The effect of the collateral cerebrovascular circulation on tolerance to carotid artery cross-clamping and on early outcome after carotid endarterectomy.

BACKGROUND: The Circle of Willis (CoW) serves as the primary source of contralateral blood supply in patients who undergo carotid artery cross-clamping (CC) for carotid endarterectomy (CEA). It has been suggested that CoW's anatomy influences CEA outcomes. The aim of this study was to evaluate associations between the cerebral collateral circulation, a positive awake test for intraoperative neurologic deficit after carotid CC and postoperative adverse neurologic events. METHODS: A systematic review was conducted searching MEDLINE, Cochrane and Web of Science databases for studies that assessed the cerebral circulation, including CoW variations, using neuroimaging techniques in patients who underwent carotid CC. For the metanalytical incidence, the statistical technique used was weight averaging. Otherwise, descriptive analysis was used due to the excessive heterogeneity of the studies. RESULTS: Eight publications, seven cohort and one case-controlled study, involving 1313 patients who underwent carotid artery cross-clamping under LRA were included in the systematic review. The incidence of positive awake test in the cohort studies ranged from 4.4% to 19.7%. Carotid artery cross-clamping (CC) resulted in positive awake test in 5% to 91% of patients with alterations in the anterior portion and in 27% to 74% with alterations in the posterior portion of the Circle of Willis. A positive awake test in patients with contralateral carotid stenosis or occlusion ranged from 5.8% to 45.7%. Contralateral carotid stenosis >70% or occlusion were associated with a positive awake test (P <.001). Patients with incomplete CoW did not have statistically significant correlation with intraoperative neurological deficits after CC. Data were insufficient to evaluate the effect of the collateral circulation on early outcome after CEA. CONCLUSION: In this systematic review, contralateral carotid artery stenosis or occlusion but not CoW abnormalities were associated with a positive awake test after carotid artery CC. Further research is needed to evaluate which specific CoW anomaly predicts neurologic deficit after CC and to confirm association between a positive awake test and clinical outcome after CEA.

Short-term outcomes after selective shunt during carotid endarterectomy: A propensity score matching analysis / Resultados a corto plazo después de shunting selectivo durante la endarterectomía carotídea con anestesia regional: un análisis de propensity score-matching

Introduction and objectives: Carotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. Material and methods: From January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. Results: Ninety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien–Dindo≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). Conclusions: In this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien–Dindo≥2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.(AU)

Introducción y objetivos: El pinzamiento carotídeo durante la endarterectomía carotídea podría provocar déficits neurológicos intraoperatorios, lo que aumenta el riesgo de accidente cerebrovascular/muerte. Si se detectan déficits, se ha recomendado la derivación carotídea para reducir el riesgo de accidente cerebrovascular. Sin embargo, la derivación puede sostener una posibilidad específica de eventos embólicos y, posteriormente, provocar daños. La evidencia actual aún es cuestionable con respecto a su claro beneficio. El objetivo es determinar si una política de derivación selectiva afecta la tasa de complicaciones después de una endarterectomía. Material y métodos: Desde enero de 2013 hasta mayo de 2021 se recuperaron todos los pacientes sometidos a endarterectomía carotídea bajo anestesia regional con alteración neurológica intraoperatoria. Los pacientes sometidos a derivación selectiva se compararon con un grupo sin derivación. Se realizó una coincidencia de puntuación de propensión (PSM) 1:1. Se calcularon las diferencias entre los grupos y los resultados clínicos recurriendo al análisis univariado. Resultados: Se seleccionaron 98 pacientes, de los cuales 23 fueron intervenidos mediante derivación. Después de la PSM se compararon 22 pacientes sin derivación con 22 pacientes emparejados con derivación. Con respecto a la demografía y las comorbilidades, ambos grupos fueron comparables a los de antes y después de la PSM, excepto por la insuficiencia cardíaca crónica, que fue más prevalente en los pacientes con derivación (26,1%, p=0,036) en el análisis previo a la PSM. En cuanto al accidente cerebrovascular a los 30 días y la puntuación de Clavien-Dindo≥2, no se encontró asociación significativa (p=0,730, p=0,635 y p=0,942, p=0,472, correspondientemente, para pre y post-PSM). Conclusiones: En esta cohorte recurrir a la derivación no demostró una ventaja con respecto a las tasas de ictus a los 30 días o Clavien-Dindo≥2...(AU)

Polyvascular Disease Influences Long-Term Cardiovascular Morbidity in Carotid Endarterectomy.

INTRODUCTION/OBJECTIVE: Carotid stenosis (CS) is an important cause of ischemic stroke. Secondary prevention lies in performing a carotid endarterectomy (CEA) procedure, the recommended treatment in most cases. When 2 or more vascular regions are simultaneously affected by atherosclerosis, mainly the carotid arteries, coronary arteries, or limb arteries, a multivessel disease polyvascular disease (PVD) is present. This study aims to assess the potential role of PVD as a long-term predictor of major adverse cardiovascular events (MACE) and all-cause mortality in patients submitted to CEA. METHODS: From January 2012 to December 2021, patients submitted to CEA for carotid stenosis in a tertiary care and referral center were eligible from a prospective database. A posthoc survival analysis was performed using the Kaplan-Meier survival curve method. The primary outcome was the incidence of long-term MACE and all-cause mortality. Secondary outcomes included acute myocardial infarction (AMI), major adverse limb events (MALE), stroke, and acute heart failure (AHF). RESULTS: A total of 207 patients were enrolled, with a median follow-up of 63 months. The mean age was 70.4 ± 8.9, and 163 (78.7%) were male. There were 65 (31.4%) patients that had 2 arterial vascular territories affected, and 29 (14.0%) patients had PVD in 3 arterial beds. On multivariable analysis, both MACE and all-cause mortality had as independent risk factors age (aHR 1.039, P = 0.003; aHR 1.041, P = 0.019), chronic kidney disease (aHR 2.524, P = 0.003; aHR 3.377, P < 0.001) and PVD2 (aHR 3.381, P < 0.001; aHR 2.665, P = 0.013). PVD1 was only associated with MACE as a statistically significant risk factor (aHR 2.531, 1.439-4.450, P < 0.001). CONCLUSIONS: PVD in patients with cerebrovascular disease (CVD) was revealed to carry a 2-fold increased risk for all-cause mortality and MACE during long-term follow-up. PVD may be a simple yet valuable tool in predicting all-cause mortality, MACE, AMI, and MALE after CEA.

Hyperfunctioning papillary thyroid carcinoma - a case report and literature review.

BACKGROUND: Malignant hyperfunctioning thyroid nodules are rare and more likely to occur in follicular cancer types rather than papillary variants. The authors present a case of a papillary thyroid carcinoma associated with a hyperfunctioning nodule. METHODS: A single adult patient submitted to total thyroidectomy with the presence of thyroid carcinoma within hyperfunctioning nodules was selected. Additionally, brief literature was conducted. RESULTS: An asymptomatic 58-year-old male was subjected to routine blood analysis and a TSH level of <0.003 mIU/L was found. Ultrasonography revealed a 21 mm solid, hypoechoic, and heterogenous nodule with microcalcifications in the right lobe. A fine needle aspiration guided by ultrasound resulted in a follicular lesion of undetermined significance. A 99mTc thyroid scintigram was followed and identified a right-sided hyperfunctioning nodule. Another cytology was performed and a papillary thyroid carcinoma was derived as a result. The patient underwent a total thyroidectomy. Postoperative histology confirmed the diagnosis and a tumor-free margin with no vascular or capsular invasions. CONCLUSION: Hyperfunctioning malignant nodules are a rare association, although a careful approach should be led since major clinical implications arise. Selective fine needle aspiration in all suspicious ≥1 cm nodules should be considered.

Catheter-Directed Thrombolysis Protocols for Deep Venous Thrombosis of the Lower Extremities-A Systematic Review and Meta-analysis.

OBJECTIVE: To summarize characteristics, complications, and success rates of different catheter-directed thrombolysis (CDT) protocols for the treatment of lower extremity deep venous thrombosis (LE-DVT). METHODS: A systematic review using electronic databases (MEDLINE, Scopus, and Web of Science) was performed to identify randomized controlled trials and observational studies related to LE-DVT treated with CDT. A random-effects model meta-analysis was performed to obtain the pooled proportions of early complications, postthrombotic syndrome (PTS), and venous patency. RESULTS: Forty-six studies met the inclusion criteria reporting 49 protocols (n = 3,028 participants). In studies that addressed the thrombus location (n = 37), LE-DVT had iliofemoral involvement in 90 ± 23% of the cases. Only four series described CDT as the sole intervention for LE-DVT, while 47% received additional thrombectomy (manual, surgical, aspiration, or pharmacomechanical), and 89% used stenting.Definition of venogram success was highly variable, being the Venous Registry Index the most used method (n = 19). Among those, the minimal thrombolysis rate (<50% lysed thrombus) was 0 to 53%, partial thrombolysis (50-90% lysis) was 10 to 71%, and complete thrombolysis (90-100%) was 0 to 88%. Pooled outcomes were 8.7% (95% confidence interval [CI]: 6.6-10.7) for minor bleeding, 1.2% (95% CI: 0.8-1.7%) for major bleeding, 1.1% (95% CI: 0.6-1.6) for pulmonary embolism, and 0.6% (95% CI: 0.3-0.9) for death. Pooled incidences of PTS and of venous patency at up to 1 year of follow-up were 17.6% (95% CI: 11.8-23.4) and 77.5% (95% CI: 68.1-86.9), respectively. CONCLUSION: Assessment of the evidence is hampered by the heterogeneity of protocols, which may be reflected in the variation of PTS rates. Despite this, CDT is a low-risk treatment for LE-DVT.

Short-term outcomes after selective shunt during carotid endarterectomy: a propensity score matching analysis.

INTRODUCTION AND OBJECTIVES: Carotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy. MATERIAL AND METHODS: From January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis. RESULTS: Ninety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien-Dindo ≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM). CONCLUSIONS: In this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien-Dindo ≥ 2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.

Incidence of myocardial injury in patients submitted to carotid endarterectomy.

Myocardial injury following noncardiac surgery (MINS) is associated with higher mortality and major adverse cardiovascular event rates in the short- and long-term in patients undergoing carotid endarterectomy (CEA). However, its incidence is still unclear in this subset of patients. Therefore, this systematic review with meta-analysis aims to determine the incidence of MINS in patients undergoing CEA. Three electronic databases MEDLINE, Scopus, and Web of Science were used to search for studies assessing the occurrence of MINS in the postoperative setting of patients undergoing CEA. The incidence of MINS was pooled by random-effects meta-analysis, with sources of heterogeneity being explored by meta-regression and subgroup analysis (general anesthesia vs. regional anesthesia). Assessment of studies' quality was performed using National Heart, Lung, and Blood Institute Study Quality Assessment Tool, and Risk of Bias 2 tools. Twenty studies were included, with a total of 117,933 participants. Four of them were RCTs, while the remaining were cohort studies. All observational cohorts had an overall high risk of bias, except for Pereira Macedo et al. Three of them had repeated population, thus only data from the most recent one was considered. On the other hand, all RCT had an overall low risk of bias. In patients under regional anesthesia, the incidence of MINS in primary studies ranged between 2% and 15.3%, compared to 0-42.5% for general anesthesia. The meta-analytical incidence of MINS after CEA was of 6.3% [95% CI 2.0-10.6%], but severe heterogeneity was observed (I2=99.1%). MINS appears to be relatively common among patients undergoing CEA. The observed severe heterogeneity points to the need for further larger studies adopting consistent definitions of MINS and equivalent cut-off values.

International Union of Angiology consensus document on vascular compression syndromes.

Vascular compression syndromes (VCS) are rare diseases, but they may cause significant symptoms interfering with the quality of life (QoL) of patients who are often in their younger age. Given their infrequent occurrence, multiform clinical and anatomical presentation, and absence of dedicated guidelines from scientific societies, further knowledge of these conditions is required to investigate and treat them using modern imaging and surgical (open or endovascular) techniques. This consensus document will focus on known VCS, affecting the arterial and venous system. The position paper, written by members of International Union of Angiology (IUA) Youth Committee and senior experts, will show an overview of pathophysiology, diagnostic, and therapeutical approaches for patients with VCS. Furthermore, this document will provide also unresolved issues that require more research that need to be addressed in the future.

Risk Of Venous Thrombosis In The Primary Care Setting During The Covid-19 Pandemic.

AIMS: This study aimed to evaluate the variability of risk factors among patients with lower limb venous thrombosis, either Deep Vein Thrombosis (DVT) or Superficial Vein Thrombosis (SVT) in community patients with recent or current SARS-CoV-2 infection compared to a historical cohort. METHODS: We performed a historical retrospective analysis of all patients who presented to a primary health care unit and were diagnosed with DVT or SVT from January 2020 to December 2021. Historic controls were selected from January 2018 to December 2019. Demographic and clinical data were collected, including BMI, use of oral combined contraception, smoking status and date of COVID-19 infection diagnosis. Univariate analysis was performed for data assessment, including Chi-Square and ANOVA tests. RESULTS: Of the 8547 patients who attended a non-programmed consultation in the timeframe, seventy-nine patients (0.9%) were diagnosed with DVT (19) or SVT (60) and were included in the study. Their mean age was 57.3 ± 15.93 years, with a female-to-male ratio of 3.2 to 1. There was no significant association between COVID-19 and the development of DVT or SVT (p=0.151). However, there was a trend observed indicating a shift in the predominant gender in patients diagnosed with these conditions (85% females in 2018 versus 53.8% in 2021; p=0.077). CONCLUSIONS: Outpatients seen by general practitioners during the pandemic of COVID-19 appear to present a trend towards an increased risk of combined DVT and SVT compared with patients of a historical cohort. Further studies are necessary to shed some light on this issue since robust evidence enables clinicians and policymakers to minimize venous thromboembolism risk in patients with SARS-CoV-2 infection.

Carotid stenting: Does stent design matter?

BACKGROUND: Carotid artery stenting (CAS) is considered an important tool in carotid revascularization. Carotid artery stenting is usually performed by using self-expandable stent with different designs. The stent design influences many physical characteristics. Also, it may affect the complication rate with special relevance to perioperative stroke, hemodynamic instability, and late restenosis. METHODS: This study comprised all consecutive patients who underwent carotid artery stenting for atherosclerotic carotid stenosis from March 2014 to May 2021. Both symptomatic patient and asymptomatic patients were included. Patients with a symptomatic carotid stenosis of ≥50% or asymptomatic carotid stenosis of ≥60% were selected for carotid artery stenting . Patients with fibromuscular dysplasia and acute or unstable plaque were not included. Variables of clinical relevance were tested in multivariable analysis using binary logistic regression model. RESULTS: A total of 728 patients were enrolled. The majority of this cohort was asymptomatic (578/728, 79.4%), while 150/728 (20.6%) were symptomatic. The mean degree of carotid stenosis was 77.82 ± 4.73%, with a mean plaque length of 1.76 ± 0.55 cm. A total of 277 (38%) patients were treated with Xact® Carotid Stent System. Successful carotid artery stenting was achieved in 698 (96%) of patients. Of these patients, stroke rate in symptomatic patients was nine (5.8%), while in asymptomatic patients was 20 (3.4%). In a multivariable analysis, the open-cell carotid stent was not associated with a differential risk for combined acute and sub-acute neurologic complications as compared with closed-cell stents. Patients treated with open cell stents had a significantly lower rate of procedural hypotension (P 0.0188) at bivariate analysis. CONCLUSION: Carotid artery stenting is considered a safe alternative to CEA that can be used in selected average surgical risk patient. Different stent designs can affect the rate of major adverse events in carotid artery stenting patients, but further studies are necessary with avoiding different bias to study the effect of different stent designs.

R2CHA2DS2-VA Predictsthe Cardiovascular Risk after Carotid Endarterectomy.

BACKGROUND: R2CHA2DS2-VA score has been used to predict short and long-term outcomes in many cardiovascular diseases. This study aims to validate the R2CHA2DS2-VA score as a long-term major adverse cardiovascular events (MACE) predictor after carotid endarterectomy (CEA). Secondary outcomes were also assessed regarding the incidence of all-cause mortality, acute myocardial infarction (AMI), major adverse limb events (MALE), and acute heart failure (AHF). METHODS: From January 2012 to December 2021, patients (n = 205) from a Portuguese tertiary care and referral center that underwent CEA with regional anesthesia (RA) for carotid stenosis (CS) were selected from a previously collected prospective database, and a posthoc analysis was performed. Demographics and comorbidities were registered. Clinical adverse events were assessed 30 days after the procedure and in the subsequent long-term surveillance period. Statistical analysis was performed by the Kaplan-Meier method and Cox proportional hazards regression. RESULTS: Of the patients enrolled, 78.5% were males with a mean age of 70.44 ± 8.9 years. Higher scores of R2CHA2DS2-VA were associated with long-term MACE (adjusted hazard ratio (aHR) 1.390; 95% confidence interval (CI) 1.173-1.647); and mortality (aHR 1.295; 95% CI 1.08-1.545). CONCLUSIONS: This study demonstrated the potential of the R2CHA2DS2-VA score to predict long-term outcomes, such as AMI, AHF, MACE, and all-cause mortality, in a population of patients submitted to carotid endarterectomy.

Clinical Characteristics and Predictors of Long-Term Prognosis of Acute Peripheral Arterial Ischemia Patients Treated Surgically.

BACKGROUND: Acute peripheral arterial ischemia is a rapidly developing loss of perfusion, resulting in ischemic clinical manifestations. This study aimed to assess the incidence of cardiovascular mortality in patients with acute peripheral arterial ischemia and either atrial fibrillation (AF) or sinus rhythm (SR). METHODS: This observational study involved patients with acute peripheral ischemia treated surgically. Patients were followed-up to assess cardiovascular mortality and its predictors. RESULTS: The study group included 200 patients with acute peripheral arterial ischemia and either AF (n = 67) or SR (n = 133). No cardiovascular mortality differences between the AF and SR groups were observed. AF patients who died of cardiovascular causes had a higher prevalence of peripheral arterial disease (58.3% vs. 31.6%, p = 0.048) and hypercholesterolemia (31.2% vs. 5.3%, p = 0.028) than those who did not die of such causes. Patients with SR who died of cardiovascular causes more frequently had a GFR <60 mL/min/1.73 m2 (47.8% vs. 25.0%, p = 0.03) and were older than those with SR who did not die of such causes. The multivariable analysis shows that hyperlipidemia reduced the risk of cardiovascular mortality in patients with AF, whereas in patients with SR, an age of ≥75 years was the predisposing factor for such mortality. CONCLUSIONS: Cardiovascular mortality of patients with acute ischemia did not differ between patients with AF and SR. Hyperlipidemia reduced the risk of cardiovascular mortality in patients with AF, whereas in patients with SR, an age of ≥75 years was a predisposing factor for such mortality.

Red blood cell distribution width as a predictor of cardiovascular outcomes in extensive aortoiliac disease.

BACKGROUND: Aortoiliac peripheral artery disease may lead to disabling lower limb claudication or to lower limb chronic threatening ischemia, which is associated with increased short and long-term morbi-mortality. The red blood cell distribution width-coefficient of variation (RDW-CV) has been able to predict outcomes in other atherosclerotic diseases, such as myocardial infarction and stroke. The main objective of this study was to assess the predictive ability of perioperative RDW-CV in accurately predicting short and long-term major adverse cardiovascular events (MACE) and all-cause mortality in patients submitted to aortoiliac revascularization due to extensive aortoiliac atherosclerotic disease. METHODS: From 2013 to 2020, patients who underwent aortoiliac revascularization due to severe aortoiliac disease were included in a prospective cohort. Blood samples were taken preoperatively and the patient's demographics, comorbidities, and postoperative outcomes were assessed. A multivariate Cox regression model was used to adjust for confounding and assess the independent effect of these prognostic factors on the outcomes. RESULTS: The study group included 107 patients. Median follow-up was 57 (95% CI: 34.4-69.6) months. Preoperative RDW-CV was increased in thirty-eight patients (35.5%). Increased RDW-CV was associated with congestive heart failure - adjusted odds ratio of 5.043 (95% CI: 1.436-17.717, P=0.012). It could predict long-term occurrence of MACE (adjusted hazard ratio [aHR] 1.065, 95% CI: 1.014-1.118, P=0.011), all-cause mortality (aHR=1.069, 95% CI: 1.014-1.126, P=0.013), acute heart failure (AHF) (aHR=1.569, 95% CI: 1.179-2.088, P=0.002), and stroke (aHR=1.343, 95% CI: 1.044-1.727, P=0.022). CONCLUSIONS: RDW is a widely available and low-cost marker that was able to independently predict long-term AHF, stroke, MACE, and all-cause mortality in patients with extensive aortoiliac disease submitted to revascularization. This biomarker could help assess which patients would likely benefit from stricter follow-up in the long-term.

The Gupta Perioperative Risk for Myocardial Infarct or Cardiac Arrest (MICA) Calculator as an Intraoperative Neurologic Deficit Predictor in Carotid Endarterectomy.

BACKGROUND: Patients undergoing carotid endarterectomy (CEA) may experiment intraoperative neurologic deficits (IND) during carotid cross-clamping. This work aimed to assess the impact of the Gupta Perioperative Myocardial Infarct or Cardiac Arrest (MICA) risk calculator in the IND. METHODS: From January 2012 to April 2021, patients undergoing CEA with regional anaesthesia for carotid stenosis with IND and consecutively control operated patients without IND were selected. A regressive predictive model was created, and a receiver operating characteristic (ROC) curve was applied for comparison. A multivariable dependence analysis was conducted using a classification and regression tree (CRT) algorithm. RESULTS: A total of 97 out of 194 included patients developed IND. Obesity showed aOR = 4.01 (95% CI: 1.66-9.67) and MICA score aOR = 1.21 (1.03-1.43). Higher contralateral stenosis showed aOR = 1.29 (1.08-1.53). The AUROC curve was 0.656. The CRT algorithm differentiated obese patients with a MICA score ≥ 8. Regarding non-obese patients, the model identified the presence of contralateral stenosis ≥ 55% with a MICA ≥ 10. CONCLUSION: MICA score might play an additional role in stratifying patients for IND in CEA. Obesity was determined as the best discrimination factor, followed by a score ≥ 8. A higher ipsilateral stenosis degree is suggested to have a part in avoiding procedure-related IND. Larger studies might validate the benefit of MICA score regarding the risk of IND.

MANAGEMENT OF THE UPPER LIMB ARTERIOVENOUS MALFORMATIONS.

Arteriovenous malformations (AVMs) involving the upper limb constitute 10% of the total AVMs. In the upper limb, AVMs are more frequent in the hand than in the arm, being the hand one of the body's regions more frequently associated with AVMs, coming after the head and neck. The total prevalence of the upper limb AVMs remains unknown and there is currently no definitive consensus for the treatment of upper limb AVMs. The purpose of this study was to review the best evidence of the treatment for the upper limb AVMs and describe their clinical characteristics and diagnosis. The majority of patients with asymptomatic AVMs follows a conservative management. In the symptomatic patients, the treatment with surgery and or chemical embolization is beneficial. The amputation can be necessary in the case of life-threatening and massive AVMs, constituting the first step in patient's rehabilitation. Although the most common option for the management of symptomatic or functional AVMs is the embolo-sclerotherapy combined with surgery, different outcomes should be taken into account to plan the treatment, specially the presence of symptoms, bleeding and heart failure.

Revised cardiac score index is a predictor of long-term outcomes after carotid endarterectomy.

Background: Cardiac complications represent the main cause of mortality after non-cardiac surgery and the Revised Cardiac Risk Index (RCRI) was created to estimate the perioperative risk of these events. It considers history of ischaemic heart disease, congestive heart failure, diabetes requiring preoperative insulin, stroke or transient ischaemic attack and renal impairment. We aim to describe the accuracy of the RCRI for predicting perioperative major adverse cardiovascular events (MACE) - a composite of heart failure, ischemic events and all-cause death. Also, the authors aimed to review the score for better prediction of cardiovascular outcomes. Patients and methods: From January 2012 to January 2020, patients who underwent Carotid endarterectomy (CEA) with regional anaesthesia (RA) were selected. RCRI was calculated for each case. Estimated and reported cardiovascular complications were compared using multivariate logistic regression and cox proportional hazards. An alternative and optimized carotid-RCRI (CtRCRI) was obtained. Overall predictive accuracy was assessed and compared by measuring model discrimination. Adjustments for overfitting and evaluation of the new model were performed by bootstrap. Results: 186 patients were selected, of which 80% were male with a mean age of 70.0±9.05 years old. The median follow-up was 50 months, interquartile range 21-69 months. None of the scores were able to predict MACE in the perioperative period. Both were associated with 30-day Clavien-Dindo ≥2 (p=0.022 and p=0.041, respectively). Regarding long-term prognosis, both were able to predict MACE (RCRI: hazard ratio (HR) 3.54 (95% confidence interval [CI] 1.04-11.48) vs. CtRCRI: HR 2.08 (95%CI 1.08-3.98) and all-cause mortality (RCRI: HR 3.33, 95%CI 0.99-11.11 vs. CtRCRI: HR 1.57, 95%CI 1.14-7.04). Conclusions: RCRI and CtRCRI did not predict MACE in the perioperative period but are good predictors of 30-day complications (Clavien-Dindo ≥2). Both RCRI and CtRCRI have good prognostic value as predictors of long-term cardiovascular events.