Balloon pulmonary angioplasty for proximal chronic thromboembolic pulmonary hypertension in patients ineligible for pulmonary endarterectomy.

Balloon pulmonary angioplasty (BPA) to treat chronic thromboembolic pulmonary hypertension (CTEPH) is generally reserved for distal obstruction precluding pulmonary endarterectomy (PEA) but can be used in patients with proximal disease who are at high surgical risk or refuse surgery. This single-center retrospective study compared BPA efficacy in patients with proximal versus distal CTEPH. Of the 478 patients, 36 had proximal disease, follow-up was 11.6 months and mean number of BPA 6. After BPA, PVR, and mean pulmonary artery pressure decreased significantly in the proximal and distal groups (from 6.5 to 4.0 WU and 39 to 31 mmHg and from 7.6 to 3.8 WU and 44 to 31 mmHg, respectively, p < 0.001 for all comparisons). NYHA class also improved significantly in both groups, from 3 to 2, whereas the 6-min walk distance, cardiac output, and serum NT pro-BNP showed significant improvements only in the distal group. Thus, when PEA for CTEPH is technically feasible but not performed due to severe comorbidities or patient refusal, BPA can produce significant hemodynamic improvements, albeit less marked than in patients with distal disease. Better patient selection to BPA might improve outcomes in patients with proximal disease who are ineligible for PEA.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease.

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Frailty Scores Impact the Outcomes of Urgent Carotid Interventions in Acute Stroke Patients: A Comprehensive Analysis of Risk and Prognosis.

INTRODUCTION: Carotid artery disease is an important cause of ischemic strokes. Patient selection for urgent carotid interventions (ie. carotid endarterectomy [uCEA] and carotid artery stenting [uCAS]) performed within 2 weeks of event during index hospitalization is primarily based on overall health and risk profile. Identifying high-risk patients remains a challenge. Frailty, a decline in function related to aging, has emerged as an important factor in the treatment of the elderly population. This study aimed to design a quantitative risk score based on frailty for patients undergoing uCEA and uCAS following an acute stroke. METHODS: A total of 307 acute stroke patients treated with uCEA or uCAS were identified from a prospectively maintained database. Frailty scores were calculated using the Hospital Frailty Risk Index based on ICD-10 codes. Stroke-specific risk categories were created based on the incidence of stroke, death, and myocardial infarction (MI) associated with frailty scores. Primary endpoints included 30-day stroke, death, and MI, while the secondary endpoint was discharge modified Rankin scale (mRS). Statistical analyses were performed using SAS software. RESULTS: The average age was 65.9 years; hypertension, history of tobacco use, and hyperlipidemia were the most common comorbidities. The median Hospital Frailty Risk Score was 27, the majority of patients in this study were in the intermediate and high risk frailty groups (50.5% and 41.7%, respectively). uCAS patients had a higher median presenting NIHSS (8 vs. 2, p<0.001) and shorter median time to intervention compared to uCEA patients (1 vs. 3 days, p=<0.001). The 30-day composite stroke, death, and MI rate was 8.1%, with higher rates observed in patients with frailty scores >30 (11.7%) and uCAS (12.2%). Hemorrhagic conversion and death were more common in uCAS patients. Functional independence (mRS 0-2) was observed in uCEA patients after minor stroke and in uCAS patients after minor or moderate stroke. Patients with high-risk frailty score (>30) presenting with a moderate stroke were more likely to be functionally dependent (mRS>2) on discharge (67% vs 41.3%, p<0.001). CONCLUSION: Frailty is a valuable prognosticative tool for clinical outcomes in patients undergoing urgent carotid interventions following an acute stroke. Higher frailty scores were associated with increased stroke, death, and MI rates. Frailty also influenced functional dependence at discharge, particularly in patients with moderate stroke. These findings highlight the importance of considering frailty in the decision-making process for carotid interventions. Further research is needed to validate these findings and explore interventions to mitigate the impact of frailty on outcomes.

Association of Centre Quality Certification with Characteristics of Patients, Management, and Outcomes Following Carotid Endarterectomy or Carotid Artery Stenting.

Background: The aim of this study was to analyze the association between center quality certifications and patients' characteristics, clinical management, and outcomes after carotid revascularization. Methods: This study is a pre-planned sub-study of the ISAR-IQ project, which analyzes data from the Bavarian subset of the nationwide German statutory quality assurance carotid database. Hospitals were classified as to whether a certified vascular center (cVC) or a certified stroke unit (cSU) was present on-site or not. The primary outcome event was any stroke or death until discharge from the hospital. Results: In total, 31,793 cases were included between 2012 and 2018. The primary outcome rate in asymptomatic patients treated by CEA ranged from 0.7% to 1.5%, with the highest rate in hospitals with cVC but without cSU. The multivariable regression analysis revealed a significantly lower primary outcome rate in centers with cSU in asymptomatic patients (aOR 0.69; 95% CI 0.56-0.86; p < 0.001). In symptomatic patients needing emergency treatment, the on-site availability of a cSU was associated with a significantly lower primary outcome rate (aOR 0.56; 95% CI 0.40-0.80; p < 0.001), whereas the presence of a cVC was associated with higher risk (aOR 3.07; 95% CI 1.65-5.72). Conclusions: This study provides evidence of statistically significant better results in some sub-cohorts in certified centers. In centers with cSU, the risk of any stroke or death was significantly lower in asymptomatic patients receiving CEA or symptomatic patients treated by emergency CEA.

Long-term mortality and morbidity after carotid endarterectomy for symptomatic and asymptomatic carotid stenosis.

OBJECTIVES: To investigate whether the occurrence of ischemic stroke due to carotid stenosis is a marker of the severity of atherosclerotic disease and of an excess risk of cardiovascular morbidity and mortality, and of all-cause mortality, after carotid endarterectomy. METHODS: Patients who had undergone a carotid endarterectomy (CEA) from June 2015 to august 2016 were included. Patients were classified into two groups, namely symptomatic and asymptomatic. Neurological event, myocardial infarction and death during early follow-up were monitored. Major adverse cardiovascular events (MACE), major limb events (MALE), and all-cause mortality were compared for patients with a CEA for an asymptomatic carotid stenosis versus those with a symptomatic stenosis. RESULTS: Among the 190 patients included, 86 (51%) had a CEA for an asymptomatic stenosis and 84 (49%) for a symptomatic stenosis. During the first 30 days, the rate of all-cause death or ischemic stroke was similar in both groups (1%, p=0.986). After 30 days, there were a total of 35 MACE (21.3%) and 15 MALE (9.1%) during mean follow-up of 53 (22.6) months. Overall cardiovascular morbidity and mortality was 30.4%, and did not differ between groups (p=0.565). New ischemic stroke occurred in 11 patients (9.1%) and was significantly more frequent in the asymptomatic group (9 (14.8%) vs 2 (3.6%) in the symptomatic group, (OR: 4.96; CI 95% [1.04-23.77]; p = 0.013)). Overall all-cause mortality was 24% in both groups (p=0.93) CONCLUSION: The occurrence of ischemic stroke of carotid origin prior to revascularization does not appear to be associated with an excess risk of cardiovascular morbidity or mortality or all-cause mortality after surgery.

Impact of postoperative cerebral hyperperfusion on 2-year cognitive outcomes of patients undergoing carotid endarterectomy.

OBJECTIVE: In 10% of patients undergoing carotid endarterectomy (CEA), the cognitive function declines postoperatively, primarily in association with postoperative cerebral hyperperfusion. In contrast, in the majority of patients undergoing CEA, long-term cognitive outcomes remain unclear. Furthermore, it is not known whether the decline in cognition due to cerebral hyperperfusion recovers on a long-term basis. This study aimed to understand how postoperative cerebral hyperperfusion affects the cognitive outcomes of patients who undergo CEA. METHODS: The participants in this prospective observational study were patients with internal carotid artery stenosis who underwent CEA. Cerebral hyperperfusion syndrome or asymptomatic cerebral hyperperfusion following CEA was determined based on brain perfusion SPECT scans and symptomatology before and after surgery. Neuropsychological testing was performed preoperatively, at 1-2 months postoperatively, and at 2 years postoperatively to investigate cognitive decline. RESULTS: A logistic regression analysis revealed that asymptomatic cerebral hyperperfusion (95% CI 13.0-84.5, p < 0.0001) and cerebral hyperperfusion syndrome (95% CI 449.7-14,237.4, p < 0.0001) were significantly associated with cognitive decline at 1-2 months postoperatively. The incidence of cognitive decline was significantly decreased at 2 years postoperatively (7%) in comparison to 1-2 months postoperatively (11%) (p = 0.0461). A logistic regression analysis also revealed that asymptomatic cerebral hyperperfusion (95% CI 3.7-36.7, p < 0.0001), cerebral hyperperfusion syndrome (95% CI 128.0-6183.6, p < 0.0001), and further strokes during the 2-year follow-up period (95% CI 1.5-78.7, p = 0.0167) were significantly associated with cognitive decline at 2 years postoperatively. The incidence of cognitive decline at 1-2 months postoperatively was significantly higher in patients with cerebral hyperperfusion syndrome (100%) than in those with asymptomatic cerebral hyperperfusion (44%) (p < 0.0001). No significant difference in incidence was observed in the former patients at 2 years postoperatively (88%), but significant reduction was found in patients with asymptomatic cerebral hyperperfusion and cognitive decline between the timepoints of 1-2 months postoperatively (100%) and 2 years postoperatively (39%) (p = 0.0001). CONCLUSIONS: Postoperative cerebral hyperperfusion causes prolonged cognitive decline at 2 years postoperatively in patients undergoing CEA.

A Case of Complete Resolution of Repeated Syncope Attacks After a Right-Sided Carotid Endarterectomy.

Syncope is a common clinical entity with variable presentations and often an elusive causal mechanism, even after extensive evaluation. In any case, global cerebral hypoperfusion, resulting from the inability of the circulatory system to maintain blood pressure (BP) at the level necessary to supply blood to the brain efficiently, is the final pathway for syncope. Steno-occlusive carotid artery disease, even if bilateral, does not usually cause syncope. However, the patient presented here had repeated syncope attacks and underwent a thorough examination for suspected cardiac disease, but no abnormality was found. Since there was severe stenosis in the right unilateral internal carotid artery (ICA), but no stenosis in the left ICA or vertebrobasilar artery (VBA), and transient left mild hemiparesis associated with syncope, carotid revascularization surgery for the right ICA was performed, and the repeated syncope attacks completely disappeared after the surgery. The patient's condition improved markedly, and no further episodes of syncope have been reported. We report the relationship between carotid artery stenosis and syncope and discuss its pathomechanism.

What Is the Best Technique for Treating Carotid Disease?

This is a comprehensive review of carotid artery revascularization techniques: Carotid Endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR). CEA is the gold standard and is particularly effective in elderly and high-risk patients. TFCAS, introduced as a less invasive alternative, poses increased periprocedural stroke risks. TCAR, which combines minimally invasive benefits with CEA's neuroprotection principles, emerges as a safer option for high-risk patients, showing comparable results to CEA and better outcomes than TFCAS. The decision-making process for carotid revascularization is complex and influenced by the patient's medical comorbidities and anatomic factors.

Sequelae of carotid endarterectomy patch infection: An otolaryngologist perspective.

BACKGROUND: Postoperative carotid endarterectomy (CEA) patch infection is a rare but well-recognized complication of CEA. It is important for otolaryngologists to be aware of the presentation and challenges in its diagnosis. METHODS: Patients who presented with a neck mass or hemorrhage and a known prior history of carotid endarterectomy with synthetic patch reconstruction were worked up with ultrasound, CT, or MRI imaging. In one case, fine needle aspiration biopsy was performed. Ultimately, all patients were taken to the operating room for neck exploration. RESULTS: Of the three patients presented in this case series, two presented with a chronic neck mass, two-to-three years after carotid endarterectomy. One patient presented acutely with hemorrhage from the carotid endarterectomy site. Carotid patch infection was diagnosed after neck exploration in all cases. Vascular surgery was consulted intra-operatively to perform definitive vascular repair. CONCLUSIONS: Infected carotid patch should be suspected in patients with a history of prior CEA, as many of the presenting complaints may resemble or mimic pathology managed by otolaryngology. The onset of symptoms can be perioperative or very delayed. A multidisciplinary approach with vascular surgery and infectious disease is required for appropriate management of these patients.

Surgical Management of Ipsilateral Internal Carotid Artery Stenosis and Unruptured Intracranial Aneurysm: Case Review and Treatment Considerations.

Introduction The coexistence of carotid artery stenosis and a concomitant downstream ipsilateral unruptured intracranial aneurysm requires unique treatment considerations to balance the risk of thromboembolic complications from carotid artery stenosis and the risk of subarachnoid hemorrhage from intracranial aneurysm rupture. These considerations include the selection of optimal treatment modalities, the order and timing of interventions, and potential management of antiplatelet agents with endovascular approaches. We present strategies to optimize treatment in such a case. Case Report We discuss the case of a 69-year-old woman with 90% stenosis of the right internal carotid artery and an ipsilateral, wide-necked, 4.8-mm, irregular-appearing right A1-2 junction aneurysm with an associated daughter sac. Open, endovascular, and mixed treatment strategies were considered. The patient selected and underwent a staged, open treatment approach with a carotid endarterectomy followed by a right craniotomy for microsurgical clipping of the aneurysm 5 days later. Both procedures were performed on daily full-dose aspirin without complications. On follow-up, the right carotid artery was widely patent, the aneurysm was secured, and the patient remained at her neurologic baseline. Discussion The presented strategy for ipsilateral carotid artery stenosis and an unruptured intracranial aneurysm initially optimized cerebral perfusion to mitigate ischemic risks while permitting timely aneurysm intervention without a need for dual antiplatelet therapy or to traverse an earlier procedure site.

Use of intermediate cervical plexus block in carotid endarterectomy -an alternative to deep cervical plexus block: a case series.

INTRODUCTION: Carotid endarterectomy is performed for patients with symptomatic carotid artery occlusions. Surgery can be performed under general and regional anesthesia. Traditionally, surgery is performed under deep cervical plexus block which is technically difficult to perform and can cause serious complications. This case series describes 5 cases in which an intermediate cervical plexus block was used in combination with a superficial cervical plexus block for Carotid endarterectomy surgery. METHODS: Five patients who were classified as American Society of Anesthesiologists 2-3 were scheduled for Carotid endarterectomy due to symptoms and more than 70% occlusion of the carotid arteries. The procedures were carried out in the University Teaching Hospital- Peradeniya, Sri Lanka. All patients were given superficial cervical plexus block followed by intermediate cervical plexus block using 2% lignocaine and 0.5% plain bupivacaine. RESULTS: Adequate anesthesia was achieved in 4 patients, and local infiltration was necessary in 1 patient. Two patients developed hoarseness of the voice, which settled 2 h after surgery. Hemodynamic fluctuations were observed in all 5 patients. No serious complications were observed. All 5 patients had uneventful recoveries. DISCUSSIONS: Regional anesthesia for CEA is preferable in patients who are medically complicated to undergo anesthesia or in patients for whom cerebral monitoring is not available. Intermediate cervical plexus block is described for thyroid surgeries in literature, but not much details on its use for carotid surgeries. Deep cervical plexus blocks has few serious complications which is not there with the use of ICPB making it a good alternative for CEA surgeries . CONCLUSIONS: Superficial cervical plexus block and intermediate cervical plexus block can be used effectively for providing anesthesia for patients undergoing Carotid endarterectomy. It is safe and easier to conduct than deep cervical plexus block and enables monitoring of cerebral function.

Cranial Nerve Injuries Post Carotid Endarterectomy: A 15-Year Prospective Study with Routine Otolaryngologist and Neurological Evaluation.

OBJECTIVE: The aim of this prospective monocentric cohort study was to analyse the risk of otolaryngologist-assessed cranial nerve injuries (CNIs) following carotid endarterectomy (CEA) in our academic centre during a 15-year period, and to identify possible risk factors for CNI development. METHODS: From January 2007 to December 2022, 3749 consecutive CEAs were performed and their data prospectively recorded in a dedicated database. Cranial nerve injuries were assessed and defined according to a standardized protocol. Instrumental ear, nose and throat (ENT) evaluations were conducted within 30 days before intervention and before discharge. Preoperative neurological assessments were carried out in all patients with symptomatic carotid stenosis, while postoperative neurological evaluations were performed in all patients. Patients with newly onset cranial nerve injuries underwent follow-up assessments at 30 days and, if necessary, at 6, 12 and 24 months. Perioperative results, including mortality, major central neurological events, and postoperative CNIs, were analyzed. Regression or persistence of lesions during follow-up visits was assessed, and multivariate analysis (binary logistic regression) was conducted to evaluate clinical, anatomical, and surgical technique factors influencing the occurrence of CNIs. RESULTS: CEAs were performed more frequently in male patients (2453 interventions, 65.5%) than in females (1296 interventions, 34.5%). The interventions were performed in asymptomatic patients in 3078 cases (82%). In 66 cases the interventions followed a previous ipsilateral CEA. At preoperative ENT evaluation, no cases of ipsilateral pre-existent CNI were recorded. The 30-day stroke and death rate was 1%. In 113 patients (3%) a postoperative neck bleeding requiring surgical revision and drainage was noted. Pre-discharge ENT evaluations identified 259 motor cranial nerve injuries, accounting for 6.9% of the entire study group. Eighteen patients had lesions in more than one cranial nerve. ENT and neurological evaluations at 30 days showed the complete resolution of 161 lesions, whereas in 98 (2.6%) cases the CNI persisted. At one year, the rate of persistent CNI was 0.4% (10 patients), whereas at two years it was 0.25% (six cases), in all but one asymptomatic. At multivariate analysis, urgent intervention in unstable patients, secondary intervention, a clamping time >40 min., a hematoma requiring revision and a postoperative stroke were independent predictors of CNI. CONCLUSIONS: Data from this prospective monocentric cohort study showed that the occurrence of CNI following CEA was low, even when an independent multi-specialist evaluation was performed. The percentage of persistent lesions at two years was negligible and in most cases asymptomatic.

Assessment of Voice Quality and Vocal Cord Paralysis After Endarterectomy.

Introduction: Recurrent laryngeal nerve palsy is a rare but important complication after endarterectomy (CEA). The impact on voice quality after this procedure is also important. The aim of the study was to assess voice quality and vocal cord function after CEA. Material and Methods: 200 patients were enrolled in the study. Inclusion criteria were indications for CEA and patient consent to the procedure. Endoscopic examination of the larynx was performed before the procedure, immediately after the procedure, on the 2nd day after the procedure, then 3 month and 6 months after the procedure. Voice was assessed by maximum phonation time (MPT), GRBAS scale, Voice Handicap Index (VHI) and the Voice-Related Quality of Life (V-RQOL) questionnaire. Results: In the study group, the results on the GRBAS scale were significantly worse and the average MPT was shorter compared to the control group. In the V-RQOL assessment, patients rated their voice as fair or good, significantly more often noticed that they had difficulty speaking loudly and being heard, and that they felt short of air when speaking. In VHI-30, the total score was significantly higher in the study group compared to the control group. Voice disorders after the procedure were reported by 68 patients, while a disorder of the recurrent laryngeal nerve was observed immediately after the procedure in 32 patients. Most vocal cord disorders were transient. Ultimately, 3% of patients were diagnosed with vocal cord paralysis. Conclusion: Cranial nerves paralysis, including the recurrent laryngeal nerve, are a common complication after CEA. Majority the paralysis is transient, but requires appropriate diagnostic and therapeutic procedures. Vocal cord evaluation is a non-invasive and widely available examination and should be performed pre- and postoperatively after all neck surgeries. The incidence of voice disorders after CEA significantly affects the quality of life of patients and requires voice rehabilitation and patient care with psychological support.

Patch Infection Following Carotid Endarterectomy: A Single-Center Audit and Literature Review.

INTRODUCTION: Carotid endarterectomy (CEA) is a surgical procedure that carries a rare but serious risk of patch infection. This study examines the management and outcomes of patch infections in CEA patients treated in our department over 23 years. A literature review of studies on prosthetic patch infection following CEA published from January 1992 up to December 31, 2022 was also carried out. METHODS: We conducted a retrospective audit of patients who underwent CEA in a hospital in Athens, Greece, between January 1, 1999, and December 31, 2022. RESULTS: Between January 1999 and December 2022, we treated seven patients with carotid patch infections who had their original CEA at our department. Staphylococcus epidermidis and Staphylococcus aureus were the most common infecting organisms. One patient (14%) died from hemorrhagic shock before surgery, while the remaining six (86%) underwent debridement, patch excision, and great saphenous vein patching. No peri-operative deaths or strokes occurred, and there were no re-infections during a median follow-up of 159 months. CONCLUSIONS: Excision of infected material followed by revascularization using a vein graft remains the prevailing treatment.

Outcomes Following Carotid Revascularization in Patients with Prior Ipsilateral Carotid Artery Stenting in the Vascular Quality Initiative.

OBJECTIVES: The outcomes of carotid revascularization in patients with prior carotid artery stenting remain understudied. Prior research has not reported the outcomes after Transcarotid artery revascularization (TCAR) in patients with previous carotid artery stenting. In this study, we compared the peri-operative outcomes of TCAR, tfCAS and CEA in patients with prior ipsilateral CAS using the VQI. METHODS: Using the Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA following prior ipsilateral carotid artery stenting. We included covariates such as age, race, sex, BMI, comorbidities (hypertension, diabetes, prior CAD, prior CABG/PCI, CHF, renal dysfunction, smoking, COPD, anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability-weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality and cranial nerve injury (CNI) following TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. RESULTS: We identified 2,137 patients undergoing revascularization following prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%) and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%,aOR:0.33[0.11-1.05]; p=0.06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%,aOR:0.80[0.16-3.98]; p=0.8). Compared with CEA, TCAR was associated with lower odds of post-operative MI (0.1% vs 14%,aOR:0.02[0.00-0.10]; p<0.001), stroke/death/MI (0.8% vs 15%,aOR:0.05[0.01-0.25]; p<0.001), and CNI (0.1% vs 3.8%,aOR:0.04[0.00-0.30]; p=0.002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1% with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (p<.001). CONCLUSIONS: In asymptomatic patients with prior ipsilateral carotid artery stenting, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably elevated in-hospital stroke/death rates. In line with the post-procedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.

POSTOPERATIVE OUTCOMES IN ANEMIC PATIENTS UNDERGOING CAROTID REVASCULARIZATION.

BACKGROUND: Preoperative anemia is associated with worse postoperative morbidity and mortality following major vascular procedures. Limited research has examined the optimal method of carotid revascularization in anemic patients. Therefore, we aim to compare the postoperative outcomes following carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among anemic patients. STUDY DESIGN: This is a retrospective review of anemic patients undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016-2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACE). Logistic regression models were used for multivariate analyses. RESULTS: Our study included 40,383 (59.3%) CEA, 9,159 (13.5%) TFCAS, and 18,555 (27.3%) TCAR cases in anemic patients. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with decreased 30-day mortality (aOR=0.45,95%CI:0.37-0.59],P<0.001), in-hospital MACE (aOR=0.58,95%CI:0.46-0.75,P<0.001) compared to TFCAS. Additionally, TCAR was associated with 20% reduction in the risk of 30-day mortality (aOR=0.80,95%CI:0.65-0.98,P=0.03), and similar risk of in-hospital MACE (aOR=0.86,95%CI:0.77-1.01, P=0.07) compared to CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR= 2,95%CI: 1.5-2.68,P<0.001), in-hospital MACE (aOR=1.7,95% CI:1.4-2,P<0.001) compared to CEA. CONCLUSIONS: In this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS is associated with a high risk of 30-day mortality and in-hospital MACE compared to CEA and TCAR in anemic patients. TCAR was associated with lower risk of 30-day mortality compared to CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in anemic patients.

Mechanical compression of the carotid artery by the pharynx in the retropharyngeal space during swallowing and the induction of stenosis and embolic stroke: illustrative case.

BACKGROUND: Compression of the carotid artery (CA) by hyoid bony structures, such as the hyoid bone and thyroid cartilage, during swallowing or neck rotation can induce stroke. However, no reports have described ischemic stroke caused by mechanical compression of the CA by the pharynx during swallowing. OBSERVATIONS: A man with left CA stenosis developed recurrent ischemic stroke in his left hemisphere. Computed tomography angiography of the neck showed that the left common carotid artery was trapped by the hyoid bone and thyroid cartilage and that the internal carotid artery (ICA) ran in the retropharyngeal space. Angiography during swallowing of a contrast agent showed dynamic compression of the left CA posterolaterally by the pharynx during swallowing, despite the fact that the CA on the healthy right side moved anteromedially. The retropharyngeal ICA was then transposed to its normal location and endarterectomy was performed. No ischemic events occurred postoperatively, and angiography showed that the left CA now moved anteromedially during swallowing. LESSONS: Movement of the pharynx during swallowing can be a risk factor for CA stenosis. It is important to evaluate the anatomical interaction between the CA and surrounding structures, as well as their dynamics, to ensure appropriate diagnosis and treatment. https://thejns.org/doi/10.3171/CASE2483.

Role of Point-of-Care Cerebral Ultrasonography in Determining the Etiology of Post-carotid Endarterectomy Deficit: A Case Report.

Carotid revascularization surgery is notorious for its neurological morbimortality. We report the case of a 74-year-old hypertensive patient, who underwent left internal carotid artery endarterectomy for a 90% stenosis under general anesthesia, presenting in the immediate postoperative period with right hemiplegia without consciousness disorders. Evaluation by cerebral ultrasound at bedside led to suspicion of intracerebral hemorrhage, which was confirmed by cerebral CT scan. The patient was treated by neuroresuscitation measures in the absence of the possibility of surgical intervention. This hemorrhage may be explained by a reperfusion injury due to the loss of cerebral autoregulation of these vessels, the loss of controlling blood pressure, and the use of heparin in vascular surgery. This is a rare but fatal complication with a high mortality rate.

Two or More Ischaemic Events Within 7 Days Before Carotid Endarterectomy Increases the Risk of Peri-operative Stroke or Death.

OBJECTIVE: The aim of this study was to determine how many pre-operative ischaemic events occurring within a specific timeframe before carotid endarterectomy (CEA) are needed to increase the peri-operative 30 day risk of stroke or death. METHODS: This was a secondary exploratory analysis based on pooled data from three observational studies sourced from a single centre. Patients with recently symptomatic conventional ≥ 50% carotid stenosis were included. The principal analysis was limited to patients presenting with stroke or transient ischaemic attack (TIA). The primary outcome was 30 day risk of peri-operative stroke or death. Whether one, two, three, or four or more ipsilateral pre-operative ischaemic events within 3, 7, 14, or 30 days before CEA were associated with the primary outcome was assessed. RESULTS: The study included 382 patients who underwent CEA with symptomatic conventional ≥ 50% carotid stenosis with stroke or TIA as the presenting event. Mean patient age ± standard deviation was 72 ± 7 years, 117 (30.6%) were female, and 6% were treated with dual antiplatelet therapy. The primary outcome occurred in 21 patients (5.5%). Two or more events within 7 days before CEA was the most discriminative definition of repeated events, with a 14.3% (8/56) risk of the primary outcome. Those who fell outside this definition of two or more events within 7 days before CEA had a 4.0% (13 of 326; p = .006) risk of experiencing the primary outcome (adjusted odds ratio 4.1, 95% confidence interval 1.6 - 10.5). Several alternative definitions were assessed, but patients with two or more events within 7 days before CEA and negative for these alternatives still had a > 10% risk of the primary outcome. CONCLUSION: Two or more ipsilateral ischaemic events within 7 days before CEA are associated with an increased risk of peri-operative stroke or death in cases with symptomatic conventional ≥ 50% carotid stenosis and TIA or stroke as the presenting event. Studies assessing whether delayed or immediate CEA is preferable for this patient group are warranted.