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Introduction: Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5 years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis. Methods: Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined. Results: We noted a statistically significant (P <.001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90 day mortality and combined neurological event and 90 day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P <.001), combined perioperative neurological ischemic event and 90 day mortality (aOR 2.13, 1.62-2.80, P <.001), long term mortality (HR 1.62, 1.12-2.29, P <.001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P =.007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA. Conclusions: Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy. [ABSTRACT FROM AUTHOR]

Objective: Several studies suggest that females have higher perioperative adverse events and decreased benefit from carotid artery revascularization with transfemoral carotid artery stenting and carotid endarterectomy (CEA) compared to males. However, there are limited data of sex-based outcomes for transcarotid artery revascularization (TCAR). Methods: A retrospective review of prospectively maintained system-wide TCAR databases was performed between December 2015-January 2022. Patients who underwent TCAR were stratified based on sex. Relevant demographics, medical conditions, anatomical characteristics, intra- and postoperative courses, and adverse events were captured. Results: 729 patients underwent TCAR, 486 (66.6%) male and 243 (33.3%) female. Males were more likely to be diagnosed with coronary artery disease (56.9% vs 47.7%, P<.01) and were active smokers (30.4% vs 21.4%, P <.01). Age, symptomatic status, BMI, hypertension, hyperlipidemia, diabetes mellitus, arrhythmia, chronic obstructive pulmonary disease, history of myocardial infarction, heart failure with reduced ejection fraction <30%, end-stage renal disease and Charlson Comorbidity Index were similar. In the perioperative period, there was no significant difference in reintervention rates (1.6% vs 1.2%, P =.75), cranial nerve palsy (.6% vs.4%, P >.99), ipsilateral stroke (1.9% vs 3.3%, P =.29), stent thrombosis (.4% vs.8%, P >.99), myocardial infarction (0% vs 0%, P >.99) and death (1.2% vs 1.2%, P >.99). In follow-up, no significant difference was found in reintervention, ipsilateral stroke, contralateral stroke, myocardial infarction, in-stent restenosis >50%, stent thrombosis, and death. Conclusions: Males and females did not have a statistically significant difference in outcomes when comparing ipsilateral stroke, in-stent thrombosis, conversion to CEA, and death after TCAR. However, our cohort comprised predominantly male patients and may conceal statistical significance as the females in our cohort did have a higher tendency toward developing complications. Future studies with a larger female cohort should be conducted to determine whether there is a true disparity of outcomes between the males and females undergoing TCAR. [ABSTRACT FROM AUTHOR]

An introduction is presented in which author discusses articles on topics including focuses on recurrent carotid stenosis rates after eversion carotid endarterectomy, after primary carotid angioplasty and stenting and after stenting for carotid restenosis following previous eCEA.

Objectives: To describe the frequency, factors associated with, and significance of surgical dissection maneuvers of the distal internal carotid artery (ICA) during carotid endarterectomy (CEA). Methods: In this retrospective analysis of prospectively collected information in patients undergoing CEA, we recorded information on demographics, risk factors and comorbidities, dissection maneuvers of the distal ICA, other operative variables and neurological outcome measures. Results: During the period July 2008 and February 2020 inclusive, 218 consecutive patients (180 males, median age 69.5 years) underwent 240 CEAs. In 117 (48.8%) of them, CEA was performed for a symptomatic stenosis. Dissection maneuvers of the distal ICA were required in 77 cases (32.1%), including division and ligation of the sternocleidomastoid vessels in 66 cases (27.5%), mobilization of the XII cranial nerve in 69 cases (28.7%, with concomitant transection of the superior root of the ansa cervicalis in 11 cases, 4.6%) and division of the posterior belly of the digastric muscle in 8 cases (3.3%). Styloid osteotomy was not required in any case. Smoking was the single predictive factor associated with the use of an adjunctive dissection maneuver (odds ratio 2.23, p = 0.009). The use of a patch was more common in smokers (16% vs 7.1% in non-smokers, odds ratio 2.48, p = 0.05). Perioperative stroke and/or death rate was 0%, not allowing testing for associations with maneuver performance. Two patients (0.8%) developed a transient ischemic attack and 4 patients (1.7%) a cranial nerve injury (CNI), including 2 patients with recurrent laryngeal nerve palsy, diagnosed on routine laryngoscopy during planning of a contralateral CEA. There was no association between CNI and dissection of the distal ICA using an operative adjunct (p = 0.60). Conclusions: Several surgical maneuvers are often required to accomplish dissection of the distal ICA beyond the point of atherosclerotic disease. When dictated by operative findings, such maneuvers are deemed safe. [ABSTRACT FROM AUTHOR]

An editorial is presented on the Carotid Revascularization Procedural Volume and Perioperative Outcomes. The article discusses that according to the 2018 European Society for Vascular Surgery (SVS) guidelines for the management of patients with carotid and vertebral artery stenosis; and 2016 systematic review reported 30-day death/stroke rates after both CAS and CEA that were published in large, contemporary administrative dataset registries.

The treatment of patients with symptomatic tandem lesions of their carotid artery is challenging. One solution is carotid endarterectomy with retrograde ipsilateral proximal endovascular intervention, but it is associated with a higher postoperative risk of stroke. Unfortunately, symptomatic patients with tandem lesions often present with stenotic, calcified supra-aortic arch vessels and require multiple modalities to adequately revascularize including staged approaches or hybrid procedures. Herein, we report the successful treatment of a symptomatic 76-year-old female with a calcific severe stenosis of her innominate artery treated by a prosthetic bypass graft from her ascending aorta to proximal common carotid artery, interval ligation, and use of TransCarotid artery revascularization with reverse-flow to treat her proximal internal carotid artery stenosis via this bypass graft. [ABSTRACT FROM AUTHOR]

Objectives: Carotid artery endarterectomy (CEA) and carotid artery stenting (CAS) are 2 effective treatment options for carotid revascularization and stroke prevention. The long-term outcomes of Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) reported similar stroke and death rate between the 2 procedures. This study presents the short- and long-term outcomes of CEA and CAS of all risk patients performed by a single vascular surgeon in a real-world setting. Methods: We retrospectively reviewed all patients who underwent CEA and CAS from September 2005 to June 2017 at our institute. Student t test, χ2, and Fisher exact tests were used to compare patient's characteristics. Multivariate logistic, cox regression models and survival analysis were used to compare postoperative and long-term outcomes between the 2 groups. Results: Over 2000 patients were evaluated for carotid artery stenosis during the study period, and 313 revascularization procedures were performed (CEA: 47%, CAS: 53%). Patients' age (Mean [95% confidence interval, CI] 68.8 [67.2-70.4] vs 69.7 [68.2-71.3], P = .40) was similar between CEA and CAS. Patients who underwent CAS had significantly higher comorbidities (chronic obstructive pulmonary disease [COPD], chronic heart failure [CHF], hyperlipidemia, and prior ipsilateral intervention, all P < .05). No difference was found in 30-day complications after CEA versus CAS including stroke (2.0% vs 1.2%), myocardial infarction (MI; 0.7% vs 1.2%), death (0% vs 1.2%) as well as combined major adverse events (stroke/death/MI; 2.7% vs 3.0%; all P > .05). Overall 7-year survival, stroke-free survival and restenosis-free survival were similar between the 2 groups (P > .5). Significant predictors of mortality were diabetes (hazard ratio, HR [95% CI]: 2.41 [1.15-5.08]), chronic kidney disease (HR [95% CI]: 4.89 [1.97-12.13]), and COPD (HR [95% CI]: 3.31 [1.43-7.71]; all P values <.05). Statin use was protective with 71% reduction in risk of mortality (HR [95% CI]: 0.29 [0.12-0.67], P = .004). Conclusion: Our experience showed comparable short- and long-term outcomes of CAS and CEA performed for carotid artery stenosis by vascular surgeon. There was no difference between single institutional long-term outcomes and CREST outcomes following CEA and CAS. [ABSTRACT FROM AUTHOR]

Background: Silent brain infarcts are common in patients at increased risk of stroke and are associated with a poor prognosis. In patients with asymptomatic carotid stenosis, similar adverse associations were claimed, but the impact of previous infarction or symptoms on the beneficial effects of carotid endarterectomy is not clear. Our aim was to evaluate the impact of prior cerebral infarction in patients enrolled in the Asymptomatic Carotid Surgery Trial, a large trial with 10-year follow-up in which participants whose carotid stenosis had not caused symptoms for at least six months were randomly allocated either immediate or deferred carotid endarterectomy. Methods: The first Asymptomatic Carotid Surgery Trial included 3120 patients. Of these, 2333 patients with baseline brain imaging were identified and divided into two groups irrespective of treatment assignment, 1331 with evidence of previous cerebral infarction, defined as a history of ischemic stroke or transient ischemic attack>6 months prior to randomization or radiological evidence of an asymptomatic infarct (group 1) and 1002 with normal imaging and no prior stroke or transient ischemic attack (group 2). Stroke and vascular deaths were compared during follow-up, and the impact of carotid endarterectomy was observed in both groups. Results: Baseline characteristics of patients with and without baseline brain imaging were broadly similar. Of those included in the present report, male gender and hypertension were more common in group 1, while mean ipsilateral stenosis was slightly greater in group 2. At 10 years follow-up, stroke was more common among participants with cerebral infarction before randomization (absolute risk increase 5.8% (1.8-9.8), p=0.004), and the risk of stroke and vascular death was also higher in this group (absolute risk increase 6.9% (1.9-12.0), p=0.007). On multivariate analysis, prior cerebral infarction was associated with a greater risk of stroke (hazard ratio=1.51, 95% confidence interval: 1.17-1.95, p=0.002) and of stroke or other vascular death (hazard ratio=1.30, 95% confidence interval: 1.11-1.52, p=0.001). At 10 years, greater absolute benefits from immediate carotid endarterectomy were seen in those patients with prior cerebral infarction (6.7% strokes immediate carotid endarterectomy vs. 14.7% delayed carotid endarterectomy; hazard ratio 0.47 (0.34-0.65), p=0.003), compared to those lower risk patients without prior cerebral infarction (6.0% vs. 9.9%, respectively; hazard ratio 0.61 (0.39-0.94), p=0.005), though it must be emphasized that the first Asymptomatic Carotid Surgery Trial was not designed to test this retrospective and non-randomized comparison. Conclusions: Asymptomatic carotid stenosis patients with prior cerebral infarction have a higher stroke risk during long-term follow-up than those without prior cerebral infarction. Evidence of prior ischemic events might help identify patients in whom carotid intervention is particularly beneficial. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate a series of patients treated electively with carotid endarterectomy (CEA), transfemoral carotid artery stenting with distal filter protection (CASdp), and transcervical carotid stenting with dynamic flow reversal (CASfr) monitored continuously with transcranial Doppler (TCD) during the procedure to detect intraoperative embolization rates.Methods: Thirty-four patients (mean age 67.6 years; 24 men) with significant carotid stenosis underwent successful TCD monitoring during the revascularization procedure (10 CEA, 8 CASdp, and 16 CASfr). Ipsilateral microembolic signals were segregated into 3 phases: preprotection (until internal carotid artery cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection (until clamp/shunt was removed, filter retrieved, or antegrade flow reestablished), and postprotection (after clamp/shunt or filter removal or restoration of normal flow).Results: CASdp showed higher embolization rates than CEA or CASfr in the preprotection phase (p<0.001). In the protection phase, CASdp was again associated with more embolization compared with CEA and CASfr (p<0.001). In the postprotection phase, no differences between the revascularization therapies were observed. CASfr and CEA did not show significant differences in intraoperative embolization during any of the phases.Conclusion: TCD recordings demonstrated a significant reduction in embolization to the brain during transcervical carotid artery stent placement with the use of dynamic flow reversal compared to transfemoral CAS using distal filters. No significant differences in microembolization could be detected between CEA and CASfr. The observed lower embolization rates and lack of adverse events suggest that transcervical CAS with dynamic flow reversal is a promising technique and may be the preferred method when performing CAS. [ABSTRACT FROM AUTHOR]

Cognitive and emotional outcomes after carotid endarterectomy (CEA) and carotid artery stenting with embolic protection device (CAS + EPD) are not clear. Patients were entered prospectively into a United States Food and Drug Administration-approved single-center physician-sponsored investigational device exemption between 2004 and 2010 and received either CEA or CAS + EPD. Patients underwent cognitive testing preprocedure and at 6, 12, and 60 months postprocedure. Cognitive domains assessed included attention, memory, executive, motor function, visual spatial functioning, language, and processing speed. Beck Depression and anxiety scales were also compared. There were a total of 38 patients that met conventional indications for carotid surgery (symptomatic with ≥50% stenosis or asymptomatic with ≥70% stenosis)-12 patients underwent CEA, whereas 26 patients underwent CAS + EPD. Both CEA and CAS + EPD patients showed postprocedure improvement in memory and executive function. No differences were seen at follow-up in regards to emotional dysfunction (depression and anxiety), attention, visual spatial functioning, language, motor function, and processing speed. Only two patients underwent neuropsychiatric testing at 60 months-these CAS + EPD patients showed sustained improvement in memory, visual spatial, and executive functions. In conclusion, cognitive and emotional outcomes were similar between CEA and CAS + EPD patients. [ABSTRACT FROM AUTHOR]

Carotid artery stenting (CAS) was presented by carotid revascularization endarterectomy versus stenting trial as a minimally invasive approach with less risk of postoperative myocardial infarction (MI) when compared to carotid endarterectomy (CEA). Our study aimed to compare the postoperative MI rate for CAS with CEA under general anesthesia (GA) and local anesthesia (LA). A retrospective study was conducted at our institution comparing CAS with CEA under LA and CEA under GA. Thirty-day postoperative MI and strokes were evaluated for the different subgroups. A total of 1127 procedures were included in the analysis: 421 CEAs under GA, 611 CEAs under LA, and 95 CAS. No significant difference in postoperative MI was encountered between CAS and CEA under LA (0.2% vs 1.1%, P = .25). The CEA under GA was found to have a statistically significant higher risk of MI compared to LA (1.2% vs 0.2%, P = .044). Our evidence suggests that CEA under LA does not have an increased risk of MI compared to CAS. [ABSTRACT FROM PUBLISHER]

The Fogarty catheter represents a major advancement for the effective removal of distal thrombi during vascular surgery, including carotid endarterectomy (CEA). One complication related to its use is injury to the cavernous carotid artery with development of a carotid cavernous fistula (CCF). Including a recent case at our institution, 21 patients with a Fogarty-related CCF have been reported since 1967. We performed a detailed review of all Fogarty-related CCFs during the treatment of carotid occlusive disease. We suggest a management algorithm for post-CEA acute carotid occlusion. [ABSTRACT FROM PUBLISHER]

We investigated the role of low-dose clonidine intravenous (IV) premedication in arterial pressure variation during and after carotid endarterectomy (CEA). A total of 84 patients, American Society of Anesthesiologists (ASA) II-III, scheduled for elective CEA under general anesthesia participated in this study. The patients were divided into 2 groups: group P (n = 42) and group C (n = 42) and received N/S 0.9% (placebo) or clonidine 1 μg/kg IV, respectively, 15 minutes before induction of anesthesia. Recovery times, number of patients needed to be treated for circulatory events (hypertension, hypotension, and bradycardia), number of circulatory events per patient, and consumption of vasoactive drugs (nitroglycerine, phenylphrine, and atropine) intraoperatively and the first 6 hours postoperatively were recorded. Significantly less hypertensive episodes were observed intraoperatively, but more hypotensive episodes were observed postoperatively in patients receiving clonidine. Intravenous premedication with low-dose clonidine (1 μg/kg) seems to be effective in preventing hypertensive episodes during CEA under general anesthesia but seems to increase the incidence of hypotension postoperatively. [ABSTRACT FROM PUBLISHER]

The role of inflammation is well established in the pathogenesis of atherosclerosis and an increased level of circulating inflammatory markers may predict the future risk of atherosclerosis progression and plaque rupture. C-reactive protein (CRP) identification by hypersensitive methods (high-sensitivity CRP [hsCRP]) has become a clinical and laboratory inflammation marker. Carotid endarterectomy (CEA) is a well-established procedure for carotid stenosis treatment which can reduce stroke rate. Internal carotid artery (ICA) restenosis reduction may be prevented by the anti-inflammatory effect of statins. This review considers the recent findings on the presence of hsCRP and C3 complement concentration and inflammatory plaque composition as well as their effects on ICA restenosis rate, following eversion CEA with emphasis on human studies. [ABSTRACT FROM PUBLISHER]

Background and purpose Accumulating evidence suggests that carotid plaque vulnerability can be used as a determinant of ischemic stroke risk stratification and carotid intervention. Novelmarkers of high-risk carotidplaquein patients areneeded. Summary of review Advances in cellular and molecular pathophysiology, the demand for accurately predicting carotid risk, and choosing the optimal prevention strategy are stimulating great interest in the development of novel surrogate markers. Biomarkers in cardiovascular disease are expected to predict the natural history, clinical outcomes, and the efficacy of disease-modifying interventions. We aimed to review the literature regarding clinical data on novel serum biomarkers related to ischemic cerebrovascular events associated with carotid artery disease. We provide background information on the biomarkers related to all aspects of carotid disease: natural history, carotid intervention strategies for symptomatic and asymptomatic patients, perioperative risk prediction, and their therapeutic implications. Conclusion At present, heterogeneous data support evidence that biological markers can help existing practices to more accurately assess patients at risk for stroke. Randomized- controlled trials for carotid artery disease and carotid intervention, incorporating biomarkers, are needed. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM PUBLISHER]

Background: It remains controversial whether patients with concomitant carotid and coronary disease should undergo operative repair separately or in combination. Methods: Patients with documented cerebrovascular disease undergoing coronary artery bypass grafting (CABG) alone were matched by propensity scoring with patients undergoing combined carotid endarterectomy (CEA)/CABG procedures and compared for the occurrence of stroke, myocardial infarction (MI), and mortality. Results: Of the 4943 patients undergoing CABG, 908 had known cerebrovascular disease. Among these, 134 underwent concomitant CEA, and these were propensity matched with 134 patients undergoing CABG only. No differences were observed in the perioperative risks of stroke (4% vs 3%, odds ratio [OR] 1.5, 95% confidence interval [CI] 0.4-5.5), MI (0.7% vs 0.7%, not significant [NS]), or combined cardiovascular events (6% vs 10%, OR 0.5, 95% CI [0.2-1.3]), although mortality (1% vs 8%, OR 0.2, 95% CI [0.04-0.8] was higher with CABG only. Discussion: Addition of CEA to CABG did not significantly alter the risk of perioperative stroke relative to propensity-matched patients undergoing CABG alone. [ABSTRACT FROM PUBLISHER]

Introduction: Ambiguity in the literature concerning potential benefits of carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) necessitated a 5-year Delphi-type survey, gauging the changing views over this period of relevant experts undertaking carotid intervention. Methods: Delphi surveys performed in 2004 and 2009 involved 2 rounds of questions combined with feedback of results from the first round between them. The questionnaire was e-mailed to UK vascular surgeons, neurosurgeons, interventional radiologists, and cardiologists. Results: In 2004 and 2009, the second round response rates were 69% and 51%, respectively. Over 5 years, there was a statistically significant reduction in support for ‘‘general anesthesia risk’’ and ‘‘contralateral occlusion’’ as indications for CAS and views that CAS ‘‘increased patient satisfaction’’ and ‘‘decreased the length of hospital stay.’’ Concerning the impact of recent trials on the professionals’ treatment routines for symptomatic and asymptomatic patients with carotid disease, 65.8% and 76.3%, respectively, had not changed their overwhelming non-CAS routines, with 32.9% and 19.7% saying clinical trial results moved them toward CEA. Conclusions: A 2009 survey of vascular experts found no increase in preference for CAS as a treatment option for advanced carotid bifurcation atherosclerosis. This, in combination with the lack of change from and indeed move toward the ‘‘gold-standard’’ CEA, demonstrates a general decline in confidence with CAS. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM PUBLISHER]

Background: Increased carotid restenosis due to revascularization therapy is associated with insulin resistance. We hypothesize that glucose control using acarbose may attenuate intimal hyperplasia in rat carotid endarterectomy model of diet-induced insulin resistance. Methods: Rats were fed low-fat complex carbohydrate (control) or high-fat sucrose (insulin resistance) for 4 months. Three days preoperatively, some high-fat-sucrose rats were on acarbose, remainder of the rats received placebo. Rat carotids were assessed with duplex pre-and postoperatively. Acarbose and placebo continued for 2 weeks. Glucose, insulin, blood flow velocities and intimal hyperplasia were determined. Results: High-fat sucrose plus acarbose attenuated intimal hyperplasia. Postdrug high-fat sucrose glucose decreased. Blood flow velocities postoperatively elevated above baseline. High-fat sucrose increased blood flow velocities postoperatively, which was attenuated with acarbose. Conclusion: Glucose control by acarbose in rat carotid endarterectomy model of diet-induced insulin resistance resulted in attenuation of intimal hyperplasia. [ABSTRACT FROM AUTHOR]

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 ¼ .78). Perioperative myocardial infarction occurred in 2 patients (2.5%) in 2002 and 2 in 2003 (2.2%, P ¼ 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. [ABSTRACT FROM AUTHOR]

Neurological complications and mortality within 30 days following carotid endarterectomy (CEA) alone or with concomitant cardiac surgery/cardiopulmonary bypass (CPB) were assessed in patients with or without contralateral occlusion of the internal carotid artery (CO-ICA). Of 335 patients undergoing CEA, 173 underwent concomitant cardiac surgery with CPB. Group A consisted of 260 patients without CO-ICA and group B of 75 patients with CO-ICA. The neurological complications (peripheral nerve damage, transient ischemic attack [TIA], prolonged reversible ischemic neurological deficit [PRIND], and stroke) and the Rankin index within 24 hours and 30 days postoperatively were compared. Strokes within 24 hours were significantly increased (P = .006) in group B (11%) compared with A (3.1%); TIA and PRIND did not differ (P = .33). The overall neurological complications and in particular for peripheral neurological damage, TIA/PRIND, and stroke did not differ within the 30-day-period postsurgery. A significantly higher stroke rate within 24 hours postsurgery occurred in patients with CO-ICA. [ABSTRACT FROM AUTHOR]

Rationale Carotid endarterectomy (CEA) and medical therapy were shown superior to medical therapy alone for symptomatic (≥50%) and asymptomatic (≥60%) stenosis. Carotid angioplasty stenting (CAS) offers a less invasive alternative. Establishing safety, efficacy, and durability of CAS requires rigorous comparison with CEA in symptomatic and asymptomatic patients. Aims The objective is to compare the efficacy of CAS versus CEA in patients with symptomatic (≥50%) or asymptomatic (≥60%) extracranial carotid stenosis. Design The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) is a prospective, randomized, parallel, two-arm, multi-center trial with blinded endpoint adjudication. Primary endpoints are analyzed using standard time-to-event statistical modeling with adjustment for major baseline covariates. Primary analysis is on an intent-to-treat basis. Study Outcomes The primary outcome is the occurrence of any stroke, myocardial infarction, or death during a 30-day peri-procedural period, and ipsilateral stroke during follow-up of up to four years. Secondary outcomes include restenosis and health-related quality of life. [ABSTRACT FROM AUTHOR]

The article focuses on a study regarding carotid endarterectomy and transfemoral carotid artery stenting with distal filters and transcervical carotid artery stenting with dynamic flow reversal.

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. [ABSTRACT FROM AUTHOR]

The General Anesthesia vs. Local Anesthesia for Carotid Surgery (GALA) trial did not show a difference in 30-day postoperative stroke, myocardial infarction and death rates between patients undergoing carotid endarterectomy (CEA) under local vs. general anesthesia. The present article discusses some limitations of the GALA trial. Firstly, the expected stroke and death rates following CEA is so low, that it was unlikely that the GALA trial would show any significant difference between local and general anesthesia. Secondly, preoperative statin use was not recorded. Thirdly, intraoperative shunt usage rates (a possible parameter for the development of stroke) varied considerably between the 2 groups (43% vs. 14%, for general vs. local anesthesia, respectively; P < .0001), as well as between UK and non-UK surgeons who always (73.6% vs. 20.8%, respectively; P < .0001), never (4.2% vs. 26%, respectively; P < .0002), or selectively (22.2% vs. 53.2%, respectively; P < .0001) used a shunt. Furthermore, no information was provided regarding the type of shunts used; for example, a traumatic shunts may be associated with lower perioperative stroke rates. These limitations could influence the interpretation of the results of the GALA trial. Due to lack of differences between the 2 groups and the presence of the above limitations, it seems likely that this trial will have little effect on clinical practice. [ABSTRACT FROM AUTHOR]

Purpose: To present a complex case involving an infected carotid-carotid bypass graft that was successfully treated with a stent-graft and subsequent surgical removal of the infected graft. Case Report: A 75-year-old woman presented with persistent purulent drainage of an infected and exposed carotid-carotid prosthetic bypass graft. Wound cultures revealed methicillin-resistant Staphylococcus aureus. She was treated with appropriate intravenous antibiotic therapy without improvement in wound drainage. Because of her comorbid conditions, a decision was made to pursue endovascular revascularization of her left and right common carotid arteries (CCA), with subsequent surgical removal of the infected prosthetic graft. The patient underwent balloon angioplasty; a 7x18-mm Omnilink stent was deployed in the innominate artery and a 7x18-mm Herculink stent in the ostial left CCA. During the same procedure, the carotid-carotid bypass graft was excluded with deployment of an 8x5g-mm Viabahn stent-graft in the right CCA. Several days later, the infected and now thrombosed carotid-carotid bypass graft was surgically removed, and an area of adjacent muscle was used to patch the previously excluded connection of the bypass from the right CCA. A saphenous vein patch was used to repair the defect in the left CCA. Her postoperative course was uneventful. At 1 year, the clinical and duplex examinations revealed satisfactory wound healing and patent left and right CCAs. Conclusion: This case indicates that a combined endovascular and surgical approach may be a safe and effective option in the treatment of carotid-carotid bypass graft infection. [ABSTRACT FROM AUTHOR]

Purpose: To describe the results and efficacy of stent treatment in patients with carotid stenosis who had aborted carotid endarterectomy procedures due to the appearance of severe electroencephalographic (EEG) alterations. Methods: A retrospective study was conducted of 18 patients (11 men; mean age 72 years, range 62-84) with symptomatic high-grade carotid artery stenoses (≥70%) who experienced severe EEG alterations during carotid endarterectomy, causing the procedure to be aborted. Twelve patients had shown no hemodynamic alterations during preoperative transcranial Doppler evaluation after external compression of the common carotid artery; the remaining 6 could not be evaluated. The patients were referred for carotid artery stenting (CAS); 7 had contralateral internal carotid artery stenosis and 5 had contralateral occlusion. Endovascular intervention was carried out using standard techniques under filter protection. Follow-up was scheduled at 3, 6, and 12 months. Results: All patients were successfully treated without immediate complications. The EEG did not display any significant alterations during the endovascular procedure. Mean follow-up was 43 months. Magnetic resonance imaging at 6 months showed no signs of cerebral ischemia. Color Doppler ultrasound imaging documented normal stent patency in all patients. Conclusion: Patients with symptomatic severe carotid stenosis (≥70%) who are considered at risk due to the appearance of severe EEG alterations during surgical treatment may benefit from CAS with respect to both major and minor complications. Larger studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Purpose: To report the technique of carotid endarterectomy (CEA) combined with retrograde balloon angioplasty and stenting of proximal "tandem" lesions in the supra-aortic trunk. Technique: Intraoperative techniques in 34 patients with 23 left common carotid artery (CCA) and 11 innominate artery lesions included general anesthesia, low-dose dextran, prosthetic patching, selective shunting, 8-F sheath entry into the native CCA before the CEA, manual CCA sizing, and balloon-expandable stent placement after predilation. The technique has a high procedural success rate (97%) and appears durable. Over a mean 34-month follow-up, 2 >70% ostial CCA restenoses were found at 24 months. Conclusions: Intraoperative innominate or left CCA balloon angioplasty/stenting combined with carotid endarterectomy is safe, effective, and durable. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the pattern of catecholamine response in patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS). Methods: Adrenaline, noradrenaline, and renin levels were measured at 5 time points in 12 patients undergoing 13 CEAs (1 bilateral) and 13 patients undergoing unilateral CAS. Arterial blood samples were taken at the following time points: (1) after induction in CEA patients or 5 minutes following first contrast injection in CAS patients, (2) 5 minutes following ICA clamp release in surgical patients or deflation of the balloon in the CAS cohort, (3) 60 minutes following ICA clamp release in surgical patients or deflation of the balloon in the CAS cohort, and (4) 24 hours following the procedure. Intraoperative blood pressure and heart rate were recorded using radial arterial monitoring. Changes in adrenaline, noradrenaline, and renin levels are expressed as ratios versus baseline. Results: Patterns of adrenaline and noradrenaline release were significantly different in patients undergoing CAS and CEA, with much higher and more variable surges of adrenaline and noradrenaline occurring in CEA patients. Adrenaline and noradrenaline levels increased significantly over baseline following carotid artery clamping in patients undergoing CEA (noradrenaline ratio before clamping: 1.54±1.25, 24 hours after unclamping: 8.38±16.35 [p<0.001]; adrenaline ratio before clamping: 1.12±0.49, 60 minutes after unclamping: 17.59±19.14 [p<0.001]). Conversely, in patients undergoing CAS, catecholamine levels remained unchanged (noradrenaline ratio before dilation: 0.96±0.23, 24 hours after the procedure: 0.92±0.32 [p=NS]; adrenaline ratio before dilation: 0.83±0.33, 60 minutes after balloon deflation: 0.56±0.32 [p=NS]). Conclusions: CAS is associated with a significantly less marked catecholamine response than CEA, which may reflect down-regulation of the sympathetic nervous... [ABSTRACT FROM AUTHOR]

Few subjects are as enduring as the management of patients with combined carotid and cardiac disease. This paper reviews the available evidence supporting and refuting the role of carotid artery disease in the pathophysiology of stroke after coronary artery bypass grafting surgery and analyzes the results of systematic reviews of staged and synchronous carotid reconstruction. The available data suggest that only about 40% of strokes (at most) could be directly attributable to ipsilateral carotid artery disease. The rate of death and stroke following staged or synchronous carotid surgery in all published series was 6% and 9%, respectively. Unfortunately, natural history data are inadequate to determine whether a policy of prophylactic carotid endarterectomy reduces the risk of stroke after cardiac surgery. [ABSTRACT FROM AUTHOR]

Background The Carotid Revascularization Endarterectomy versus Stenting Trial ( CREST) received five years' funding ($21 112 866) from the National Institutes of Health to compare carotid stenting to surgery for stroke prevention in 2500 randomized participants at 40 sites. Aims Herein we evaluate the change in the CREST budget from a fixed to variable-cost model and recommend strategies for the financial management of large-scale clinical trials. Methods Projections of the original grant's fixed-cost model were compared to the actual costs of the revised variable-cost model. The original grant's fixed-cost budget included salaries, fringe benefits, and other direct and indirect costs. For the variable-cost model, the costs were actual payments to the clinical sites and core centers based upon actual trial enrollment. We compared annual direct and indirect costs and per-patient cost for both the fixed and variable models. Differences between clinical site and core center expenditures were also calculated. Results Using a variable-cost budget for clinical sites, funding was extended by no-cost extension from five to eight years. Randomizing sites tripled from 34 to 109. Of the 2500 targeted sample size, 138 (5·5%) were randomized during the first five years and 1387 (55·5%) during the no-cost extension. The actual per-patient costs of the variable model were 9% ($13 845) of the projected per-patient costs ($152 992) of the fixed model. Conclusions Performance-based budgets conserve funding, promote compliance, and allow for additional sites at modest additional cost. Costs of large-scale clinical trials can thus be reduced through effective management without compromising scientific integrity. [ABSTRACT FROM AUTHOR]

First-bite syndrome (FBS) is an infrequently encountered complication of parapharyngeal space surgery. Patients experience excruciating pain in the ipsiltateral parotid gland region at the first bite of each meal, which improves with subsequent mastication. This is thought to be due to parotid gland sympathetic denervation from surgery with resultant hypersensitivity to parasympathetic impulses. There is no consensus on best treatment for FBS although symptoms tend to improve with time. There are only 2 case reports linking carotid endarterectomy and FBS so far. We report the third case of FBS after carotid endarterectomy to raise awareness among vascular surgeons of the possibility of this complication. [ABSTRACT FROM PUBLISHER]

A recent trial attempted to investigate the role of locoregional anesthesia (LA) in carotid endarterectomy (CEA) compared with general anesthesia. The hypothesis regarding the advantage of LA is based on the intraprocedural neurologic evaluation and the early identification of neurologic deficit. The trial has not demonstrated the superiority of the rocoregional anesthesia versus general anesthesia and revealed equal results concerning the prevention of stroke. We analyze the reasons which explain why the hypothesis regarding the advantage of LA in CEA, in comparison to general anesthesia cannot be answered. [ABSTRACT FROM AUTHOR]

In this article the author discusses the significant role of endovascular treatment in managing severe carotid artery stenosis despite the lack of evidence for its efficacy and safety from clinical trials. He looks into the risks of carotid artery stenting (CAS) that uses a random effect model, the long-term efficacy of stenting, and periprocedural risks after stenting. He mentions the importance of performing the intervention safely, improving technique, and the patient selection information.

The article presents a case study of a 62-year-old Greek man who was referred for right carotid endarterectomy for symptomatic internal carotid artery stenosis. The patient has reportedly recovered from a mild right hemispheric infarct and has a moderate haemophilia. He underwent excision of the pseudotumour under continuous factor IX cover. It offers information on haemophilic pseudotumour and concludes that surgical excision is an effective treatment method.

The authors used claims data from Blue Cross and Blue Shield Michigan for a 3-year period to study usage of antihypertensive and antiplatelet agents, and statins, after carotid endarterectomy and compared it with results from the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Prescription of drugs and use for a sustained 1- year period was examined. They found the statin prescription rate was 70%, 66%, and 73% for the 3 study years and the average sustained statin use was 38%. Use of antiplatelet medications (5%) and angiotensin-converting enzyme inhibitors (19%) was also low. The authors concluded that statin use has increased after carotid endarterectomy compared with NASCET but remains below 40%. [ABSTRACT FROM AUTHOR]