Safety of Shunting Strategies During Carotid Endarterectomy: A Vascular Quality Initiative Data Analysis.

OBJECTIVE: This study aimed to evaluate in hospital outcomes after carotid endarterectomy (CEA) according to shunt usage, particularly in patients with contralateral carotid occlusion (CCO) or recent stroke. Data from CEAs registered in the Vascular Quality Initiative database between 2012 and 2020 were analysed, excluding surgeons with < 10 CEAs registered in the database, concomitant procedures, re-interventions, and incomplete data. METHODS: Based on their rate of shunt use, participating surgeons were divided in three groups: non-shunters (< 5%), selective shunters (5 - 95%), and routine shunters (> 95%). Primary outcomes of in hospital stroke, death, and stroke and death rate (SDR) were analysed in symptomatic and asymptomatic patients. RESULTS: A total of 113 202 patients met the study criteria, of whom 31 147 were symptomatic and 82 055 were asymptomatic. Of the 1 645 surgeons included, 12.1% were non-shunters, 63.6% were selective shunters, and 24.3% were routine shunters, with 10 557, 71 160, and 31 579 procedures in each group, respectively. In the univariable analysis, in hospital stroke (2.0% vs. 1.9% vs. 1.6%; p = .17), death (0.5% vs. 0.4% vs. 0.4%; p = .71), and SDR (2.2% vs. 2.1% vs. 1.8%; p = .23) were not statistically significantly different among the three groups in the symptomatic cohort. The asymptomatic cohort also did not show a statistically significant difference for in hospital stroke (0.9% vs. 1.0% vs. 0.9%; p = .55), death (0.2% vs. 0.2% vs. 0.2%; p = .64), and SDR (1.0% vs. 1.1% vs. 1.0%; p = .43). The multivariable model did not show a statistically significant difference for the primary outcomes between the three shunting cohorts. On subgroup analysis, the SDRs were not statistically significantly different for patients with CCO (3.3% vs. 2.5% vs. 2.4%; p = .64) and those presenting with a recent stroke (2.9% vs. 3.4% vs. 3.1%; p = .60). CONCLUSION: No statistically significant differences were found between three shunting strategies for in hospital SDR, including in patients with CCO or recent stroke.

Endovascular treatment of an iatrogenic right subclavian artery pseudoaneurysm associated with an arteriovenous fistula.

This report describes the case of a frail 36-year-old patient who underwent an endovascular treatment of a right subclavian artery pseudoaneurysm (SAP) associated with an arteriovenous fistula secondary to a traumatic central venous catheter insertion. The deployment of a covered stent from the innominate to the right common carotid artery combined with coiling of the SAP and the internal mammary artery was performed. Two additional covered stents were deployed from the vertebral artery to the distal subclavian artery to preserve right upper extremity circulation. This case highlights the feasibility of an endovascular treatment of a complex SAP in a candidate unsuitable for open surgery.