinical and surgical strategies, the latter being performed by conventional or endovascular techniques. The management of stenosis of the carotid bifurcation is mainly aimed at preventing stroke and has been the subject of extensive investigation. The role of clinical treatment has been re-emphasized, but carotid endarterectomy remains the first-line treatment for symptomatic patients with 50% to 99% stenosis and for asymptomatic patients with 60% to 99% stenosis. Stent angioplasty is reserved for symptomatic patients with stenosis of 50% to 99% and at high risk for open surgery due to anatomical or clinical reasons. Currently, the endovascular procedure is not recommended for asymptomatic patients who are able to undergo conventional surgical treatment. Brazil presents a trend similar to that of other countries in North America and Europe, keeping endarterectomy as the main indication for the treatment of carotid stenosis and reserving the endovascular procedure for cases in which there are contraindications for the first intervention. However, we must improve our results by reducing complications, notably the overall mortality rate.

Dual Monitoring with Stump Pressure and Electroencephalography During Carotid Endarterectomy

BACKGROUND: Intraoperative monitoring during carotid endarterectomy is crucial for cerebral protection. We investigated the results of carotid endarterectomy under dual monitoring with stump pressure and electroencephalography. METHODS: We retrospectively reviewed the medical records of 50 patients who underwent carotid endarterectomy between March 2010 and February 2016. We inserted a temporary shunt if the stump pressure was lower than 35 mm Hg or if any intraoperative change was observed on electroencephalography. RESULTS: Seventeen (34%) patients used a temporary shunt, and the mean stump pressure was 26.8 mm Hg in the shunt group and 46.5 mm Hg in the non-shunt group. No postoperative mortality or bleeding occurred. Postoperatively, there were 3 cases (6%) of minor stroke, all of which took place in the shunt group. A comparison of the preoperative and the intraoperative characteristics of the shunt group with those of the non-shunt group revealed no statistically significant difference between the 2 groups (p <0.01). CONCLUSION: Dual monitoring with stump pressure and electroencephalography was found to be a safe and reliable monitoring method with results comparable to those obtained using single monitoring. Further study should be performed to investigate the precise role of each monitoring method.

Hemodynamic Depression of Early Carotid Revascularization on Ischemic Stroke Patients with Symptomatic Carotid Stenosis

BACKGROUND: Carotid revascularization is frequently complicated by hemodynamic depression (HD), which can increase the risk of stroke or vascular death. However, no studies yet exist describing the correlation between the timing of carotid revascularization and HD. The present study investigated whether carotid revascularization in the early phase of a stroke had an impact on the incidence of HD. METHODS: A retrospective study of consecutive ischemic stroke patients who underwent carotid revascularization was designed to compare the incidence of HD between early and late carotid revascularization. Early carotid revascularization was defined as carotid artery stenting or endarterectomy within two weeks of stroke onset. HD was defined as hypotension or bradycardia within five days of carotid revascularization. RESULTS: Of 69 carotid revascularizations, HD occurred in 29 (42.0%). The incidence of HD did not differ significantly between the early and late phase groups (48.0% vs. 38.6%, respectively, P =0.449). Patients with HD had undergone more carotid artery stenting than those without HD (79.3% vs. 35%, respectively, P < 0.001). Age, sex, hypertension, diabetes, heart disease, antihypertensive medication, and severity of carotid stenosis did not differ between patients with and without HD. CONCLUSION: The present research suggests that early carotid revascularization is as safe as late carotid revascularization with regard to HD.