Selective Shunting during Carotid Endarterectomy

Vascular ◽  
2005 ◽  
Vol 13 (1) ◽  
pp. 23-27 ◽  
Author(s):  
Thelinh Q. Nguyen ◽  
Linda Lind ◽  
E. John Harris
Keyword(s):  
General Anesthesia ◽  
Carotid Endarterectomy ◽  
Transient Ischemic Attack ◽  
Cranial Nerve ◽  
High Grade ◽  
Amaurosis Fugax ◽  
Shunt Group ◽  
Ischemic Attack ◽  
Cerebral Monitoring ◽  
Selective Shunt

Carotid endarterectomy (CEA) is an effective treatment for significant carotid atherosclerosis. Perioperative stroke, a devastating complication, may be partially circumvented by shunting. However, routine shunt use is not without complications and does not benefit every patient. Our study is designed to determine whether CEA under general anesthesia, without cerebral monitoring, can be safely done with shunting only in the presence of poor internal carotid artery back-bleeding or contralateral carotid occlusion or critical stenosis. The medical records of 995 carotid operations were reviewed. A subset of 117 operations was performed on 112 patients using selective shunting. Data were analyzed and outcomes compared. For the selective shunt group, indications for redo operations ( n = 13) were recurrent asymptomatic high-grade stenosis in 69% and amaurosis fugax or transient ischemic attack in 31%. Indications for primary CEA ( n = 104) were asymptomatic high-grade stenosis in 59%, amaurosis fugax or transient ischemic attack in 36%, previous stroke in 3%, and global ischemia in 2%. A selective shunt was used in 29% of all symptomatic and 11% of all asymptomatic patients. No cerebral monitoring was used. There were no perioperative deaths and no permanent cranial nerve injuries, and there was one stroke (0.8%) from postoperative carotid thrombosis in a shunted patient. The average length of stay was 1.6 days for the non-shunt group and 2.2 days for the shunt group. The routine shunt group ( n = 878) had an overall stroke rate of 0.7%, no permanent cranial nerve deficits, and a mean hospital stay of 2.6 days. CEA under general anesthesia with selective shunting can be performed safely without cerebral monitoring.

scholarly journals Complete Superior and Inferior Sagittal Sinus Thromboses With Multiple Cranial Nerve Pareses and Transient Ischemic Attack. Case Report.

2002 ◽  
Vol 42 (9) ◽  
pp. 383-386 ◽  
Author(s):  
Cahide TOPSAKAL ◽  
Mutlu CIHANGIROGLU ◽  
Metin KAPLAN ◽  
Ismail AKDEMIR ◽  
Murat TIFTIKCI
Keyword(s):  
Case Report ◽  
Transient Ischemic Attack ◽  
Cranial Nerve ◽  
Sagittal Sinus ◽  
Ischemic Attack ◽  
Multiple Cranial Nerve

Obstructed Flow

2016 ◽  
Author(s):  
Ji Y. Chong ◽  
Michael P. Lerario
Keyword(s):  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Early Period ◽  
Carotid Stenting ◽  
Symptomatic Carotid ◽  
Symptomatic Carotid Stenosis ◽  
Ischemic Attack

Patients with symptomatic carotid stenosis benefit from revascularization. The risk of recurrent stroke is highest during the early period after a transient ischemic attack or stroke. Carotid endarterectomy and carotid stenting are options for treatment and should be considered within the first 2 weeks if feasible.

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

2019 ◽  
Vol 32 (4) ◽  
pp. 294-302 ◽  
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.

A Retrospective Study on Early Carotid Endarterectomy within 48 Hours after Transient Ischemic Attack and Stroke in Evolution

2014 ◽  
Vol 28 (1) ◽  
pp. 227-238 ◽  
Author(s):  
Emanuele Ferrero ◽  
Michelangelo Ferri ◽  
Andrea Viazzo ◽  
Carmelo Labate ◽  
Giuseppe Berardi ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Carotid Endarterectomy ◽  
Transient Ischemic Attack ◽  
Ischemic Attack

Outcomes of Carotid Revascularization in the Treatment of Restenosis After Prior Carotid Endarterectomy

Stroke ◽  
2021 ◽  
Author(s):  
Nadin Elsayed ◽  
Ganesh Ramakrishnan ◽  
Isaac Naazie ◽  
Sharvil Sheth ◽  
Mahmoud B. Malas
Keyword(s):  
Carotid Endarterectomy ◽  
Transient Ischemic Attack ◽  
Multivariate Logistic Regression Analysis ◽  
Hospital Outcomes ◽  
Lower Odds ◽  
Carotid Revascularization ◽  
Increased Risk ◽  
Significant Difference ◽  
Ischemic Attack ◽  
Stroke Death

Background and Purpose: Restenosis after carotid endarterectomy (CEA) is associated with an increased risk of ipsilateral stroke. The optimal procedural modality for this indication has yet to be determined. Here, we evaluate the in-hospital outcomes of transcarotid artery revascularization (TCAR), redo-CEA, and transfemoral carotid artery stenting (TFCAS) in a large contemporary cohort of patients who underwent treatment for restenosis after CEA. Methods: We performed a retrospective analysis of all patients in the vascular quality initiative database who underwent TCAR, redo-CEA, or TFCAS after ipsilateral CEA between September 2016 and April 2020. Patients with prior ipsilateral CAS were excluded from this analysis. In-hospital outcomes following TCAR versus CEA and TCAR versus TFCAS were evaluated using multivariate logistic regression analysis. Results: A total of 4425 patients were available for this analysis. There were 963 (21.8%) redo-CEA, 1786 (40.4%) TFCAS, and 1676 (37.9%) TCAR. TCAR was associated with lower odds of in-hospital stroke/death (odds ratio [OR], 0.41 [95% CI, 0.24–0.70], P =0.021), stroke (OR, 0.46 [95% CI, 0.23–0.93], P =0.03), myocardial infarction (MI; OR, 0.32 [95% CI, 0.14–0.73], P =0.007), stroke/transient ischemic attack (OR, 0.42 [95% CI, 0.24–0.74], P =0.002), and stroke/death/MI (OR, 0.41 [95% CI, 0.24–0.70], P =0.001) when compared with redo-CEA. There was no significant difference in the odds of death between the 2 groups (OR, 0.99 [95% CI, 0.28–3.5], P =0.995). TCAR was also associated with lower odds of stroke/transient ischemic attack (OR, 0.37 [95% CI, 0.18–0.74], P =0.005) when compared with TFCAS. There was no significant difference in the odds of stroke, death, MI, stroke/death, or stroke/death/MI between TCAR and TFCAS. Conclusions: TCAR was associated with significantly lower odds of in-hospital stroke, MI, stroke/transient ischemic attack, stroke/death, and stroke/death/MI when compared with redo-CEA and lower odds of in-hospital stroke/transient ischemic attack when compared with TFCAS. Additional long-term studies are warranted to establish the role of TCAR for the treatment of restenosis after CEA.

Stress-Strain Profile of Carotid Plaque With and Without Juxtaluminal Hemorrhage/Thrombus: A Possible Mechanism for Subsequent Cerebrovascular Events

2011 ◽  
Author(s):  
Zhongzhao Teng ◽  
Umar Sadat ◽  
Jonathan H. Gillard
Keyword(s):  
High Risk ◽  
Transient Ischemic Attack ◽  
Carotid Plaque ◽  
Recurrent Events ◽  
Atherosclerotic Plaques ◽  
High Grade ◽  
Benefit Ratio ◽  
Clear Cut ◽  
Cerebrovascular Events ◽  
Ischemic Attack

Patients suffering from a transient ischemic attack (TIA) are at high risk of a stroke or recurrent TIA, with about half of all recurrent events during the seven days after a TIA occurring in the first 24 hours. These events are usually caused by thromboembolization from ruptured carotid atherosclerotic plaques. Large trials have shown that carotid endarterectomy benefits patients with high grade carotid stenosis, but the risk-to-benefit ratio was less clear-cut for symptomatic patients with moderate stenosis (50–69%). Therefore, identification of high-risk plaques within this group could significantly decrease the ratio.

Hyperglycemia Independently Increases the Risk of Perioperative Stroke, Myocardial Infarction, and Death after Carotid Endarterectomy

Neurosurgery ◽  
2006 ◽  
Vol 58 (6) ◽  
pp. 1066-1073 ◽  
Author(s):  
Matthew J. McGirt ◽  
Graeme F. Woodworth ◽  
Benjamin S. Brooke ◽  
Alexander L. Coon ◽  
Shamik Jain ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Carotid Endarterectomy ◽  
Transient Ischemic Attack ◽  
Multivariate Logistic Regression Analysis ◽  
Interquartile Range ◽  
Morbidity And Mortality ◽  
Perioperative Stroke ◽  
Surgical Critical Care ◽  
Increased Risk ◽  
Ischemic Attack

Abstract OBJECTIVE: Clinical and experimental evidence suggests that hyperglycemia lowers the neuronal ischemic threshold, potentiates stroke volume in focal ischemia, and is associated with morbidity and mortality in the surgical critical care setting. It remains unknown whether hyperglycemia during carotid endarterectomy (CEA) predisposes patients to perioperative stroke and operative related morbidity and mortality. METHODS: The clinical and radiological records of all patients undergoing CEA and operative day glucose measurement from 1994 to 2004 at an academic institution were reviewed and 30-day outcomes were assessed. The independent association of operative day glucose before CEA and perioperative morbidity and mortality were assessed via multivariate logistic regression analysis. RESULTS: One thousand two hundred and one patients with a mean age of 72 ± 10 years (748 men, 453 women) underwent CEA (676 asymptomatic, 525 symptomatic). Overall, stroke occurred in 46 (3.8%) patients, transient ischemic attack occurred in 19 (1.6%), myocardial infarction occurred in 19 (1.6%), and death occurred in 17 (1.4%). Increasing operative day glucose was independently associated with perioperative stroke or transient ischemic attack (Odds ratio [OR], 1.005; 95% confidence interval [CI], 1.00–1.01; P = 0.03), myocardial infarction (OR, 1.01; 95% CI, 1.004–1.016; P = 0.017), and death (OR, 1.007; 95% CI, 1.00–1.015; P = 0.04). Patients with operative day glucose greater than 200 mg/dl were 2.8-fold, 4.3-fold, and 3.3-fold more likely to experience perioperative stroke or transient ischemic attack (OR, 2.78; 95% CI, 1.37–5.67; P = 0.005), myocardial infarction (OR, 4.29; 95% CI, 1.28–14.4; P = 0.018), or death (OR, 3.29; 95% CI, 1.07–10.1; P = 0.037), respectively. Median and interquartile range length of hospitalization was greater for patients with operative day glucose greater than 200 mg/dl (4 d [interquartile range, 2–15 d] versus 3 d [interquartile range, 2–7 d]; P < 0.05). CONCLUSION: Independent of previous cardiac disease, diabetes, or other comorbidities, hyperglycemia at the time of CEA was associated with an increased risk of perioperative stroke or transient ischemic attack, myocardial infarction, and death. Strict glucose control should be attempted before surgery to minimize the risk of morbidity and mortality after CEA.

The study of transcarotid artery revascularization under local versus general anesthesia with results from the Society for Vascular Surgery Vascular Quality Initiative

Vascular ◽  
2020 ◽  
Vol 28 (6) ◽  
pp. 784-793 ◽  
Author(s):  
Dipankar Mukherjee ◽  
Devon T Collins ◽  
Chang Liu ◽  
Neul Ha ◽  
Jeffrey Jim
Keyword(s):  
Myocardial Infarction ◽  
Length Of Stay ◽  
General Anesthesia ◽  
Local Anesthesia ◽  
Transient Ischemic Attack ◽  
Primary Outcome ◽  
Composite Outcome ◽  
Reversal Time ◽  
Secondary Outcomes ◽  
Ischemic Attack

Objective The primary purpose of this study was to examine any potential difference in clinical outcomes between transcarotid artery revascularization performed under local anesthesia compared with general anesthesia by utilizing a large national database. Methods The primary outcome of the study was a composite endpoint of postoperative in-hospital stroke, myocardial infarction and mortality following transcarotid artery revascularization for the index procedure. Secondary outcomes included a composite outcome of postoperative in-hospital stroke, transient ischemic attack, myocardial infarction and mortality along with several subsets of its components and each individual component, flow reversal time (min), radiation dose (GY/cm2), contrast volume utilized (mL), total procedure time (min), extended total length of stay (>1 day) and extended postoperative length of stay (>1 day). Statistical analyses employed both descriptive measures to characterize the study population and analytic measures such as multivariable mixed-effect linear and logistic regressions using both unmatched and propensity-score matched cohorts. Results A total of 2609 patients undergoing transcarotid artery revascularization between the years 2016 and 2018 in the US were identified, with 82.3% performed under general anesthesia and 17.7% under local anesthesia. The primary composite outcome was observed in 2.3% of general anesthesia patients versus 2.6% of local anesthesia patients ( p = 0.808). The rate of postoperative transient ischemic attack and/or myocardial infarction was 1.6% with general anesthesia versus 1.1% with local anesthesia ( p = 0.511). For adjusted regression analysis, general anesthesia and local anesthesia were comparable in terms of primary outcome (OR: 0.72; 95% CI: 0.27–1.93, p = 0.515). As for the secondary outcomes, no significant differences were found except for contrast, where the results demonstrated significantly less need for contrast with procedures performed under general anesthesia (coefficient: 4.94; 95% CI: 1.34–8.54, p = 0.007). A trend towards significance was observed for lower rate of postoperative transient ischemic attack and/or myocardial infarction (OR: 0.33; 95% CI: 0.09–1.18, p = 0.088) and lower flow reversal time under local anesthesia (coefficient: –0.94: 95% CI: –2.1–0.22, p = 0.111). Conclusions Excellent outcomes from transcarotid artery revascularization for carotid stenosis were observed in the VQI database between the years 2016 and 2018, under both local anesthesia and general anesthesia. The data demonstrate the choice of anesthesia for transcarotid artery revascularization does not appear to have any effect on clinical outcomes. Surgical teams should perform transcarotid artery revascularization under the anesthesia type they are most comfortable with.

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