Desfechos de curto prazo da cirurgia de carótida: experiência no "mundo real" em um centro único de formação profissional / Short term outcomes of carotid surgery: the real-world experience of a single teaching center

Resumo Contexto A abordagem cirúrgica para estenose carotídea sintomática está consolidada na literatura para a prevenção de eventos neurológicos, devendo seguir padrões ótimos de qualidade. Entretanto, há uma crescente preocupação relacionada à possibilidade ou não de replicar os dados dos trabalhos controlados no mundo real. Objetivos Avaliar a população com estenose carotídea sintomática submetida a cirurgia e seus desfechos de curto prazo em um contexto de mundo real em um centro de formação profissional. Métodos Tratou-se de um estudo observacional realizado por meio de coleta de dados em prontuário de janeiro de 2012 a janeiro de 2023. Foram excluídos pacientes operados por outras etiologias e com cirurgia cardíaca concomitante. Resultados Foram incluídos 70 pacientes submetidos a angioplastia ou endarterectomia carotídea. Os subgrupos populacionais submetidos a angioplastia ou endarterectomia foram semelhantes. Houve diferença estatisticamente relevante quanto à modalidade anestésica e ao tempo cirúrgico maior para o subgrupo de endarterectomia carotídea. Houve quatro casos de acidente vascular encefálico isquêmico, e três deles estavam relacionados à lesão, sendo dois menores e um maior. Dessa forma, a taxa de acidente vascular encefálico maior relacionado à lesão foi de 1,43% e de qualquer acidente vascular encefálico relacionado à lesão, de 4,29%. A taxa total de eventos adversos cardiovasculares maiores foi de 5,71%. Houve um caso de infarto agudo do miocárdio no grupo angioplastia e nenhum óbito. Não houve diferença estatística entre os grupos de endarterectomia e angioplastia quanto aos desfechos principais. Conclusões Os desfechos acidente vascular encefálico isquêmico, infarto agudo do miocárdio, óbito e eventos adversos cardiovasculares maiores neste centro são semelhantes aos encontrados em estudos clínicos randomizados, demonstrando viabilidade da manutenção deste tratamento em centros com programas de ensino.

Abstract Background Surgical treatment of symptomatic extracranial carotid stenosis is well established for preventing neurological events and should adhere to optimal quality standards. However, there is growing concern as to whether results of controlled trials are replicable in real-world settings. Objectives To assess a symptomatic carotid stenosis population that underwent surgery and its short-term outcomes in a real-world context at a professional training center. Methods Observational study using data collected from medical records from January 2012 to January 2023. Patients undergoing operations for other carotid diseases and with concomitant heart surgery were excluded. Results A total of 70 patients undergoing angioplasty or carotid endarterectomy were included. Population subsets undergoing angioplasty or endarterectomy were similar. Differences in anesthetic modality and a longer operative time in the carotid endarterectomy subgroup were statistically significant. There were 4 cases of stroke, only 3 of which (2 minor and 1 major) were related to the index lesion. Thus, the rate of major operation-related stroke was 1.43% and the rate of any lesion-related stroke was 4.29%. There was 1 case of AMI in the angioplasty group and there were no deaths in the sample. The overall rate of major adverse cardiovascular events was 5.71%. There were no statistical differences between the endarterectomy and angioplasty groups regarding the main outcomes. Conclusions The rates of outcomes of ischemic stroke, acute myocardial infarction, death, and major adverse cardiovascular events at this center are in line with the rates reported by randomized controlled trials, demonstrating the feasibility of carotid surgery in centers with teaching programs.

Correlation between hemodynamic characteristics or dynamic cerebral autoregulation and postoperative hyperperfusion in patients undergoing carotid endarterectomy / 中华超声影像学杂志

Objective:To investigate the hemodynamic characteristics and dynamic cerebral autoregulation(dCA) of patients with severe carotid stenosis before carotid endarterectomy(CEA), and to analyze their correlations with hyperperfusion after CEA.Methods:A total of 63 patients with unilateral severe carotid artery atherosclerotic stenosis who underwent CEA were consecutively recruited prospectively in Xuanwu Hospital, Capital Medical University from January 2021 to August 2021. According to postoperative hyperperfusion, patients were divided into hyperperfusion group (13 cases) and non-hyperperfusion group (50 cases). The general clinical data and hemodynamic parameters were compared between the two groups. The dCA was evaluated by the transfer function analysis that measured the fluctuation amplitude of mean cerebral blood flow velocity(CBFV) with blood pressure change, the time difference of phase with blood pressure change, and the correlation between mean CBFV and blood pressure change. The value of dCA for predicting postoperative hyperperfusion was analyzed through the ROC curve and the area under the curve(AUC).Results:①The proportion of hypertension in hyperperfusion group was higher than that in non-hyperperfusion group ( P<0.05). ②The peak systolic velocity (PSV) at the stenosis lesion of the internal carotid artery, the end-diastolic velocity (EDV) at the stenosis lesion of the internal carotid artery and the ratio of PSV at the stenosis lesion of the internal carotid artery to the distal internal carotid artery in the hyperperfusion group were higher than the non-hyperperfusion group.And the PSV of the ipsilateral middle cerebral artery in the hyperperfusion group was lower than the non-hyperperfusion group (all P<0.05). ③In the very low-frequency and low-frequency region, the phase in the hyperperfusion group was lower than that in the non-hyperperfusion group (all P<0.05), while there was no significant difference in the high-frequency regions( P>0.05). In the three regions of very low-frequency, low-frequency and high-frequency, there were no significant differences in the gain and coherence between the two groups(all P>0.05). ④The best cutoff value of phase in the very low-frequency was 33.28 for predicting hyperperfusion after CEA (AUC=0.766, 95% CI=0.629-0.904, P=0.03), with the specificity of 0.700, and sensitivity of 0.846. Conclusions:There are differences in hemodynamics and dCA between the hyperperfusion group and the non-hyperperfusion group after CEA. The impaired preoperative dynamic cerebral autoregulation is an independent predictor of postoperative hyperperfusion.

Carotid endarterectomy combined with vertebral artery transposition treating vertebral artery V1 segment stenosis combined with ipsilateral carotid artery stenosis / 中国胸心血管外科临床杂志

@#Objective    To explore the treatment outcome of carotid endarterectomy combined with vertebral artery transposition in patients with severe stenosis to occlusion of the vertebral artery V1 segment and the ipsilateral carotid artery. Methods    From June 2017 to September 2020, patients with severe stenosis to occlusion of the vertebral artery V1 segment and the ipsilateral carotid artery treated with carotid endarterectomy combined with vertebral artery transposition in Fuwai Hospital were retrospectively analyzed. Results    Finally 12 patients were enrolled, including 10 males and 2 females with an average age of 67.8±6.0 years. Twelve patients were successfully operated and the follow-up time was 1-3 years. The stenosis degree of the V1 segment of the vertebral artery decreased from 83.5%±11.8% to 24.9%±14.3% (P<0.001). The stenosis degree of carotid artery decreased from 85.6%±11.0% to 0% (P<0.001). Postoperative follow-up showed that the symptoms of symptomatic patients before surgery improved. The 1-year and 3-year patency rates were 100.0%, and there were no peripheral nerve injury complications, perioperative deaths or strokes. Conclusion    Carotid endarterectomy combined with vertebral artery transposition can treat ipsilateral carotid artery  stenosis and vertebral artery stenosis at the same time, improve blood supply to the brain, improve patients' symptoms and has high promotion value.

Association between platelet lymphocyte ratio and neutrophil lymphocyte ratio and clinical outcomes following carotid endarterectomy / Associação do índice plaqueta-linfócito e do índice neutrófilo-linfócito com desfechos clínicos após endarterectomia de carótida

Abstract Background Approximately 30% of stroke cases result from carotid disease. Although several risk factors for complications after carotid endarterectomy have been identified, the existence of a biomarker that can estimate postoperative risk in these patients has not yet been proven. Objectives This study aimed to investigate correlations between the platelet-lymphocyte ratio (PLR) and the neutrophil-lymphocyte ratio (NLR) and postoperative clinical outcomes in patients undergoing carotid endarterectomy. Methods A retrospective study was conducted, including 374 patients who underwent carotid endarterectomy between 2002 and 2019 due to moderate to high extracranial internal carotid artery stenosis. Their platelet-lymphocyte ratio and neutrophil-lymphocyte ratios were obtained from the same blood samples. Results There was a statistically significant correlation between the PLR and the occurrence of restenosis (p < 0.01) and acute myocardial infarction (AMI) after endarterectomy (p = 0.03). Additionally, there was a statistically significant correlation between the PLR and the combined outcomes stroke and/or AMI and/or death (p = 0.03) and stroke and/or AMI and/or death and/or restenosis (p < 0.01). However, there were no significant correlations between NLR and these outcomes (p = 0.05, p = 0.16). Conclusions The platelet-lymphocyte ratio proved to be a useful test for predicting occurrence of strokes, acute myocardial infarctions, and deaths during the postoperative period after carotid endarterectomy. It was also associated with the risk of postoperative restenosis.

Resumo Contexto Aproximadamente 30% dos casos de acidente vascular cerebral (AVC) resultam de doença carotídea. Embora vários fatores de risco para complicações pós-endarterectomia carotídea tenham sido identificados, ainda não foi comprovada a existência de um biomarcador que possa estimar o risco pós-operatório nesses pacientes. Objetivos Correlacionar o índice plaqueta-linfócito (IPL) e o índice neutrófilo-linfócito (INL) com os desfechos clínicos pós-operatórios em pacientes submetidos a endarterectomia carotídea. Métodos Estudo retrospectivo que incluiu 374 pacientes submetidos a endarterectomia carotídea, entre 2009 e 2019, por estenose extracraniana da artéria carótida interna. O IPL e o INL foram calculados, tendo sido obtidos das mesmas amostras de sangue. Resultados Houve correlação estatisticamente significativa entre IPL e presença de reestenose (p<0,01) e infarto agudo do miocárdio (IAM) após endarterectomia (p=0,03). Os desfechos combinados AVC e/ou IAM e/ou óbito e AVC e/ou IAM e/ou óbito e/ou reestenose apresentaram, respectivamente, correlação estatisticamente significativa com o IPL (p=0,03; p<0,01) e não significativa com o INL (p=0,05; p=0,16). Conclusões O IPL mostrou-se um teste útil, capaz de predizer os desfechos de AVC e/ou IAM e/ou óbito em pacientes no pós-operatório de endarterectomia carotídea, relacionando-se também com risco de reestenose pós-operatória.

Caracterización de la morbilidad de la endarterectomía carotídea / Characterization of the morbidity of carotid endarterectomy

Introducción: El 80 por ciento de los accidentes cerebrovasculares resulta de tipo isquémico y al menos el 20-30 por ciento está provocado por estenosis de la arteria carótida extracraneal. La endarterectomía carotídea tiene como principal objetivo eliminar las placas de ateroma, que son fuentes de émbolos para el encéfalo, y mejorar el flujo sanguíneo a este órgano. Objetivo: Caracterizar la morbilidad de la endarterectomía carotídea en el Hospital General Docente "Enrique Cabrera" desde 2018 hasta 2021. Métodos: Se realizó un estudio de tipo descriptivo y corte transversal a 32 pacientes, a los cuales se les realizó endarterectomía carotídea. La recolección de los datos se efectuó mediante la revisión de historias clínicas. El período de estudio abarcó desde enero de 2018 hasta enero de 2021. Resultados: Predominó el sexo masculino (65,6 por ciento) y la media de edad fue de 68,8 años. Los factores de riesgo más frecuentes resultaron la hipertensión arterial y el tabaquismo con 75 por ciento y 65,6 por ciento, respectivamente. La enfermedad cerebrovascular con secuela mínima constituyó la forma clínica más frecuente en el 40,6 por ciento de los casos. Se encontró asociación estadísticamente significativa entre diabetes mellitus y formas clínicas, y entre enfermedad arterial periférica y la aparición de complicaciones. La carótida izquierda resultó la más afectada con 53 por ciento y el porcentaje de estenosis, entre 70 por ciento y 99 por ciento, se encontró en el 55,9 por ciento de los pacientes. Con mayor frecuencia se presentaron las complicaciones: lesión de nervios craneales (5,8 por ciento) y hematoma cervical (5,8 por ciento). La endarterectomía por eversión se realizó en el 97 por ciento de los casos. Conclusiones: Se demostró la seguridad y el éxito de la endarterectomía carotídea. La mayoría de los pacientes tuvo una evolución satisfactoria, y se presentaron escasas complicaciones y mortalidad nula(AU)

Introduction: 80 percent of strokes result in ischemic type and at least 20-30 percent are caused by stenosis of the extracranial carotid artery. Carotid endarterectomy has as its main objective to remove atheromatous plaques, which are sources of emboli for the brain, and improve blood flow to this organ. Objective: To characterize the morbidity of carotid endarterectomy at the "Enrique Cabrera" General Teaching Hospital from 2018 to 2021. Methods: A descriptive, cross-sectional study was conducted in 32 patients, who underwent carotid endarterectomy. Data collection was carried out by reviewing medical records. The study period spanned from January 2018 to January 2021. Results: The male sex predominated (65.6 percent) and the mean age was 68.8 years. The most frequent risk factors were high blood pressure and smoking with 75 percent and 65.6 percent, respectively. Cerebrovascular disease with minimal sequelae was the most frequent clinical form in 40.6 percent of cases. A statistically significant association was found between diabetes mellitus and clinical forms, and between peripheral arterial disease and the occurrence of complications. The left carotid was the most affected with 53 percent and the percentage of stenosis, between 70 percent and 99 percent, was found in 55.9 percent of patients. The following complications were the most common: cranial nerve injury (5.8 percent) and cervical hematoma (5.8 percent). Eversion endarterectomy was performed in 97 percent of cases. Conclusions: The safety and success of carotid endarterectomy were demonstrated. Most of the patients had a satisfactory evolution, and there were few complications and zero mortality(AU)

Coexisting Coronary and Carotid Artery Disease: What We Did, What Happened

ABSTRACT Introduction: There is no complete consensus on the three surgical methods and long-term consequences for coexisting coronary and carotid artery disease. We retrospectively evaluated the surgical results in this high-risk group in our clinic for a decade. Methods: Between 2005 and 2015, 196 patients were treated for combined carotid and coronary artery disease. A total of 50 patients were operated on with the staged method, 40 of which had carotid endarterectomy (CEA) priority, and 10 had coronary artery bypass grafting (CABG) priority. CABG and CEA were simultaneously performed in 82 patients; and in 64 asymptomatic patients with unilateral carotid artery lesions and stenosis over 70%, only CABG was done (64 patients). Results were evaluated by uni-/multivariate analyses for perioperative, early, and late postoperative data. Results: In the staged group, interval between the operations was 2.82±0.74 months. Perioperative and early postoperative (30 days) parameters did not differ between groups (P-value < 0.05). Postoperative follow-up time was averaged 94.9±38.3 months. Postoperative events were examined in three groups as (A) deaths (all cause), (B) cardiovascular events (non-fatal myocardial infarction, recurrent angina, congestive heart failure, palpitation), and (C) fatal neurological events (amaurosis fugax, transient ischemic attack, and stroke). When group C events were excluded, event-free actuarial survival rates were similar in all three methods (P=0.740). Actuarial survival rate was significantly different when all events were included (P=0.027). Neurological events increased markedly between months 34 and 66 (P=0.004). Conclusion: Perioperative and early postoperative event-free survival rates were similar in all three methods. By the beginning of the 34th month, the only CABG group has been negatively separated due to neurological events. In the choice of methodology, "most threatened organ priority'' was considered as clinical parameter.

Comparison Between Treatment Strategies of Carotid Stenosis in Patients Undergoing Coronary Artery Bypass Grafting

ABSTRACT Introduction: In patients undergoing coronary artery bypass grafting (CABG), stroke is a major complication that increases morbidity and mortality. The presence of carotid stenosis (CS) increases risk of stroke, and the optimal treatment remains uncertain due to the lack of randomized clinical trials. The aim of this study is to compare three management approaches to CS in patients submitted to CABG. Methods: From 2005 to 2015, 79 consecutive patients with significant CS submitted to CABG were retrospectively evaluated. Patients were divided in three groups, according to CS treatment: 17 underwent staged carotid endarterectomy (CEA)-CABG, 26 underwent synchronous CEA-CABG, and 36 underwent isolated CABG without carotid intervention. The primary outcomes were composed by 30-day postoperative acute myocardial infarction (MI), 30-day postoperative stroke, and death due to all causes during the follow-up. Results: Patients were evaluated during an average 2.05 years (95% confidence interval = 1.51-2.60) of follow-up. Major adverse cardiac events, including death, postoperative MI, and postoperative stroke, occurred in 76.5% of the staged group, 34.6% of the synchronous group, and 33.3% of the isolated CABG group (P=0.007). As for MI, the rates were 29.4%, 3.85%, and 11.1% (P=0.045), respectively. There was no statistically significant difference in total mortality rates (35.3%, 30.8%, and 25.0%, respectively; P=0,72) and stroke (29.4%, 7.7%, and 8.3%, respectively; P=0,064) between groups. Conclusion: Staged CEA-CABG is associated with higher major adverse cardiac events and MI rate when compared to the strategy of synchronous and isolated CABG, but without statistically difference in total mortality during the entire follow-up.

The Effect of Hemodynamic Parameters on Cerebral Oxygenization During Carotid Endarterectomy

Abstract Objective/Introduction: Near-infrared spectroscopy (NIRS) is a non-invasive technique to detect cerebral ischemia by monitoring changes in regional cerebral oxygenation (rSO2) in the frontal lobes. However, there are no studies showing the changes in NIRS values in response to hemodynamic variations during stages of carotid endarterectomy (CEA) procedure and clinical implications of these changes. The aim of this study was to determine if hemodynamic changes affect NIRS values during carotid endarterectomy and if our results may help to provide strategies for hemodynamic management in these patients. Methods: A total of 50 consecutive patients undergoing CEA were prospectively included in the study. NIRS was measured at first minute after clamping of carotid artery, and then systolic blood pressure was increased above 150 mmHg. NIRS values from both hemispheres were recorded simultaneously at certain time points and were analyzed to evaluate the changes at different stages of operation and to assess correlations with hemodynamic parameters. Results: NIRS values on the right and left sides were correlated with systolic (right P<0.001, R2:0.24; left P=0.02, R2:0.10) diastolic (right P<0.001, R2:0.36; left P=0.001, R2:0.18) and mean (right P<0.001, R2:0.33; left P=0.003, R2:0.17) blood pressures when the patient was under general anaesthesia. NIRS values were significantly lower than pre-incision values just after clamping of carotid artery in both hemispheres (P=0.005 for the right and P<0.001 for the left side). Conclusion: NIRS values measured in our study show that there is a correlation between hemodynamic changes and cerebral oxygenation. This effect is especially pronounced while the patient is asleep and intubated, which implies the importance of close monitoring of patients with carotid disease during any surgery requiring general anaesthesia.

Tongdu Tiaoshen acupuncture combined with carotid endarterectomy for carotid artery stenosis: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the clinical therapeutic effect of Tongdu Tiaoshen acupuncture combined with carotid endarterectomy (CEA) and simple CEA on carotid artery stenosis (CAS).@*METHODS@#A total of 60 patients with CAS were randomized into an observation group (30 cases, 2 cases dropped off) and a control group (30 cases, 3 cases dropped off). Both groups were treated with eversion CEA (eCEA). The conventional treatment of internal medicine and antiplatelet drugs i.e. aspirin enteric-coated tablet and clopidogrel hydrogen sulfate tablet were given in the control group for 4 weeks. On the basis of the treatment in the control group, Tongdu Tiaoshen acupuncture was applied at Baihui (GV 20), Fengfu (GV 16), Yamen (GV 15), cervical Jiaji (EX-B 2), Dazhui (GV 14), etc. in the observation group, once a day, 1-day rest was taken after 6-day treatment, 2 weeks were as one course and totally 2 courses were required. The carotid intima-media thickness (IMT) before and after treatment was detected by ultrasonic diagnostic apparatus, the TCM symptom score was compared before and after treatment and in the follow-up of 6 months after treatment, the clinical efficacy was evaluated in the two groups. The occurrence of endpoints within 1 year was recorded.@*RESULTS@#After treatment, the carotid IMT and TCM symptom scores were decreased compared before treatment in the both groups (P<0.05), and the changes in the observation group were greater than the control group (P<0.05). In the follow-up, the TCM symptom scores were decreased compared before treatment in the both groups (P<0.05). The total effective rate was 96.4% (27/28) in the observation group, which was superior to 88.9% (24/27) in the control group (P<0.05). There were 1 case of stoke in the observation group and 2 cases of stroke in the control group within 1-year follow-up, and there was no significant difference in the number of endpoints between the two groups within 1 year (P>0.05).@*CONCLUSION@#Tongdu Tiaoshen acupuncture combined with CEA can effectively reduce the IMT in patients with CAS, improve the TCM symptom score, the efficacy is superior to simple CEA treatment.

Hemodynamic depression after carotid surgery: Incidence, risk factors and outcomes

Abstract Introduction: Hemodynamic Depression (HD) characterized by hypotension and bradycardia is a complication of carotid surgery due to direct autonomic stimulation in the carotid sinus. The authors believe the incidence of HD is high and possibly related to major cardiac complications. Methods: Analysis of patient records during admissions for carotid surgery between January 2014 and December 2018 in two hospitals. HD was defined as bradycardia or hypotension in the first 24 postoperative hours. Bradycardia was defined as heart rate < 50bpm; hypotension as systolic blood pressure < 90 mmHg, continuous use of vasopressors, or a drop in SBP > 20% compared to preoperative values. Myocardial infarction, stroke, and cardiovascular death were defined as adverse events. Results: Overall, 237 carotid surgeries (178 endarterectomies, 59 angioplasties) were studied, and the global incidence of HD was 54.4% (hypotension in 50.2%, bradycardia in 11.0%, and hypotension and bradycardia in 6.8%). The independent predictors of HD were asymptomatic carotid stenosis (OR = 1.824; 95% CI 1.014 −3.280; p = 0.045), endovascular surgery (OR = 3.319; 95% CI 1.675−6.576; p = 0.001) and intraoperative hypotension or bradycardia (OR = 2.144; 95% CI 1.222−3.762; p = 0.008). Hypotension requiring continuous vasopressor infusion was the only factor independently associated with adverse cardiovascular events (OR = 5.504; 95% CI 1.729-17.529; p = 0.004). Discussion/conclusion: Incidence of Hemodynamic Depression after carotid surgery is high and independently associated with surgical technique, symptomatic repercussion of the carotid stenosis, and intraoperative hypotension or bradycardia. Hypotension requiring the continuous infusion of vasopressors was independently associated with the occurrence of MACE.

Landmarks for the hypoglossal nerve within the anterior cervical triangle / Topografía del nervio hipogloso en el triángulo cervical anterior

SUMMARY: Cranial nerve injury is one of the neurologic complications following carotid endarterectomy. The hypoglossal nerve is one of the most frequently injured nerves during carotid endarterectomy. Guidelines suggest that proper anatomic knowledge is crucial to avoid cranial nerve injury. The aim of the present study is to provide landmarks for the localization of the hypoglossal nerve during carotid endarterectomy. 33 anterior cervical triangles of formalin-fixed adult cadavers were dissected. The "carotid axis" was defined and measured, the level of the carotid bifurcation within the carotid axis was registered. "High carotid bifurcation" was considered for those carotid bifurcation found in the upper 25 mm of the carotid axis. The distance between the hypoglossal nerve and the carotid bifurcation was measured (length 1). The relationship between the hypoglossal nerve and the posterior belly of the digastric muscle was registered. For caudal positions, the distance between hypoglossal nerve and posterior belly of the digastric muscle was determined (length 2). Carotid axis range 88.3 mm-155.4 mm, average 125.8 mm. Level of the carotid bifurcation within the carotid axis range 75.3 mm-126.5 mm, mean 102.5 mm. High carotid bifurcation was found in 19 cases (57 %). Length 1 ranged from 1.6 mm to 38.1, mean 17.5. Finally, in 29 specimens (87.8 %) the hypoglossal nerve was caudal to posterior belly of the digastric muscle, whereas in 4 cases (12.2 %) it was posterior. Length 2 ranged from 1 mm to 17.0 mm, mean 6.9 mm. Distances between the hypoglossal nerve and nearby structures were determined. These findings may aid the surgeon in identifying the hypoglossal nerve during carotid endarterectomy and thus prevent its injury.

RESUMEN: La lesión de pares craneales es una de las complicaciones neurológicas posteriores a la endarterectomía carotídea. El nervio hipogloso es uno de los nervios lesionados más frecuentemente durante la endarterectomía carotídea. Las guías de actuación clínica sugieren que el conocimiento anatómico adecuado es crucial para evitar lesiones de los nervios craneales. El objetivo del presente estudio fue proporcionar puntos de referencia para la ubicación del nervio hipogloso durante la endarterectomía carotídea. Se disecaron 33 triángulos cervicales anteriores de cadáveres adultos fijados en solución a base de formaldehído. Se definió y midió el "eje carotídeo", se registró el nivel de la bifurcación carotídea dentro del eje carotídeo. Se consideró una "bifurcación carotídea alta" para aquellas bifurcaciones carotídeas encontradas en los 25 mm superiores del eje carotídeo. Se midió la distancia entre el nervio hipogloso y la bifurcación carotídea (longitud 1). Se registró la relación entre el nervio hipogloso y el vientre posterior del músculo digástrico. Para las posiciones caudales, se determinó la distancia entre el nervio hipogloso y el vientre posterior del músculo digástrico (longitud 2). Rango del eje carotídeo 88,3 mm-155,4 mm, media 125,8 mm. Rango del nivel de la bifurcación carotídea dentro del eje carotídeo 75,3 mm-126,5 mm, media 102,5 mm. Se encontró una bifurcación carotídea alta en 19 casos (57 %). La longitud 1 osciló entre 1,6 mm y 38,1, con una media de 17,5. Finalmente, en 29 muestras (87,8 %) el nervio hipogloso fue caudal al vientre posterior del músculo digástrico, mientras que en 4 casos (12,2 %) fue posterior. La longitud 2 osciló entre 1 mm y 17,0 mm, con una media de 6,9 mm. Se determinaron las distancias entre el nervio hipogloso y las estructuras cercanas. Estos hallazgos pueden ayudar al cirujano a identificar el nervio hipogloso durante la endarterectomía carotídea y así prevenir su lesión.

Endarterectomía de carótida bilateral en un mismo tiempo quirúrgico / Bilateral carotid endarterectomy at the same surgical time

Los pacientes con estenosis bilateral presentan una elevada incidencia de clínica hemisférica e infartos cerebrales en relación con la primera carótida y en espera de una segunda cirugía de la carótida contralateral estenótica. La endarterectomía de carótida bilateral en un mismo tiempo quirúrgico representa todo un reto para el cirujano vascular por las complicaciones que puede conllevar. Pero puede realizarse una correcta selección del paciente con bajo riesgo quirúrgico, un análisis de la localización y las características de las placas que provocan la estenosis, y una técnica analgésica que permita monitorear constantemente la disfunción cerebral y siga los principios técnicos. Este estudio tuvo el objetivo de asociar los criterios anteriores a un caso de la endarterectomía de carótida bilateral en un mismo tiempo quirúrgico. Se seleccionó un paciente masculino de 72 años que había sufrido ataques transitorios de isquemia sin secuelas neurológicas. Se realizó el procedimiento sin complicaciones perioperatorias ni posoperatorias, por lo que se propone como una alternativa segura a llevar a cabo en pacientes con estenosis bilateral(AU)

Patients with bilateral stenosis have a high incidence of hemispheric clinical and cerebral infarctions in relation to the first carotid and waiting for a second surgery of the stenotic contralateral carotid. Bilateral carotid endarterectomy at the same surgical time represents a challenge for the vascular surgeon because of the complications it can entail. But a correct selection of the patient with low surgical risk can be made, an analysis of the location and characteristics of the plaques that cause stenosis, and also an analgesic technique that allows constant monitoring of brain dysfunction and follows technical principles. This study aimed to associate the above criteria with a case of bilateral carotid endarterectomy at the same surgical time. A 72-year-old male patient who had suffered transient ischemic attacks without neurological sequelae was selected. The procedure was performed without perioperative or postoperative complications, so it is proposed as a safe alternative to be carried out in patients with bilateral stenosis(AU)

Endarterectomía carotídea, resultados a mediano y largo plazo / Carotid endarterectomy, medium to long-term results

Resumen Introducción: Entre el 50% al 80% de los pacientes con un ictus, presentan lesión de la arteria carótida común o interna, de estos un 15% a 30% quedan con discapacidad severa, y el 20% requiere de institucionalización. Objetivo: Analizar las variables epidemiológicas involucradas en la estenosis carotídea y los resultados a mediano-largo plazo de la endarterectomía carotídea. Materiales y Método: Estudio observacional, descriptivo y retrospectivo, donde se analizan 103 endarterectomías carotídeas sucesivas, realizadas en 97 pacientes, en un período de 12 años (2007 a 2018), en el Servicio de Cirugía del Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Sexo masculino 64,9%, edad promedio 70,2 años, sintomáticos 65,9%, presentación clínica más frecuente el ataque isquémico transitorio (48,4%), morbilidad global inmediata del procedimiento 20,3%, AVE perioperarorio 3,9% (ninguno discapacitante), disfunción de nervios periféricos 5,8%, mortalidad operatoria 70% y cuando se efectúa en un plazo menor a 2 semanas del evento isquémico. Conclusión: La endarterectomía carotídea sigue siendo el procedimiento quirúrgico de elección para tratar la estenosis carotídea severa; realizada en centros con experiencia, es un procedimiento seguro y eficaz en la prevención del infarto cerebral.

Introduction: Between 50 and 80% of patients with a stroke, have lesions of the common or internal carotid artery, of these 15 to 30% are severely disabled, and 20% require institutionalization. Aim: To analyze the epidemiological variables involved in carotid stenosis, and the medium to long-term results of carotid endarterectomy. Materials and Method: Observational, descriptive and retrospective study, analyzed 103 successive carotid endarterectomies procedures in 97 patients, in a period of 12 years (2007 to 2018), in the Surgery Department of the Dr. Eduardo Pereira Hospital, Valparaíso, Chile. Results: Male sex 64.9%, average age 70.2 years, symptomatic 65.9%, most frequent clinical presentation, transient ischemic attack (48.4%), immediate global morbidity of the procedure 20.3%, peri-operative AVE 3.9% (none disabling), peripheral nerve dysfunction 5.8%, operative mortality 70%, and when performed within a period less than 2 weeks of the ischemic event. Conclusion: Carotid endarterectomy remains the surgical procedure of choice, to treat severe carotid stenosis, performed in experienced centers, it is a safe and effective procedure in the prevention of cerebral ischemia.

Effect of different shunt strategies on cerebral infarction after carotid endarterectomy / 北京大学学报(医学版)

OBJECTIVE@#The key point of anesthesia management in carotid endarterectomy (CEA) is to maintain adequate cerebral perfusion during carotid artery occlusion. Placement of shunt is one of the common surgical methods. This study analyzed the effects of different shunt strategies on cerebral infarction after carotid endarterectomy.@*METHODS@#A total of 443 patients who underwent CEA under general anesthesia within 2 years were divided into imaging group (based on preoperative imaging data as the basis for shunt) and stump pressure group (based on intraoperative stump pressure as the basis for shunt). The preoperative demographic data, past medical history, degree of cervical vascular stenosis, blood pressure at each time point during the perioperative period, vascular blocking time, whether to place the shunt, postoperative hospital stay, cerebral infarction during hospitalization, and other adverse events were collected and compared between the two groups. On this basis, the preoperative and intraoperative conditions with significant differences were matched with propensity scores, and the influence of different shunt strategies on postoperative cerebral infarction was analyzed.@*RESULTS@#In the study, 268 patients in the imaging group and 175 patients in the stump pressure group underwent CEA under general anesthesia. There were statistically significant differences in basic conditions and blood pressure at each time point between the two groups. After matching the propensity scores, 105 patients in each of the two groups were matched. The basic conditions of the patients before surgery and the difference in blood pressure of the two groups at each time point were not statistically significant. There was no significant diffe-rence in the incidence of postoperative cerebral infarction between the two groups (1.9% vs. 1.0%, P>0.999). The intraoperative shunt rate in the imaging group was lower than that in the stump pressure group (0 vs. 22.9%, P < 0.001). The postoperative hospital stay in the imaging group was 8 (7, 8) days, which was longer than the stump pressure group 5 (4, 6) days (P < 0.001).@*CONCLUSION@#The rate of the shunt was lower according to preoperative imaging examination than that according to the residual pressure in our hospital. There is no significant difference in the incidence of cerebral infarction during the postoperative hospital stay. The effect of different shunt strategies on cerebral infarction needs further study.

Complicaciones posoperatorias en la fase temprana de la endarterectomía carotídea / Postoperative complication in the early stage of carotid endarterectomy

Introducción: La enfermedad carotídea es una de las formas de presentación de la enfermedad cerebrovascular, que se encuentra entre las principales causas de morbi-mortalidad y de invalidez en el mundo. La endarterectomía carotídea resulta el tratamiento quirúrgico por excelencia. Objetivo: Caracterizar las complicaciones posoperatorias en la fase temprana de la endarterctomia carotídea en un período de cinco años. Métodos: Se realizó un estudio descriptivo y retrospectivo de corte transversal en 35 pacientes ingresados en el Instituto de Angiología, que fueron operados mediante endarterectomía carotídea por presentar enfermedad carotídea. Se analizaron las variables sociodemográficas, clínicas y quirúrgicas. Se utilizó la estadística descriptiva e inferencial. Resultados: Hubo un predominio del sexo masculino (72,2 por ciento) y de los mayores de 60 años. Las comorbilidades más frecuentes fueron la hipertensión arterial (94,4 por ciento), el tabaquismo (77,8 por ciento) y la enfermedad arterial periférica (61,1 por ciento). El 50 por ciento de todos los pacientes presentó complicaciones en la fase temprana de la cirugía sin mortalidad; la más frecuente resultó el hematoma de la herida (44,4 por ciento), que estuvo presente en el 50 por ciento de las endarterectomías convencionales. Los operados con anestesia general presentaron mayor número de complicaciones, excepto el hematoma, que se observó más en el empleo de anestesia loco-regional. El ictus posoperatorio ocurrió en pacientes con anestesia general. Conclusiones: Las características de las complicaciones posoperatorias en la fase temprana de la endarterectomía carotídea identificadas se asociaron con los tipos de endarterectomía y anestesia, y las comorbilidades(AU)

Introduction: Carotid disease is one of the onset manifestations of cerebrovascular disease, which is among the main causes of morbidity, mortality and disability worldwide. Carotid endarterectomy is the gold standard surgical treatment. Objective: To characterize postoperative complications in the early phase of carotid endarterectomy. Methods: A descriptive and retrospective cross-sectional study was carried out with 35 patients admitted to the Institute of Angiology and who underwent carotid endarterectomy due to carotid disease. Sociodemographic, clinical and surgical variables were analyzed. Descriptive and inferential statistics were used. Results: There was a predominance of males (72.2 perecnt) and of patients aged more than 60 years. The most frequent comorbidities were arterial hypertension (94.4 percent), smoking (77.8 percent), and peripheral arterial disease (61.1 percent). 50 percent of all patients presented complications in the early phase of surgery and without mortality; the most frequent was wound hematoma (44.4 percent), accounting for 50 percent of conventional endarterectomies. Those operated on with general anesthesia presented a greater number of complications, except for hematoma, observed more in the use of local-regional anesthesia. Postoperative stroke occurred in patients under general anesthesia. Conclusions: The characteristics of postoperative complications identified in the early phase of carotid endarterectomy were associated with the types of endarterectomy, anesthesia, and comorbidities(AU)

Role of Carotid Artery Stenting in Prevention of Stroke for Asymptomatic Carotid Stenosis: Bayesian Cross-Design and Network Meta-Analyses

BACKGROUND AND OBJECTIVES: There is insufficient evidence regarding the optimal treatment for asymptomatic carotid stenosis.METHODS: Bayesian cross-design and network meta-analyses were performed to compare the safety and efficacy among carotid artery stenting (CAS), carotid endarterectomy (CEA), and medical treatment (MT). We identified 18 studies (4 randomized controlled trials [RCTs] and 14 nonrandomized, comparative studies [NRCSs]) comparing CAS with CEA, and 4 RCTs comparing CEA with MT from MEDLINE, Cochrane Library, and Embase databases.RESULTS: The risk for periprocedural stroke tended to increase in CAS, compared to CEA (odds ratio [OR], 1.86; 95% credible interval [CrI], 0.62–4.54). However, estimates for periprocedural myocardial infarction (MI) were quite heterogeneous in RCTs and NRCSs. Despite a trend of decreased risk with CAS in RCTs (OR, 0.70; 95% CrI, 0.27–1.24), the risk was similar in NRCSs (OR, 1.02; 95% CrI, 0.87–1.18). In indirect comparisons of MT and CAS, MT showed a tendency to have a higher risk for the composite of periprocedural death, stroke, MI, or nonperiprocedural ipsilateral stroke (OR, 1.30; 95% CrI, 0.74–2.73). Analyses of study characteristics showed that CEA-versus-MT studies took place about 10-year earlier than CEA-versus-CAS studies.CONCLUSIONS: A similar risk for periprocedural MI between CEA and CAS in NRCSs suggested that concerns about periprocedural MI accompanied by CEA might not matter in real-world practice when preoperative evaluation and management are working. Maybe the benefits of CAS over MT have been overestimated considering advances in medical therapy within10-year gap between CEA-versus-MT and CEA-versus-CAS studies.

Analysis of diagnosis and treatment for acute thromboembolism occlusion caused by severe internal carotid artery stenosis: A case report / 中国脑血管病杂志

Ultrasonography revealed that a ease of acute internal carotid artery (ICA) occlusion caused by acute thrombosis due to severe stenosis and intraplaque hemorrhage. The patient is male and 81 years old with blurred vision in the right eye. Carotid artery ultrasound ( CDU) showed that severe stenosis of right proximal ICA, the discontinuous fibrous cap at the top of atherosclerotic plaques, and intraplaque hemorrhage. Besides, the blood flow of the right distal ICA disappeared suddenly during the examination. Therefore, ICA occlusion caused by acute thrombosis was detected by CDU. The patient was followed-up day by day using ultrasonography and treated with dual antiplatelet therapy. Three days later, CDU showed that the right ICA was re-open but still accompanied by severe stenosis. The patient was treated by carotid endarterectomy for revascularization after six days of admission. According to this process of diagnosis and treatment, carotid ultrasound provides an important clinical role for the diagnosis, treatment, and follow-up of acute thrombosis with carotid artery stenosis.

Surgical treatment of carotid web: one case report / 中华神经科杂志

The patient was a middle-aged male with the recurrent transient ischemic attack caused by carotid web,and the common symptoms include recurrent left limb weakness and numbness.According to the results of the CT angiography,the digital substraction angiography,the magnetic resonance angiography and the colour-Doppler ultrasound of the neck,the patient was considered with carotid artery web.After conventional medical treatment such as anti-platelet aggregation,lipid regulation and improvement of cerebral circulation,the patient's symptoms did not improve significantly.Later,the patient underwent carotid endarterectomy.The pathological examination results of the tissue from the surgery confirmed the patient with carotid artery web.Moreover,after surgery,the patient did not experience transient ischemic attack any more.

Surgical treatment of carotid web: one case report / 中华神经科杂志

The patient was a middle-aged male with the recurrent transient ischemic attack caused by carotid web, and the common symptoms include recurrent left limb weakness and numbness. According to the results of the CT angiography, the digital substraction angiography, the magnetic resonance angiography and the colour-Doppler ultrasound of the neck, the patient was considered with carotid artery web. After conventional medical treatment such as anti-platelet aggregation, lipid regulation and improvement of cerebral circulation, the patient′s symptoms did not improve significantly. Later, the patient underwent carotid endarterectomy. The pathological examination results of the tissue from the surgery confirmed the patient with carotid artery web. Moreover, after surgery, the patient did not experience transient ischemic attack any more.

Avaliação da resposta hemodinâmica cerebral através da monitorização com a espectroscopia próxima ao infravermelho (NIRS) em pacientes com doença aterosclerótica da artéria carótida submetidos a endarterectomia / Evaluation of the brain hemodynamic response by means of near-infrared spectroscopy (NIRS) monitoring in patients with atherosclerotic carotid disease undergoing endarterectomy

Resumo Contexto A espectroscopia próxima ao infravermelho (NIRS) é uma técnica não invasiva que detecta as alterações hemodinâmicas teciduais. A NIRS pode monitorar de forma contínua as informações fisiológicas vasculares intracranianas. Por ser portátil, ela pode ser utilizada à beira do leito e no centro cirúrgico. Objetivos Avaliar as possíveis alterações hemodinâmicas cerebrais durante a endarterectomia em pacientes com estenoses maiores que 70% utilizando NIRS. Métodos Foram avaliados 10 voluntários portadores de doença carotídea aterosclerótica com indicação de endarterectomia. Após a seleção dos pacientes, que responderam um questionário com dados epidemiológicos e informações referentes à presença de comorbidades, a doença foi confirmada por métodos diagnósticos. No procedimento cirúrgico, utilizou-se a NIRS para monitorização. Foram avaliadas as variáveis saturação de oxigênio (SatO2), hemoglobina total (HbT), hemoglobina reduzida (HbR) e hemoglobina oxigenada (HbO) nos três tempos cirúrgicos pré-, trans e pós-clampeamento carotídeo. Utilizou-se p < 0,05 como nível de significância. Resultados A avaliação dos resultados obtidos por meio das medidas registradas pela NIRS permite afirmar que HbR e SatO2 variam ao longo das etapas da cirurgia. Durante o clampeamento, a variável HbR mostra valores mais elevados que nas outras duas etapas da cirurgia. Por outro lado, a variável SatO2 mostra redução durante o clampeamento. Conclusões A NIRS é um método viável e aplicável de monitorização intracerebral, não invasivo e em tempo real, durante a endarterectomia carotídea, capaz de medir de forma precisa as mudanças das condições hemodinâmicas capilares intracerebrais.

Abstract Backgrounds Near-infrared spectroscopy (NIRS) is non-invasive technique that detects hemodynamic alterations in tissues. It enables continuous monitoring of intracerebral vascular physiologic information. Due to its portable nature, NIRS may be used bedside or in the operating room. Objectives To evaluate use of NIRS for intraoperative monitoring of the brain hemodynamic response, during carotid endarterectomy. Methods 10 patients with atherosclerotic carotid disease scheduled for endarterectomy were evaluated. After patients had been selected, they answered a questionnaire on epidemiological data and information about comorbidities and then carotid disease was confirmed with diagnostic methods. NRIS monitoring was used during the surgical procedure. The variables analyzed before, during and after carotid clamping were oxygen saturation (SatO2), total hemoglobin (THb), reduced hemoglobin (RHb), and oxyhemoglobin (OHb). A p value of <0.05 was considered statistically significant. Results The results obtained from NIRS show that RHb and SatO2 vary during the different stages of surgery. RHb levels are higher during clamping, when compared with the other two surgical stages. On the other hand, SatO2 is lower during clamping. Conclusions During carotid endarterectomy, NIRS is a feasible, real-time, and non-invasive intracranial monitoring method that accurately and reliably measures the changes in intracerebral capillary hemodynamic conditions.