Carotid Artery Operation Delay During the Covid-19 Pandemic: Results of a Multicenter International Study.

BACKGROUND: To measure the impact of the COVID-19 pandemic on the management of patients with carotid artery stenosis. METHODS: We prospectively collected data from 25 centers (19 centers in the United States and 6 centers internationally) on postponed carotid artery operations between March 2020 and January 2022. We describe the characteristics of these patients and their planned operations, along with outcomes including mortality and neurological deterioration during the period of operative delay due to the COVID-19 pandemic. RESULTS: A total of 1,220 vascular operations were postponed during the pandemic, of them 96 patients presented with significant carotid stenosis (median stenosis of 71%; interquartile range; 70-80) and 80% of them were planned for carotid endarterectomy. Most patients were asymptomatic (69%), and 31% of patients were symptomatic (16% of patients had a stroke, 15% of patients had a transient ischemic attack, and 1% of patients experienced amaurosis fugax). The median length of surgical delay was 71 days (interquartile range: 45.5, 115.5). At the data entry time, 62% of patients had their carotid operations postponed and successfully completed. Most postponements (72%) were due to institutional policies aimed at resource conservation. During the delay, no patient decompensated or required an urgent operation. A total of 5 patients (5%) with carotid stenosis died while awaiting operations due to COVID-19. CONCLUSIONS: Our study of a cohort of patients with carotid artery stenosis who underwent a median delay of 71 days during the COVID-19 pandemic showed a disparate operation delay between US regions and internationally, most postponements were due to hospital policy, and none of the patients deteriorated or required an emergency surgery during the delay.

Variation in Carotid Artery Stenosis Measurements Among Facilities Seeking Carotid Stenting Facility Accreditation.

BACKGROUND: Based on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of extracranial carotid atherosclerotic disease. However, the rigor and consistency with which stenosis is measured outside of clinical trials are unclear. In an agreement study using a cross-sectional sample, we compared the percent stenosis as measured by real-world physician operators to that measured by independent expert reviewers. METHODS: As part of the carotid stenting facility accreditation review, images were obtained from 68 cases of patients who underwent carotid stent placement. Data collected included demographics, stroke severity measures, and the documented degree of stenosis, termed operator-reported stenosis (ORS), by 34 operators from 14 clinical sites. The ORS was compared with reviewer-measured stenosis (RMS) as assessed by 5 clinicians experienced in treating carotid artery disease. RESULTS: The median ORS was 90.0% (interquartile range, 80.0%-90.0%) versus a median RMS of 61.1% (interquartile range, 49.8%-73.6%), with a median difference of 21.8% (interquartile range, 13.7%-34.4%), P<0.001. The median difference in ORS and RMS for asymptomatic versus symptomatic patients was not statistically different (24.6% versus 19.6%; P=0.406). The median difference between ORS and RMS for facilities granted initial accreditation was smaller compared with facilities whose accreditation was delayed (17.9% versus 25.5%, P=0.035). The intraclass correlation between ORS and RMS was 0.16, indicating poor agreement. If RMS measurements were used, 72% of symptomatic patients and 10% of asymptomatic patients in the population examined would meet the Centers for Medicare and Medicaid Services criteria for stent placement. CONCLUSIONS: Real-world operators tend to overestimate carotid artery stenosis compared with external expert reviewers. Measurements from facilities granted initial accreditation were closer to expert measurements than those from facilities whose accreditation was delayed. Since decisions regarding carotid revascularization are often based on percent stenosis, such measuring discrepancies likely lead to increased procedural utilization.

Trends in mortality and postoperative complications among octogenarian patients undergoing carotid endarterectomy.

BACKGROUND: Elderly patients represent a large portion of patients undergoing vascular surgery. This study aims to assess the contemporary frequency of octogenarians undergoing carotid endarterectomy (CEA) and to evaluate their postoperative complications and survival rates. METHODS: The Vascular Quality Initiative (VQI) dataset was queried for patients who underwent elective CEA between 2012 and 2021. Patients aged >90 years were excluded, as well as emergent and combined cases. The population was divided into two age groups: <80 years and ≥80 years. Frailty scores were generated using Vascular Quality Initiative variables grouped into 11 domains historically associated with frailty. Patients with scores within the first 25th percentile, between the 25th and 50th percentile, and above the 75th percentile were categorized into low, medium, and high frailty classes, respectively. Procedural indications were defined as hard (stenosis ≥80% or ipsilateral neurologic symptoms) or soft. Primary outcomes of interest were 2-year stroke-free and 2-year overall survival comparing (i) octogenarians with nonoctogenarians and (ii) octogenarians by frailty class. Standard statistical methods were used. RESULTS: Overall, 83,745 cases were included in this analysis. Between 2012 and 2021, a consistent proportion averaging 17% of CEA patients were octogenarians. Among this age group, the proportion of patients undergoing CEA for hard indications increased over time from 43.7% to 63.8% (P < .001). This increase was accompanied by a statistically significant increase in the combined 30-day perioperative stroke and mortality rate from 1.56% in 2012 to 2.96% in 2021 (P = .019). A Kaplan-Meier analysis showed a significantly lower 2-year stroke-free survival among octogenarians compared with the younger group (78.1% vs 87.6%; P < .001). Similarly, there was a significantly lower 2-year overall survival among octogenarians compared with the younger group (90.5% vs 95.1%; P < .001). Multivariate Cox proportional hazard analyses showed that high frailty class was associated with increased 2-year stroke risk (hazard ratio, 2.26; 95% confidence interval, 1.61-3.17; P < .001) and 2-year mortality (hazard ratio, 2.43; 95% confidence interval, 1.71-3.47; P < .001). Repeat Kaplan-Meier analysis stratifying octogenarians by frailty class revealed that octogenarians with low frailty can have stroke-free and overall survival rates comparable with nonoctogenarians (88.2% vs 87.6% [P = .158] and 96.0% vs 95.1% [P = .151], respectively). CONCLUSIONS: Chronological age should not be regarded as a contraindication for CEA. Frailty score calculation is a better predictor for postoperative outcomes and is an appropriate tool to risk stratify octogenarians, aiding in the decision between best medical treatment or intervention. The risk benefit assessment for high frailty class octogenarians is paramount because the postoperative risks may outweigh the long-term survival benefits of the prophylactic CEA.

Revisiting carotid endarterectomy: Neobulb technique using external carotid artery as a patch.

OBJECTIVES: This study describes an alternative carotid bifurcation endarterectomy technique in which the external carotid artery is used as a suture patch. METHODS: Charts of ten patients with atherosclerotic carotid stenosis that were treated using the neobulb technique between 2002 and 2019 were reviewed. RESULTS: No major surgical adverse event was observed in the postoperative assessments. No postoperative common or internal carotid stenosis was observed in the mid- or long-term follow-up. CONCLUSIONS: The neobulb technique allows carotid endarterectomy closure without a synthetic or venous patch, using the external carotid artery as an autologous patch, while preserving distal flow into the external carotid artery branches.

Risk Factors for Stroke After Carotid Paraganglioma Surgery.

BACKGROUND: The Carotid Paraganglioma Cooperative International Registry (CAPACITY) is an international registry composed of 1,432 patients with carotid body tumors (CBT) from 11 centers from 4 countries. The aim of this study was to identify risk factors for patients who presented stroke after carotid paraganglioma resection. METHODS: Clinical characteristics and demographics of patients who presented transoperatively and postoperatively stroke from the CAPACITY database were retrospectively gathered. Regression analysis was performed using single logistic regression with Omnibus' test for possible factors that might contribute to present stroke. RESULTS: Out of 1,432 patients, 8 (0.5%) female patients presented stroke. Median age was 53 years (range: 41-70 years). Six strokes occurred transoperatively, diagnosed clinically in the immediate postoperative period. Of them, none of the patients received any further treatment. Three of them died on postoperative day 2, 3, and 4. Two patients developed stroke during the first 24 postoperative hours, patients showed dysarthria, and aphasia. One of them was reintervened with thrombectomy due to thrombosis of the common carotid artery the other patient was treated conservatively. Median follow-up was 16 months (range: 2-72 months). Single logistic regression analysis revealed a history of diabetes mellitus (odds ratio (OR) 7.62), carotid artery disease (OR 17.51), and vascular lesion (OR 2.37) to have significantly increased odds of stroke during CBT surgery. CONCLUSIONS: In the present study history of diabetes mellitus, carotid artery disease, and vascular lesion had increased odds of stroke during CBT surgery. Findings are limited by low event rate and even larger cohorts are needed to fully define preventive preoperative strategies for preventing stroke.

Caracterización de la morbilidad de la endarterectomía carotídea / Characterization of the morbidity of carotid endarterectomy

Introducción: El 80 por ciento de los accidentes cerebrovasculares resulta de tipo isquémico y al menos el 20-30 por ciento está provocado por estenosis de la arteria carótida extracraneal. La endarterectomía carotídea tiene como principal objetivo eliminar las placas de ateroma, que son fuentes de émbolos para el encéfalo, y mejorar el flujo sanguíneo a este órgano. Objetivo: Caracterizar la morbilidad de la endarterectomía carotídea en el Hospital General Docente "Enrique Cabrera" desde 2018 hasta 2021. Métodos: Se realizó un estudio de tipo descriptivo y corte transversal a 32 pacientes, a los cuales se les realizó endarterectomía carotídea. La recolección de los datos se efectuó mediante la revisión de historias clínicas. El período de estudio abarcó desde enero de 2018 hasta enero de 2021. Resultados: Predominó el sexo masculino (65,6 por ciento) y la media de edad fue de 68,8 años. Los factores de riesgo más frecuentes resultaron la hipertensión arterial y el tabaquismo con 75 por ciento y 65,6 por ciento, respectivamente. La enfermedad cerebrovascular con secuela mínima constituyó la forma clínica más frecuente en el 40,6 por ciento de los casos. Se encontró asociación estadísticamente significativa entre diabetes mellitus y formas clínicas, y entre enfermedad arterial periférica y la aparición de complicaciones. La carótida izquierda resultó la más afectada con 53 por ciento y el porcentaje de estenosis, entre 70 por ciento y 99 por ciento, se encontró en el 55,9 por ciento de los pacientes. Con mayor frecuencia se presentaron las complicaciones: lesión de nervios craneales (5,8 por ciento) y hematoma cervical (5,8 por ciento). La endarterectomía por eversión se realizó en el 97 por ciento de los casos. Conclusiones: Se demostró la seguridad y el éxito de la endarterectomía carotídea. La mayoría de los pacientes tuvo una evolución satisfactoria, y se presentaron escasas complicaciones y mortalidad nula(AU)

Introduction: 80 percent of strokes result in ischemic type and at least 20-30 percent are caused by stenosis of the extracranial carotid artery. Carotid endarterectomy has as its main objective to remove atheromatous plaques, which are sources of emboli for the brain, and improve blood flow to this organ. Objective: To characterize the morbidity of carotid endarterectomy at the "Enrique Cabrera" General Teaching Hospital from 2018 to 2021. Methods: A descriptive, cross-sectional study was conducted in 32 patients, who underwent carotid endarterectomy. Data collection was carried out by reviewing medical records. The study period spanned from January 2018 to January 2021. Results: The male sex predominated (65.6 percent) and the mean age was 68.8 years. The most frequent risk factors were high blood pressure and smoking with 75 percent and 65.6 percent, respectively. Cerebrovascular disease with minimal sequelae was the most frequent clinical form in 40.6 percent of cases. A statistically significant association was found between diabetes mellitus and clinical forms, and between peripheral arterial disease and the occurrence of complications. The left carotid was the most affected with 53 percent and the percentage of stenosis, between 70 percent and 99 percent, was found in 55.9 percent of patients. The following complications were the most common: cranial nerve injury (5.8 percent) and cervical hematoma (5.8 percent). Eversion endarterectomy was performed in 97 percent of cases. Conclusions: The safety and success of carotid endarterectomy were demonstrated. Most of the patients had a satisfactory evolution, and there were few complications and zero mortality(AU)

Outcomes of Arteriotomy Closure Technique for Carotid Endarterectomy: Bovine Pericardial Patch Closure versus Primary Closure.

INTRODUCTION: The aim of our study was to compare the primary closure (PRC) and patch angioplasty closure (PAC) of carotid artery following carotid endarterectomy (CEA). METHODS: Data of patients who underwent CEA in the period from January 2005 to June 2020 were reviewed through files. Demographic characteristics, information about the operation, and postoperative follow-up outcomes of the patients were compared. RESULTS: Of the 144 CEA cases included in the study, PRC and PAC were applied to 62 (43.7%) and 82 (56.3%) patients, respectively, for the carotid artery closure. Duration of surgery and carotid artery clamping time were not different between the PRC and PAC groups (106.73±17.13 minutes vs. 110.48±20.67 minutes, P=0.635; 24.25±11.56 minutes vs. 25.19±8.99 minutes, P=0.351, respectively). Postoperative respiratory impairment was more common in the PRC group (P=0.012); however, nerve injuries (P=0.254), surgical wound hematomas (P=0.605), surgical site infections (P=0.679), and mortality (P=0.812) were not significantly different between the groups. During the mean patient follow-up time of 26.13±19.32 months, restenosis was more common in the PRC group than in the PAC group (n=26, 41.9% vs. n=4, 4.9%, respectively; P=0.003). Frequencies of stroke (n=4, 2.8% vs. n=2, 2.4%, respectively; P=0.679), transient ischemic attacks (n=2, 1.4% vs. n=0, 0%, respectively; P=0.431), and mortality (n=4, 6.5% vs. n=4, 4.9%, respectively; P=0.580) were not significantly different between the PRC and PAC groups. CONCLUSION: We are of the opinion that the PAC method is effective and safe for carotid artery closure in patients undergoing CEA.

Short-Term Outcomes of Transfemoral Carotid Artery Stenting and Carotid Endarterectomy in Symptomatic Patients: Data from a Multicentric Prospective Registry in Brazil.

BACKGROUND: Transfemoral carotid artery stenting (TF-CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. Because their main objective is to prevent future ischemic events, regular reassessment of the outcomes is mandatory for providing the best therapy. The purpose of this study was to describe the practice and the outcomes of TF-CAS and CEA in symptomatic patients in public university hospitals in Brazil, using data from a prospective multicentric registry. METHODS: A prospective 8-year observational study of patients with symptomatic carotid artery atherosclerotic disease that underwent TF-CAS and CEA in 5 public university hospitals affiliated with the RHEUNI (Registry Project of Vascular Disease in the Public University Hospitals of São Paulo). All consecutive procedures were included. The indications for the procedures were determined by each surgeon's individual discretion, in accordance with a preoperative risk evaluation. The outcome measures were any 30-day follow-up death, stroke, myocardial infarction (MI), and their combined outcome (major adverse cardiovascular events [MACE]). The registration of the study was made at clinicaltrials.gov NCT02538276. RESULTS: From January 2012 through December 2019, 376 consecutive and symptomatic patients were included in the study records. There were 152 TF-CAS procedures (40.4%) and 224 CEA procedures (59.5%). All completed the 30-day follow-up period. Occurrence of death (TF-CAS: 0.66% × CEA: 0.66%, P = 0.99), stroke (TF-CAS: 4.61% × CEA: 4.46%, P = 0.99), and MI (TF-CAS: 0.66% × CEA: 0%, P = 0.403) were similar in both groups, without statistically significant differences. MACE rate did not differ in both groups (TF-CAS: 5.92% × CEA: 4.46%, P = 0.633). CONCLUSIONS: Data from a prospective registry of 5 Brazilian university hospitals showed that TF-CAS and CEA in symptomatic patients had similar 30-day perioperative rates of death, stroke, and MI and their combination.

Impact of implementing good care and management practice guidelines in carotid revascularization procedures.

BACKGROUND: Studies assessing the effect of implementing good practice management guidelines (GPMG) in carotid revascularization within the same hospital are scarce. Thus, we aimed to evaluate the impact of GPMG implementation on the clinical outcomes of carotid revascularization procedures within a quaternary hospital. METHOD: We retrospectively studied 177 patients with atherosclerotic carotid disease who underwent revascularization (carotid endarterectomy and carotid artery stenting) at a quaternary hospital between January 2012 and December 2019. The patients were divided into two groups: the pre-guideline group with 73 patients and the post-guideline group with 104 patients who underwent the procedures before and after the implementation of GPMG, respectively. RESULTS: Twelve (16.4%) and 3 (2.9%) patients had neurological complications in the pre- and post-guideline groups, respectively (p = 0.001); most complications were cases of ischemic stroke. There were fewer complications in men than in women (OR = 0.22; 95% CI 0.06-0.77). A significant decrease in neurological complications was observed in the carotid artery stenting group (pre-guideline 25.7% vs post-guideline 13.2%; p = 0.004). Logistic regression analysis of the predisposing factors for neurological complications in carotid endarterectomy and carotid artery stenting demonstrated that the implementation of GPMG was a determining factor for the improved results (odds ratio = 0.11, 95% CI 0.02-0.59). CONCLUSIONS: Implementing GPMG for carotid revascularization resulted in better clinical results, with decreased neurological complications in patients that underwent angioplasty and endarterectomy.

A systematic review of cognitive function after carotid endarterectomy in asymptomatic patients.

OBJECTIVE: Asymptomatic carotid stenosis has been associated with a progressive decline in neurocognitive function. However, the effect of carotid endarterectomy (CEA) on this process is poorly understood. We aimed to evaluate preoperative and postoperative cognitive function changes in asymptomatic patients after CEA. METHODS: A systematic review of the existing reports in PubMed/MEDLINE, Embase, and Cochran databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement recommendations. All original retrospective or prospective studies (including cohort, cross-sectional, case-control, pilot studies, etc) and clinical trials that compared pre and postoperative neurocognitive function in asymptomatic patients with carotid stenosis after CEA, which were published from January 2000 to April 2021 were identified and considered eligible for inclusion in the study. RESULTS: Thirteen studies (502 CEAs) comparing cognitive function changes before and after CEA were identified. In 7 studies with a total 272 patients, a mean age range of 67.3 ± 4.8 to 76.35 years old, and follow-up ranging between 1 and 12 months, overall cognitive function improved after CEA. However, in 6 studies with a total sample of 230, a mean age range of 68.6 ± 6.9 to 74.4 ± 6.1 years, and follow-up ranged from 24 hours to 3 years, showed no change or decline in overall cognitive function after procedures. CONCLUSIONS: The lack of standardization of specific cognitive tests and cognitive function assessment timing after CEA does not allow for definite conclusions to be made. However, improving brain perfusion with a combination of CEA and statin therapy may be a protective strategy against cognitive function decline.

Asymptomatic Preoperative Leukocytosis Before Carotid Endarterectomy is Associated With Increased Risk of Stroke: A Study From NSQIP Database.

BACKGROUND: Carotid endarterectomy (CEA) is the gold standard operation for treating carotid artery stenosis in patients with symptomatic carotid stenosis of more than 50% and asymptomatic carotid stenosis of more than 80%. Asymptomatic leukocytosis before CEA represents a clinical dilemma for surgeons about the management options. The objectives of this study are to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in patients undergoing CEA and to assess the relationship between asymptomatic preoperative leukocytosis and postoperative complications in the cohort of patients with symptomatic carotid stenosis. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database for the years 2011-2019 was utilized for this analysis. Patients with preoperative sepsis, septic shock, pneumonia, wound infections, disseminated cancer, renal failure, and history of chronic steroid use were excluded. The remaining patients were sub-grouped based on white blood cell (WBC) count: Normal WBC (<11k/µL) and High WBC (≥11k/µL). Bivariate analysis between the patient characteristics and preoperative WBC levels was performed following simple and multiple regression analysis. A P-value of <0.05 was set as significant. RESULTS: Of the 26,332 patients in the study cohort, 7.4% (n =1,946) had preoperative leukocytosis. Patients with preoperative leukocytosis were relatively younger (mean age: 41.5 +/- 9.7 vs 44.3 +/- 9.1; P< 0.001) and more likely to be females (43% vs. 38.5; P< 0.001) than patients with normal WBC count. Patients with preoperative leukocytosis were also more likely to have DM, COPD, a bleeding disorder, be smokers, and be functionally dependent. The analysis revealed that patients with preoperative leukocytosis had a significantly higher rate of stroke, length of stay (LOS)>1- week, acute occlusion or revision, acute renal failure, and return to OR when compared to patients with normal WBC count. Furthermore, patients with high WBC count also experienced higher occurrences of infectious complications, such as wound dehiscence, wound infections, pneumonia, and sepsis. However, there was no difference in the overall 30-day mortality. Multivariate regression analysis showed patients with preoperative leukocytosis had anincreased risk of stroke (AOR 1.5, CI: 1.1-1.9, P = 0.009), LOS>1 week (AOR 1.3, CI: 1.1-1.5, P = 0.003), and return to OR (AOR 1.3, CI: 1.0-1.8, P = 0.030). The increased LOS was especially more pronounced in symptomatic carotid stenosis patients with preoperative leukocytosis. The occurrence of LOS>1 week was 4.91% in asymptomatic stenosis patients with high WBC count compared to 21.5% in symptomatic stenosis patients with high WBC count (P< 0.001). CONCLUSIONS: Patients with asymptomatic preoperative leukocytosis undergoing CEA have a significantly higher risk of stroke and infectious complications in the postoperative period. Furthermore, patients with symptomatic carotid disease are especially at an increased risk of prolonged LOS. A routine preoperative hematological evaluation may be recommended as a risk assessment tool for patients undergoing CEA, and postponing the elective operation in patients with asymptomatic CEA may be advised unless a thorough preoperative infectious workup is completed.

The Effect of Hemodynamic Parameters on Cerebral Oxygenization During Carotid Endarterectomy.

OBJECTIVE/INTRODUCTION: Near-infrared spectroscopy (NIRS) is a non-invasive technique to detect cerebral ischemia by monitoring changes in regional cerebral oxygenation (rSO2) in the frontal lobes. However, there are no studies showing the changes in NIRS values in response to hemodynamic variations during stages of carotid endarterectomy (CEA) procedure and clinical implications of these changes. The aim of this study was to determine if hemodynamic changes affect NIRS values during carotid endarterectomy and if our results may help to provide strategies for hemodynamic management in these patients. METHODS: A total of 50 consecutive patients undergoing CEA were prospectively included in the study. NIRS was measured at first minute after clamping of carotid artery, and then systolic blood pressure was increased above 150 mmHg. NIRS values from both hemispheres were recorded simultaneously at certain time points and were analyzed to evaluate the changes at different stages of operation and to assess correlations with hemodynamic parameters. RESULTS: NIRS values on the right and left sides were correlated with systolic (right P<0.001, R2:0.24; left P=0.02, R2:0.10) diastolic (right P<0.001, R2:0.36; left P=0.001, R2:0.18) and mean (right P<0.001, R2:0.33; left P=0.003, R2:0.17) blood pressures when the patient was under general anaesthesia. NIRS values were significantly lower than pre-incision values just after clamping of carotid artery in both hemispheres (P=0.005 for the right and P<0.001 for the left side). CONCLUSION: NIRS values measured in our study show that there is a correlation between hemodynamic changes and cerebral oxygenation. This effect is especially pronounced while the patient is asleep and intubated, which implies the importance of close monitoring of patients with carotid disease during any surgery requiring general anaesthesia.

Endarterectomía de carótida bilateral en un mismo tiempo quirúrgico / Bilateral carotid endarterectomy at the same surgical time

Los pacientes con estenosis bilateral presentan una elevada incidencia de clínica hemisférica e infartos cerebrales en relación con la primera carótida y en espera de una segunda cirugía de la carótida contralateral estenótica. La endarterectomía de carótida bilateral en un mismo tiempo quirúrgico representa todo un reto para el cirujano vascular por las complicaciones que puede conllevar. Pero puede realizarse una correcta selección del paciente con bajo riesgo quirúrgico, un análisis de la localización y las características de las placas que provocan la estenosis, y una técnica analgésica que permita monitorear constantemente la disfunción cerebral y siga los principios técnicos. Este estudio tuvo el objetivo de asociar los criterios anteriores a un caso de la endarterectomía de carótida bilateral en un mismo tiempo quirúrgico. Se seleccionó un paciente masculino de 72 años que había sufrido ataques transitorios de isquemia sin secuelas neurológicas. Se realizó el procedimiento sin complicaciones perioperatorias ni posoperatorias, por lo que se propone como una alternativa segura a llevar a cabo en pacientes con estenosis bilateral(AU)

Patients with bilateral stenosis have a high incidence of hemispheric clinical and cerebral infarctions in relation to the first carotid and waiting for a second surgery of the stenotic contralateral carotid. Bilateral carotid endarterectomy at the same surgical time represents a challenge for the vascular surgeon because of the complications it can entail. But a correct selection of the patient with low surgical risk can be made, an analysis of the location and characteristics of the plaques that cause stenosis, and also an analgesic technique that allows constant monitoring of brain dysfunction and follows technical principles. This study aimed to associate the above criteria with a case of bilateral carotid endarterectomy at the same surgical time. A 72-year-old male patient who had suffered transient ischemic attacks without neurological sequelae was selected. The procedure was performed without perioperative or postoperative complications, so it is proposed as a safe alternative to be carried out in patients with bilateral stenosis(AU)

Epidemiological Analysis of 37,424 Carotid Artery Stenosis Intervention Procedures During 11 Years in the Public Health System in Brazil: Stenting has Been More Common Than Endarterectomy.

BACKGROUND: Stroke is a leading cause of death worldwide, with carotid atherosclerosis accounting for 10-20% of cases. In Brazil, the Public Health System provides care for roughly two-thirds of the population. No studies, however, have analysed large-scale results of carotid bifurcation surgery in Brazil. METHODS: This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2019 in the country through web scraping of publicly available databases. RESULTS: Between 2008 and 2019, 37,424 carotid bifurcation revascularization procedures were performed, of which 22,578 were CAS (60.34%) and 14,846 (39.66%) were CEA. There were 620 in-hospital deaths (1.66%), 336 after CAS (1.48%) and 284 after CEA (1.92%) (P = 0.032). Governmental reimbursement was US$ 77,216,298.85 (79.31% of all reimbursement) for CAS procedures and US$ 20,143,009.63 (20.69%) for CEA procedures. The average cost per procedure for CAS (US$ 3,062.98) was higher than that for CEA (US$ 1,430.33) (P = 0.008). CONCLUSIONS: In Brazil, the frequency of CAS largely surpassed that of CEA. In-hospital mortality rates of CAS were significantly lower than those of CEA, although both had mortality rates within the acceptable rates as dictated by literature. The cost of CAS, however, was significantly higher. This is a pioneering analysis of carotid artery disease management in Brazil that provides, for the first time, preliminary insight into the fact that the low adoption of CEA in the country is in opposition to countries where utilization rates are higher for CEA than for CAS.

Preoperative Dependent Functional Status Is Associated With Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients.

BACKGROUND: Both Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the most common procedures to treat patients with symptomatic, and asymptomatic high-grade carotid stenosis. Poor preoperative functional status (FS) is increasingly being recognized as predictor for postoperative outcomes. The purpose of this study is to determine the impact of preoperative functional status on the outcomes of patients who undergo CEA or CAS. METHODS: Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from the years 2011-2018. All patients in the database who underwent CEA or CAS during this time period were identified. Patients were then further divided into 2 subgroups: FS-Independent and FS-dependent. Bivariate and multivariate analyses was performed for pre, intra and post-operative variables with functional status. Outcomes for treatment of symptomatic carotid disease were compared to those with asymptomatic disease among the cohort of functionally dependent patients. RESULTS: A total of 27,163 patients (61.2% Males, 38.8% Females) underwent CEA (n = 26,043) or CAS (n = 1,120) from 2011-2018. Overall, primary outcomes were as follows: mortality 0.77% (n = 210) and stroke 1.87% (n = 507).Risk adjusted multivariate analysis showed that FS-D patients undergoing CEA had higher mortality (AOR 3.06, CI 1.90-4.92, P < 0.001), longer operative times (AOR 1.36, CI 1.17-1.58, P< 0.001) higher incidence of unplanned reoperation (AOR 1.68, CI 1.19-2.37, P = 0.003), postoperative pneumonia (AOR 5.43, CI 1.62 - 18.11, P = 0.006) and ≥3 day LOS (AOR 3.05, CI 2.62-3.56, P < 0.001) as compared to FS-I patients. FS-D patients undergoing CAS had higher incidence of postoperative pneumonia (AOR 20.81, CI 1.66-261.54, P = 0.019) and higher incidence of LOS ≥3 days (AOR 2.18, CI 1.21-3.93, P < .01) as compared to FS-I patients. Survival analysis showed that the best 30-day survival was observed in FS-I patients undergoing CEA, followed by FS-I patients undergoing CAS, followed by FS-D patients undergoing CEA, followed by FS-D patients undergoing CAS. FS-D status increased mortality after CEA by 2.11%. When the outcomes of CAS and CEA were compared to each other for the cohort of FS-D patients, CAS was associated with higher incidence of stroke (AOR 3.46, CI 0.32-1.97, P= 0.046), shorter operative times (AOR 0.25, CI 0.12-0.52, P < 0.001) and higher incidence of pneumonia (AOR 11.29, CI 1.32-96.74, P = 0.027). Symptomatic patients undergoing CEA had higher LOS as compared to symptomatic patients undergoing CAS, and asymptomatic patients undergoing CEA or CAS. CONCLUSIONS: FS-D patients, undergoing CEA have higher mortality as compared to FS-I patients undergoing CAS. FS-D patients undergoing CAS have higher incidence of postoperative pneumonia and longer LOS as compared to FS-I patients. For the cohort of FS-D patients undergoing either CEA or CAS, CAS was associated with higher risk of stroke and reduced operative times. Risk benefit ratio for any carotid intervention should be carefully assessed before offering it to FS-D patients. Preoperative Dependent Functional Status Is Associated with Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients.

Evaluation of Factors Associated with, and Outcomes for Patients with Nonhome Discharge Destinations Following Carotid Endarterectomy.

INTRODUCTION: Following a carotid endarterectomy (CEA) procedure, patients are discharged to their homes or other locations than home such as an acute care facility or skilled nursing facility based on their functional status and level of medical attention needed. Decision-making for discharge destination following a CEA to home or nonhome locations is important due to the differences in survival and postoperative complications. While primary outcomes such as mortality and occurrence of stroke following CEA have been extensively studied, there is a paucity of information characterizing outcomes of discharge destination and the factors associated. The purpose of this study was to explore the factors associated with discharge to nonhome destinations after CEA, and outcomes after discharge. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent CEA from 2011 to 2018. Patients were divided into two groups based on their discharge destination (home versus nonhome). Univariate and multivariate analysis were performed for preoperative and intraoperative factors associated with different discharge destinations. Postoperative complications associated with discharge to nonhome destinations were analyzed and mortality after discharge from hospital was compared between the 2 groups. RESULTS: A total of 25,094 patients met the criteria for inclusion in the study, of which 39% were females and 61% were males; median age was 71 years. Twenty four thousand one hundred twenty-five patients (93.13%) were discharged to home (Group I) and 1,779 (6.87%) were discharged to nonhome destinations (Group II). Following preoperative and intraoperative factors were associated with discharge to nonhome locations: older age, diabetes mellitus, functional independent status, transfer from other hospitals, symptomatic status, need for preoperative blood transfusions, severe ipsilateral carotid stenosis, elective CEA, need for intraoperative shunt and general anesthesia (all P< 0.05). Following postoperative complications had statistically significant association with discharge to nonhome destinations: postoperative blood transfusion, pneumonia, unplanned intubation, longer than 48 hours on ventilator, development of stroke, myocardial infarction, deep vein thrombosis, and sepsis (all P< 0.05). Mortality after discharge from hospital was 0.39% (n = 100). Mortality among those who were discharged to home was 0.29% vs. 1.63% for those who were discharged to nonhome locations (P< 0.05). CONCLUSIONS: Majority of the patients after CEA are discharged back to their homes. This study identifies the factors which predispose patients discharged to locations, other than home. Patients who are not discharged home have higher mortality as compared to those who are discharged to their homes.