Association of Tumor Volumetry with Postoperative Outcomes for Cervical Paraganglioma.

Objectives: To analyze the association of tumor volume with outcome after surgery for cervical paraganglioma. Materials and Methods: This retrospective study included consecutive patients undergoing surgery for cervical paraganglioma from 2009-2020. Outcomes were 30-day morbidity, mortality, cranial nerve injury, and stroke. Preoperative CT/MRI was used for tumor volumetry. An association between the volume and the outcomes was explored in univariate and multivariable analyses. A receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated. The study was conducted and reported according to the STROBE statement. Results: Volumetry was successful in 37/47 (78.8%) of included patients. A 30-day morbidity occurred in 13/47 (27.6%) patients with no mortality. Fifteen cranial nerve lesions occurred in eleven patients. The mean tumor volume was 6.92 cm3 in patients without and 15.89 cm3 in patients with complications (p = 0.035) and 7.64 cm3 in patients without and 16.28 cm3 in patients with cranial nerve injury (p = 0.05). Neither the volume nor Shamblin grade was significantly associated with complications on multivariable analysis. The AUC was 0.691, indicating a poor to fair performance of volumetry in predicting postoperative complications. Conclusions: Surgery for cervical paraganglioma bears a relevant morbidity with a particular risk of cranial nerve lesions. Tumor volume is associated with morbidity, and MRI/CT volumetry can be used for risk stratification.

Open Surgical Thrombendarterectomy Versus Endovascular Treatment in Occlusive Processes of the Femoral Artery Bifurcation.

BACKGROUND: The standard treatment of occlusive processes of the femoral artery bifurcation is thrombendarterectomy (TEA). Endovascular techniques (ENDO) have recently been put forward as a potential alternative. It is unclear so far which modality yields better outcomes with respect to long-term revascularization and periprocedural complications. Method: Multiple databases were systematically searched for pertinent publications (publication date November 1965 to February 2022). From the included studies, individual patient data (IPD) were requested. Aggregate data (AD) were used when no IPD were available. Primary and secondary patency (PP and SP), perioperative morbidity/mortality, and further endpoints were determined separately for TEA and ENDO and compared with each other. AD for each modality were summarized in meta-analyses. Time-to-event analyses and comparative meta-analyses with PP as primary endpoint were carried out using IPD. Results: 42 studies (3 IPD, 39 AD; 27 TEA, 12 ENDO, 3 comparisons of TEA versus ENDO) were included. In the combined meta-analysis of IPD and AD, PP for TEA was 97% at 6 months and 92% at 12 months, while PP for ENDO was 84% at 6 months and 85% at 12 months. The differences were not statistically significant. The comparative meta-analysis regarding PP did not reveal any significant differences either (TEA versus ENDO: HR 0.30 [0.06; 1.48]). SP at 12 months was 97% (TEA) and 93% (ENDO). The periprocedural morbidity was 16% for TEA and 9% for ENDO. Conclusion: In light of a higher PP, even without formal statistical proof of superiority, TEA can still be considered the standard treatment for occlusive processes of the femoral artery bifurcation. METHODS: Multiple databases were systematically searched for pertinent publications (publication date November 1965 to February 2022). From the included studies, individual patient data (IPD) were requested. Aggregate data (AD) were used when no IPD were available. Primary and secondary patency (PP and SP), perioperative morbidity/mortality, and further endpoints were determined separately for TEA and ENDO and compared with each other. AD for each modality were summarized in meta-analyses. Time-to-event analyses and comparative meta-analyses with PP as primary endpoint were carried out using IPD. RESULTS: 42 studies (3 IPD, 39 AD; 27 TEA, 12 ENDO, 3 comparisons of TEA versus ENDO) were included. In the combined meta-analysis of IPD and AD, PP for TEA was 97% at 6 months and 92% at 12 months, while PP for ENDO was 84% at 6 months and 85% at 12 months. The differences were not statistically significant. The comparative meta-analysis regarding PP did not reveal any significant differences either (TEA versus ENDO: HR 0.30 [0.06; 1.48]). SP at 12 months was 97% (TEA) and 93% (ENDO). The periprocedural morbidity was 16% for TEA and 9% for ENDO. CONCLUSION: In light of a higher PP, even without formal statistical proof of superiority, TEA can still be considered the standard treatment for occlusive processes of the femoral artery bifurcation.

Perioperative functional imaging after extracranial carotid endarterectomy for the detection of cerebral hyperperfusion syndrome.

INTRODUCTION: SyngoDynaPBVNeuro® is a tool to perform cerebral blood volume (CBV) measurements intraoperatively by functional imaging producing CT-like images. Aim of this prospective study was to analyze the clinical relevance and benefit of CBV measurement with regard to neurological complications like cerebral hyperfusion syndrome (CHS). METHODS: Forty-five patients undergoing endarterectomy (CEA) of the internal carotid artery were included; functional imaging with CBV measurement was performed before and after CEA. To evaluate and analyze CBV, six regions of interest (ROI) were identified for all patients with an additional ROI in patients with symptomatic ICA stenosis and previous stroke. The primary endpoint of the study was a perioperative change in CBV measurements. Secondary outcomes were incidence of stroke, TIA, CHS, and perioperative morbidity and mortality. RESULTS: Thirty-day stroke incidence and thirty-day mortality were 0%. Thirty-day morbidity was 6.7%. Two patients from the asymptomatic group suffered from transient neurological symptoms without signs of intracerebral infarction in CT or MR scan, meeting diagnostic criteria for CHS. In 83.3% of ROIs in these patients, an increase of blood volume was detected. Overall, 26.7% patients suffered from unilateral headache as expression of potential CHS. A total of 69.4% of ROIs in patients with postoperative unilateral headache showed an increase when comparing pre- and postoperative CBV measurements. CONCLUSION: The results show that increased CBV measured by functional imaging is a possible surrogate marker of neurological complications like CHS after CEA. By using intraoperative CBV measurement, the risk of CHS can be estimated early and appropriate therapeutic measures can be applied.

Impact of routine completion angiography on outcome after carotid endarterectomy.

OBJECTIVE: The objective of this study was to analyze the impact of completion digital subtraction angiography (cDSA) after carotid endarterectomy (CEA) on technical and early clinical results. METHODS: This retrospective study included consecutive patients undergoing CEA from January 2011 to January 2015. Routine cDSA was performed in all patients. Study end points were the incidence of pathologic findings on completion angiography necessitating intraoperative revision, type of revision, periprocedural stroke rate, mortality, morbidity, and recurrent stenosis rate during follow-up (median, 5 months; range, 0-39 months). RESULTS: There were 827 procedures performed in 770 patients (male, 72.5%; median age, 70.6 years) with extracranial internal carotid artery (ICA) stenosis (asymptomatic, 57.3%); 426 patients underwent conventional endarterectomy (cCEA) with patch angioplasty (51.6%), 393 patients (47.5%) received an eversion technique (eCEA), and 8 patients (1%) underwent other revascularization. Immediate surgical revision based on angiographic findings after CEA was performed in 6.9% (57/827) of cases. Reasons for revision of the ICA were mural thrombus in 7.0% (4/57), dissections in 7.0% (4/57), residual stenosis in 8.7% (5/57), and intimal flaps of ICA in 1.8% (1/57). In six cases, combined pathologic changes of the ICA and external carotid artery led to revision. Thirty-five revisions (4.2%) were performed for isolated pathologic angiographic findings of the external carotid artery; in two cases, revision was performed for residual stenosis of the common carotid artery. There was no significant difference regarding the frequency of revision between surgical techniques (cCEA, 56.4%; eCEA, 63.6%; P = .76). However, mural thrombus as a reason for revision was more common in the cCEA group; plaque residues were more common in the eCEA group. Periprocedural (30-day) stroke rate was 0.5% (4/827); six additional patients suffered transient ischemic attack (0.7%). The mortality rate within 30 days was 0.1% (1/827); 30-day morbidity was 4.2% (35/827). The rate of recurrent stenosis (>50%) during follow-up was 0.8%. There was no significant correlation between pathologic findings on cDSA with consecutive revision and perioperative stroke rate, recurrent stenosis rate, mortality, or morbidity. CONCLUSIONS: In this study, cDSA after CEA detected findings leading to immediate intraoperative surgical revision in a relevant proportion of cases. Therefore, cDSA represents a reasonable quality control without being associated with significantly prolonged operating times. Whether cDSA reduces perioperative stroke rate, procedure-related mortality, morbidity, or incidence of early recurrent stenosis cannot be proven with the current study design.

Outcome of carotid artery stenting in the hands of vascular surgeons.

OBJECTIVES: To analyze the procedural and clinical outcomes of carotid artery stenting (CAS) in the hands of endovascular trained vascular surgeons. METHODS: Between April 2008 to May 2013, 1197 patients were treated for extracranial internal carotid artery (ICA) stenosis. The proportion of endovascular treated patients was 5.0% (CAS n = 60 vs. carotid endarterectomy (CEA) n = 1137). All patients in the CAS group (44 males, median age 70 years) were treated by two senior vascular surgeons experienced in endovascular methods. Restenosis was the indication for CAS in 32 out of 60 patients (53.3%). Further indications were contralateral ICA occlusion (n = 14, 23.3%), radiogenic ICA stenosis (n = 5, 8.3%), high-risk candidates for CEA (n = 4, 6.6%), and the presence of contralateral recurrent paresis (n = 2, 3.3%). High-risk patients for CEA were defined as patients with history of severe cardiac disease and patients with impaired general condition. 84.4% (n = 27) of the restenosis were asymptomatic with a mean degree of stenosis of 83.7%, and 12.9% (n = 4) were symptomatic (degree of stenosis of 90%). Mean procedural and fluoroscopy time were 61 and 14 min. Study endpoints were periprocedural stroke-related mortality and morbidity, restenosis rate, and overall survival. Follow-up was performed by duplex ultrasound with a median follow-up period of 12 months (range 1-55). RESULTS: The periprocedural stroke rate of CAS within 30 days was 3.3% (one ischemic stroke, one intracranial hemorrhage); two additional patients suffered TIA (3.3%). None of the patients had a myocardial infarction perioperatively. The mortality rate was 0. CAS procedures were completed in 90.0% (n = 54) of cases. Dropout rate was 8.3% (n = 5) for morphological reasons (e.g., carotid kinking). Intraoperative complication rate was 1.7% (n = 1) including one patient who suffered intraoperative rupture of access vessels. The conversion rate with subsequent CEA procedure was 6.6% (n = 4 of 5). The restenosis rate during follow-up was 3.3% after CAS. The reintervention rate during the median follow-up period of 12 months (1-55 months) was 5.5% (n = 3/54). Two patients received a reintervention with successful balloon angioplasty; in one case, a diagnostic angiography was performed excluding the presence of a relevant restenosis. No additional stent was implanted. The survival rate was 100% at 1 year, 90.4% at 2 years, and 77.7% at 3 years. CONCLUSION: CAS, in the hands of vascular surgeons, is feasible with a moderate perioperative risk in a highly selected patient cohort. A procedure termination rate of approximately 10% shows that the complementary therapy using CAS procedure is not overused by surgeons.

Results of common femoral artery thromboendarterectomy evaluation of a traditional surgical management in the endovascular era.

OBJECTIVE: The aim of this study was to investigate the long-term outcome of common femoral artery thromboendarterectomy in patients with peripheral arterial occlusive disease. METHODS: The study retrospectively evaluated 713 vessels in 655 patients (75% male; mean age, 69.4 ± 9.5 years) who underwent common femoral thromboendarterectomy from January 2006 until May 2012 in two high-volume vascular centers. Critical limb ischemia was present in 221 patients, and intermittent claudication was present in 434. Three patent tibial arteries, described as runoff vessels, were available in 33% of the cohort, two were present in 28.3%, one runoff vessel was present in 23.4%, and 15.2% (n = 102) showed no runoff option. Hybrid procedures were used to treat 255 limbs (35.8%). The primary end point was primary patency (PP). Secondary patency (SP), limb salvage, and survival were the secondary end points. RESULTS: Survival rates were 93.9%, 83.0%, 74.1%, and 60.1% at 1, 3, 5, and 7 years, respectively. PP was 78.5% and SP was 89.1% at 7 years. Patency rates were 97.3% (PP) and 97.8% (SP) at 6 months and 90.2% (PP) and 98.3% (SP) at 3 years, respectively, with 76 target lesion revascularizations. No significant difference was demonstrated for PP rates stratified for nonhybrid procedures and hybrid procedures (78.1% vs 78.6%; P = .22) and for critical limb ischemia vs intermittent claudication (76.3% vs 79.4%; P = .20) at 7 years. The mean ± standard deviation ankle-brachial index increased from 0.46 ± 0.3 preoperatively to 0.81 ± 0.2 postoperatively and to 0.77 ± 0.3 at 7 years (P < .001). A total of 20 major amputations were performed, achieving a limb salvage rate of 92.6%. Procedure-related complications occurred in 11.5% during 7 years of follow-up. CONCLUSIONS: Open surgery for common femoral artery stenosis is safe and effective in the long-term. Endovascular therapy will need to compete with these excellent results.