Eversion vs conventional carotid endarterectomy: a systematic review.

OBJECTIVE: to determine whether eversion carotid endarterectomy (CEA) was safe and more effective than conventional CEA. METHODS: controlled trials comparing eversion vs conventional technique for CEA were identified from the Cochrane Stroke Review Group database plus additional hand searching. Researchers were contacted to identify additional published and unpublished studies. Randomised and pseudorandomised trials comparing eversion to conventional techniques in patients undergoing CEA were examined. Outcomes included stroke and death, carotid restenosis/occlusion, and local complications. RESULTS: five trials were included comprising 2465 patients and 2590 arteries. There were no significant differences in the rate of perioperative stroke or death (1.7% vs 2.6%, odds ratio [OR] 0.44, 95% confidence interval [CI] 0.10-1.82) and stroke during follow-up (1.4% vs 1.7%; OR: 0.84; 95% CI: 0.43-1.64) between eversion and conventional CEA techniques. Eversion CEA was associated with a significantly lower rate of restenosis >50% during follow-up (2.5% vs 5.2%, OR: 0.48, 95% CI: 0.32-0.72). There were no statistically significant differences in local complications between the eversion and conventional group. When eversion procedures were compared with patch procedures only, non-significant differences were found in primary outcomes. CONCLUSIONS: eversion CEA may be associated with low risk of arterial occlusion and restenosis. However, numbers are too small to definitively assess the benefits and disadvantages of eversion CEA. Reduced restenosis rates did not appear to be associated with clinical benefit in terms of reduced stroke risk, either perioperatively or later. Until further evidence is available, the choice of the CEA technique should be based on the experience and familiarity of the individual surgeon.     

Uncomplicated carotid endarterectomy: factors contributing to blood pressure instability precluding safe early discharge

This study was undertaken to identify preoperative and intraoperative factors that correlate with the need for postoperative vasoactive medication (VM) use. Clinical data from 100 carotid endarterectomies (CEAs) performed in 93 patients were reviewed. Baseline comorbidities, medications, perioperative physiologic data, and operative technique were evaluated for their association with the need for postoperative VM use. Statistical analysis included univariate and multivariate logistic regression with odds ratios (ORs) and 95% confidence intervals (CIs) reported. Hemodynamic instability affected 43 patients, of whom 32 had VM started in the postanesthesia care unit (PACU). No patient who was hemodynamically stable in the PACU later required VM. The only preoperative factor associated with a need for postoperative VM was a prior stroke (OR 4.5; 95% CI 1.2-16.2; p = .02). Intraoperative factors associated with the need for postoperative VM included use of a shunt (OR 5.1; 95% CI 1.2-22.2; p = .03) and a peak intraoperative systolic blood pressure greater than 200 mm Hg (OR 5.1; 95% CI 1.2-22.2; p = .03). The number and type of preoperative blood pressure medications, preoperative hypertension, comorbidities, symptomatic presentation, and intraoperative use of VM did not correlate with postoperative VM use. There were two strokes and no deaths. Patients undergoing CEA who are hemodynamically stable in the PACU appear to be reasonable candidates for same-day discharge and warrant further prospective study.     

Long-term effect of carotid endarterectomy on carotid sinus baroreceptor function and blood pressure control

In order to assess whether carotid endarterectomy had any long-term hypotensive effect, by altering the function of the carotid sinus baroreceptors, blood pressure and carotid sinus baroreceptor function were recorded in 25 patients undergoing carotid endarterectomy. No overall change in blood pressure was recorded 6 months after surgery. Sinus function was shown to decrease in 2 (8 per cent), to remain unchanged in 15 (60 per cent) and to increase in 8 (32 per cent) patients 6 months postoperatively. There was no relationship between changes in sinus function and changes in blood pressure over the 6 months period. Thus, carotid endarterectomy has no long-term hypotensive effect.     

Myocardial infarction following carotid endarterectomy: a review of 683 operations.

In a series of 683 consecutive carotid endarterectomies, there were 16 postoperative myocardial infarctions which resulted in five deaths. Of 399 operations on patients with no previous history of heart disease, there were only two myocardial infarctions (0.5%). Two hundred and eighty-four operations were performed on patients with heart disease, and vasopressors were administered in 135 of these procedures. For these patients the risk of myocardial infarction increased from 2.0% to 8.1% with the use of vasopressors (P less than 0.001). The management of the patient with stable heart disease undergoing carotid endarterectomy is discussed.     

Carotid surgery following previous carotid endarterectomy is safe and effective

With the perceived high risk of repeat carotid surgery, carotid angioplasty and stenting have been advocated recently as the preferred treatment of recurrent carotid disease following carotid endarterectomy. An experience with the operative treatment of recurrent carotid disease to document the risks and benefits of this procedure is presented. A review of a prospectively acquired vascular registry over a 10-year period (Jan. 1990-Jan. 2000) was undertaken to identify patients undergoing repeat carotid surgery following previous carotid endarterectomy. All patients were treated with repeat carotid endarterectomy, carotid interposition graft, or subclavian-carotid bypass. The perioperative stroke and death rate, operative complications, life-table freedom from stroke, and rates of recurrent stenosis were documented. During the study period 56 patients underwent repeat carotid surgery, comprising 6% of all carotid operations during this period. The indication for operation was symptomatic disease recurrence in 41 cases (73%) and asymptomatic recurrent stenosis >/=80% in 15 cases (27%). The average interval from the prior carotid endarterectomy to the repeat operation was 78 months (range 3 weeks-297 months). The operations performed included repeat carotid endarterectomy with patch angioplasty in 31 cases (55%), interposition grafts in 19 cases (34%), and subclavian-carotid bypass in 6 cases (11%). There were three perioperative strokes with one resulting in death for a perioperative stroke and death rate of 5.4%. One minor transient cranial nerve (CN IX) injury occurred. Mean follow-up was 29 months (range, 1-116 months). Life-table freedom from stroke was 95% at 1 year and 90% at 5 years. Recurrent stenosis (>/=80%) developed in three patients (5.4%) during follow-up, including one internal carotid artery occlusion. Two patients (3.6%) underwent repeat surgery. Repeat surgery for recurrent cerebrovascular disease following carotid endarterectomy is safe and provides durable freedom from stroke. Most patients are candidates for repeat endarterectomy with patching, but interposition grafting is often required. These results strongly support the continued role of repeat carotid surgery in the treatment of recurrent carotid disease.     

Patient selection for carotid stenting versus endarterectomy: a systematic review

Carotid artery stenting has emerged as an alternative to carotid endarterectomy for the treatment of severe extracranial carotid stenosis in patients with anatomic or clinical factors that increase their risk of complications with surgery, yet there remains a substantial amount of variability and uncertainty in clinical practice in the referral of patients for stenting vs endarterectomy. By undertaking a thorough review of the literature, we sought to better define which subsets of patients with "high-risk" features would be likely to preferentially benefit from carotid stenting or carotid endarterectomy. Although only a single randomized trial comparing the outcomes of carotid stenting with distal protection and endarterectomy has been completed, a wealth of observational data was reviewed. Relative to endarterectomy, the results of carotid stenting seem favorable in the setting of several anatomic conditions that render surgery technically difficult, such as restenosis after prior endarterectomy, prior radical neck surgery, and previous radiation therapy involving the neck. The results of stenting are also favorable among patients with severe concomitant cardiac disease. Carotid endarterectomy, alternatively, seems to represent the procedure of choice among patients 80 years of age or older in the absence of other high-risk features. Overall, existing data support the concept that carotid stenting and endarterectomy represent complementary rather than competing modes of therapy. Pending the availability of randomized trial data to help guide procedural selection, which is likely many years away, an objective understanding of existing data is valuable to help select the optimal mode of revascularization therapy for patients with severe carotid artery disease who are at heightened surgical risk.     

A systematic review of outcomes following staged and synchronous carotid endarterectomy and coronary artery bypass.

OBJECTIVES: to determine the overall cardiovascular risk for patients with combined cardiac and carotid artery disease undergoing synchronous coronary artery bypass (CABG) and carotid endarterectomy (CEA), staged CEA then CABG and reverse staged CABG then CEA. DESIGN: systematic review of 97 published studies following 8972 staged or synchronous operations. RESULTS: mortality was highest in patients undergoing synchronous CEA+CABG (4.6%, 95% CI 4.1-5.2). Reverse staged procedures (CABG-CEA) were associated with the highest risk of ipsilateral stroke (5.8%, 95% CI 0.0-14.3) and any stroke (6.3%, 95% CI 1.0-11.7). Peri-operative myocardial infarction (MI) was lowest following the reverse staged procedure (0.9%, 95% CI 0.5-1.4) and highest in patients undergoing staged CEA-CABG (6.5%, 95% CI 3.2-9.7).The risk of death+/-any stroke was highest in patients undergoing synchronous CEA+CABG (8.7%, 95% CI 7.7-9.8) and lowest following staged CEA-CABG (6.1%, 95% CI 2.9-9.3). The risk of death/stroke or MI was 11.5% (95% CI 10.1-12.9) following synchronous procedures versus 10.2% (95% CI 7.4-13.1) after staged CEA then CABG. CONCLUSIONS: 10-12% of patients undergoing staged or synchronous procedures suffered death or major cardiovascular morbidity (stroke, MI) within 30 days of surgery. Overall, there was no significant difference in outcomes for staged and synchronous procedures and no comparable data for patients with combined cardiac and carotid disease not undergoing staged or synchronous surgery.     

Meta-analysis and systematic review of the relationship between hospital volume and outcome following carotid endarterectomy.

OBJECTIVES: This study investigated the relationship between annual hospital volume and the outcomes in carotid endarterectomy and quantified critical volume threshold for this procedure. DATA SOURCES: PubMed, EMBASE and the Cochrane library were searched for all articles on the volume-outcome relationship in CEA. REVIEW METHODS: Articles were included if they presented data on post-operative mortality and/or stroke rates and annual hospital volume of CEA. The review conformed to the QUOROM statement. The data were meta-analysed and a pooled effect estimate of volume on the stroke and/or mortality rates from CEA quantified, along with the critical volume threshold. RESULTS: Twenty-five articles, encompassing 936 436 CEA, were analysed. Significant relationships between mortality rate and stroke rate and annual volume were seen. Overall, the pooled effect estimate was odds ratio 0.78 [95% confidence interval 0.64-0.92], in favour of surgery at higher volume units, with a critical volume threshold of 79 CEA per annum. CONCLUSIONS: Significantly lower mortality and stroke rates were achieved at hospitals providing a higher annual hospital volume of CEA. Hospitals wishing to provide CEA should adhere to minimum volume criteria.     

N-acetylcysteine to reduce renal failure after cardiac surgery: a systematic review and meta-analysis

Purpose: To assess the effect of N-acetylcysteine (NAC) on acute renal failure and important clinical outcomes after cardiac surgery. Methods: Two reviewers performed literature searches, using EMBASE and PubMed, of randomized controlled trials investigating the renoprotective effect of N-acetylcysteine in cardiac surgery. Treatment effects were calculated as relative risks (RR) with 95% confidence intervals (CI). Heterogeneity and publication bias were assessed using the I² test and funnel plots, respectively. Meta regression was performed to assess the effect of baseline renal function and the use of aprotinin on renal function. Results: Seven randomized controlled trials (RCTs) (n=1000) were identified. No study could demonstrate, either independently or meta-analytically, an improvement in the postoperative increase in creatinine, mortality (RR 0.93, 95% CI 0.4 to 2.07), renal failure requiring renal replacement therapy (RR 1.01, 95% CI 0.49 to 2.12), myocardial infarction (RR 0.88, 95% CI 0.36 to 1.88), atrial fibrillation (RR 0.88, 95% CI 0.70 to 1. 10), or stroke (RR 0.69, 95% CI 0.27 to 1.69). There was a small, though significant increase in postoperative blood loss among patients treated with NAC (weighted mean difference I 19 mL 95% CI 51, 187). After meta regression neither increase in postoperative creatinine (r²=0.33) nor renal replacement therapy (r²=0.04) was associated with the baseline creatinine or with NAC dose (r²=0.04). Conclusion: This analysis did not find that treatment with NAC was associated with clinical renal protection during cardiac surgery, or improvement in other clinical outcomes.     

The blood supply of the hypoglossal nerve and its relevance to carotid endarterectomy.

Since the hypoglossal nerve is liable to injury during carotid endarterectomy and similar procedures, its blood supply was examined in microinjection studies of human cadavers. The nerve is supplied by arteries that arise from the ascending pharyngeal artery as it exits from the hypoglossal canal, the occipital artery as the nerve passes under its branch to the sternomastoid muscle, direct branches from the external carotid artery, and branches from the ascending pharyngeal artery just near the bifurcation of the common carotid artery. Within and close to the tongue, the nerve is supplied by branches from the lingual artery. Damage to the vessels supplying the nerve may account for some cases of hypoglossal palsy after carotid endarterectomy. Possible mechanisms are ischaemia, thermal or electrical injury from diathermy current conducted to the nerve, or intraneural haematoma from rupturing one or more of these fine vessels.     

Accessory nerve palsy following carotid endarterectomy. Report of two cases

Two patients who had an accessory nerve palsy following carotid endarterectomy are presented. Both patients had high carotid bifurcations necessitating unusually high retraction and dissection. The ipsilateral accessory nerve was injured in the anterior cervical triangle in both cases. It is believed that vigorous lateral retraction of the superior aspect of the sternocleidomastoid muscle led to a stretch injury of the nerve. The symptoms completely resolved in both patients within 6 months.     

Anesthesia for carotid endarterectomy: a review

Cardiovascular diseases are associated with high rates of morbidity and mortality. Carotid artery stenosis causes between 20% and 25% of ischemic strokes, especially when an embolism is the underlying cause. Carotid endarterectomy is the treatment of choice when stenosis exceeds 60%. It is important to have an understanding of how to manage perioperative factors that can decrease the risk of stroke, infarction, and death. In contrast to the findings of earlier meta-analyses, the recent GALA trial of general versus local anesthesia concluded that the rates of stroke, myocardial infarction, and mortality during or soon after surgery are similar for both types of anesthesia.     

Systematic review and meta-analysis of postcarotid endarterectomy hypertension after eversion versus conventional carotid endarterectomy

Objective

Blood pressure (BP) instability after carotid endarterectomy (CEA) is a risk factor for cerebrovascular and cardiovascular complications. The role of the operative technique in the development of post-CEA hemodynamic instability is unclear. The primary goal of this study was to systematically review the literature to determine whether hypertension in the early postoperative period is dependent on the surgical technique used.

颈动脉内膜剥脱术和颈动脉支架的前瞻性随机对照研究

目的 评价颈动脉内膜剥脱术和颈动脉支架治疗颈动脉狭窄的近期和中期临床效果.方法 前瞻性单中心随机对照研究,自2004年5月至2006年12月,将同意入组的40例有症状(狭窄程度>50%)和无症状(狭窄程度>70%)颈动脉狭窄患者随机分为两组,即颈动脉内膜剥脱术组(CEA)和颈动脉支架组(CAS).一期观察终点是术后30 d内出现严重脑梗死或死亡;二期观察终点是各种手术并发症、急性脑缺血发作、偏瘫、急性心肌梗死和术后18个月内的脑卒中、死亡和再狭窄等,同时回顾性分析两组总的住院费用.结果 CEA和CAS两组患者术前一般资料、临床症状、伴随疾病等因素均无差异.CEA组20例23支颈动脉手术(3例分别行双侧CEA),术中应用转流管9条(39.1%),颈动脉补片12条(52.2%);CAS组20例23支颈动脉支架(3例行双侧CAS),应用脑保护装置21个(91.3%).CEA和CAS两组术后30 d内神经系统并发症(4.3%对8.7%,P=0.46)、急性心肌梗死(4.3%对0,P=0.31)和伤口血肿(8.7%对0,P=0.14)等差异均无统计学意义,至术后18个月无短暂性脑缺血发作和再狭窄病例.CEA和CAS两组平均住院费用分别为(16 450.95±6188.76)和(70 130.15±11 999.02)元人民币,差异有统计学意义(P<0.01).结论 CEA和CAS术后30 d和术后18个月的并发症、病死率和临床疗效无明显差异,但CAS的住院花费明显高于CEA.     

Carotid endarterectomy in patients with contralateral carotid occlusion: review of a 10-year experience

A total of 116 carotid endarterectomies were performed in patients with a totally occluded opposite internal carotid artery over a 10-year period from 1983 until 1992. The average age of patients was 66.4 years; 75% were men and 25% were women. The average degree of stenosis on the operated side was 76.7%. Twenty-one patients (18.1%) had had a documented previous stroke referrable to the side of the occlusion; 22 had a neurologic deficit attributable to the occluded vessel at the time of preoperative evaluation. Indications for surgery included transient ischemic attacks in 35 (30.2%), ipsilateral stroke in 10 (8.6%). amaurosis fugax in 11 (9.5%), and high-grade asymptomatic stenosis in 60 (51.7%). Forty-eight percent of the procedures were performed using local anesthesia, with intraluminal shunts inserted in all except one patient. The combined 30-day mortality and stroke morbidity in this population was 4.3%, which is comparable with a combined stroke and death rate of 4.0% among 956 patients without contralateral carotid occlusion undergoing endarterectomy during this period. This experience suggests that endarterectomy can be performed safely in the patient with internal carotid occlusion and is an important mechanism for the prevention of stroke.