Best Medical Treatment in Patients with Asymptomatic Carotid Stenosis: Myth or Reality?

BACKGROUND: Approximately 1.4 million strokes/year causing about 1.1 million deaths annually occur in Europe and 10%-15% of those strokes are result of thromboembolism from a previously significant asymptomatic carotid stenosis (ACS). Medical treatment has improved considerably in the last 15 years; however, its success depends on patient compliance. The aim of our study was to evaluate, in patients with ACS, the implementation and patient adherence to best medical treatment (BMT). Additionally, we sought to determine the "real-world" incidence of cerebrovascular/coronary events in a cohort of nonoperated ACS patients and weighing this risk against surgical complications in patients with ACS undergoing surgical treatment at our Department. METHODS: Patients with ACS ≥ 60% identified by a carotid ultrasound performed at our Department were retrospectively evaluated. Patients selected to BMT were excluded if the follow-up period was inferior to 2 years, as well as patients lost in follow-up, with missing clinical information and submitted to carotid stenting. Patients' data collection was supported by hospital reporting system and data were introduced into a database created for the purpose. Statistical analysis was performed using SPSS-25 software. RESULTS: After exclusion criteria were applied, the last 120 consecutive patients (60 with ACS submitted do carotid endarterectomy and 60 with ACS under BMT) were retrospectively evaluated. Twenty one patients had ipsilateral events for more than 6 months. Most patients had hypertension (n = 107; 89%), dyslipidemia (n = 101; 84%), 40% had diabetes, 33% diagnosed coronary disease, 32% were overweight or obese, and 17% were current smokers. Blood pressure control, normal weight, statin with/without ezetimibe association, and antiaggregant therapy were only achieved in 33 patients and only 5 had additionally low-density lipoprotein levels < 70 mg/dL, hemoglobin A1c < 7%, and were nonsmokers. Of the 60 patients assigned to medical treatment, 3 (5%) had a stroke at 2 years of follow-up, which was fatal in 1 patient. Among patients submitted to carotid endarterectomy, perioperative stroke was documented in 3% of the patients, none of them disabling or fatal. CONCLUSIONS: Although some recent studies report a risk of ipsilateral stroke of only 0.34% per year in patients with ACS ≥ 50% under BMT therapy in our everyday practice strict compliance to medical treatment fails in most patients. In consequence, we think that a "one-size-fits-all" guideline policy may not be appropriate for all patients and the management of specific ACS patients may need to be individualized.

[The Impact of Patient Transfer After Rupture of an Abdominal Aortic Aneurysm]. / O Impacto da Transferência de Doentes após Rutura de Aneurisma da Aorta Abdominal.

OBJECTIVE: determine whether patient transfer adversely affects the survival of ruptured abdominal aortic aneurysm (rAAA) patients after conventional surgery. METHODS: We performed a retrospective review of all patients undergoing attempted repair of an rAAA at a tertiary center, over January 2008 and December 2014. Patients were divided into those presenting directly to our center and those transferred from another hospital. The main outcome variable was 24-hour or 30-day mortality, with secondary variables including time to surgical treatment, length of intensive care unit stay and total length hospitalization. RESULTS: 78 patients (88% men) underwent attempted open repair of an rAAA during this period, 69% (54 cases) were transferred from another institution. Both groups were similar in terms of demographic characteristics, comorbidities and hemodynamic stability. The overall mortality rate was 51% at 30 days. Transferred patients took twice as long as direct patients to get to the operating room (median 7,9 vs. 3,9 horas, p < 0,05), Although the difference for surgery treatment, there was no difference in 24-hour and 30-day mortality between the transferred group and direct group (26% e 50% vs. 29% e 58%, p < 0,05). Mean intensive care unit stay (median, 12 vs. 4 dias, p = 0,04) and total hospitalization (median 11 vs. 4 dias, p = 0,04) were sustantially superior in the transferred group. CONCLUSIONS: Transfer of patients with RAAA in this series results in a doubling of the time interval between initial patient presentation and arrival in the operating room. This, however, did not result in any disadvantage in the survival rate between the groups. The total length and resources consumption were higher in the transfer group. These results may be attributed to a pre-selection of patients (clinically stable) who are able to tolerate such a delay in surgical treatment, secondary to transfer.

Objetivo: Determinar se a transferência inter-hospitalar afecta adversamente a sobrevida de doentes com rutura de aneurisma da aorta abdominal (rAAA), submetidos a cirurgia convencional. Métodos: Efetuamos uma análise retrospetiva dos rAAA tratados sequencialmente por cirurgia convencional, num centro de referenciação terciária, no período compreendido entre janeiro 2008 e dezembro de 2014. Os casos foram divididos entre os que se apresentram diretamente neste centro e os que foram alvo de transferência. Analisou-se a mortalidade às 24 horas, a mortalidade aos 30 dias e, como outcomes secundários, incluíram-se o tempo de chegada ao bloco operatório, duração de internamento na unidade de cuidados intensivos (UCI) e o tempo de internamento total. Resultados: Neste período, um total de 78 casos (88% do género masculino) foram submetidos a cirurgia convencional por rAAA, 69% (54 casos) transferidos de outra instituição. Ambos os grupos mostraram semelhanças nas características demográficas, bem como no perfil de comorbilidades e estadio de estabilidade hemodinâmica. A mortalidade global foi de 51% aos 30 dias. O tempo de chegada ao bloco operatório do grupo transferido foi 2 vezes superior (mediana 7,9 vs. 3,9 horas, p < 0,05). Apesar da diferença para início da prestração de cuidados cirúrgicos específicos, a mortalidade às 24 horas e aos 30 dias não diferiu entre entre o grupo transferido e o direto (26% e 50% vs. 29% e 58%, p < 0,05) respectivamente. O tempo de internamento na UCI (mediana, 12 vs. 4 dias, p = 0,04) e a duração total de internamento (mediana 11 vs. 4 dias, p = 0,04) foram substancialmente maiores para o grupo transferido. Conclusões: O resultado da transferência inter-hospitalar, nesta série de doentes, resultou numa duplicação do tempo de admissão no bloco operatório Contudo, não se verificou qualquer desvantagem em relação à sobrevida entre os grupos. A duração da hospitalização e consumo de recursos foi maior no grupo transferido. Estes resultados podem dever-se à possível seleção de doentes transferidos (clinicamente estáveis) que conseguem tolerar o atraso na instituição do tratamento cirúrgico, decorrente da transferência.