Viewing Readiness-for-Residency through Binoculars: Mapping Competency-Based Assessments to the AAMC's 13 Core Entrustable Professional Activities (EPAs).

Construct: The construct being assessed is readiness-for-residency of graduating medical students, as measured through two assessment frameworks. Background: Readiness-for-residency of near-graduate medical students should be but is not consistently assessed. To address this, the Association of American Medical Colleges (AAMC), in 2014, identified and described 13 core Entrustable Professional Activities (EPAs), which are tasks that all residents should be able to perform unsupervised upon entering residency. However, the AAMC did not initially provide measurement guidelines or propose standardized assessments. We designed Night-onCall (NOC), an immersive simulation for our near-graduating medical students to assess and address their readiness-for-residency, framed around tasks suggested by the AAMC's core EPAs. In adopting this EPA assessment framework, we began by building upon an established program of competency-based clinical skills assessments, repurposing competency-based checklists to measure components of the EPAs where possible, and designing new checklists, when necessary. This resulted in a blended suite of 14 checklists, which theoretically provide substantive assessment of all 13 core EPAs. In this paper, we describe the consensus-based mapping process conducted to ensure we understood the relationship between competency and EPA-based assessment lenses and could therefore report meaningful feedback on both to transitioning students in the NOC exercise. Approach: Between January-November 2017, five clinician and two non-clinician health professions educators at NYU Grossman School of Medicine conducted a rigorous consensus-based mapping process, which included each rater mapping each of the 310 NOC competency-based checklist items to lists of entrustable behaviors expected of learners according to the AAMC 13 core EPAs. Findings: All EPAs were captured to varying degrees by the 14 NOC checklists (overall Intraclass Correlation Coefficient (ICC) = 0.77). Consensus meetings resolved discrepancies and improved ICC values for three (EPA-9, EPA-10, EPA-12) of the four EPAs that initially showed poor reliability. Conclusions: Findings suggest that with some limitations (e.g., EPA-7 "form clinical questions/retrieve evidence") established competency-based assessments can be repurposed to measure readiness-for-residency through an EPA lens and both can be reported to learners and faculty.

Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement.

OBJECTIVES: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. MATERIALS AND METHODS: A literature review was performed with a focus on data from recent studies. RESULTS: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. CONCLUSIONS: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.

Modifiable risk factor burden and the prevalence of peripheral artery disease in different vascular territories.

BACKGROUND: The precise relationship between risk factor burden and prevalence of peripheral artery disease (PAD) in different vascular territories (PAD, carotid artery stenosis [CAS], and abdominal aortic aneurysms [AAAs]) is unclear. METHODS: We investigated the association of modifiable risk factors (hypertension, hypercholesterolemia, smoking, diabetes, and sedentary lifestyle) with any and type-specific peripheral vascular disease (PVD) among 3.3 million patients in the U.S., aged 40 to 99, who underwent screening bilateral ankle brachial indices, carotid duplex ultrasound, and abdominal aortic ultrasound in the Life Line Screening program between 2004 and 2008. Multivariate logistic regression analysis was used to estimate the odds of disease in different risk factor categories. Population-attributable risk was calculated to estimate the proportion of disease that could be potentially ascribed to modifiable risk factors. RESULTS: Among 3,319,993 participants, prevalence of any PVD was 7.51% (95% confidence interval [CI], 7.50%-7.53%). PAD was present in 3.56% (95% CI, 3.54%-3.58%), CAS in 3.94% (95% CI, 3.92%-3.96%), and AAAs in 0.88% (95% CI, 0.86%-0.89%). The multivariate-adjusted prevalence with the presence of 0, 1, 2, 3, 4, and 5 modifiable risk factors was 2.76, 4.63, 7.12, 10.73, 16.00, and 22.08 (P < .0001 for trend) for any PVD; 1.18, 2.09, 3.28, 5.14, 8.32, and 12.43 (P < .0001 for trend) for PAD; 1.41, 2.36, 3.72, 5.73, 8.48, and 11.58 (P < .0001 for trend) for CAS; and 0.31, 0.54, 0.85, 1.28, 1.82, and 2.39 (P < .0001 for trend) for AAAs, respectively. These associations were similar for men and women. For every additional modifiable risk factor that was present, the multivariate-adjusted odds of having vascular disease increased significantly (any PVD [odds ratio (OR), 1.58; 95% CI, 1.58-1.59]; PAD [OR, 1.62; 95% CI, 1.62-1.63]; CAS [OR, 1.57; 95% CI, 1.56-1.57]; and AAA [OR, 1.51; 95% CI, 1.50-1.53]). CONCLUSIONS: This very large contemporary database demonstrates that risk factor burden is associated with an increased prevalence of PVD, and there is a graded association between the number of risk factors present and the prevalence of PAD, CAS, and AAAs.

The prevalence of carotid artery stenosis varies significantly by race.

OBJECTIVE: Certain races are known to be at increased risk for stroke, and the prevalence of carotid artery stenosis (CAS) is thought to vary by race. The goal of this report was to study the prevalence of CAS in different races by analyzing a population of subjects who underwent vascular screening examinations. METHODS: The study data were provided by Life Line Screening. The cohort consists of self-referred individuals who paid for vascular screening tests. Subjects <40 and >100 years of age and those who reported a prior stroke or carotid artery intervention were excluded. Of the remaining 3,291,382 subjects, 3.7% did not self-identify a race. CAS was defined as stenosis in either internal carotid artery ≥50% by duplex ultrasound velocity criteria. RESULTS: The 3,291,382 subjects available for analysis consisted of Caucasian (2,845,936 [90%]), African American (97,502 [3.1%]), Hispanic (75,240 [2.4%]), Asian (60,982 [1.9%]), and Native American (87,757 [2.8%]) individuals. The prevalence of CAS was 3.4% in females and 4.2% in males (P ≤ .001). Controlling for gender and age, there was marked variation in the prevalence of CAS (P < .001) by race. Native American subjects had the highest prevalence of CAS across all age categories and in both sexes. Caucasian subjects had the second highest prevalence of CAS across most age decades and in both sexes. Among males, African American individuals had the lowest prevalence of CAS in nearly all age categories. In contrast to males, Asian females had the lowest prevalence of CAS compared with females of other races in most age groups. Multivariate analysis adjusting for atherosclerotic risk factors in addition to age confirmed race as a significant independent predictor of CAS. Compared with Caucasian subjects, African American (odds ratio [OR], 0.65), Asian (OR, 0.69), and Hispanic (OR, 0.74) subjects had a significantly lower risk of CAS, whereas Native American (OR, 1.3) subjects had a significantly higher risk of CAS. CONCLUSIONS: The prevalence of clinically significant CAS varies significantly by race. Native American and Caucasian individuals have the highest prevalence of CAS, whereas African American males and Asian females appear to have the lowest prevalence. This information adds evidence to the hypothesis that the increased stroke rate in African American subjects is likely not related to extracranial cerebrovascular disease. Furthermore, this is a novel report of an extremely high prevalence of CAS in the Native American population.

Hormone replacement therapy is associated with a decreased prevalence of peripheral arterial disease in postmenopausal women.

BACKGROUND: The effect of hormone replacement therapy (HRT) in postmenopausal women on the development of peripheral atherosclerosis remains in question. The goal of this study was to analyze the use of HRT in a large population of postmenopausal women and to determine its association with the prevalence of peripheral arterial disease (PAD). METHODS: A prospective database of patients who underwent voluntary vascular screening was used. Identification of patients as postmenopausal, and their use of HRT, was based on patient questionnaires. PAD was defined to be present if either lower extremity ankle-brachial index was ≤0.9. RESULTS: Analysis was performed on data from 847,982 postmenopausal women; 433,178 (51.1%) reported having used HRT. HRT subjects were slightly older than patients who had not used HRT (64.5 years vs. 63.6 years). Caucasian women were significantly more likely to have used HRT than non-Caucasian women (52.4% vs. 47.6%). HRT subjects were significantly more likely to have smoked cigarettes (42.8% vs. 40.6%), to have hypertension (47.9% vs. 45.1%), and to have hypercholesterolemia (55% vs. 51.5%) than women who had not used HRT (all P < 0.001). However, HRT subjects were significantly less likely to have diabetes mellitus (8.6% vs. 10.2%, P < 0.001). Despite the increased prevalence of several atherosclerotic risk factors among women who used HRT, they were significantly less likely to have PAD (3.3% vs. 4.1%, P < 0.001). Multivariate analysis adjusting for age, race, and medical comorbidities that predispose toward the development of atherosclerosis confirmed that HRT was independently associated with a decreased risk of PAD (odds ratio: 0.8, 95% confidence interval: 0.78-0.82). In subsets of postmenopausal women with known atherosclerotic risk factors, the significant effect of HRT on the prevalence of PAD was maintained; in women with either a smoking history, hypertension, hypercholesterolemia, diabetes, or age of ≥70 years, the odds ratio of HRT use with regard to PAD remained approximately 0.8. CONCLUSIONS: The use of HRT in postmenopausal women appears to be associated with a significant reduction in the prevalence of PAD in this population-based study. This association appeared to be significant even in postmenopausal women with known atherosclerotic risk factors. These observational data may suggest a relationship between HRT and the prevalence of PAD that has not been the specific subject of previous randomized prospective studies.

Comparison of Recent Practice Guidelines for the Management of Patients With Asymptomatic Carotid Stenosis.

Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German-Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients.The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German-Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German-Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.

Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An international, multispecialty, expert review and position statement.

The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement was to reconcile the conflicting views on the topic. A literature review was performed with a focus on data from recent studies. Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.

Celiac artery dissection from heavy weight lifting.

In this case report, we present a 45-year-old man who experienced abdominal pain while bench-pressing heavy weights. A computed tomography angiogram showed a dissection of the celiac artery extending into the hepatic and splenic arteries, with thrombus in the false lumen into the common hepatic artery. With resolution of his symptoms, he was discharged after several days of warfarin and metoprolol therapy. To our knowledge, this is the first reported case of a dissection of the celiac artery and its branches caused by weight lifting.

Two case presentations and surgical management of Bow Hunter's syndrome associated with bony abnormalities of the C7 vertebra.

Bow Hunter's syndrome is a condition in which patients experience vertebrobasilar symptoms on head turn. It may be a consequence of intrinsic factors such as atherosclerosis, or it may be secondary to mechanical compression. Most commonly, this occurs at the level of C2 or above. We present two rare cases of Bow Hunter's syndrome secondary to mechanical compression at the level of C7. Discussed are the anatomic conditions leading to this syndrome in these two patients, the methodology for confirming the diagnosis, and the successful management by partial resection of the transverse processes compressing the vertebral arteries.

Is carotid artery stenting a fair alternative to carotid endarterectomy for symptomatic carotid artery stenosis? A commentary on the AHA/ASA guidelines.

UNLABELLED: The recent guidelines by the American Heart Association/American Stroke Association (AHA/ASA) and several other associations recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients (Class I; LEVEL OF EVIDENCE: B). The term "alternative" may easily be misinterpreted as "equivalent" to justify the widespread use of CAS. However, current evidence indicates that for symptomatic patients, CAS produces inferior outcomes compared with CEA. It is likely that with technical improvements, better patient selection, and better physician experience, CAS outcomes will improve in the future. CAS may then become a fair alternative to CEA, at least in certain patient subgroups. Based on current evidence, however, we are not there yet and it seems unfair to spin the AHA/ASA guidelines to conclude that we are.

Development of a novel scoring tool for the identification of large ≥5 cm abdominal aortic aneurysms.

OBJECTIVE: Current screening recommendations for abdominal aortic aneurysm (AAA) target >3-cm diameter aneurysms in ever-smoking 65- to 75-year-old males. However, more than 50% of AAA ruptures occur in individuals outside this patient cohort, and only a subset of AAAs detected are large enough to warrant surgery. In this analysis, we evaluated more than 3 million screened individuals and developed a scoring tool to identify ≥5-cm diameter AAAs in the entire population at risk. METHODS: Between 2003 and 2008, demographics and risk factors were collected from 3.1 million people undergoing ultrasound screening for AAA by Life Line Screening, Inc. Using multivariable logistic regression analysis, we identified risk factors and developed a scoring system to predict the presence of ≥5-cm diameter AAAs. RESULTS: Smoking had a profound influence on the risk of AAA, which increased with number of cigarettes smoked and years of smoking, and decreased following smoking cessation. Novel findings included a protective effect of exercise, normal weight, and Black/Hispanic race/ethnicity. Using these and other factors, the scoring system provided good predictive accuracy (C-statistic = 0.82), when tested against the validation subset of the study cohort. The model predicts the presence of 121,000 ≥5 cm AAA in the US population (prevalence: 0.14%). Demonstrating the inadequacy of the current screening recommendations, only 35% of these aneurysms were among males aged 65 to 75 years. CONCLUSIONS: Based on the largest cohort of patients ever screened for AAA, we developed a screening strategy that can identify large AAAs in a broad population of individuals at risk.

Clinical course of asymptomatic patients with carotid duplex scan end diastolic velocities of 100 to 124 centimeters per second.

OBJECTIVE: With the decline of diagnostic angiography, clinicians increasingly rely upon duplex scan criteria to select appropriate asymptomatic candidates for carotid intervention. Some recent trials have enrolled patients for intervention based upon end diastolic velocities (EDVs) as low as 100 cm/second, and peak systolic velocities (PSVs) as low as 230 cm/second. In as much as we have used more selective duplex scan criteria, we reviewed the course of asymptomatic patients who had EDVs from 100 to 124 cm/second. METHODS: Of the patients evaluated in our Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) accredited laboratory from 2002 to 2007, 144 patients had an EDV 100 to 124 cm/second. Of these, 47 patients underwent initial carotid intervention for concomitant symptoms (10), contralateral occlusion (3), or other imaging findings felt to warrant intervention. The remaining 97 asymptomatic patients were followed. One patient had both arteries fall within this EDV range. The mean follow-up for the 98 arteries was 29.1 months (range, 2-116 months). RESULTS: Five patients (5.2%) developed ipsilateral symptoms consisting of one stroke and four transient ischemic attacks (TIAs), at a mean time of 35.3 months (range, 12-58 months). Twenty-six patients (26.8%), including 3 who also developed ipsilateral symptoms, progressed to having an EDV of ≥ 125 cm/second at a mean time of 24 months (range, 2-58). Two of these (2.1%) progressed directly to occlusion without symptoms and with no documented interim worsening of stenosis. CONCLUSION: For asymptomatic individuals with an initial EDV of 100 to 124 cm/second, the risk of ipsilateral stroke is small and, therefore, medical management is appropriate in most cases. However, the risk of progression to a more severe degree of stenosis, often warranting carotid intervention, is clinically meaningful. Yearly duplex scan follow-up is necessary to assess disease progression in this patient cohort.

Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals.

BACKGROUND: Abdominal aortic aneurysm (AAA) disease is an insidious condition with an 85% chance of death after rupture. Ultrasound screening can reduce mortality, but its use is advocated only for a limited subset of the population at risk. METHODS: We used data from a retrospective cohort of 3.1 million patients who completed a medical and lifestyle questionnaire and were evaluated by ultrasound imaging for the presence of AAA by Life Line Screening in 2003 to 2008. Risk factors associated with AAA were identified using multivariable logistic regression analysis. RESULTS: We observed a positive association with increasing years of smoking and cigarettes smoked and a negative association with smoking cessation. Excess weight was associated with increased risk, whereas exercise and consumption of nuts, vegetables, and fruits were associated with reduced risk. Blacks, Hispanics, and Asians had lower risk of AAA than whites and Native Americans. Well-known risk factors were reaffirmed, including male gender, age, family history, and cardiovascular disease. A predictive scoring system was created that identifies aneurysms more efficiently than current criteria and includes women, nonsmokers, and individuals aged <65 years. Using this model on national statistics of risk factors prevalence, we estimated 1.1 million AAAs in the United States, of which 569,000 are among women, nonsmokers, and individuals aged <65 years. CONCLUSIONS: Smoking cessation and a healthy lifestyle are associated with lower risk of AAA. We estimated that about half of the patients with AAA disease are not eligible for screening under current guidelines. We have created a high-yield screening algorithm that expands the target population for screening by including at-risk individuals not identified with existing screening criteria.

Risk factors for perioperative death and stroke after carotid endarterectomy: results of the new york carotid artery surgery study.

BACKGROUND AND PURPOSE: The benefit of carotid endarterectomy is heavily influenced by the risk of perioperative death or stroke. This study developed a multivariable model predicting the risk of death or stroke within 30 days of carotid endarterectomy. METHODS: The New York Carotid Artery Surgery (NYCAS) Study is a population-based cohort of 9308 carotid endarterectomies performed on Medicare patients from January 1998 through June 1999 in New York State. Detailed clinical data were abstracted from medical charts to assess sociodemographic, neurological, and comorbidity risk factors. Deaths and strokes within 30 days of surgery were confirmed by physician overreading. Multivariable logistic regression was used to identify independent patient risk factors. RESULTS: The 30-day rate of death or stroke was 2.71% among asymptomatic patients with no history of stroke/transient ischemic attack (TIA), 4.06% among asymptomatic ones with a distant history of stroke/TIA, 5.62% among those operated on for carotid TIA, 7.89% of those with stroke, and 13.33% in those with crescendo TIA/stroke-in-evolution. Significant multivariable predictors of death or stroke included: age >/=80 years (OR, 1.30; 95% CI, 1.03 to 1.64), nonwhite (OR, 1.83; 1.23 to 2.72), admission from the emergency department (OR, 1.95; 1.50 to 2.54), asymptomatic but distant history of stroke/TIA (OR, 1.40; 1.02 to 1.94), TIA as an indication for surgery (OR, 1.81; 1.39 to 2.36), stroke as the indication (OR, 2.40; 1.74 to 3.31), crescendo TIA/stroke-in-evolution (OR, 3.61; 1.15 to 11.28), contralateral carotid stenosis >/=50% (OR, 1.44; 1.15 to 1.79), severe disability (OR, 2.94; 1.91 to 4.50), coronary artery disease (OR, 1.51; 1.20 to 1.91), and diabetes on insulin (OR, 1.55; 1.10 to 2.18). Presence of a deep carotid ulcer was of borderline significance (OR, 2.08; 0.93 to 4.68). CONCLUSIONS: Several sociodemographic, neurological, and comorbidity risk factors predicted perioperative death or stroke after carotid endarterectomy. This information may help inform decisions about appropriate patient selection, assessments about the impact of different surgical processes of care on outcomes, and facilitate comparisons of risk-adjusted outcomes among providers.

Racial and ethnic disparities in outcomes and appropriateness of carotid endarterectomy: impact of patient and provider factors.

BACKGROUND AND PURPOSE: Prior work documented racial and ethnic disparities in incidence of stroke, stroke risk factors, and use of carotid endarterectomy. Less is known about disparities in outcomes and appropriateness of carotid endarterectomy or reasons for such inequalities. METHODS: This was a population-based cohort of carotid endarterectomy performed in Medicare beneficiaries in New York. Clinical data were abstracted from medical charts to assess sociodemographics, clinical indication for carotid endarterectomy, disease severity, comorbidities, and deaths and strokes within 30 days of surgery. Appropriateness was based on validated criteria from a national expert panel. Differences in patients, providers, outcomes, and appropriateness were compared using chi(2) tests. Differences in risk-adjusted rates of death or nonfatal stroke were compared using multiple logistic regression accounting for patient, physician, and hospital-level risk factors. RESULTS: Overall, 95.3% of patients undergoing carotid endarterectomy were white, 2.5% black, and 2.2% Hispanic (N=9093). Minorities had more severe neurological disease and more comorbidities and were more likely to be cared for by lower-volume surgeons and hospitals (P<0.0001). Rates of 30-day death/stroke were higher in Hispanics (9.5%) and blacks (6.9%) than whites (3.8%; P<0.0001). Multivariable analyses that adjusted for presurgical patient risk and provider characteristics found that blacks no longer had significantly worse outcomes (OR=1.37; CI, 0.78 to 2.40), although the higher risk of death/stroke in Hispanics persisted (OR=1.87; CI, 1.09 to 3.19). Minorities had higher rates of inappropriate surgery (Hispanics 17.6%, black 13.0%, white 7.9%; P<0.0001) largely due to higher comorbidity. CONCLUSIONS: Minorities had worse outcomes and higher rates of inappropriate surgery. Differences in underlying presurgical risk factors and provider characteristics explained the higher risk of complications in blacks, but not Hispanics.

Outcome of carotid endarterectomy for acute neurological deficit.

We reviewed our experience with urgent carotid intervention in the setting of acute neurological deficits. Between June 1992 and August 2008, a total of 3145 carotid endarterectomies (CEA) were performed. Twenty-seven patients (<1.0%) were categorized as urgent. The mean age was 74.1 years (range 56-93 years) with 16 (60%) men, and 11 (40%) women, Symptoms included extremity weakness or paralysis (n=13), amaurosis fugax (n=6), speech difficulty (n=2), and syncope, (n=3). Three patients exhibited a combination of these symptoms. Three open thrombectomy were performed. Regional anesthesia was used in 13 patients (52%). Seventeen patients (67%), required shunt placement. At 30-days, 2 patient (7%) suffered a stroke, and 1 (4%) died. Urgent CEA can be performed safely. A stroke rate of 7% is acceptable in those who may otherwise suffer a dismal outcome without intervention.

A study of cognitive dysfunction in patients having carotid endarterectomy performed with regional anesthesia.

BACKGROUND: In previous studies, we found that approximately 25% of patients having carotid endarterectomy with general anesthesia (CEA general) develop cognitive dysfunction compared with a surgical control Group 1 day and 1 mo after surgery. In this study, we tested the hypothesis that patients having CEA with regional anesthesia (CEA regional) will develop significant cognitive dysfunction 1 day after surgery compared with a control group of patients receiving sedation 1 day after surgery. We did not study persistence of dysfunction. METHODS: To test this hypothesis, we enrolled 60 patients in a prospective study. CEA regional was performed with superficial and deep cervical plexus blocks in 41 patients. The control group consisted of 19 patients having coronary angiography or coronary artery stenting performed with sedation. A control group is necessary to account for the "practice effect" associated with repeated cognitive testing. The patients from the CEA regional group were enrolled at New York Medical Center and the control group at Columbia-Presbyterian Medical Center. The cognitive performance of all patients was evaluated using a previously validated battery of neuropsychometric tests. Differences in performance, 1 day after compared with before surgery, were evaluated by both event-rate and group-rate analyses. RESULTS: On postoperative day 1, 24.4% of patients undergoing CEA regional had significant cognitive dysfunction, where "significant" was defined as a total deficit score > or =2 SD worse than the mean performance in the control group. CONCLUSIONS: Patients undergoing CEA regional had an incidence of cognitive dysfunction which was not different than patients having CEA general as previously published and compared with a contemporaneously enrolled group.