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Objetivo: Analizar los factores de riesgo y resultados de la endarterectomía carotídea (EC) en el hospital Metropolitano de la Florida Dra. Eloísa Díaz Insunza. Materiales y métodos: Se trata de un estudio observacional, retrospectivo y descriptivo, donde se analizan 89 endarterectomías carotídea, en un período de 8 años (enero del 2015 a enero de 2023) realizadas en 85 pacientes, los pacientes fueron divididos en 2 grupos, sintomáticos y asintomáticos, con respecto a las complicaciones fueron clasificadas en mayores y menores. Resultados: Se realizaron 89 endarterectomías carotídeas desde enero del 2015 hasta enero del 2023. El grupo sintomático corresponde a 78 (87,64%) pacientes, el grupo asintomático 11 (12,35%). 62 en hombres (69,66%) y 27 en mujeres (30,33%). Hubo muerte en 1 (1,12%) solo paciente, perteneciendo éste al grupo sintomático. Accidentes vasculares perioperatorios en 3 (3,37%) pacientes, todos con secuelas neurológicas presentes a 30 días post-operatorios (uno de estos fallecido en post-operatorio inmediato). Hematomas en 5 (5,61%) casos, 4 (3,56%) que requirieron intervención quirúrgica para drenaje del mismo. Lesión neurológica periférica en 1 (1,12%) solo paciente que corresponde a lesión del laríngeo recurrente. 1 (1,12%) caso de infección superficial de herida operatoria. 1 (1,12%) caso de síndrome de reperfusión cerebral Discusión: Todas las grandes series y guías internacionales demuestran el amplio beneficio de la endarterectomía carotídea en la prevención de eventos neurológicos. Conclusión: La endarterectomía carotídea sigue siendo el tratamiento de elección en la estenosis carotídea sintomática, realizada en centros con experiencia presenta resultados excelentes en cuanto a la prevención de nuevos eventos neurológicos.
Objective: To analyze the risk factors and short-term results of the carotid endarterectomy in our hospital. Materials and method: The present is an observational, retrospective and descriptive study, where 89 carotid endarterectomies are analyzed in a period of 8 years (January 2015 to January 2023) performed in 85 patients, the patients were divided in to two groups, symptomatic and asymptomatics, as for the complications there were divided in minor and mayor. Results: 89 carotid endarterectomies where perform between January 2015 to January 2023. In the symptomatic group are 78 (87.64%) patients, in the asymptomatic group there are 11 patients (12.35%). 62 where male (69.66%) and 27 where women (30.33%). Only 1 (1.12%) patient died, this one from the symptomatic group. Perioperatory stroke in 3 (3.37%) patients, all of them with neurologic secuela at 30 days of post operatory. 5 (5.61%) cases of post operatory hematomas 4 of them requiring reintervention. There was 1 (1.12%) patient with neurologic affection. 1 (1.12%) case of superficial wound infection. Conclusion: The carotid endarterectomy remains as the gold standard to prevent strokes in symptomatic patients. Performed in high volume centers it has excellent results as for the prevention of new strokes.
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Resumo Contexto A abordagem cirúrgica para estenose carotídea sintomática está consolidada na literatura para a prevenção de eventos neurológicos, devendo seguir padrões ótimos de qualidade. Entretanto, há uma crescente preocupação relacionada à possibilidade ou não de replicar os dados dos trabalhos controlados no mundo real. Objetivos Avaliar a população com estenose carotídea sintomática submetida a cirurgia e seus desfechos de curto prazo em um contexto de mundo real em um centro de formação profissional. Métodos Tratou-se de um estudo observacional realizado por meio de coleta de dados em prontuário de janeiro de 2012 a janeiro de 2023. Foram excluídos pacientes operados por outras etiologias e com cirurgia cardíaca concomitante. Resultados Foram incluídos 70 pacientes submetidos a angioplastia ou endarterectomia carotídea. Os subgrupos populacionais submetidos a angioplastia ou endarterectomia foram semelhantes. Houve diferença estatisticamente relevante quanto à modalidade anestésica e ao tempo cirúrgico maior para o subgrupo de endarterectomia carotídea. Houve quatro casos de acidente vascular encefálico isquêmico, e três deles estavam relacionados à lesão, sendo dois menores e um maior. Dessa forma, a taxa de acidente vascular encefálico maior relacionado à lesão foi de 1,43% e de qualquer acidente vascular encefálico relacionado à lesão, de 4,29%. A taxa total de eventos adversos cardiovasculares maiores foi de 5,71%. Houve um caso de infarto agudo do miocárdio no grupo angioplastia e nenhum óbito. Não houve diferença estatística entre os grupos de endarterectomia e angioplastia quanto aos desfechos principais. Conclusões Os desfechos acidente vascular encefálico isquêmico, infarto agudo do miocárdio, óbito e eventos adversos cardiovasculares maiores neste centro são semelhantes aos encontrados em estudos clínicos randomizados, demonstrando viabilidade da manutenção deste tratamento em centros com programas de ensino.
Abstract Background Surgical treatment of symptomatic extracranial carotid stenosis is well established for preventing neurological events and should adhere to optimal quality standards. However, there is growing concern as to whether results of controlled trials are replicable in real-world settings. Objectives To assess a symptomatic carotid stenosis population that underwent surgery and its short-term outcomes in a real-world context at a professional training center. Methods Observational study using data collected from medical records from January 2012 to January 2023. Patients undergoing operations for other carotid diseases and with concomitant heart surgery were excluded. Results A total of 70 patients undergoing angioplasty or carotid endarterectomy were included. Population subsets undergoing angioplasty or endarterectomy were similar. Differences in anesthetic modality and a longer operative time in the carotid endarterectomy subgroup were statistically significant. There were 4 cases of stroke, only 3 of which (2 minor and 1 major) were related to the index lesion. Thus, the rate of major operation-related stroke was 1.43% and the rate of any lesion-related stroke was 4.29%. There was 1 case of AMI in the angioplasty group and there were no deaths in the sample. The overall rate of major adverse cardiovascular events was 5.71%. There were no statistical differences between the endarterectomy and angioplasty groups regarding the main outcomes. Conclusions The rates of outcomes of ischemic stroke, acute myocardial infarction, death, and major adverse cardiovascular events at this center are in line with the rates reported by randomized controlled trials, demonstrating the feasibility of carotid surgery in centers with teaching programs.
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Resumo A doença cerebrovascular extracraniana tem sido intensamente investigada em todo o mundo, sendo tema de suma importância para os cirurgiões vasculares. A presente Diretriz foi elaborada pela Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) em sucessão à Diretriz de 2015. As doenças de etiologia não ateroscleróticas não foram incluídas nesse documento. O objetivo desta Diretriz é congregar as evidências mais robustas nessa área para auxiliar os especialistas no processo decisório do tratamento. Foi utilizada a metodologia AGREE II e o sistema da Sociedade Europeia de Cardiologia para as recomendações e níveis de evidências. As recomendações foram graduadas de I a III, e os níveis de evidência classificados em A, B e C. A presente Diretriz foi dividida em 11 capítulos, que tratam dos vários aspectos da doença cerebrovascular extracraniana: diagnóstico, tratamentos e complicações, de forma atualizada e com as recomendações propostas pela SBACV.
Abstract Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Clinically,tandem carotid artery stenosis(TCAS)is a relatively rare atherosclerotic disease,and with the development of interventional techniques,its treatment has become more and more minimally invasive,and the technical feasibility of hybrid surgery(HS)has been already confirmed for long time.In recent years,with the increasing of the number of patients and the deepening of research both at home and abroad,it has been found that the safety and effectiveness of HS for TCAS are still questionable,and it is particularly important to choose the appropriate treatment for such patients.This article aims to make a comprehensive review about the HS for TCAS,focusing on its surgical process,comparison of its surgical methods,and the current controversies over the treatment of TCAS,with the hope that clinicians can get a more comprehensive understanding about this surgical method.(J Intervent Radiol,2024,32:95-99)
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Objective To analyze the budget impact of a price increase for carotid endarterectomy(CEA)on the total expenditure of health insurance expenditure in China.Methods We set 2021 as the base year,and 2022-2026 as the study years.A budget impact analysis model was developed to calculate the expenditure of health insurance funds over the next 5 years following a 30%price increase for carotid endarterectomy.Data on the target population,treatment costs,and market share changes both nationwide and in four sample cities were used.The data was collected in May to Jul 2022.Results The price increase for carotid endarterectomy will reduce total health insurance fund expenditures nationwide by 143.176 2 million yuan over five years.Total health insurance fund expenditures in the sample cities will also decrease to varying degrees.The higher the price increase for the surgical procedure,the greater the decrease in total expenditure of the health insurance fund.The market share of the surgical procedure has the greatest impact on the total expenditure of the health insurance fund.Conclusion Increasing the price of carotid endarterectomy may lead to increase in its market share and decline in the health insurance fund expenditures in future five years.
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Objective:To investigate the safety and efficacy of balloon pulmonary angioplasty (BPA) for residual pulmonary hypertension (PH) of chronic thromboembolic pulmonary hypertension(CTEPH) after pulmonary endarterectomy (PEA).Methods:Patients diagnosed as PH after PEA in China-Japan Friendship Hospital from Oct 2016 to Jun 2022 were included. The indication for BPA was decided on the basis of a consensus of the multi-disciplinary team for all patients with CTEPH. Before treatment, the patient′s exercise tolerance and pulmonary artery flow parameters were evaluated. A comparative analysis of various parameters before BPA treatment and at the last BPA was conducted. 6-min walk distance (6MWD) was analyzed using the paired Wilcoxon test; N-terminal pro-brain natriuretic peptide (NT-proBNP), mixed venous oxygen saturation, mean pulmonary arterial pressure (mPAP), cardiac index (CI) and pulmonary vascular resistance (PVR) were compared using the paired-samples t-test. WHO functional class was compared using McNemar′s test. Results:Twenty patients with a total of 130 vessels underwent 46 sessions of BPA treatment. The postoperative 6-minute walk distance (6MWD) [447 (415, 485) m] showed a significant improvement compared to the preoperative baseline [389 (335, 470) m] ( Z=6.52, P<0.05), Postoperative mixed venous oxygen saturation (72.0%±1.9%) showed a significant improvement compared to the preoperative levels (64.0%±2.7%) ( t=2.14, P<0.05).Postoperatively, plasma NT-proBNP [(351.9±129.9) pg/ml], mPAP [(24.2±1.9) mmHg], and PVR [(3.0±1.4) WU] significantly decreased compared to preoperative levels [(982.5±426.2) pg/ml, (33±2.1) mmHg, (8.0±1.6) WU)] ( t=3.38, 1.22, 2.10, P<0.05 for all). Postoperatively, there was a significant improvement in WHO functional class (Ⅰ，Ⅱ，Ⅲ，Ⅳ: 14, 4, 2, 0 cases) compared to preoperative status (Ⅰ，Ⅱ，Ⅲ，Ⅳ: 0, 13, 5, 2 cases) ( χ2=20.17, P<0.05). Four cases of pulmonary artery dissection and one episode of hemoptysis occurred postoperatively, with no other complications reported. Conclusions:BPA can significantly improve exercise tolerance and hemodynamic parameters for residual PH after PEA. BPA is a relatively safe and effective treatment for residual PH after PEA.
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Objective:To investigate the impact of intraoperative multimodal neurophysiological monitoring combined with blood pressure precise control on incidence of acute cerebral infarction after carotid endarterectomy.Methods:A retrospective study was peformed; 305 patients with atherosclerotic stenosis of the carotid artery admitted to and accepted carotid endarterectomy in Department of Vascular Neurosurgery, Dong'e County People's Hospital from January 2020 to September 2023 were selected. Intraoperative multimodal neurophysiological monitoring combined with traditional empirical modalities for blood pressure control was applied to 153 patients admitted to our hospital from January 2020 to December 2021 (control group), and intraoperative multimodal neurophysiological monitoring combined with blood pressure precise control (based on monitored sensory or motor wave amplitude changes) was applied to 152 patients admitted to our hospital from January 2022 to September 2023 (experimental group). Difference in postoperative acute cerebral infarction incidence between the 2 groups was compared.Results:The experimental group had significantly lower postoperative acute cerebral infarction incidence compared with the control group (4.6% vs. 13.0%, P<0.05). The experimental group had significantly lower postoperative asymptomatic acute cerebral infarction incidence compared with the control group (3.3% vs. 9.8%, P<0.05), while no significant difference was noted in postoperative symptomatic acute cerebral infarction incidence between the 2 groups ( P>0.05). Conclusion:Intraoperative multimodal neurophysiological monitoring combined with blood pressure precise control can reduce the postoperative acute cerebral infarction incidence in patients accepted carotid endarterectomy, especacailly postoperative asymptomatic acute cerebral infarction incidence, thereby enhancing surgical safety.
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Introducción: La isquemia crítica de los miembros inferiores es el estadio último de un proceso con un pronóstico muy desfavorable, tanto para la extremidad como para la supervivencia. El 50 % de estos pacientes acaba en amputación mayor y tiene una mortalidad anual del 20 %. Objetivo: Caracterizar la cirugía arterial infrainguinal en la isquemia crítica de los miembros inferiores. Métodos: Estudio descriptivo, de corte longitudinal y prospectivo a pacientes operados de cirugía infrainguinal por isquemia crítica de las extremidades inferiores entre enero de 2017 y enero de 2020. La muestra quedó conformada por 73 pacientes. Las variables estudiadas fueron edad, sexo, factores de riesgo, clasificación de Fontaine, técnicas quirúrgicas, lugar de las anastomosis, conducta, tipos de injertos, complicaciones, tasa de salvamento de la extremidad y mortalidad. Resultados: Se encontró que el 82,1 % superaba los 60 años de edad, y que el 60,2 % eran hombres. Los factores de riesgo más frecuentes resultaron: hipertensión arterial (73,9 %) y diabetes (63 %). El estadio iv fue el más común (56,1 %), la cirugía más realizada fue el puente femoropopliteo (42,4 %), las anastomosis a arteria femoral común (73,4 %) y poplítea proximal (17,6 %). La vena autóloga destacó como la más utilizada (60 %), la trombosis resultó la complicación que más se presentó (56 %). La tasa de salvamento fue de un 61,6 % y la mortalidad de 6,8 % al sexto mes. Conclusiones: Los hombres mayores de 60 años con factores de riesgo son más propensos a padecer una isquemia crítica de miembros inferiores. Se obtuvo una evolución favorable en la mayoría de los casos, con un bajo índice de letalidad quirúrgica global.
Introduction: Critical ischemia of the lower limbs is the last stage of a process with a very unfavorable prognosis, both for the limb and for survival. 50 % of these patients end up in major amputation. Annual mortality is 20 %. Objective: To characterize infrainguinal arterial surgery in critical ischemia of the lower limbs. Methods: Descriptive, longitudinal and prospective study of patients who underwent infrainguinal surgery for critical ischemia of the lower limbs between January 2017 and January 2020. The sample consisted of 73 patients. The variables studied were age, sex, risk factors, Fontaine classification, surgical techniques, location of anastomosis, behavior, types of grafts, complications, limb salvage rate, and mortality. Results: It was found that 82.1 % were over 60 years of age, and that 60.2 % were men. The most common risk factors were hypertension (73.9 %) and diabetes (63 %). Stage iv was the most common (56.1 %), the most commonly performed surgeries were femoropopliteal bypass (42.4 %), common femoral artery anastomosis (73.4 %) and proximal popliteal artery (17.6 %). The autologous vein stood out as the most used (60 %), and thrombosis was the most common complication (56 %). The salvage rate was 61.6 %; and mortality of 6.8 % at the sixth month. Conclusions: Men over 60 years with risk factors are more likely to suffer from critical lower limb ischemia. A favorable outcome was obtained in most cases, with a low overall surgical fatality rate.
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ABSTRACT Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe disease treated with pulmonary endarterectomy. Our study aims to reveal the differences in liquid modalities and operation modifications, which can affect the patients' mortality and morbidity. Methods: One hundred twenty-five patients who were diagnosed with CTEPH and underwent pulmonary thromboendarterectomy (PTE) at our center between February 2011 and September 2013 were included in this retrospective study with prospective observation. They were in New York Heart Association functional class II, III, or IV, and mean pulmonary artery pressure was > 40 mmHg. There were two groups, the crystalloid (Group 1) and colloid (Group 2) liquid groups, depending on the treatment fluids. P-value < 0.05 was considered statistically significant. Results: Although the two different fluid types did not show a significant difference in mortality between groups, fluid balance sheets significantly affected the intragroup mortality rate. Negative fluid balance significantly decreased mortality in Group 1 (P<0.01). There was no difference in mortality in positive or negative fluid balance in Group 2 (P>0.05). Mean duration of stay in the intensive care unit (ICU) for Group 1 was 6.2 days and for Group 2 was 5.4 days (P>0.05). Readmission rate to the ICU for respiratory or non-respiratory reasons was 8.3% (n=4) in Group 1 and 11.7% (n=9) in Group 2 (P>0.05). Conclusion: Changes in fluid management have an etiological significance on possible complications in patient follow-up. We believe that as new approaches are reported, the number of comorbid events will decrease.
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Abstract Background Previous studies indicate an inverse relationship between hospital volume and mortality after carotid endarterectomy. However, data at the level of Brazil are lacking. Objectives To assess the relationship between hospital carotid endarterectomy procedure volumes and mortality in the state of São Paulo. Methods Data from the São Paulo State Hospital Information System on all carotid endarterectomies performed between 2015 and 2019 were analyzed. Hospitals were categorized into clusters by annual volume of surgeries (1-10, 11-25, and ≥26). Multiple logistic regression models were used to determine whether the volume of carotid endarterectomy procedures was an independent predictor of in-hospital mortality among patients undergoing this procedure. Results Crude in-hospital mortality was nearly 60 percent lower in patients who underwent carotid endarterectomy at the highest volume hospitals than among those who underwent endarterectomy at the lowest volume hospitals (unadjusted OR of survival to hospital discharge, 2.41; 95% CI, 1.11-5.23; p = 0.027). Although this lower rate represents 1.5 fewer deaths per 100 patients treated, high-volume centers are more likely than low-volume centers to perform elective procedures, thus the analysis did not retain statistical significance when adjusted for admission character (OR, 1.69; 95% CI, 0.74-3.87; p = 0.215). Conclusions In a contemporary Brazilian registry, higher volume carotid endarterectomy centers were associated with lower in-hospital mortality than lower volume centers. Further studies are needed to verify this relationship considering the presence of symptoms in patients.
Resumo Contexto Estudos indicam uma relação inversa entre volume hospitalar e mortalidade após endarterectomia carotídea. Entretanto, não há dados a nível brasileiro. Objetivos Avaliar a relação entre volume hospitalar de endarterectomia carotídea e mortalidade no estado de São Paulo. Métodos Foram analisados dados do Sistema de Informação Hospitalar do Estado de São Paulo de todas as endarterectomias carotídeas realizadas entre 2015 e 2019. Os hospitais foram categorizados em grupos de acordo com o volume anual de cirurgias (1-10, 11-25 e ≥26). Modelos de regressão logística múltipla foram usados para determinar se o volume de endarterectomias carotídeas era um preditor independente de mortalidade intra-hospitalar entre os pacientes submetidos a esse procedimento. Resultados A mortalidade intra-hospitalar foi quase 60% menor nos pacientes submetidos a endarterectomia carotídea nos hospitais de maior volume em comparação aos pacientes submetidos a endarterectomia nos hospitais de menor volume (OR não ajustado de sobrevida após alta hospitalar, 2,41; IC 95%, 1,11-5,23; p = 0,027). Embora essa taxa mais baixa represente 1,5 menos mortes por 100 pacientes tratados, os centros de alto volume são mais propensos do que os centros de baixo volume a realizarem procedimentos eletivos; portanto, a análise não reteve significância quando ajustada para o caráter de admissão (OR, 1,69; IC 95%, 0,74-3,87; p = 0,215). Conclusões Em um registro brasileiro contemporâneo, centros com maior volume de endarterectomia carotídea foram associados a menor mortalidade intra-hospitalar em comparação aos centros de menor volume. Mais estudos são necessários para verificar essa relação considerando a presença de sintomas em pacientes.
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Objective:To investigate the hemodynamic characteristics and dynamic cerebral autoregulation(dCA) of patients with severe carotid stenosis before carotid endarterectomy(CEA), and to analyze their correlations with hyperperfusion after CEA.Methods:A total of 63 patients with unilateral severe carotid artery atherosclerotic stenosis who underwent CEA were consecutively recruited prospectively in Xuanwu Hospital, Capital Medical University from January 2021 to August 2021. According to postoperative hyperperfusion, patients were divided into hyperperfusion group (13 cases) and non-hyperperfusion group (50 cases). The general clinical data and hemodynamic parameters were compared between the two groups. The dCA was evaluated by the transfer function analysis that measured the fluctuation amplitude of mean cerebral blood flow velocity(CBFV) with blood pressure change, the time difference of phase with blood pressure change, and the correlation between mean CBFV and blood pressure change. The value of dCA for predicting postoperative hyperperfusion was analyzed through the ROC curve and the area under the curve(AUC).Results:①The proportion of hypertension in hyperperfusion group was higher than that in non-hyperperfusion group ( P<0.05). ②The peak systolic velocity (PSV) at the stenosis lesion of the internal carotid artery, the end-diastolic velocity (EDV) at the stenosis lesion of the internal carotid artery and the ratio of PSV at the stenosis lesion of the internal carotid artery to the distal internal carotid artery in the hyperperfusion group were higher than the non-hyperperfusion group.And the PSV of the ipsilateral middle cerebral artery in the hyperperfusion group was lower than the non-hyperperfusion group (all P<0.05). ③In the very low-frequency and low-frequency region, the phase in the hyperperfusion group was lower than that in the non-hyperperfusion group (all P<0.05), while there was no significant difference in the high-frequency regions( P>0.05). In the three regions of very low-frequency, low-frequency and high-frequency, there were no significant differences in the gain and coherence between the two groups(all P>0.05). ④The best cutoff value of phase in the very low-frequency was 33.28 for predicting hyperperfusion after CEA (AUC=0.766, 95% CI=0.629-0.904, P=0.03), with the specificity of 0.700, and sensitivity of 0.846. Conclusions:There are differences in hemodynamics and dCA between the hyperperfusion group and the non-hyperperfusion group after CEA. The impaired preoperative dynamic cerebral autoregulation is an independent predictor of postoperative hyperperfusion.
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Objective To explore the effect of eversion carotid endarterectomy(eCEA)on the cog-nitive function in elderly carotid artery stenosis patients with different ages.Methods A total of 56 elderly patients undergoing eCEA in Department of Vascular Surgery of No.920 Hospital of Joint Logistics Support Force from May 2019 to May 2022 were enrolled and divided into a 60-69 year old group(31 cases)and a 70-80 year old group(25 cases).Mini-mental state examination(MMSE)Scale was used to analyze the patients within 1 week before surgery and 1 and 6 months after surgery.Results In the 60-69 years old group,their MMSE scores in 1 and 6 months after surgery were significantly higher than those before surgery(24.71±3.67 vs 23.52±3.70,P＜0.05;25.48±3.19 vs 23.52±3.70,P＜0.01).For the 70-80 year old group,the MMSE score in 6 months after surgery was obviously higher than that before surgery and that in 1 month after sur-gery(25.44±3.42 vs 23.76±3.81,P＜0.01;25.44±3.42 vs 23.90±3.65,P＜0.01).The improve-ment of MMSE score between 1 month after surgery and before surgery was notably more obvi-ous in the 60-69 year old group than the 70-80 year old group,but the improvement between 6 months and 1 month after surgery was statistically declined in the 60-69 year old group than the 70-80 year old group(P＜0.05).Conclusion eCEA can significantly improve cognitive function in elderly patients with carotid artery stenosis,and obvious efficacy is observed in the early stage in the 60-69 years old patients.
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Objective:To analyze the clinical characteristics and management strategy of carotid web (CW)-related stroke and improve the understanding of CW.Methods:The clinical data of 6 patients with CW-related stroke treated at Xuanwu Hospital, Capital Medical University, from January 2018 to September 2022 were retrospectively analyzed. Relevant data included clinical manifestations, bronchial magnetic resonance imaging (MRI), CT angiography (CTA)/digital subtraction angiography (DSA), carotid ultrasonography, and transcranial color-coded Doppler sonography (TCCD). Treatments and follow-ups were also reported.Results:All 6 patients were middle-aged or young, without traditional risk factors for cerebrovascular disease. The male-to-female ratio was 2∶4. All patients had recurrent strokes, with a score of 2-4 on the National Institutes of Health Stroke Scale at the time of onset. Head MRI showed 5 patients with cerebral infarction in the middle cerebral artery supply area; 1 patient had no intracranial infarction. No significant stenosis of the vessels at the site of the CW was observed in any of the 6 patients. Four patients had ipsilateral stenosis or occlusion of the middle cerebral artery, 1 patient had microembolic signals in the middle cerebral artery, and 1 patient had no significant abnormalities in the intracranial artery. All 6 patients were initially diagnosed by ultrasound. Diagnoses were confirmed by CTA/DSA in 5 cases; the other patient did not show any significant abnormalities. All 6 patients underwent a carotid endarterectomy after a pathological examination to confirm the diagnosis. Postoperatively, regular antiplatelet aggregation and statin lipid-lowering therapies were administered. A follow-up of 0.5 to 5.2 years showed no stroke recurrence in any patient.Conclusions:CW-related stroke is a rare cause of cryptogenic stroke and has a high recurrence rate. For stroke patients who do not have traditional risk factors for cerebrovascular disease while repeatedly experiencing embolic events of the internal carotid artery system, attention should be paid to the combination of the carotid and cerebral arteries, and comprehensive hemodynamic characteristics should be checked for the presence of a CW. Carotid artery ultrasound and TCCD combined with other imaging methods can improve the detection rate of a CW. Simple antiplatelet aggregation therapy cannot effectively prevent stroke recurrence. For patients with confirmed CW-related cerebral infarction, surgical resection can be performed, and the treatment effect can be evaluated using ultrasonography.
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Objective:To investigate whether the fluctuation of blood pressure variability (BPV) before carotid endarterectomy (CEA) is related to postoperative cerebral perfusion changes in patients with carotid artery stenosis.Methods:A prospective observational cohort study was performed. Forty-seven patients with carotid artery stenosis accepted CEA in Department of Neurosurgery, Guangdong Provincial People's Hospital Affiliated to Southern Medical University from January 2019 to December 2022 were chosen. Patients' blood pressure was closely monitored 3 d before surgery (4 times/d) to obtain their BPV (the maximum △, based on the maximum absolute differences between systolic or diastolic blood pressures measured continuously during the observation period). At the same time, the changes of cerebral perfusion 3 d after surgery were monitored (criteria of cerebral hyperperfusion: newly-appeared delirium and hyperactivity after anesthesia resuscitation or intracranial hemorrhage found by imaging examination; criteria of cerebral hypoperfusion: newly-appeared speech and motor function deficits or aggravation of original cerebral ischemia symptoms after anesthesia resuscitation, or new-found cerebral infarction by imaging examination). Receiver operating characteristic (ROC) curve was used to evaluate the predictive efficacy of BPV before CEA in postoperative cerebral perfusion changes.Results:In these 47 patients, 9 patients (19.1%) had postoperative cerebral perfusion changes: 2 had neurological deficits due to postoperative cerebral infarction, and the other 7 had short-term postoperative delirium or focal neurological deficits (returned to normal after appropriate adjustment of blood pressure). Area under the ROC curve (AUC) of BPV before CEA in predicting postoperative cerebral perfusion changes was 0.876 ( P=0.001, 95% CI: 0.775-0.977). These 47 patients were divided into high BPV group ( n=16) and low BPV group ( n=31) according to the optimal index threshold (27.00), and the statistics showed that significant difference in incidence of cerebral perfusion changes after CEA was noted between the 2 groups ( P<0.05); incidence of postoperative cerebral perfusion changes in the high BPV group was 15.5 times higher than that in the low BPV group ( RR=15.500, P<0.001, 95% CI: 2.120-113.320). Conclusion:BPV before CEA in patients with carotid artery stenosis can well predict the occurrence of postoperative cerebral perfusion changes.
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Carotid endarterectomy (CEA) is an important measure for stroke prevention in patients with asymptomatic severe carotid artery stenosis and symptomatic moderate to severe carotid artery stenosis. The anesthesia types of CEA include general anesthesia (GA) and regional anesthesia (RA). The existing low-quality evidence shows that there is no significant difference in the incidence of stroke and death within 30 days of operation between RA and GA. However, some recent studies have shown that the incidence of perioperative complications during CEA under RA is significantly lower than that under GA. Further high-quality research is needed to clarify the risks and benefits of CEA under RA and GA.
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Objective:To investigate the effect of ultrasound-guided stellate ganglion block (SGB) on cerebral oxygen metabolism and serum S100B protein during carotid endarterectomy (CEA).Methods:Patients aged 40-75 years old, classified as Grade Ⅱ-Ⅲ by the American Society of Anesthesiologists (ASA), and underwent elective CEA under general anesthesia at the Affiliated Suzhou Hospital of Nanjing Medical University from June 2021 to April 2023 were prospectively enrolled. They were randomly divided into an SGB group and a control group. Before anesthesia induction, the SGB group underwent ipsilateral SGB under the ultrasound guidance, while the control group did not undergo SGB. The right subclavian vein catheterization was performed under the ultrasound guidance during the general anesthesia. The mean arterial pressure (MAP) and heart rate (HR) were recorded before induction of general anesthesia (T0), during tracheal intubation (T1), before vascular occlusion (T2), after vascular opening (T3), and at the end of surgery (T4), as well as the pressure of the jugular vein bulb at each time point from T1 to T4. Arterial blood and jugular venous bulb blood were collected at various time points for blood gas analysis. Jugular venous bulb oxygen saturation (SjvO 2), arteriovenous oxygen content difference (AVDO 2), cerebral oxygen extraction rate (COER), lactate production rate (LPR) and lactate oxygen index (LOI) were calculated. The serum S100B concentration in the jugular vein bulb blood at various time points was detected with enzyme-linked immunosorbent assay. The incidence of postoperative hoarseness, hematoma, dizziness, diaphragmatic nerve block, nausea, and vomiting were recorded. Results:A total of 82 patients conducted CEA were included, with 41 patients in the SGB group and 41 in the control group. During anesthesia induction and surgery in the SGB group, HR was significantly lower than that in the control group, and the MAP and HR during tracheal intubation and at the beginning of surgery were also more stable than those in the control group (all P<0.05). In the SGB group, the changes in SjvO 2, AVDO 2, and COER were relatively smaller from T1 to T3, while SjvO 2 increased, and AVDO 2 and CEOR decreased at T4. In contrast, the control group showed a decrease in SjvO 2, AVDO 2, and COER at T3 and a slight increase at T4. At all time points, SjvO 2 in the SGB group was significantly higher than that in the control group ( P<0.05). AVDO 2 and COER in both groups gradually decreased over time, and the control group was significantly higher than the SGB group at all time points (all P<0.05). LPR and LOI increased at T1 to T4 in both groups, reaching their highest value at T3 and decreasing at T4. There was statistically significant difference at T4 and at T2 in the control group (all P<0.05). The LPR and LOI of the control group were significantly higher than those of the SGB group at all time points (all P<0.05). In addition, the serum S100B levels in both groups increased first and then decreased, but the T2-T4 levels in the SGB group were significantly lower than those in the control group at all time points (all P<0.05). The incidence of perioperative adverse events in the SGB group was significantly lower than that in the control group ( P<0.05). Conclusion:Performing ipsilateral SGB before CEA surgery can effectively inhibit stress response, maintain intraoperative hemodynamic stability, improve brain tissue oxygen supply, and have a certain neuroprotective effect.
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Objective:To investigate the effect of carotid endarterectomy(CEA) in the treatment of symptomatic carotid artery near-occlusion(CNO).Methods:Clinical symptoms, imaging examination, treatment and prognosis of 122 symptomatic CNO patients admitted to China-Japan Friendship Hospital from Jan 2014 to Jan 2020 undergoing CEA were retrospectively analyzed. Patients were divided into two groups based on the collapse condition,full collapse group(54 cases) and non-full collapse group(68 cases).Results:The difference was insignificant between the two groups at the 30-day and 12-month occurrence rate of primary endpoints(1.85% vs. 4.41%, P=0.629;7.41% vs. 4.41%, P=0.698).Postoperative re-stenosis occurred in one case in the non-full collapse group 8 months after CEA. Conclusions:CEA can achieve good curative effect for patients with CNO with recurrent symptoms, irrelevant to the existence of distal full collapse. The shunt can prevent intraoperative hypoperfusion and postoperative hyperperfusion.
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Objective:To evaluate the prognosis of off-pump coronary artery bypass grafting combined(OPCABG) with coronary endarterectomy(CE) treating the diffuse coronary artery disease.Methods:From January 2012 to December 2014, the clinical data of 2 496 OPCABG patients in our department were retrospectively analyzed, and they were divided into OPCABG group and OPCABG+ CE group. After 1∶1 matching via the propensity score matching method, the perioperative prognosis, long-term survival and adverse cardiovascular and cerebrovascular events(MACCE) were compared between the two groups.Results:A total of 238 pairs of patients were included after propensity score matching. The incidence of postoperative AMI in the OPCABG+ CE group was significantly higher than that in the OPCABG group(5.04% vs. 1.68%, P=0.042). With an average follow-up of 7.3 years, there was no significant difference in the cumulative survival rate(92.44% vs. 88.65%, P=0.159) and long-term MACCE(10.92% vs. 15.13%, P=0.173) between the two groups. Compared with the OPCABG group, the recurrence of angina pectoris(CCS grade Ⅲ-Ⅳ) in the OPCABG+ CE group increased significantly(20.16% vs. 12.60%, P=0.026). Conclusion:The risk of early AMI and long-term angina recurrence after OPCABG+ CE is significantly increased, but the long-term survival and MACCE of OPCABG+ CE and OPCABG are comparable.
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@#Objective To explore the treatment outcome of carotid endarterectomy combined with vertebral artery transposition in patients with severe stenosis to occlusion of the vertebral artery V1 segment and the ipsilateral carotid artery. Methods From June 2017 to September 2020, patients with severe stenosis to occlusion of the vertebral artery V1 segment and the ipsilateral carotid artery treated with carotid endarterectomy combined with vertebral artery transposition in Fuwai Hospital were retrospectively analyzed. Results Finally 12 patients were enrolled, including 10 males and 2 females with an average age of 67.8±6.0 years. Twelve patients were successfully operated and the follow-up time was 1-3 years. The stenosis degree of the V1 segment of the vertebral artery decreased from 83.5%±11.8% to 24.9%±14.3% (P<0.001). The stenosis degree of carotid artery decreased from 85.6%±11.0% to 0% (P<0.001). Postoperative follow-up showed that the symptoms of symptomatic patients before surgery improved. The 1-year and 3-year patency rates were 100.0%, and there were no peripheral nerve injury complications, perioperative deaths or strokes. Conclusion Carotid endarterectomy combined with vertebral artery transposition can treat ipsilateral carotid artery stenosis and vertebral artery stenosis at the same time, improve blood supply to the brain, improve patients' symptoms and has high promotion value.
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Carotid artery stenosis is an important cause of ischemic stroke. Carotid endarterectomy and carotid artery stenting are the effective methods for treating carotid artery stenosis, but postoperative restenosis remains a challenge. The pathogenesis of postoperative restenosis is currently not fully understood. However, multiple factors, including biomarkers, imaging features, and surgical related factors, have been proven to be associated with postoperative restenosis and can predict the occurrence of postoperative restenosis. This article reviews the predictors of restenosis after carotid endarterectomy and carotid artery stenting.