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Background: Transcarotid artery revascularization (TCAR) is growing in popularity. Although major clinical end-points such as stroke rate and mortality are well-known, patient reported outcomes such as pain, and length of stay are among the purported benefits that are as yet untested. We sought to determine if there are differences in pain and other clinical outcomes when comparing carotid endarterectomy (CEA) and TCAR., Methods: We performed a retrospective review of 326 patients undergoing TCAR (n = 50) or CEA (n = 276) from 2019-2023. Primary outcomes of interest were maximum pain numeric rating scales (NRS) reported in the post-anesthesia care unit (PACU) and on postoperative days (POD) zero and 1, and oral morphine milligram equivalents (OMMEs) received intraoperatively through POD1. Secondary outcomes included length of stay (LOS), complications, and 30-day emergency department (ED) returns/readmissions., Results: Fifty TCAR and 150 CEA patients were included in the propensity score matched cohorts. TCAR patients reported lower pain-NRS in PACU ( P < .001) and on POD0 ( P = .002), but similar pain scores on POD1 ( P = .112). Postoperatively, TCAR patients were less likely to receive opioids (52% vs 75.3%, P = .003) and received less OMME from PACU through POD1 (12.8 ± 16.2 vs 23.2 ± 27.2, P = .001). After adjusting for age, sex, BMI, prior chronic opioid use, and prior carotid surgery, TCAR patients were approximately 70% less likely to receive post-operative opioids. No significant differences in LOS, 30-day ED returns/readmissions, or complications were observed between groups., Conclusions: Compared with CEA, patients undergoing TCAR reported lower pain scores and consumed fewer narcotics overall. However, the absolute difference was modest, and pain scores were low in both cohorts. Differences in pain and post-operative narcotic use may be of less importance when deciding between TCAR and CEA. Total non-opioid protocols may be feasible in both approaches., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Both true and false extracranial carotid artery aneurysms (ECAA) are a potential source of morbidity and mortality. While ECAA have historically been treated surgically, endovascular reconstruction with stenting is an emerging treatment option. The aim of our study was to report clinical/radiologic outcomes following endovascular repair of ECAAs., Methods: A comprehensive systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines., Results: A total of 68 case reports and case series, comprising 162 patients, were included. Most patients presented with at least one symptom or sign related to the ECAA (89.5%; N = 145/162). In 42.6% (N = 69/162) and 46.3% (N = 75/162) of the cases polytetrafluoroethylene covered and uncovered stents were deployed respectively. Immediate post-procedural imaging demonstrated complete aneurysm exclusion in 86.4% (N = 140/162) of the cases and minimal filling of the aneurysm sack in 10.5% (N = 17/162) of all cases. Perioperative adverse event rates were 3.1% for stroke, 1.2% for transient ischemic attack (TIA) and 4.3% for mortality. During a mean follow-up of 21.8months, there were additionally observed one stroke, two TIAs and three deaths. Overall 88.6 % of the patients (N = 117/132) remained asymptomatic, partially recovered or at least did not suffer from new neurologic deficits during follow up, with no signs of stenosis or occlusion of the carotid artery., Conclusions: Endovascular stenting for the treatment of ECAAs is feasible with acceptable short- and long-term clinical and radiologic outcomes. Prospective real-world studies are needed to further validate the safety and the long-term patency of endovascular repair.

Background: Race has been associated with inferior outcomes after multiple procedures, but the association of socioeconomic status with procedures for cerebrovascular disease is not well established., Materials and Methods: Elective carotid artery stenting (CAS) and carotid endarterectomy (CEA) procedures were identified in the National Inpatient Sample, 2012 to 2014. Median household income was estimated from patient ZIP codes. Chi-square and multivariable logistic regression analysis evaluated outcomes, accounting for age, race, gender, comorbidities, procedure, income, insurance, and hospital characteristics., Results: We identified 234 825 carotid procedures (205 835 CEA and 28 990 CAS). Blacks and Hispanics were more likely to be among the lowest quartile income patients (LQIPs) compared to whites (53.5% and 38.7% vs 27.0%, respectively; P < .0002). Compared to highest income quartile patients, LQIP had lower rates of private insurance (16.3% vs 22.0%) and higher Medicaid use (4.7% vs 2.0%; all P < .0002). Lowest quartile income patients were more likely to receive CAS (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.27-1.37), as were blacks and Hispanics (OR = 1.09, 95% CI: 1.02-1.26; OR = 1.31, 95% CI: 1.24-1.40, respectively). In multivariable regression, postoperative stroke was associated with LQIP, black race, and Hispanic ethnicity (OR = 1.16, 95% CI: 1.06-1.28; OR = 1.52, 95% CI: 1.33-1.73; OR = 1.43, 95% CI: 1.24-1.64, respectively). Subgroup analysis demonstrated that whites also had higher odds of stroke in the lower income quartile (OR = 1.2, 95% CI: 1.1-1.4). Mortality was associated with LQIP (OR = 1.6, 95% CI: 1.2-2.1), black race (OR = 1.8, 95% CI: 1.4-2.5), and CAS (OR = 1.3, 95% CI: 1.1-1.6). Length of stay in the lowest income quartile was longer than in patients with the highest income ( P < .0001)., Conclusions: Race was associated with increased hospital mortality, postoperative stroke, and overall complications after carotid procedures. Lower income was significantly associated with increased stroke and mortality irrespective of race. Disparate utilization and outcomes for carotid procedures are multifactorial. Efforts to reduce disparities will need to focus on race and other socioeconomic factors.

Objectives: The Model of End-Stage Liver Disease (MELD) score has been traditionally utilized to prioritize for liver transplantation; however, recent literature has shown its value in predicting surgical outcomes for patients with hepatic dysfunction. The benefit of carotid endarterectomy in asymptomatic patients is dependent on low perioperative morbidity. Our objective was to use MELD score to predict outcomes in asymptomatic patients undergoing carotid endarterectomy., Methods: Patients undergoing carotid endarterectomy were identified in the National Surgical Quality Improvement Program data sets from 2005 to 2012. The Model of End-Stage Liver Disease score was calculated using serum bilirubin, creatinine, and the international normalized ratio (INR). Patients were grouped into low (<9), moderate (9-14), and high (15+) MELD classifications. The effect of the MELD score on postoperative morbidity and mortality was assessed by multivariable logistic and gamma regressions and propensity matching., Results: There were 7966 patients with asymptomatic carotid endarterectomy identified. The majority 5556 (70%) had a low MELD score, 1952 (25%) had a moderate MELD score, and 458 (5%) had a high MELD score. High MELD score was independently predictive of postoperative death, increased length of stay, need for transfusion, pulmonary complications, and a statistical trend toward increased cardiac arrest/myocardial infarction. The Model of End-Stage Liver Disease score did not affect postoperative stroke, wound complications, or operative time., Conclusion: High MELD score places asymptomatic patients undergoing carotid endarterectomy at a higher risk of adverse outcomes in the 30 days following surgery. This provides further empirical evidence for risk stratification when considering treatment for these patients. Outcomes of medical management or carotid stenting should be investigated in high-risk patients., (© The Author(s) 2016.)

A pilot randomized controlled trial that evaluated the effect of remote ischemic preconditioning (RIPC) on clinical outcomes following major vascular surgery was performed. Eligible patients were those scheduled to undergo open abdominal aortic aneurysm repair, endovascular aortic aneurysm repair, carotid endarterectomy, and lower limb revascularization procedures. Patients were randomized to RIPC or to control groups. The primary outcome was a composite clinical end point comprising any of cardiovascular death, myocardial infarction, new-onset arrhythmia, cardiac arrest, congestive cardiac failure, cerebrovascular accident, renal failure requiring renal replacement therapy, mesenteric ischemia, and urgent cardiac revascularization. Secondary outcomes were components of the primary outcome and myocardial injury as assessed by serum troponin values. The primary outcome occurred in 19 (19.2%) of 99 controls and 14 (14.1%) of 99 RIPC group patients (P = .446). There were no significant differences in secondary outcomes. Our trial generated data that will guide future trials. Further trials are urgently needed., (© The Author(s) 2015.)

Objective: Carotid angioplasty and stenting (CAS) has challenged carotid endarterectomy (CEA) as the therapy of choice for carotid disease. This meta-analysis aims at summarizing the most current body of evidence., Methods: All prospective, controlled clinical trials comparing CEA versus CAS were included. The outcome measures of interest were relative risk (RR) of 30-day stroke, 30-day stroke/death, long-term risk of stroke, and risk of restenosis., Results: The RR of 30-day stroke for CAS was 1.6 times that of CEA (RR 1.6; 95%CI 1.2-2.0, P = .001). The 30-day RR of stroke/death was 1.5 times higher for CAS (RR 1.5; 95%CI 1.1-2.1, P = .008). There was a higher risk of long-term stroke (RR 1.2; 95%CI 1.0-1.5, P = .043). The risk of restenosis was twice for CAS (RR 1.8; 95%CI 1.1-3.1, P = .04)., Conclusion: The 30-day RR of stroke, stroke/death, long-term risk of stroke, and risk of restenosis are consistently higher for carotid artery stenting (CAS).

Purpose: The aim of the study was to compare the outcome after carotid endarterectomy (CEA) in patients with and without diabetes mellitus., Methods: We prospectively recorded the data from patients who underwent CEA. A patient was considered diabetic when he reported the use of antidiabetic medication. De novo diagnosis of diabetes was defined as the first demonstration of a fasting glucose serum concentration >126 mg/dL or >200 mg/dL after glucose load. An early adverse outcome was defined as the occurrence of ipsilateral minor or major stroke and/or death during the 30-day postoperative period., Results: The stroke and death rate was significantly higher in diabetic patients (n = 380) compared to the controls (n = 971; 4.5% versus 1.5%, P = .002). Multivariate analysis showed a significant association between the presence of diabetes and 30-day stroke and death rate (OR 2.94, CI 1.46-5.97, P = .003)., Conclusions: Diabetic patients are at greater risk for perioperative stroke and death.

Objectives: To evaluate the transition process from conventional carotid endarterectomy (cCEA) to eversion carotid endarterectomy (eCEA)., Methods: Patients operated with carotid endarterectomy (CEA; 164 patients, 171 CEA) in 2002-2003 were retrospectively included., Results: In 2002, cCEA was applied in 64 (80%) and eCEA in 16 (20%) patients. There was an inversion on the preponderant surgical technique in 2003 (cCEA in 34 patients [37%] and eCEA in 57 patients [63%]). Perioperative stroke or death occurred in 3 patients (3.8%) in 2002 and 5 (5.5%) in 2003 (P = .78). Perioperative myocardial infarction occurred in 2 patients (2.5%) in 2002 and 2 in 2003 (2.2%, P = 1.00). Median follow-up was 83 (79-86) and 70 (67-74) months for the 2002 and 2003 cohorts, respectively, and there were no differences in survival or ipsilateral stroke between the groups., Conclusions: The transition from cCEA to eCEA is possible without significant changes in morbidity and mortality perioperatively and during follow-up.

Background: Pseudoaneurysm (PA) after carotid endarterectomy (CEA) is a rare complication with incidence less than 1%. There is a potential for rupture, embolization, thrombosis or compression of cranial nerves., Objective: We reviewed our experience and compare it to the literature to raise awareness of this rare though serious condition. It is crucial to treat these patients early to avoid the hazardous consequences., Methods: A review of the case records of patients who had CEA at University Hospital Birmingham (UHB) NHS Foundation Trust from 1990-2007, was undertaken. Information of patients including their aetiology, presenting features, treatment and results was collected. The English-language literature was searched using PubMed database for post CEA pseudoaneurysm., Results: Five patients developed post CEA PA. This represents 0.4% of the 1200 CEA performed at our hospital in the last 18 years. The timing of their presentation varied from three days to eight months after the original operation. All had patch reconstruction after CEA. Patches were intact at exploration of the PAs. There was one death and one stroke. The literature revealed 154 carotid PAs after CEA and two cases following carotid stenting 52 of these cases had infected PA. Patients with synthetic patches have the least incidence of infection. More than 80% had open surgery and 9% had endovascular repair., Conclusion: Post CEA surveillance is necessary to detect patients with PA early. Factors that favour infection must be avoided. Endovascular repair of carotid PA should be encouraged in specialised centres.

The purpose of this study was to review experience with carotid artery surgery based on findings obtained solely from duplex scanning with special regard to unexpected findings during surgery and the early outcome. From January 1993 through December 1999, 271 consecutive patients underwent 287 carotid endarterectomies (CEAs), 229 (80%) of which were performed solely based on duplex scan findings. During the study period 5,932 carotid artery duplex scans were performed in 4,466 patients. Of 589 patients with internal carotid artery (ICA) stenosis 70%, 246 underwent CEA compared to 25 of 156 with 50-69% ICA stenosis. The indications for CEA were transient ischemic attack (TIA) in 88 (30.7%), amaurosis fugax in 60 (20.9%), previous stroke in 91 (31.7%) and asymptomatic disease in 48 (16.7%) cases. There were no statistically significant differences between the groups operated on with and without preoperative angiography with respect to the indications for surgery, associated risk factors, or the degree of stenosis on the contralateral side. In patients undergoing surgery without angiography, there were no unexpected findings that influenced the performance of surgery, in all except 1. There were no significant differences in perioperative morbidity and mortality in patients undergoing surgery with and without conventional angiography. The combined mortality and major stroke rates were 3.4% and 2.2%, respectively. It is concluded that CEA can safely be performed without preoperative angiography in cases with conclusive duplex scan findings.