Editor's Choice - Early and Late Outcomes after Transcarotid Revascularisation for Internal Carotid Artery Stenosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: Transcarotid/transcervical revascularisation (TCAR) is an alternative to carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS). This review aimed to evaluate pooled data on patients undergoing TCAR. DATA SOURCES: Medline, Embase, Scopus, and Cochrane Library databases were used. REVIEW METHODS: This systematic review was conducted under Systematic Reviews and Meta-Analysis guidelines. Eligible studies (published online up to September 2020) reported 30 day mortality and stroke/transient ischaemic attack (TIA) rates in patients undergoing TCAR. Data were pooled in a random effects model and weight of effect for each study was also reported. Quality of studies was evaluated according to Newcastle - Ottawa scale. RESULTS: Eighteen studies (three low, seven medium, and eight high quality) included 4 852 patients (4 867 TCAR procedures). The pooled 30 day mortality rate was 0.7% (n = 32) (95% confidence interval [CI] 0.5 - 1.0), 30 day stroke rate 1.4% (n = 62) (95% CI 1.0 - 1.7), and 30 day stroke/TIA rate 2.0% (n = 92) (95% CI 1.4 - 2.7). Pooled technical success was 97.6% (95% CI 95.9 - 98.8). The cranial nerve injury rate was 1.2% (95% CI 0.7 - 1.9) (n = 14; data from 10 studies) while the early myocardial infarction (MI) rate was 0.4% (95% CI 0.2 - 0.6) (n = 16; data from 17 studies). The haematoma/bleeding rate was 3.4% (95% CI 1.7 - 5.8) (n = 135; data from 10 studies), with one third of these cases needing drainage or intervention. Within a follow up of 3 - 40 months the restenosis rate was 4% (95% CI 0.1 - 13.1) (data from nine studies; n = 64/530 patients) and death/stroke rate 4.5% (95% CI 1.8 - 8.4) (data from five studies; n = 184/3 742 patients). Symptomatic patients had a higher risk of early stroke/TIA than asymptomatic patients (2.5% vs. 1.2%; odds ratio 1.99; 95% CI 1.01 - 3.92); p = .046; data from eight studies). CONCLUSION: TCAR is associated with promising early and late outcomes, with symptomatic patients having a higher risk of early cerebrovascular events. More prospective comparative studies are needed in order to verify TCAR as an established alternative treatment technique.

Chylous Ascites Following Open Abdominal Aortic Aneurysm Repair: An Unusual Complication.

Chylous ascites is a rare complication after abdominal aortic aneurysm repair. Accumulation of chyle within the close space of the peritoneal cavity may cause severe discomfort to the patient, complicating the postoperative course. Prompt diagnosis is needed to adopt measures for reducing lymph leakage and contributing to lymphatic fistula closure. Fortunately, conservative treatment is successful in the majority of cases. In the rare cases that do not respond to conservative treatment, surgery becomes mandatory. Accurate preoperative localization of lymph leakage is a prerequisite for a successful outcome. Postoperative chyloperitoneum has a benign course and an excellent prognosis.

Carotid endarterectomy in an asymptomatic patient with contralateral agenesis of the internal carotid artery.

A 64-year-old man was referred to the vascular surgery department with an incidental finding of right internal carotid artery stenosis during thyroid ultrasound imaging. Carotid artery color duplex revealed an ulcerated type III plaque producing stenosis of the right internal carotid artery of 70% and agenesis of the left internal carotid artery. Further imaging with computed tomography angiography confirmed the initial findings and excluded cerebral vascular malformations and ischemic cerebral infarcts. The patient was treated with endarterectomy of the right internal carotid artery with elective shunting and synthetic patch closure.