Endarterectomía carotídea / Carotid endarterectomy

El autor de este artículo describe personalmente la técnica de la endarterectomía carotídea clásica con algunos detalles personales que puedan ser de utilidad o de reflexión para el lector.(AU)

The author of this paper personally describes the classical carotid endarterectomy technique with some personaldetails that may be useful or thought-provoking for the reader.(AU)

Actualización del abordaje de la hipertensión pulmonar tromboembólica crónica / Update in the management of chronic thrombo-embolic pulmonary hypertension

La hipertensión pulmonar tromboembólica crónica (HPTEC) es una forma potencialmente curable de hipertensión pulmonar (HP) que aparece hasta en 3% de los pacientes tras una embolia pulmonar (EP). En estos pacientes, la EP no se resuelve, dando paso a coágulos fibróticos organizados, con el desarrollo de HP precapilar debido a la obstrucción proximal de las arterias pulmonares. También puede desarrollarse una microvasculopatía distal que contribuye al aumento de la resistencia vascular pulmonar (RVP). La ecocardiografía transtorácica (ETT) es la exploración que permite establecer la sospecha de HP. La gammagrafía pulmonar de ventilación-perfusión (V/Q) es la herramienta fundamental en el estudio de los pacientes con sospecha de HPTEC; si es normal, prácticamente la descarta. El cateterismo cardiaco derecho es obligatorio para el diagnóstico. La HPTEC se define como la existencia de síntomas, defectos de perfusión residuales e HP precapilar tras un periodo mínimo de tres meses de anticoagulación. La angiografía pulmonar ayuda a determinar la extensión y la accesibilidad quirúrgica de las lesiones tromboembólicas. Las personas con HPTEC son candidatas a anticoagulación indefinida. La endarterectomía pulmonar es el tratamiento de elección, resultando en una mejoría clínica y hemodinámica significativa. Aproximadamente un 25% de los pacientes presentan HP residual postendarterectomía. La angioplastia pulmonar con balón (APB) es una técnica endovascular dirigida a lesiones más distales, de utilidad para sujetos con HPTEC inoperable o HP persistente/recidivante postendarterectomía. Ambos tipos de pacientes también se pueden beneficiar de tratamiento farmacológico para la HP. Las tres terapias constituyen los pilares de la terapia, que ha evolucionado hacia un enfoque multimodal.(AU)

Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.(AU)

Update in the management of chronic thrombo-embolic pulmonary hypertension. / Actualización del abordaje de la hipertensión pulmonar tromboembólica crónica.

Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.

Desfechos de curto prazo da cirurgia de carótida: experiência no "mundo real" em um centro único de formação profissional / Short term outcomes of carotid surgery: the real-world experience of a single teaching center

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.

Estrategias para el abordaje en la enfermedad estenooclusiva de la arteria femoral común. El rol de la evidencia científica / Strategies for the management of steno-occlusive common femoral artery disease. The role of scientific evidence

La lesión estenótica u oclusiva confinada a la arteria femoral común (AFC) es bastante infrecuente. tradicionalmente, el tratamiento de referencia para esta entidad ha sido la endarterectomía femoral común (EFC). Este artículo tiene como objetivo realizar una revisión general de todas las estrategias terapéuticas actuales (cirugía abierta y abordajes endovasculares e híbridos) para el tratamiento de la lesión estenótica u oclusiva aislada de la AFC. Se realizó una búsqueda bibliográfica electrónica utilizando Pubmed y Google. Se analizaron las ventajas y las desventajas de cada técnica de revascularización y se informó de los resultados. La EFC demostró un alto éxito técnico y excelentes tasas de permeabilidad. Sin embargo, se asoció con una morbilidad local significativa, mayor duración de la estancia hospitalaria y mayores costos médicos en comparación con las terapias endovasculares. Los enfoques terapéuticos mínimamente invasivos mostraron resultados aceptables con complicaciones locales menores, pero tasas de permeabilidad más bajas en comparación con la cirugía abierta. Esta revisión sugiere la necesidad de más estudios comparativos aleatorios para evaluar el verdadero balance beneficio-riesgo de la EFC tradicional frente a las nuevas terapias mínimamente invasivas para tratar lesiones aisladas de la AFC.(AU)

isolated atherosclerotic stenosis or occlusion of the common femoral artery (CFa) is rather uncommon. traditionally,the standard of care of this entity has been the common femoral artery endarterectomy (CFe).this manuscript provides a general review of all the current therapeutical strategies (open surgery, endovascularand hybrid approaches) used to treat isolated CFa stenoses or occlusions.an electronic bibliographic search was performed on the Pubmed and Google databases. advantages and dis-advantages of each revascularization technique were analyzed and the outcomes reported. Common femoralendarterectomy (CFe) showed high technical success and excellent patency rates. However, it was associated withsignificantly local morbidities, longer lengths of stay and higher medical costs compared with endovascular ther-apies. minimally invasive therapeutical approaches showed acceptable outcomes with minor local complicationsbut lower patency rates compared to open surgery.Further randomized comparative studies are needed to assess the true benefit-risk ratio of traditional CFe vs newminimally invasive therapies for CFa disease.(AU)

Posterior cervical triangle approach for carotid endarterectomy: Technical note and results / El triángulo cervical posterior como abordaje en la endarterectomía carotídea: nota técnica y resultados

Introduction Carotid endarterectomy (CEA) is usually performed using the anterior cervical triangle as a surgical corridor but, when needed, the retromandibular space makes dissection of higher structures difficult in some cases. The posterior cervical triangle (PCT) can be useful in these demanding cases. Methods We retrospectively reviewed cases from July 2013 to November 2019 in which PCT was used as an approach for CEA. The surgical technique used was explained, and the complications and evolution of the patients were analysed. Results We found 7 CEAs performed through this approach, of which 2 presented transient trapezius paresis. There were no cases of severe complications in this series. Conclusion The PCT approach for performing CEA represents a useful and easy technique that avoids the need for mandibular mobilisation or osteotomies for lesions located in anatomically high carotid bifurcations (AU)

Introducción La endarterectomía carotídea (ECA) se suele realizar utilizando el triángulo cervical anterior como corredor quirúrgico, pero el espacio retromandibular dificulta en algunos casos la disección de estructuras de localización superior. El triángulo cervical posterior (TCP) puede ser útil en estos casos complejos. Métodos Se ha realizado un estudio retrospectivo de los casos atendidos en nuestra unidad utilizando el TCP como abordaje en ECA desde julio de 2013 hasta noviembre de 2019. Se explica la técnica quirúrgica empleada y se han revisado las complicaciones y evolución de los pacientes. Resultados Se realizaron 7 ECA a través de este abordaje. Dos pacientes presentaron paresia transitoria del trapecio. No hubo casos de complicaciones graves en esta serie. Conclusión El abordaje por el TCP para la realización de ECA representa una técnica útil y técnicamente simple, que evita procedimientos de movilización mandibular para lesiones localizadas en bifurcaciones carotídeas anatómicamente altas (AU)

Posterior cervical triangle approach for carotid endarterectomy: Technical note and results.

INTRODUCTION: Carotid endarterectomy (CEA) is usually performed using the anterior cervical triangle as a surgical corridor but, when needed, the retromandibular space makes dissection of higher structures difficult in some cases. The posterior cervical triangle (PCT) can be useful in these demanding cases. METHODS: We retrospectively reviewed cases from July 2013 to November 2019 in which PCT was used as an approach for CEA. The surgical technique used was explained, and the complications and evolution of the patients were analysed. RESULTS: We found 7 CEAs performed through this approach, of which 2 presented transient trapezius paresis. There were no cases of severe complications in this series. CONCLUSION: The PCT approach for performing CEA represents a useful and easy technique that avoids the need for mandibular mobilisation or osteotomies for lesions located in anatomically high carotid bifurcations.

Evaluating the efficacy and safety of rivaroxaban as a warfarin alternative in chronic thromboembolic pulmonary hypertension patients undergoing pulmonary endarterectomy: A randomized clinical trial.

BACKGROUND AND AIM: Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by the obstruction of the main pulmonary artery due to thrombosis and vascular remodeling. Regarding the need for anticoagulant therapy in CTEPH patients, this study aimed to compare rivaroxaban with warfarin in terms of its efficacy and safety in patients undergoing endarterectomy surgery. METHODS: The study was a parallel clinical trial in patients who underwent endarterectomy following CTEPH. A total of 96 patients were randomly selected and assigned to two groups: warfarin-treated (control) and rivaroxaban-treated (intervention). Patients were clinically assessed for re-thrombosis, re-admission, bleeding, and mortality in the first, third, and sixth months after surgery. RESULTS: There was no significant difference in the occurrence of thrombosis between the two groups within the first, third-, and sixth-months post-surgery (p=0.52, 1, 0.38 respectively). Moreover, the mortality rate (p=0.9), bleeding rate (p=0.06), and re-admission rate (p=0.15) showed no significant differences between the two groups. CONCLUSION: Rivaroxaban may be as effective as warfarin in treating CTEPH patients after endarterectomy in the short term and can be used as an anticoagulant in these patients. However, studies with long-term follow-ups are needed to consolidate the strategy of treating these patients with rivaroxaban.

Association between Hospital Carotid Endarterectomy Procedure Volumes and In-Hospital Mortality in São Paulo State / Associação do volume hospitalar de endarterectomia carotídea com a mortalidade intra-hospitalar no estado de São Paulo

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.

Association between platelet lymphocyte ratio and neutrophil lymphocyte ratio and clinical outcomes following carotid endarterectomy / Associação do índice plaqueta-linfócito e do índice neutrófilo-linfócito com desfechos clínicos após endarterectomia de carótida

Abstract Background Approximately 30% of stroke cases result from carotid disease. Although several risk factors for complications after carotid endarterectomy have been identified, the existence of a biomarker that can estimate postoperative risk in these patients has not yet been proven. Objectives This study aimed to investigate correlations between the platelet-lymphocyte ratio (PLR) and the neutrophil-lymphocyte ratio (NLR) and postoperative clinical outcomes in patients undergoing carotid endarterectomy. Methods A retrospective study was conducted, including 374 patients who underwent carotid endarterectomy between 2002 and 2019 due to moderate to high extracranial internal carotid artery stenosis. Their platelet-lymphocyte ratio and neutrophil-lymphocyte ratios were obtained from the same blood samples. Results There was a statistically significant correlation between the PLR and the occurrence of restenosis (p < 0.01) and acute myocardial infarction (AMI) after endarterectomy (p = 0.03). Additionally, there was a statistically significant correlation between the PLR and the combined outcomes stroke and/or AMI and/or death (p = 0.03) and stroke and/or AMI and/or death and/or restenosis (p < 0.01). However, there were no significant correlations between NLR and these outcomes (p = 0.05, p = 0.16). Conclusions The platelet-lymphocyte ratio proved to be a useful test for predicting occurrence of strokes, acute myocardial infarctions, and deaths during the postoperative period after carotid endarterectomy. It was also associated with the risk of postoperative restenosis.

Resumo Contexto Aproximadamente 30% dos casos de acidente vascular cerebral (AVC) resultam de doença carotídea. Embora vários fatores de risco para complicações pós-endarterectomia carotídea tenham sido identificados, ainda não foi comprovada a existência de um biomarcador que possa estimar o risco pós-operatório nesses pacientes. Objetivos Correlacionar o índice plaqueta-linfócito (IPL) e o índice neutrófilo-linfócito (INL) com os desfechos clínicos pós-operatórios em pacientes submetidos a endarterectomia carotídea. Métodos Estudo retrospectivo que incluiu 374 pacientes submetidos a endarterectomia carotídea, entre 2009 e 2019, por estenose extracraniana da artéria carótida interna. O IPL e o INL foram calculados, tendo sido obtidos das mesmas amostras de sangue. Resultados Houve correlação estatisticamente significativa entre IPL e presença de reestenose (p<0,01) e infarto agudo do miocárdio (IAM) após endarterectomia (p=0,03). Os desfechos combinados AVC e/ou IAM e/ou óbito e AVC e/ou IAM e/ou óbito e/ou reestenose apresentaram, respectivamente, correlação estatisticamente significativa com o IPL (p=0,03; p<0,01) e não significativa com o INL (p=0,05; p=0,16). Conclusões O IPL mostrou-se um teste útil, capaz de predizer os desfechos de AVC e/ou IAM e/ou óbito em pacientes no pós-operatório de endarterectomia carotídea, relacionando-se também com risco de reestenose pós-operatória.

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)

Endarterectomía carotídea por eversión / Carotid endarterectomy by eversion

La técnica de la endarterectomía carotídea por eversión no es novedosa como pudiera parecer, pero es cierto que quedó en desuso, a pesar de los excelentes resultados, principalmente debido a la dificultad de inserción del shunt que en las décadas setenta y ochenta del siglo pasado se empleaba de forma rutinaria. Los autores de este artículo describen la modalidad que ellos realizan, una endarterectomía carotídea por eversión modificada, sin seccionar la arteria carótida en ningún momento, y que fue ya descrita por Cooley y modificada por Anderson. Ellos señalan cuidadosamente los pasos e indican los trucos para que el procedimiento sea satisfactorio. En la mayoría de los casos la realizan con anestesia local y hacen una arteriografía de control intraoperatoria.(AU)

The technique of carotid endarterectomy by eversion is not new as it might seem, but it is true that it stopped being used, despite the excellent results, mainly because the difficulty of inserting the shunt that in the seventies and eighties of the last century was routinely used. The authors describe in this paper the modality that they perform, a modified eversion carotid endarterectomy without sectioning the carotid artery at any time, and that was already described by Cooley and modified by Anderson. They carefully point out the steps and describe the tricks to make the procedure successful. In most cases, they do it under local anesthesia and systematically carry out an intraoperative control angiography.(AU)

Carotid artery screening in high risk asymptomatic individuals: outcomes of 3000 carotid screening.

OBJECTIVES: The primary aims of the study to evaluate the efficacy of carotid screening tests to identify asymptomatic carotid artery stenosis among high-risk patients and early prevention of stroke. BACKGROUND: The estimated prevalence of asymptomatic severe carotid stenosis (≥70%) in the general adult population ranges up to 3.1%. However, the prevalence is higher in comorbid individuals. This makes it important to perform screening testing for early diagnosis and treatment in predetermined high-risk patients. MATERIAL AND METHODS: In this prospective study, 3000 selected patients screened during March 2017 and September 2018 at the most populated family health center. Participants selected among registered individuals who have at least one of the risk factors such as hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking. All the participants were asymptomatic and above the age of 55. Bilateral carotid artery screening performed by Duplex Ultrasonography (DUSG) at the first call and one year later. Patients with severe carotid and/or coronary artery stenosis treated by surgical revascularization or stent implantation in the light of the latest guidelines. CONCLUSION: Carotid screening among high-risk asymptomatic individuals is of great importance to identify severe carotid artery as well as coronary artery stenosis. Patient education during screening may play a crucial role in preventing the disease.

OBJETIVOS: Los objetivos principales del estudio fueron evaluar la eficacia de las pruebas de detección de carótidas para identificar la estenosis asintomática de la arteria carótida en pacientes de alto riesgo y la prevención temprana del accidente cerebrovascular. ANTECEDENTES: La prevalencia estimada de estenosis carotídea grave asintomática (≥70%) en la población adulta general varía hasta el 3,1%. Sin embargo, la prevalencia es mayor en individuos comórbidos. Esto hace que sea importante realizar pruebas de detección para el diagnóstico y el tratamiento tempranos en pacientes predeterminados de alto riesgo. MATERIAL Y MÉTODOS: En este estudio prospectivo, 3000 pacientes seleccionados fueron evaluados durante marzo de 2017 y septiembre de 2018 en el centro de salud familiar más poblado. Participantes seleccionados entre individuos registrados que tienen al menos uno de los factores de riesgo como hipertensión, hiperlipidemia, diabetes mellitus, obesidad y tabaquismo. Todos los participantes estaban asintomáticos y tenían más de 55 años. Cribado bilateral de la arteria carótida realizado por ecografía dúplex (DUSG) en la primera llamada y un año después. Pacientes con estenosis severa de carótidas y/o arterias coronarias tratados mediante revascularización quirúrgica o implantación de stents a la luz de las últimas guías. CONCLUSIÓN: El cribado carotídeo en individuos asintomáticos de alto riesgo es de gran importancia para identificar la estenosis grave de la arteria carótida y la arteria coronaria. La educación del paciente durante el cribado puede desempeñar un papel fundamental en la prevención de la enfermedad.

Determinants of success in treating acute ischemic cerebral and ocular ischemia through carotid revascularization. An observational study of a case series / Determinantes do sucesso no tratamento da isquemia cerebral e ocular aguda por meio da revascularização carotídea. Um estudo observacional de uma série de casos

ABSTRACT Objective: stroke etiology is ischemia in 85%, and in circa 25% of these, the source is the extracranial carotid. Recurrence is frequent and usually more severe. Carotid revascularization prevents new ischemic strokes. The sooner the treatment is undertaken, complete recovery chances are greater with less recurrences. But, historically, intervention in the acute setting was catastrophic. Objective: Identify determinants of success when carotid revascularization after a recent cerebral ischemic event is performed. Materials and Methods: A cohort of 50 subjects underwent carotid revascularization after ischemic symptoms, within a period of 71 months. The currently diagnostic tools were used, and the symptoms stratified by the Rankin scale. The extension of the cerebral lesion and the source location the source of the event was analyzed. Results: indications were based on the Rankin Scale (R0: 35.4%; R1: 45.8%; R2:18.8% and R3: zero), on the location of the source and the absence of ischemic areas greater than 15mm. An early surgical approach was adopted in all patients. Extreme care was applied to control arterial pressure. At discharge, no additional deficits were observed. Conclusions: carotid revascularization after ischemic events can be achieved without additional morbidity and no recurrences, using the most appropriate therapy in the shortest time, in patients with Rankin Scale up to 2, absence of intracranial hemorrhage and single or multiple ischemic intracerebral areas, with 15mm or less in their greater dimension.

RESUMO Introdução: isquemia é a etiologia do acidente vascular cerebral em 85% dos casos e em cerca de 25% destes, a fonte é a carótida extracraniana. Recorrência é frequente e usualmente mais grave que a inicial. A revascularização carotídea previne novos acidentes. Quanto mais cedo for realizado o tratamento, maiores as chances de recuperação e menor o risco de recorrência. Mas, historicamente, os resultados das intervenções precoces eram catastróficos. Objetivos: identificar determinantes de sucesso da revascularização carotídea após um evento isquêmico cerebral recente. Materiais e Métodos: uma coorte de 50 pacientes foi submetida à revascularização carotídea após sintomas isquêmicos, em um período de 71 meses. Foram empregados os métodos de investigação atuais e os sintomas estratificados pela Escala de Rankin. A extensão das lesões cerebrais e a fonte do evento foram estudados e analisados. Resultados: as indicações foram baseadas na escala de Rankin (R0: 35.4%; R1: 45.8%; R2: 18.8% e R3: zero), na localização da fonte e na ausência de áreas isquêmicas com menos de 15mm. Uma abordagem cirúrgica precoce foi empregada em todos os pacientes. Cuidados extremos com a pressão arterial foram aplicados. Na alta hospitalar, nenhum déficit adicional foi observado. Conclusões: a revascularização carotídea após eventos isquêmicos pode ser realizada sem morbidade adicional ou recorrências, empregando a terapêutica mais apropriada no período de tempo mais curto, em pacientes classificados como Rankin até 2, na ausência de hemorragia intracraniana e com áreas isquêmicas intracerebrais únicas ou múltiplas, com menos de 15mm em sua maior dimensão.

Tratamento combinado na dissecção de artéria mesentérica superior: desafio terapêutico / Combination treatment for superior mesenteric artery dissection: therapeutic challenge

Resumo A dissecção da artéria mesentérica superior é uma causa rara de dor abdominal, com quadro clínico variável. Seu diagnóstico é difícil, e não existe consenso sobre suas opções terapêuticas; elas variam em torno de tratamento conservador, correção aberta, endovascular ou combinada. Descrevemos o caso de um homem de 45 anos com dissecção isolada da artéria mesentérica superior, com quadro de dor abdominal persistente após tentativa de tratamento conservador. Ele foi submetido à revascularização cirúrgica aberta devido à localização e complexidade da dissecção. O tratamento com endarterectomia, arterioplastia com remendo de pericárdio bovino e acesso retrógrado para abertura da mesentérica com stent foi realizado com sucesso. A angina abdominal foi totalmente resolvida após estabilização do quadro. A combinação de abordagem aberta e endovascular deve ser considerada como terapia para casos de dissecção complexa isolada da artéria mesentérica superior.

Abstract Dissection of the superior mesenteric artery is a rare cause of abdominal pain, with a variable clinical picture. It is difficult to diagnose and there is no consensus on treatment options, which range from conservative treatment to open, endovascular, or combination repair. We describe the case of a 45-year-old man with isolated dissection of the superior mesenteric artery and persistent abdominal pain after conservative treatment had been attempted. He underwent open surgical revascularization due to the location and complexity of the dissection. Treatment consisting of endarterectomy, arterioplasty with bovine pericardium patch, and retrograde access to open the mesenteric artery with a stent was successful. Abdominal angina was completely resolved after the condition had stabilized. A combination of open and endovascular approaches should be considered as treatment for cases of isolated complex dissection of the superior mesenteric artery.

Landmarks for the hypoglossal nerve within the anterior cervical triangle / Topografía del nervio hipogloso en el triángulo cervical anterior

SUMMARY: Cranial nerve injury is one of the neurologic complications following carotid endarterectomy. The hypoglossal nerve is one of the most frequently injured nerves during carotid endarterectomy. Guidelines suggest that proper anatomic knowledge is crucial to avoid cranial nerve injury. The aim of the present study is to provide landmarks for the localization of the hypoglossal nerve during carotid endarterectomy. 33 anterior cervical triangles of formalin-fixed adult cadavers were dissected. The "carotid axis" was defined and measured, the level of the carotid bifurcation within the carotid axis was registered. "High carotid bifurcation" was considered for those carotid bifurcation found in the upper 25 mm of the carotid axis. The distance between the hypoglossal nerve and the carotid bifurcation was measured (length 1). The relationship between the hypoglossal nerve and the posterior belly of the digastric muscle was registered. For caudal positions, the distance between hypoglossal nerve and posterior belly of the digastric muscle was determined (length 2). Carotid axis range 88.3 mm-155.4 mm, average 125.8 mm. Level of the carotid bifurcation within the carotid axis range 75.3 mm-126.5 mm, mean 102.5 mm. High carotid bifurcation was found in 19 cases (57 %). Length 1 ranged from 1.6 mm to 38.1, mean 17.5. Finally, in 29 specimens (87.8 %) the hypoglossal nerve was caudal to posterior belly of the digastric muscle, whereas in 4 cases (12.2 %) it was posterior. Length 2 ranged from 1 mm to 17.0 mm, mean 6.9 mm. Distances between the hypoglossal nerve and nearby structures were determined. These findings may aid the surgeon in identifying the hypoglossal nerve during carotid endarterectomy and thus prevent its injury.

RESUMEN: La lesión de pares craneales es una de las complicaciones neurológicas posteriores a la endarterectomía carotídea. El nervio hipogloso es uno de los nervios lesionados más frecuentemente durante la endarterectomía carotídea. Las guías de actuación clínica sugieren que el conocimiento anatómico adecuado es crucial para evitar lesiones de los nervios craneales. El objetivo del presente estudio fue proporcionar puntos de referencia para la ubicación del nervio hipogloso durante la endarterectomía carotídea. Se disecaron 33 triángulos cervicales anteriores de cadáveres adultos fijados en solución a base de formaldehído. Se definió y midió el "eje carotídeo", se registró el nivel de la bifurcación carotídea dentro del eje carotídeo. Se consideró una "bifurcación carotídea alta" para aquellas bifurcaciones carotídeas encontradas en los 25 mm superiores del eje carotídeo. Se midió la distancia entre el nervio hipogloso y la bifurcación carotídea (longitud 1). Se registró la relación entre el nervio hipogloso y el vientre posterior del músculo digástrico. Para las posiciones caudales, se determinó la distancia entre el nervio hipogloso y el vientre posterior del músculo digástrico (longitud 2). Rango del eje carotídeo 88,3 mm-155,4 mm, media 125,8 mm. Rango del nivel de la bifurcación carotídea dentro del eje carotídeo 75,3 mm-126,5 mm, media 102,5 mm. Se encontró una bifurcación carotídea alta en 19 casos (57 %). La longitud 1 osciló entre 1,6 mm y 38,1, con una media de 17,5. Finalmente, en 29 muestras (87,8 %) el nervio hipogloso fue caudal al vientre posterior del músculo digástrico, mientras que en 4 casos (12,2 %) fue posterior. La longitud 2 osciló entre 1 mm y 17,0 mm, con una media de 6,9 mm. Se determinaron las distancias entre el nervio hipogloso y las estructuras cercanas. Estos hallazgos pueden ayudar al cirujano a identificar el nervio hipogloso durante la endarterectomía carotídea y así prevenir su lesión.

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)

Importancia de la arteriografía cerebral y la monitorización neurofisiológica intraoperatoria en la endarterectomía carotídea / Importance of cerebral angiography and intraoperative neuromonitoring in carotid endarterectomy

Cada vez es más frecuente indicar una endarterectomía carotídea en función de la información proporcionada por pruebas no invasivas, como la eco-Doppler, la angio-RM o la angio-TAC, obviando la necesidad de la arteriografía. Presentamos un caso de estenosis carotídea sintomática izquierda del 80% en la que la arteriografía cerebral constató la ausencia del segmento A1 derecho y llenado del territorio cerebral anterior bilateral solo desde el lado izquierdo. A los 90 segundos del pinzamiento de las arterias en el cuello se produjo una disminución brusca de la oximetría cerebral y de la amplitud de los potenciales somatosensoriales, que cedieron tras el despinzamiento inmediato. Se desestimó realizar la endarterectomía y se colocó un stent carotídeo sin complicaciones. Este caso ejemplifica la importancia de conocer el estado de la circulación cerebral distalmente a la estenosis. De haberse intentado realizar la endarterectomía sin tener en cuenta la información proporcionada por la arteriografía, posiblemente habría ocurrido una isquemia bihemisférica grave (AU)

It is an increasingly common practice to indicate a carotid endarterectomy procedure based on the information provided by non-invasive tests like Duplex ultrasound, MR angiography or CT angiography, thereby obviating the performance of a conventional cerebral angiography. We present a case of symptomatic left carotid artery 80% stenosis in which cerebral angiography showed absence of the right A1 segment and bilateral anterior cerebral artery territories that filled only from a left injection. Just 90 seconds after carotid artery clamping at the neck, brain oximetry and somatosensory evoked potentials significantly dropped, that recovered after immediate clamp removal. Endarterectomy was dismissed and a carotid stent was successfully placed. This case highlights the importance of knowing the dynamics of cerebral blood circulation distal to the stenosis. If endarterectomy had been attempted, unawareness of the information provided by the cerebral angiography would have likely result in severe bi-hemispheric ischemia (AU)

Endarterectomía carotídea, resultados a mediano y largo plazo / Carotid endarterectomy, medium to long-term results

Resumen Introducción: Entre el 50% al 80% de los pacientes con un ictus, presentan lesión de la arteria carótida común o interna, de estos un 15% a 30% quedan con discapacidad severa, y el 20% requiere de institucionalización. Objetivo: Analizar las variables epidemiológicas involucradas en la estenosis carotídea y los resultados a mediano-largo plazo de la endarterectomía carotídea. Materiales y Método: Estudio observacional, descriptivo y retrospectivo, donde se analizan 103 endarterectomías carotídeas sucesivas, realizadas en 97 pacientes, en un período de 12 años (2007 a 2018), en el Servicio de Cirugía del Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Sexo masculino 64,9%, edad promedio 70,2 años, sintomáticos 65,9%, presentación clínica más frecuente el ataque isquémico transitorio (48,4%), morbilidad global inmediata del procedimiento 20,3%, AVE perioperarorio 3,9% (ninguno discapacitante), disfunción de nervios periféricos 5,8%, mortalidad operatoria 70% y cuando se efectúa en un plazo menor a 2 semanas del evento isquémico. Conclusión: La endarterectomía carotídea sigue siendo el procedimiento quirúrgico de elección para tratar la estenosis carotídea severa; realizada en centros con experiencia, es un procedimiento seguro y eficaz en la prevención del infarto cerebral.

Introduction: Between 50 and 80% of patients with a stroke, have lesions of the common or internal carotid artery, of these 15 to 30% are severely disabled, and 20% require institutionalization. Aim: To analyze the epidemiological variables involved in carotid stenosis, and the medium to long-term results of carotid endarterectomy. Materials and Method: Observational, descriptive and retrospective study, analyzed 103 successive carotid endarterectomies procedures in 97 patients, in a period of 12 years (2007 to 2018), in the Surgery Department of the Dr. Eduardo Pereira Hospital, Valparaíso, Chile. Results: Male sex 64.9%, average age 70.2 years, symptomatic 65.9%, most frequent clinical presentation, transient ischemic attack (48.4%), immediate global morbidity of the procedure 20.3%, peri-operative AVE 3.9% (none disabling), peripheral nerve dysfunction 5.8%, operative mortality 70%, and when performed within a period less than 2 weeks of the ischemic event. Conclusion: Carotid endarterectomy remains the surgical procedure of choice, to treat severe carotid stenosis, performed in experienced centers, it is a safe and effective procedure in the prevention of cerebral ischemia.

Endarterectomía carotídea como procedimiento quirúrgico de obstrucción y/o estenosis de arteria carótida interna / Carotid endarterectomy as a surgical procedure of carotid obstruction and/or stenosis

La endarterectomía carotídea es el procedimiento quirúrgico de elección para tratar la obstrucción y/o estenosis de la arteria carótida extracraneal y prevenir los eventos neurológicos. La aparición de síntomas depende de la gravedad y progresión de la lesión, del adecuado flujo colateral, de las características de la placa y de la presencia de otros factores de riesgo. Analizamos el resultado de la endarterectomía carotídea como procedimiento quirúrgico de elección para la estenosis carotídea, así como la presentación de un caso clínico de un adulto mayor con oclusión del 100% y la resolución completa de los síntomas posteriores al procedimiento quirúrgico (AU)

Endarterectomy of the carotid is the surgical procedure of choice to treat obstruction and/or stenosis of the extracranial carotid artery and prevent neurological events. The appearance of symptoms depends on the severity and progression of the lesion, the adequate collateral flow, the characteristics of the plaque and the presence of other risk factors. We analyze the result of carotid endarterectomy as the surgical procedure of choice for carotid stenosis as well as the presentation of a clinical case of an elderly adult patient with 100% occlusion and complete resolution of symptoms after the surgical procedure (AU)