Can NIRS be a surrogate indicator of elective shunt in carotid endarterectomy? A single-center observational retrospective study says no.

BACKGROUND: Neuromonitoring during carotid endarterectomy (CEA) under general anesthesia is desirable and may be useful for preventing brain ischemia, but the selection of the most appropriate method remains controversial. PURPOSE: To determine the effectiveness of near infrared spectroscopy (NIRS) compared to multimodality intraoperative neuromonitoring (IONM) in indicating elective shunts and predicting postoperative neurological status. METHODS: This is a retrospective observational study including 86 consecutive patients with CEA under general anesthesia. NIRS and multimodality IONM were performed during the procedure. IONM included electroencephalography (EEG), somatosensory evoked potentials (SSEPs) and transcranial motor-evoked potentials (TcMEPs). Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated for each neuromonitoring modality. RESULTS: NIRS presented a sensitivity and a specificity for detecting brain ischemia of 77.7% and 89.6%, respectively (PPV = 46.6% and NPV = 97.2%). In contrast, a 100% sensitivity and specificity for multimodality IONM was determined (PPV and NPV = 100%). No significant difference (in demographical or clinical data) between "true positive" and "false-positive" patients was identified. Among the methods included in multimodality IONM, EEG showed the best results for predicting postoperative outcome after CEA (PPV and NPV=100%). CONCLUSION: NIRS is inferior to multimodality IONM in detecting brain ischemia and predicting postoperative neurological status during CEA under general anesthesia.

Anaesthesia and multimodality intraoperative neuromonitoring in carotid endarterectomy. Chronological evolution and effects on intraoperative neurophysiology.

Contingency data was retrospectively collected to evaluate the historical and current ability to provide multimodality intraoperative neurophysiological monitoring during carotid endarterectomy under two conditions: total intravenous anaesthesia (TIVA) and low dose halogenated anaesthesia (SEVO). 229 patients were monitored during carotid endarterectomy procedures under general anaesthesia between 2012 and 2020. 121 Patients were monitored with SEVO at a minimum alveolar concentration less than 0.7 and 108 were monitored using TIVA, according to common anaesthetic practice standards in our hospital across the years. Multimodality IONM was established with electroencephalography, somatosensory evoked potentials and motor evoked potentials. As compared to TIVA, patients monitored with SEVO showed significantly higher motor evoked potential thresholds (313.52 ± 77.74 SEVO and 218.93 V ± 103.2 V TIVA p < 0.05) and lower reproducibility. Electroencephalography and somatosensory evoked potentials showed no significant differences among the groups. When using SEVO, multimodality intraoperative neurophysiological monitoring during carotid endarterectomy could mask or miss a motor isolated change in patients in spite of low dose minimum alveolar concentration and of apparently adequate electroencephalography and somatosensory evoked potentials for monitoring. Given these difficulties, we believe the chronological transfer to TIVA could have improved our ability to establish multimodality intraoperative neurophysiological monitoring during carotid endarterectomy in recent times.

Hybrid Repair of an Innominate Artery Mycotic Aneurysm with an "On-The-Table" Customized Endograft.

BACKGROUND: The objective of this report is to present a challenging case of a mycotic aneurysm of the innominate artery (IA) in a patient with a bovine aortic arch. MATERIALS AND METHODS: An 85-year-old woman presented with intermittent fever and positive blood cultures for Staphylococcus aureus. An echocardiogram and a positron emission tomography-computed tomography were performed, showing a hypermetabolic dilation of the IA compatible with a mycotic aneurysm with a type one bovine aortic arch. Conventional open arch repair and total endovascular repair with a custom-made aortic endograft were rejected given the elderly age and need for urgent repair. Treatment was achieved with a hybrid procedure, including a left carotid transposition and exclusion of the aneurysm with a modified Endurant II® iliac limb (two stents were cut off and it was resheathed in an inverted fashion) released through a prosthetic graft sutured onto the right axillary artery, followed by coil embolization of the sac. One year after the repair, the patient is well with complete exclusion of the aneurysm. CONCLUSIONS: Under the need for urgent repair, "on-the-table" modification of standard endograft components can be an effective solution for aneurysm exclusion when off-the-shelf endovascular stent grafts do not meet the anatomical requirements.

The Use Of The Gore® Hybrid Vascular Graft For Treatment Of Complex Iliofemoral Revascularization Procedures.

PURPOSE: To describe the uses and advantages of hybrid vascular grafts (HVGs) for complex iliofemoral revascularization procedures. CASE REPORT: We report 3 cases of iliofemoral occlusions repaired with the Gore HVG, used as an alternative technique to standardized common femoral artery (CFA) endarterectomy associated with iliac stenting or open repair. The indication in each of the 3 cases was different: In the first case, there was an absent CFA secondary to a mycotic pseudoaneurysm, in the second case, an iatrogenic lesion of the posterior wall of the CFA during the intervention was performed, and in the third case, the indication was because of thrombosis of a previous iliofemoral revascularization procedure. CONCLUSION: Although we only present 3 cases, the Gore HVG can be useful for complex iliofemoral revascularizations, serving as an alternative to standardized CFA endarterectomy plus iliac stenting in cases where there is a damaged or absent CFA, especially in high-surgical risk patients.

Complex Aortic Aneurysm: A Current Indication for Debranching.

Conventional open repair of thoracoabdominal aortic aneurysms is still associated with severe complications and shows immediate mortality rates up to 20%. Although there is an increasing number of cases treated exclusively by an endovascular approach, renovisceral debranching still represents a valid alternative in high-risk patients for open surgery and in those patients where endovascular procedures are not feasible due to anatomic limitations or are not available when patients cannot wait for treatment. Herein we report the case of a patient with multiple surgical interventions and an extensive aortic aneurysm, complicated with a chronic contained rupture of the renovisceral aorta, who was successfully treated by means of a hybrid technique involving renovisceral debranching after discarding a pure endovascular management due to anatomical criteria.