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

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

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

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

BACKGROUNDMyocardial infarction is an important cause of mortality after carotid endarterectomy (CEA). Sevoflurane provides myocardial protection to patients undergoing coronary surgery, but whether it also reduces the incidence of myocardial injury in CEA patients is unclear. In this study, we evaluated the cardioprotective effect of low-dose sevoflurane with propofol in patients undergoing CEA.

METHODSThis was a single-center, prospective, randomized study conducted between November 2011 and December 2013. The study population of 122 patients who underwent CEA were randomly assigned to two groups. Group A (n = 62) received propofol for anesthetic maintenance, and Group B (n = 60) additionally received 0.8% end-tidal sevoflurane. The bispectral index was kept at 40-60. Myocardial injury, defined as cardiac troponin I (cTnI) levels >0.04 ng/ml, was the primary end-point. Levels of cTnI were measured before anesthesia, and at 4, 24, and 72 h after surgery. Perioperative hemodynamic parameters and adverse cardiovascular events after surgery were also recorded.

RESULTSMyocardial injury was detected in 18 patients in Group A and 7 in Group B. The difference was statistically significant (29.0% vs. 11.7%, P = 0.018). The hemodynamic parameters were comparable between the groups, as were adverse cardiovascular events (P = 0.619).

CONCLUSIONSLow-dose sevoflurane inhalation along with propofol reduces the incidence of myocardial injury in symptomatic patients after CEA.

Aged ; Drug Administration Schedule ; Endarterectomy, Carotid ; methods ; Female ; Humans ; Male ; Methyl Ethers ; administration & dosage ; therapeutic use ; Middle Aged ; Myocardium ; metabolism ; Propofol ; administration & dosage ; therapeutic use ; Troponin I ; metabolism

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

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

BACKGROUNDCoexistent carotid and coronary artery diseases are common and patients with them remain at a high risk for perioperative stroke or myocardial infarction after coronary bypass surgery. The aim of this study was to investigate the effect of combined carotid endarterectomy (CEA) and off-pump coronary artery bypass grafting (CABG) in patients with coexistent carotid and coronary artery diseases.

METHODSBetween January 2002 and December 2007, consecutive patients with coexistent carotid and coronary artery diseases underwent one-stage unilateral CEA and off-pump CABG in Heart Institute of Nanjing First Hospital Affiliated to Nanjing Medical University. Perioperative complications were assessed and follow-up was carried out.

RESULTSA total of 51 cases of isolated off-pump CABG and unilateral CEA, including 34 right and 17 left, were performed. The mean blocked time of carotid artery in CEA was (25.5 +/- 7.0) minutes. The mean number of distal grafts per patient was 3.30 +/- 0.45. The mean ventilation time, intensive care unit stay, and postoperative hospital stay was (11.3 +/- 5.4) hours, (2.1 +/- 0.9) days, and (12.5 +/- 6.1) days respectively. None of the patients had stroke or myocardial infarct. There was one perioperative death due to acute cardiac failure, resulting in an operative mortality of 1.96%. Follow-up was completed for 47 patients (92.16%) with a mean follow-up of (39.5 +/- 12.5) months. None of the patients manifested stroke, new angina or newly developed cardiac infarct. No late death occurred.

CONCLUSIONCombined CEA and off-pump CABG is a safe and effective procedure in selected patients with coexistent carotid and coronary artery diseases.

Aged ; Carotid Artery Diseases ; surgery ; Coronary Artery Bypass, Off-Pump ; adverse effects ; methods ; Coronary Artery Disease ; surgery ; Endarterectomy, Carotid ; adverse effects ; methods ; Female ; 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

OBJECTIVE: The aim of this study was to examine the incidence of ischemia during protected carotid artery stenting (CAS) as well as to compare the protective efficacy of the balloon and filter devices on diffusion-weighted MR imaging (DWI). MATERIALS AND METHODS: Seventy-one consecutive protected CAS procedures in 70 patients with a severe (> 70%) or symptomatic moderate (> 50%) carotid artery stenosis were examined. A balloon device (PercuSurge GuardWire) and a filter device (FilterWire EX/EZ, Emboshield) was used in 33 cases (CAS-B group) and 38 cases (CAS-F group) to prevent distal embolization, respectively. All the patients underwent DWI within seven days before and after the procedures. The number of new cerebral ischemic lesions on the post-procedural DWI were counted and divided into ipsilateral and contralateral lesions according to the relationship with the stenting side. RESULTS: New cerebral ischemic lesions were detected in 13 (39.4%) out of the 33 CAS-Bs and in 15 (39.5%) out of the 38 CAS-Fs. The mean number of total, ipsilateral and contralateral new cerebral ischemic lesion was 2.39, 1.67 and 0.73 in the CAS-B group and 2.11, 1.32 and 0.79 in the CAS-F group, respectively. No statistical differences were found between the two groups (p = 0.96, 0.74 and 0.65, respectively). The embolic complications encountered included two retinal infarctions and one hemiparesis in the CAS-B group (9.09%), and one retinal infarction, one hemiparesis and one ataxia in the CAS-F group (7.89%). There was a similar incidence of embolic complications in the two groups (p = 1.00). CONCLUSION: The type of distal protection device used such as a balloon and filter does not affect the incidence of cerebral embolization after protected CAS.
Adult ; Aged ; Aged, 80 and over ; *Balloon Occlusion ; Blood Vessel Prosthesis Implantation/*instrumentation ; Brain Ischemia/*pathology ; Carotid Stenosis/*surgery ; *Diffusion Magnetic Resonance Imaging ; Endarterectomy, Carotid/adverse effects/methods ; Female ; Humans ; Intracranial Embolism/prevention & control ; Male ; Middle Aged ; Paresis/etiology ; Retinal Artery Occlusion/etiology ; Severity of Illness Index ; *Stents