Quantitative Optical Coherence Tomography Angiography Detects Retinal Perfusion Changes in Carotid Artery Stenosis.

BACKGROUND: Carotid artery stenosis (CAS) is a multifaceted disease characterized by possible ocular involvement. Treatment with carotid endarterectomy helps to restore cerebral perfusion, which may prevent ocular and cerebral complications. The main aim was to assess retinal and choroidal vascular perfusion changes before and after endarterectomy in patients affected by CAS. METHODS: The design of the study was prospective and observational, including patients affected by CAS and healthy controls. The follow-up was 3 months. We performed quantitative optical coherence tomography (OCT) angiography (OCTA) analyses of retinal perfusion changes, before and after endarterectomy. The main outcome measures were the quantitative changes of choroidal thickness (CT), retinal nerve fiber layer (RNFL), and ganglion cell layer (GCL); vessel density (VD); and vessel tortuosity (VT) OCTA metrics were also measured. RESULTS: Sixty eyes of 30 patients affected by CAS and 30 eyes of 30 controls were included. We separately considered the ipsilateral eyes to CAS, the contralateral eyes to CAS, and the healthy eyes. Visual symptoms were absent in all the patients. RNFL and GCL resulted similar between patients and controls (p > 0.05). CT was significantly thinner in ipsilateral eyes than controls (p < 0.01), and it resulted unchanged after surgery (p > 0.05). VD resulted significantly altered only in some plexa of the ipsilateral eyes (p < 0.01), whereas VT disclosed decreased values of the entire retinal vascular network, both in ipsilateral and contralateral eyes (p < 0.05). Endarterectomy was followed by statistically significant improvement of retinal perfusion (p < 0.05). CONCLUSION: Optical coherence tomography angiography can noninvasively detect postendarterectomy retinal perfusion improvements in CAS patients with baseline diabetes and hypertension as a systemic risk factor.

Combined carotid endarterectomy and coronary artery bypass grafting

Objective: To evaluate the perioperative and long-term outcomese of combined coronary artery bypass grafting and carotid endartectomy performed in our Institute.Methods: From January 1992 to Apri1 2004, 158 patients with a mean age of 66.3 years (range 42-81) underwent combined carotid endartectomy and coronary artery bypass grafting. Selection criteria were symptomatic ot asymptomatic 70-99 por cento carotid stenosis and unstable coronary symptoms or coronary anatomy judged to preclude safe endarterectomy. Carotid duplex scanning was introduced as a routine screening test from 1996 for patients candidate to coronary artery bypass grafting. Patients presenting fop carotid endartectomy were subjected to further cardiological study only if deemed to be at high cardiac risk. Results: Perioperative mortality was 5.7 por cento. Causes of death were: myocardial infarction with multiorgan failure (four patients),irreversible left ventricular fibrillation (three patients) and low ejection syndrome complicated by stroke and ventricular fibrillation (two patients). The perioperative stroke cate was 1.3 por cento. Mean follow-up was 49 months (range 1-138): 22 patients were lost at follow-up and of remaining 136 patients 21 (15.4 por cento) died. Causes of late mortality were: eight myocardial infarctions, tive cancers, six congestive heartfailure and two abdominal aortic aneurysm rupture. Late stroke rate was 2.2 por cento (two patients with contralateral stroke and one with ipsilateral stroke). One asymptomatic carotid occlusion and three [ carotid restenosis were also observed. Discussion: The low stroke cate observed in our series suggest the use of combined carotid endartectomy and coronary artery bypassgrafting in patients with significant symptomatic and asymptomatic carotid artery stenosis that need myocardial revascularization. Poor len-ventricular function, unstable angina and bilateral carotid artery stenosis, account for the high perioperative mortality associated with this approach.

Carotid endarterectomy: experience in 5425 cases.

From 1992 to December 2002, 3967 patients (2619 males; 1348 females) with a mean age of 68.4A years (range 32-92) underwent 5425 carotid endarterectomy (CE) procedures at our institute. Neurological history was positive for stroke in 1130 cases (21%) and for transient ischemic attack (TIA) in 2121 cases (39%). In 2174 cases (40%) patients were neurologically asymptomatic or presented nonspecific symptoms. Our current clinical protocol has been designed to optimize resources and reduce complications. Some of the major features, along with the respective percentages in this series, are as follows. Duplex scanning was performed at a validated laboratory as the principal preoperative exam (86.9%). Locoregional anesthesia and neurological monitoring were performed during carotid cross-clamping (96.3%). Selective shunting was carried out with a Javid shunt (10.7%). The choice of surgical technique was made according to carotid anatomy and cerebral tolerance of cross-clamping. Those used were a standard technique (now abandoned, 12.1%), synthetic patching (46.4%), and eversion endarterectomy (41.5%). Intraoperative completion arteriography was routinely performed for eversion endarterectomy and only in dubious cases with other techniques. The option of staying in an postoperative intensive care unit (ICU) was available (selective use, 2%). In uncomplicated cases, early discharge (after 1.5 postoperative days) was considered safe. The overall perioperative mortality was 0.37% (20/5425). Causes of death were myocardial infarction in seven cases, ischemic stroke in six cases, hemorrhagic stroke in five cases, respiratory failure caused by cervical hematoma in one case, and wound infection in one case. Perioperative neurological morbidity was 1.31% (71/5425); there were 43 major and 28 minor strokes. In conclusion, CE is effective for stroke prevention when there is significant symptomatic and asymptomatic carotid stenosis, as low mortality and morbidity may be achieved in an experienced center. At our institute, the reduction of costs did not have negative consequences on the quality of the surgical care.