Is the Endovascular Treatment of Carotid Stenosis in High-Risk Patients Really Safer than Carotid Endarterectomy?

Background: In the present study the perioperative complication rate is compared between high- and low-risk patients when carotid endarterectomy (CEA) is routinely performed under local anaesthesia (LA). Patients and methods: From January 2000 through June 2008 1220 consecutive patients underwent CEA under LA. High-risk patients fulfilled at least one of the following characteristics: ASA 4 classification, “hostile neck”, recurrent ICA stenosis, contralateral ICA occlusion, age ≥ 80 years. The combined complication rate comprised any new neurological deficit (TIA or stroke), myocardial infarction or death within 30 days after CEA, which was compared between patient groups. Results: Overall 309 patients (25%) were attributed to the high-risk group, which differed significantly regarding sex distribution (more males: 70% vs. 63%, p = 0,011), neurological presentation (more asymptomatic: 72% vs. 62%, p = 0,001) and shunt necessity (33% vs. 14%, p < 0,001). In 32 patients 17 TIAs and 15 strokes were observed. In 3 patients a myocardial infarction occurred. Death occurred in one patient following a stroke and in another patient following myocardial infarction, leading to a combined complication rate of 2,9% (35/1220). In the multivariate analysis only previous neurological symptomatology (OR 2,85, 95% CI 1,38-5,91) and intraoperative shunting (OR 5,57, 95% CI 2,69-11,55) were identified as independent risk factors for an increased combined complication rate. Conclusions: With the routine use of LA, CEA was not associated with worse outcome in high-risk patients. Considering the data reported in the literature, it does not appear justified to refer high-risk patients principally to carotid angioplasty and stenting (CAS) when LA can be chosen to perform CEA.

Download Full-text

Carotid endarterectomy in high-risk patients: A challenge for endovascular procedure protocols

Surgery ◽

10.1016/s0039-6060(03)00169-7 ◽

2004 ◽

Vol 135 (1) ◽

pp. 74-80 ◽

Cited By ~ 14

Author(s):

Enzo Ballotta ◽

Giuseppe Da Giau ◽

Claudio Baracchini ◽

Renzo Manara

Keyword(s):

High Risk ◽

Carotid Endarterectomy ◽

Endovascular Procedure ◽

High Risk Patients ◽

Risk Patients

Download Full-text

A ruptured penetrating atherosclerotic ulcer of the ascending aorta: a case report of an endovascular repair with extending the length of the aortic coverage by debranching the innominate artery

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz043 ◽

2019 ◽

Vol 3 (2) ◽

Cited By ~ 1

Author(s):

Josephine Chenesseau ◽

Pierre-Antoine Barral ◽

Philippe Piquet ◽

Marine Gaudry

Keyword(s):

Cardiac Surgery ◽

High Risk ◽

Endovascular Treatment ◽

Endovascular Repair ◽

Innominate Artery ◽

Ascending Aorta ◽

Stent Grafts ◽

Penetrating Atherosclerotic Ulcer ◽

High Risk Patients ◽

Risk Patients

Abstract Background An endovascular approach to the management of a ruptured plaque in the ascending aorta may be an alternative to open surgery in high-risk patients. This option may become inevitable due to the number of elderly patients unfit for open cardiac surgery. There are very few stent grafts able to fit the ascending aorta and in emergency cases, most medical teams have been limited to current thoracic aortic endografts, the shortest of which measure 10 cm. Case summary We report a case of an endovascular repair of a ruptured penetrating atherosclerotic ulcer of the ascending aorta. The patient was considered for open cardiac surgery but was evaluated at a high mortality risk based on his age, his medical history, and significant calcifications on his aorta. Our vascular surgical team decided then to perform an endovascular repair with extending the length of the aortic coverage by debranching the innominate artery. Discussion Endovascular treatment of an acute ruptured aorta is feasible in high-risk patients with thoracic endovascular stent grafts and coverage of the innominate artery. Endovascular treatment of the ascending aorta is at its infancy and in need of further research. New stent grafts designed for the ascending aorta are in progress and should increase the numbers of interventions in the years to come.

Download Full-text

Carotid Endarterectomy Remains Safe in High-Risk Patients

Journal of Vascular Surgery ◽

10.1016/j.jvs.2020.01.007 ◽

2020 ◽

Vol 71 (3) ◽

pp. e39

Author(s):

Nathan M. Droz ◽

Sean P. Lyden ◽

James Bena ◽

Christopher J. Smolock ◽

David Hardy ◽

...

Keyword(s):

High Risk ◽

Carotid Endarterectomy ◽

High Risk Patients ◽

Risk Patients

Download Full-text

Postoperative ischemic events in patients undergoing carotid artery stenting using algorithmic selection for embolic protection

The Neuroradiology Journal ◽

10.1177/1971400919839644 ◽

2019 ◽

Vol 32 (4) ◽

pp. 294-302 ◽

Cited By ~ 1

Author(s):

Yasuhiro Kawabata ◽

Norio Nakajima ◽

Hidenori Miyake ◽

Shunichi Fukuda ◽

Tetsuya Tsukahara

Keyword(s):

High Risk ◽

Carotid Artery ◽

Carotid Endarterectomy ◽

Transient Ischemic Attack ◽

Carotid Artery Stenting ◽

Minor Stroke ◽

High Risk Patients ◽

Embolic Protection ◽

Risk Patients ◽

Ischemic Attack

Purpose Carotid artery stenting (CAS) is a valuable alternative to carotid endarterectomy, especially in high-risk patients. However, the reported incidences of perioperative stroke and death remain higher than for carotid endarterectomy, even when using embolic protection devices (EPDs) during CAS. Our purpose was to evaluate 30-day major adverse events after CAS when selecting the most appropriate EPD. Methods We reviewed the clinical outcomes of 61 patients with 64 lesions who underwent CAS with EPDs. Patients who underwent CAS associated with thrombectomy and who had a preoperative modified Rankin scale score >3 were excluded from the analysis. The EPD was selected based on symptoms, carotid wall magnetic resonance imaging and lesion length, and we analyzed combined 30-day complication rates (transient ischemic attack, minor stroke, major stroke or death). Results Forty-nine patients were men and 12 were women. The median age was 72 years (range: 59–89 years) and 44 lesions were asymptomatic. A filter-type EPD was selected in 23 procedures, distal-balloon protection in 14 procedures and proximal-occlusive protection in 27 procedures. Two patients (3.1%) experienced a transient ischemic attack and one patient (1.6%) had a minor stroke within 30 days of the procedure. No patients experienced procedure-related morbidities (modified Rankin score >2) or death. Conclusions The perioperative stoke rate was low when we selected a proximal-occlusive-type EPD in high-risk patients with vulnerable carotid artery disease. Our algorithm for EPD selection was an effective tool in the perioperative management of carotid artery stenosis.

Download Full-text

The Risks of Carotid Endarterectomy in “High-risk” Patients

Neurosurgery ◽

10.1097/00006123-199809000-00237 ◽

1998 ◽

Vol 43 (3) ◽

pp. 685-685

Author(s):

Hulda B. Magnadottir ◽

Robert E. Harbaugh

Keyword(s):

High Risk ◽

Carotid Endarterectomy ◽

High Risk Patients ◽

Risk Patients

Download Full-text

Perioperative management of high risk patients with cardiopulmonary disease undergoing carotid endarterectomy or extracranial-intracranial bypass

Neurosurgery ◽

10.1097/00006123-198204000-00002 ◽

1982 ◽

Vol 10 (4) ◽

pp. 422???7

Author(s):

M B Pritz ◽

G W Kindt

Keyword(s):

High Risk ◽

Carotid Endarterectomy ◽

Perioperative Management ◽

High Risk Patients ◽

Cardiopulmonary Disease ◽

Risk Patients

Download Full-text

Perioperative Management of High Risk Patients with Cardiopulmonary Disease Undergoing Carotid Endarterectomy or Extracranial-Intracranial Bypass

Neurosurgery ◽

10.1227/00006123-198204000-00002 ◽

1982 ◽

Vol 10 (4) ◽

pp. 422-427 ◽

Cited By ~ 4

Author(s):

Michael B. Pritz ◽

Glenn W. Kindt

Keyword(s):

High Risk ◽

Carotid Endarterectomy ◽

Perioperative Management ◽

Myocardial Function ◽

Perioperative Period ◽

Medical Problems ◽

High Risk Patients ◽

Increased Risk ◽

Risk Patients ◽

Cardiopulmonary Monitoring

Abstract Among a large group of patients who underwent either carotid endarterectomy or extracranial-intracranial (EC-IC) bypass were 13 patients who had cardiopulmonary monitoring performed by a dye dilution technique either with or without a thermodilution Swan-Ganz catheter. Each patient had at least two significant medical problems that were thought to place him or her at increased risk. The usefulness of this monitoring approach in the perioperative management of these patients is demonstrated by several clinical examples. No patient sustained myocardial infarction, congestive heart failure, or new neurological deficit during the perioperative period. Our experience suggests that high risk patients can safely undergo either carotid endarterectomy or EC-IC bypass provided that careful attention is paid to myocardial function and the state of hydration.

Download Full-text