The benefit of deferred carotid revascularization in patients with moderate-severe disabling cerebral ischemic stroke.

OBJECTIVE: Symptomatic carotid artery stenosis needs revascularization within 2 weeks by carotid endarterectomy (CEA) to reduce the risk of symptom recurrence; however, the optimal timing of intervention is yet to be defined in patients with large-volume cerebral ischemic lesion (LVCIL) and modified Rankin scale (mRS) score ≥3. The aim of this study was to determine the most appropriate timing for CEA in patients with a recent stroke and LVCIL. METHODS: Data from patients with symptomatic carotid stenosis with LVCIL and mRS score of 3 or 4 from 2007 to 2017 were considered. Patients were submitted to CEA if they had a stable clinical condition and life expectancy >1 year. LVCIL was defined as a cerebral ischemic lesion of volume >4000 mm3. Perioperative stroke and death were evaluated by stratifying for timing of CEA by χ2 test and multiple logistic regression. Patients with similar characteristics (LVCIL and mRS score of 3 or 4) unfit for CEA served as the control group for recurrence of stroke at 1-year follow-up. RESULTS: In an 11-year period, of a total 4020 CEAs, 126 (2.9%) were performed in patients with a moderate stroke and LVCIL occurring in the same admission. The patients' median age was 69 years (interquartile range [IQR], 10 years); 72% (91) were male, with mRS score of 3 (IQR, 1) and LVCIL volume of 20,000 mm3 (IQR, 47,000 mm3). The median time elapsed from symptoms to CEA was 7 weeks (IQR, 8 weeks). Overall perioperative stroke/death was 7.3% (eight strokes and one death). By selective timing evaluation of the postoperative events, CEA performed within 4 weeks was associated with a significantly higher rate of stroke/death compared with patients operated on after 4 weeks: 11.9% (8/67) vs 1.7% (1/59; P = .03). By logistic regression, CEA within 4 weeks was an independent (from sex, cerebral ischemic lesion volume, dyslipidemia, and carotid stenosis) predictor of postoperative stroke/death (odds ratio, 8.2; 95% confidence interval, 1.01-73). In the same period, 101 patients were considered unfit for CEA for dementia (n = 22), severe comorbidities (n = 55), or short (<1-year) life expectancy (n = 24), and 43 (43%) survived at 1 year. At 1 year, the perioperative/recurrent stroke after CEA vs patients unfit for CEA was similar (6.2% vs 13.9%; P = .11), but CEA performed after 4 weeks led to significantly lower perioperative/recurrent stroke (1.7% vs 13.9%; P = .02). CONCLUSIONS: The surgical risk of CEA in patients with a recent moderate-severe ischemic stroke and LVCIL is high. However, if the intervention is delayed >4 weeks, its benefit seems significant.

Cystic Adventitial Disease of the Popliteal Artery: Radical Surgical Treatment After Several Failed Approaches. A Case Report and Review of the Literature.

Adventitial cystic disease is a rare nonatheromatous cause of popliteal artery disease. We report the case of a 49-year-old male patient who presented with left calf claudication caused by adventitial cystic disease. Popliteal artery resection followed by autologous vein graft interposition and Percutaneous Transluminal Angioplasty (PTA) stenting led to recurrence. The patient was finally successfully treated by bypass with autologous vein. No postoperative complications occurred, and patency was preserved at 33-month follow-up. Several different treatment options are possible; however, a primary radical surgical treatment with extra-anatomical medial bypass with autologous vein seems preferable.

Is size of infarct or clinical picture that should delay urgent carotid endarterectomy? A meta-analysis.

INTRODUCTION: The best timing for carotid endarterectomy in patients with stroke is still matter of debate, particularly in case of significant cerebral ischemic lesion or neurological deterioration. The present review and meta-analysis aimed to report the best evidence in the outcome of patients submitted to urgent (<48h) or standard elapsing time (<2-week) CEA for stroke and to evaluate the impact of cerebral ischemic lesion size and clinical manifestation in the postoperative outcome. EVIDENCE ACQUISITION: A systematic review and meta-analysis was performed by searching through Scopus and PubMed all papers reporting carotid endarterectomy (CEA) outcome (stroke and stroke/death) in patients who suffered a stable stroke, treated within 48h and 2 weeks from symptoms. A subgroup analysis of studies reporting the presence and size of cerebral lesion and clinical manifestation was planned. The pooled 30-day stroke and stroke/death risk (effect size) was expressed by crude percentage and 95% confidence interval (CI), by random effect model. EVIDENCE SYNTHESIS: Sixteen studies were included in the meta-analysis, 7 reporting the CEA outcome performed <48h from stroke and 13 reporting the outcome of CEA performed <2-week. The effect size of stroke and stroke/death of CEA performed <48h from symptoms was 7.4% (95% CI: 3.7-11.2) and 7.9% (95% CI: 4.0-11.8) respectively, and for CEA <2-week was 4.5% (95% CI: 2.8-6.3) and 5.4% (95% CI: 3.4-7.4) respectively. The authors agreed in considering the severity of stroke and the volume of the cerebral ischemic lesion a risk factor for postoperative complication however, due to the extremely high heterogeneity of the studies data, the effect size was not calculated. Two studies evaluated the effect of the cerebral ischemic lesion distribution; the presence of a border-zone infarct was associated with a significant increase in the risk of postoperative stroke/death rate compared with territorial cerebral ischemic lesion (OR: 6.0; 95%CI 1.1-32.0). CONCLUSIONS: CEA for patients with a recent stroke is associated with 5.4% and 7.9% of stroke/death. A large volume of the cerebral ischemic lesion and a deteriorated neurological status are associated with a higher perioperative risk; urgent carotid revascularization seems to further increase this risk.