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OBJECTIVE: The aim of this study was to determine how many pre-operative ischaemic events occurring within a specific timeframe before carotid endarterectomy (CEA) are needed to increase the peri-operative 30 day risk of stroke or death. METHODS: This was a secondary exploratory analysis based on pooled data from three observational studies sourced from a single centre. Patients with recently symptomatic conventional ≥ 50% carotid stenosis were included. The principal analysis was limited to patients presenting with stroke or transient ischaemic attack (TIA). The primary outcome was 30 day risk of peri-operative stroke or death. Whether one, two, three, or four or more ipsilateral pre-operative ischaemic events within 3, 7, 14, or 30 days before CEA were associated with the primary outcome was assessed. RESULTS: The study included 382 patients who underwent CEA with symptomatic conventional ≥ 50% carotid stenosis with stroke or TIA as the presenting event. Mean patient age ± standard deviation was 72 ± 7 years, 117 (30.6%) were female, and 6% were treated with dual antiplatelet therapy. The primary outcome occurred in 21 patients (5.5%). Two or more events within 7 days before CEA was the most discriminative definition of repeated events, with a 14.3% (8/56) risk of the primary outcome. Those who fell outside this definition of two or more events within 7 days before CEA had a 4.0% (13 of 326; p = .006) risk of experiencing the primary outcome (adjusted odds ratio 4.1, 95% confidence interval 1.6 - 10.5). Several alternative definitions were assessed, but patients with two or more events within 7 days before CEA and negative for these alternatives still had a > 10% risk of the primary outcome. CONCLUSION: Two or more ipsilateral ischaemic events within 7 days before CEA are associated with an increased risk of peri-operative stroke or death in cases with symptomatic conventional ≥ 50% carotid stenosis and TIA or stroke as the presenting event. Studies assessing whether delayed or immediate CEA is preferable for this patient group are warranted.
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BACKGROUND: The aim of the study was to investigate long-term patient consequences of cranial nerve injury (CNI) caused by carotid endarterectomy (CEA) in patients with identified CNI at the 30-day follow-up. METHODS: Consecutive patients operated for symptomatic carotid artery stenosis 2015-2019 with a documented CNI at the 30-day follow-up after CEA were recruited to this cross-sectional survey. Telephone interviews were conducted >1 year after CEA utilizing survey instruments developed to uncover CNI symptoms. Patients graded their symptoms on a 4-point scale: 1) no symptoms; 2) mild symptoms; 3) moderate symptoms; and 4) severe symptoms. RESULTS: Altogether, 477 patients underwent CEA, of which 82 were diagnosed with CNI; 70/82 patients remained alive at the time for the survey and 68 patients completed the interview. The mean follow-up time was 3.7 years. Severe persistent CNI symptoms were reported in 2/68 (2.9%), moderate symptoms in 1/68 (1.5%) and mild symptoms in 14/68 (21%) whereas 51/68 patients (75%) reported no residual symptoms. When extrapolating these findings to all patients, approximately 4.4% reported persistent symptoms at the long-term follow-up and only 0.8% reported moderate or severe symptoms. CONCLUSIONS: The long-term consequences of CNI following CEA are benign in most patients, with a high rate of symptom resolution and a very low rate of persistent clinically significant symptoms.
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Estenosis Carotídea , Traumatismos del Nervio Craneal , Endarterectomía Carotidea , Accidente Cerebrovascular , Humanos , Endarterectomía Carotidea/efectos adversos , Estudios Transversales , Factores de Riesgo , Traumatismos del Nervio Craneal/diagnóstico , Traumatismos del Nervio Craneal/etiología , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Estenosis Carotídea/complicaciones , Resultado del Tratamiento , Accidente Cerebrovascular/etiología , Estudios RetrospectivosRESUMEN
BACKGROUND: The benefit of carotid endarterectomy (CEA) or stenting (CAS) for symptomatic stenosis depends on the timing in relation to the presenting event. As the risk of recurrent events is highest in the early phase, guidelines recommend a short delay. The purpose of this national audit was to study the effects of more expedient carotid intervention on the risk of recurrent ischaemic events. METHODS: Data on all CEA and CAS for symptomatic stenosis, including both recurrent ischaemic events during the waiting time to carotid intervention and peri-operative 30 day complication rates, were obtained from the Swedish Vascular Registry between May 2008 and December 2015. The National Prescribed Drug Registry provided data on preventive medication prior to hospitalisation with the presenting event. The primary endpoint was a recurrent cerebral ischaemic event occurring after the presenting event up to 30 days of post-operative follow up. RESULTS: A total of 6814 procedures for symptomatic carotid stenosis were studied. The proportion of recurrent ischaemic events, meaning all secondary events occurring after the presenting event up to 30 days follow up with inclusion of all pre- and post-intervention recurrences was recorded. These recurrent events decreased over time, from 31% in 2008-2009 to 21% in 2014-2015 (p < .01, chi-square test). In parallel, the median waiting time for carotid intervention decreased from 13 (IQR 6-27) to 7 days (IQR 4-12). Baseline demographic variables and comorbidities were similar during the study period. The proportion of pre-operative recurrences were reduced from 25% to 18% (p < .01, chi-square test) while the peri-operative stroke and/or death rate was 3.6%, and improved slightly during the study. CONCLUSIONS: A substantial reduction in the secondary ischaemic event rate was observed when the median waiting time for CEA/CAS was reduced, and this was not counterbalanced by any increase in the peri-operative complication rate.
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Estenosis Carotídea/cirugía , Isquemia/cirugía , Stents/efectos adversos , Resultado del Tratamiento , Anciano , Endarterectomía Carotidea/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Medición de Riesgo , Factores de Riesgo , Tiempo de TratamientoRESUMEN
OBJECTIVE: Extracranial carotid artery aneurysms (CAAs) are rare but confer risk of stroke, rupture, and local symptoms. Few cases have been reported, even from large centers, and therefore knowledge of the disease is limited. The purpose of this study was to review epidemiology, surgical treatment, and outcomes of CAAs in a nationwide setting using the Swedish National Registry for Vascular Surgery (Swedvasc). METHODS: Data on all surgical interventions for CAAs from January 1997 to December 2011 were retrieved from the Swedvasc registry. Additional clinical information was collected from hospital records. RESULTS: A total of 48 cases of CAAs were identified. The cause was atherosclerosis in 34 cases, infection in 2, and pseudoaneurysm in 12. The most common presentation was a pulsatile mass with or without local symptoms. Aneurysms isolated to the internal carotid artery predominated. Resection with end-to-end anastomosis was the most common technique used for treatment. Among true aneurysms, 24% had a known synchronous aneurysm elsewhere. Stroke-free survival (n = 48) was 90% after 30 days and 85% after 1 year. A total of 12.5% patients experienced permanent cranial nerve injury and 33% experienced any complication. CONCLUSIONS: CAAs are rare entities in vascular surgery. In terms of stroke-free survival, the Swedish national results approach reports from large volume centers. The relatively high risk for permanent cranial nerve injury advocates caution when performing surgery on CAAs.
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Aneurisma/epidemiología , Aneurisma/cirugía , Enfermedades de las Arterias Carótidas/epidemiología , Enfermedades de las Arterias Carótidas/cirugía , Arteria Carótida Interna/cirugía , Procedimientos Quirúrgicos Vasculares , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica , Aneurisma/diagnóstico , Aneurisma/mortalidad , Enfermedades de las Arterias Carótidas/diagnóstico , Enfermedades de las Arterias Carótidas/mortalidad , Trastornos Cerebrovasculares/epidemiología , Traumatismos del Nervio Craneal/epidemiología , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Suecia/epidemiología , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND AND PURPOSE: Current Swedish guidelines recommend that carotid endarterectomy should be performed within 14 days of a qualifying neurological event, but it is not clear if very urgent surgery after an event is associated with increased perioperative risk. The aim of this study was to determine how the time between the event and carotid endarterectomy affects the procedural risk of mortality and stroke. METHODS: We prospectively analyzed data on all patients who underwent carotid endarterectomies for symptomatic carotid stenosis between May 12, 2008, and May 31, 2011, with records in the Swedish Vascular Registry (Swedvasc). Patients were divided according to time between the qualifying event and surgery (0-2 days, 3-7 days, 8-14 days, 15-180 days). Stroke rate and mortality at 30 days postsurgery were determined. RESULTS: We analyzed data for 2596 patients and found that the combined mortality and stroke rate for patients treated 0 to 2 days after qualifying event was 11.5% (17 of 148) versus 3.6% (29 of 804), 4.0% (27 of 677), and 5.4% (52 of 967) for the groups treated at 3 to 7 days, 8 to 14 days, and 15 to 180 days, respectively. In a multivariate analysis, time was an independent risk factor for perioperative complications: patients treated at 0 to 2 days had a relative OR of 4.24 (CI, 2.07-8.70; P<0.001) compared with the reference 3- to 7-day group. CONCLUSIONS: In this study of patients treated for symptomatic carotid disease, it was safe to perform surgery as early as Day 3 after a qualifying neurological event in contrast to patients treated within 0 to 2 days, which has a significantly increased perioperative risk.
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Atención Ambulatoria , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Accidente Cerebrovascular/epidemiología , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Prospectivos , Análisis de Regresión , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Suecia , Factores de TiempoRESUMEN
OBJECTIVE: Increased vascularization is considered an important contributing factor for plaque vulnerability. Microvascular proliferative disease in patients with diabetes results in renal damage and visual loss. We assessed the hypothesis that vascularization in carotid atherosclerotic tissue is increased in diabetic patients, especially in the critical shoulder regions of the plaque. METHODS: Carotid endarterectomy specimens, clinical data, and blood samples were collected from patients with symptomatic carotid artery stenosis (median 85 days after clinical event) and pharmacologic treatment for diabetes (n = 26) or no diabetes (n = 85). Plaques were fixed in formalin and transverse tissue sections prepared. Histopathology and immunohistochemistry were performed for detection of endothelial cells (anti-CD34), macrophages (anti-CD68), vascular endothelial growth factor (VEGF), and its receptor (VEGFR-2). Neovascularization was assessed as CD34(+) neovessel density in the entire section area and by the presence or absence of CD34(+) vessels in the shoulder and cap regions of the plaques. RESULTS: The patient groups did not differ significantly in neovascularization in the entire transverse sections (2.0 vs 2.1 vessels/mm(2); P = .61) or in the fibrous cap (52% of the patients in both groups; P = .95). Neovascularization of the plaque shoulder regions was observed in 52% of the diabetic patients and in 26% of the nondiabetic patients (P = .028). VEGF-stained areas were similar in the two patient groups (0.4% and 0.2% of shoulder area; P = .61). Patients with diabetes had more VEGFR-2 (1.0% vs 0.2% of shoulder area; P < .016) and less CD68 staining (0.4% vs 3.6% of shoulder area; P < .008). Time from clinical event to surgery was positively associated with neovascularization of the plaque shoulder regions (≤90 days, 18% of patients; >90 days, 50% of patients; P = .002), independently of diabetes status. CONCLUSIONS: Diabetes was associated with increased vascularization of the shoulder regions in patients with symptomatic carotid atherosclerotic plaques. This was accompanied by increased expression of VEGFR-2. The increased vascularization of the plaque shoulder regions may help explain why patients with diabetes are at increased risk of atherosclerotic complications.