Carotid artery stenosis is relatively common and is a significant cause of ischemic stroke, but carotid revascularization can reduce the risk of ischemic stroke in patients with significant symptomatic stenosis. Carotid endarterectomy has been and remains the gold standard treatment to reduce the risk of carotid artery stenosis. Carotid artery stenting (CAS) (or carotid artery stent implantation) is another method of carotid revascularization, which has developed rapidly over the last 30 years. To date, the frequency of use of CAS is increasing, and clinical outcomes are improving with technical advancements. However, the value of CAS remains unclear in patients with significant carotid artery stenosis. This review article discusses the basic concepts and procedural techniques involved in CAS.
Carotid Arteries ; Carotid Stenosis ; Constriction, Pathologic ; Endarterectomy, Carotid ; Humans ; Methods ; Percutaneous Coronary Intervention ; Stents ; Stroke

OBJECTIVETo analyze the effectiveness and costs of the eversion carotid endarterectomy (eCEA) and the carotid endarterectomy with patch angioplasty (pCEA) in treating carotid artery stenosis.

METHODSPatients with carotid artery stenosis who underwent the carotid endarterectomy in the vascular surgery department of Peking Union Medical College Hospital from October 2009 to October 2012 were enrolled in this study. According to the two different surgical procedures, the patients were divided into eCEA group and pCEA group.

RESULTSThe two groups were not significantly different in terms of gender ,age ,risk factors, stenosis degree of carotid artery, and the ratio of bilateral lesions (all P>0.05).The ratio of shunt and antibiotics application, operative time, hospitalization cost, and length of hospital stay in the eCEA group were significantly lower than those in pCEA group (P<0.05).The therapeutic effectiveness, complications, surgery-related death, restenosis, and ipsilateral stroke were not significantly different between these two groups (P>0.05).

CONCLUSIONBoth surgical procedures are safe and effective in treating the carotid artery stenosis;however, eCEA has lower cost when compared with pCEA and therefore can be used as the first choice.

Aged ; Carotid Artery, Internal ; surgery ; Carotid Stenosis ; surgery ; Endarterectomy, Carotid ; methods ; Female ; Humans ; Male ; Middle Aged ; Retrospective Studies

Endarterectomy, Carotid ; methods ; Female ; Humans ; Male ; Methyl Ethers ; therapeutic use ; Myocardium ; metabolism ; Propofol ; therapeutic use

OBJECTIVETo evaluate the routine use of Brener shunt during carotid endarterectomy (CEA).

METHODSA prospective audit of the results of 58 consecutive CEA was performed, with routine use of Brener shunt in surgical hospital, Rostock university in Germany. Intraoperative and postoperative complications of CEA were reviewed.

RESULTSIn this study, the successful rate of insertion of shunt was 100%. The perioperative stroke/death rate at 30 days was 0, but the TIA rate was 2 cases (3.5%), which was related with previous stroke and contralateral internal carotid occlusion. 2 cases (3.5%) had minor operative complications.

CONCLUSIONSThe routine use of Brener shunt has a less rate of intraoperative and early postoperative neurologic complications during CEA. But experience in a large number of shunting procedure is needed.

Aged ; Endarterectomy, Carotid ; methods ; Female ; Humans ; Male ; Middle Aged ; Prospective Studies

BACKGROUND: Intraoperative monitoring during carotid endarterectomy is crucial for cerebral protection. We investigated the results of carotid endarterectomy under dual monitoring with stump pressure and electroencephalography. METHODS: We retrospectively reviewed the medical records of 50 patients who underwent carotid endarterectomy between March 2010 and February 2016. We inserted a temporary shunt if the stump pressure was lower than 35 mm Hg or if any intraoperative change was observed on electroencephalography. RESULTS: Seventeen (34%) patients used a temporary shunt, and the mean stump pressure was 26.8 mm Hg in the shunt group and 46.5 mm Hg in the non-shunt group. No postoperative mortality or bleeding occurred. Postoperatively, there were 3 cases (6%) of minor stroke, all of which took place in the shunt group. A comparison of the preoperative and the intraoperative characteristics of the shunt group with those of the non-shunt group revealed no statistically significant difference between the 2 groups (p <0.01). CONCLUSION: Dual monitoring with stump pressure and electroencephalography was found to be a safe and reliable monitoring method with results comparable to those obtained using single monitoring. Further study should be performed to investigate the precise role of each monitoring method.
Carotid Artery Diseases ; Electroencephalography* ; Endarterectomy, Carotid* ; Hemorrhage ; Humans ; Intraoperative Neurophysiological Monitoring ; Medical Records ; Methods ; Monitoring, Intraoperative ; Mortality ; Retrospective Studies ; Stroke

OBJECTIVETo observe the effect of using eversion carotid endarterectomy (eCEA) for carotid stenosis.

METHODSTwenty four patients with carotid stenosis (stenosis grade 65% approximately 95%), of which 18 were symptomatic and 6 were asymptomatic, were treated by eCEA under regional anesthesia. All patients underwent preoperative cervical duplex and DSA, CT or MRA scanning examination. The eversion technique involved an oblique transection of the internal carotid artery at the carotid bulb and a subsequent endarterectomy by everting the internal carotid artery over the atheromatous plaque.

RESULTSThere was no perioperative mortality and stroke. Transient ischemic attacks (TIA) disappeared, cerebral ischemia symptom improved in our patients. But there were mini chronic symptom of cerebral ischemia in 4 patients with both carotid arterial stenosis.

CONCLUSIONCarotid eversion endarterectomy appears to be a universally applicable, safe, and durable operative technique.

Aged ; Carotid Stenosis ; surgery ; Endarterectomy, Carotid ; methods ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Treatment Outcome

OBJECTIVETo evaluate the clinical effects of carotid endarterectomy for carotid stenosis and occlusion.

METHODSFrom August 2005 to November 2008 moderate and severe carotid stenosis or occlusion were found in 16 patients by Doppler ultrasonography (DUS), MRA, CTA, DSA. The stenosis degree ranged from 60% to 99% in 14 patients and complete occlusion in 2 patients. Twelve patients underwent standard carotid endarterectomy (sCEA) in whom 2 patients were placed carotid shunt and 1 patient underwent carotid patch angioplasty. Four patients underwent eversion carotid endarterectomy (eCEA). All operations were performed by microscope.

RESULTSThere was no stroke, transient ischemic attack and mortality perioperatively and during follow-up from 1 month to 3 years. The ICA flow detected by follow-up duplex scan and MRA was unobstructed. The primary cerebral ischemic symptoms were obviously improved or disappeared after operation. The postoperative complications included one case of upper gastrointestinal hemorrhage and one case of hoarseness and bucking, which disappeared after medical treatment.

CONCLUSIONSCEA is an effective way for treating carotid stenosis. Different operative methods and techniques deal with different carotid lesions to achieve better effect. Microsurgical technique is useful for exposure of high ICA bifurcation and avoid effectively cranial nerve injury and other complications.

Adult ; Aged ; Carotid Stenosis ; surgery ; Endarterectomy, Carotid ; methods ; Female ; Follow-Up Studies ; Humans ; Male ; Microsurgery ; Middle Aged ; Treatment Outcome

OBJECTIVETo evaluate the value of oblique-sagittal black-blood contrast-enhanced magnetic resonance imaging (OB-CEMRI) in atherosclerotic carotid artery (CA) assessment before carotid endarterectomy (CEA).

METHODSTwenty-five patients with symptomatic atherosclerotic stenosis in the carotid artery (involving 26 arteries) were scheduled for CEA. OB-CEMRI and digital subtraction angiography (DSA) were conducted within 1 week prior to CEA, and two radiologists independently assessed the location of maximal lumen stenosis, plaque rupture, degree of maximal lumen stenosis and plaque involvement on DSA and OB-CEMRI images. The differences of DSA and the OB-CEMRI in analyzing the plaque conditions were assessed in comparison with matched histological sections of the excised specimens.

RESULTSCompared with the corresponding histological specimens, both DSA (κ=0.807) and OB-CEMRI (κ=0.812) showed a good consistency in defining the location of the maximal lumen stenosis. OB-CEMRI showed a better performance in detecting plaque rupture with higher sensitivity (90.0%) and specificity (83.3%) than DSA (40.0% and 66.7%, respectively). No significant difference was found between DSA and the OB-CEMRI in evaluating the degree of maximal lumen stenosis [(77.33∓3.79)% vs (76.02∓3.95)%, P=0.648]. Compared with the histological examination, OB-CEMRI appeared to underestimate the stenosis. The plaque extent on OB-CEMRI was larger than that on DSA (18.96∓4.96 mm vs 14.80∓3.78 mm, P=0.004), and similar to that by histological examination (18.13∓4.57 mm, P=0.506).

CONCLUSIONSOB-CEMRI allows noninvasive and objective detection of the location of the maximal lumen stenosis, plaque rupture, and plaque extent, though with a lower accuracy than DSA in the assessment of the maximal lumen stenosis. OB-CEMRI combined with DSA offers a more reliable means for preoperative evaluation of the carotid artery plaques for CEA.

Aged ; Angiography, Digital Subtraction ; Carotid Artery Diseases ; pathology ; Carotid Stenosis ; Endarterectomy, Carotid ; methods ; Female ; Humans ; Magnetic Resonance Angiography ; Magnetic Resonance Imaging ; methods ; Male ; Middle Aged

The results of surgical bypass and endarterectomy in Takayasu's arteritis (TA) were reported to be poor compared to usual atherosclerosis patients. However, if ischemic symptoms due to occlusive disease were severe, surgical procedures were inevitable. We report surgical experience of 5 patients with TA. Five women (ranged from 26 to 58 yr) were operated between June 1998 and May 2004. Three patients showed occlusion of main branches of aortic arch and had symptoms of cerebral ischemia. One patient showed near total occlusion in the midabdominal aorta and had symptoms of orthopnea and uncontrolled hypertension. One patient showed total occlusion of abdominal aorta at the level of aortic bifurcation and had a symptom of severe claudication on both legs. Bypasses from the ascending aorta to the carotid artery were performed in 3 cases. Bypass from the thoracic aorta to the left common iliac artery was performed in one case and endarterectomy of abdominal aorta in one case. The ischemic symptoms related with arterial occlusion were resolved after surgery. And the symptoms of cardiac failure disappeared. The symptomatic TA frequently required arterial reconstruction. The symptomatic improvement and excellent mid-term patency could be expected after arterial reconstruction and endarterectomy.
Adult ; Endarterectomy, Carotid/methods ; Female ; Humans ; Middle Aged ; Migraine Disorders/etiology ; Postoperative Complications ; Takayasu's Arteritis/radiography/*surgery ; Treatment Outcome

BACKGROUND: The surgical strategies for carotid endarterectomy (CEA) vary in terms of the anesthesia method, neurological monitoring, shunt usage, and closure technique, and no gold-standard procedure has been established yet. We aimed to analyze the feasibility and benefits of CEA under regional anesthesia (RA) and CEA under general anesthesia (GA).METHODS: Between June 2012 and December 2017, 65 patients who had undergone CEA were enrolled, and their medical records were prospectively collected and retrospectively reviewed. A total of 35 patients underwent CEA under RA with cervical plexus block, whereas 30 patients underwent CEA under GA. In the RA group, a carotid shunt was selectively used for patients who exhibited negative results on the awake test. In contrast, such a shunt was used for all patients in the GA group.RESULTS: There were no cases of postoperative stroke, cardiovascular events, or mortality. Nerve injuries were noted in 4 patients (3 in the RA group and 1 in the GA group), but they fully recovered prior to discharge. Operative time and clamp time were shorter in the RA group than in the GA group (119.29±27.71 min vs. 161.43±20.79 min, p<0.001; 30.57±6.80 min vs. 51.77±13.38 min, p<0.001, respectively). The hospital stay was shorter in the RA group than in the GA group (14.6±5.05 days vs. 18.97±8.92 days, p=0.022). None of the patients experienced a stroke or restenosis during the 27.23±20.3-month follow-up period.CONCLUSION: RA with a reliable awake test reduces shunt use and decreases the clamp and operative times of CEA, eventually resulting in a reduced length of hospital stay.
Anesthesia ; Anesthesia, Conduction ; Anesthesia, General ; Carotid Arteries ; Cervical Plexus Block ; Endarterectomy ; Endarterectomy, Carotid ; Follow-Up Studies ; Humans ; Length of Stay ; Medical Records ; Methods ; Mortality ; Myocardial Infarction ; Operative Time ; Prospective Studies ; Retrospective Studies ; Stroke