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)

Preoperative carotid duplex scanning in patients undergoing coronary artery bypass grafting

Abstract Objective: The aim of this study was to determine the prevalence and risk factors of carotid artery stenosis (CAS) using carotid duplex ultrasound in patients undergoing coronary artery bypass grafting (CABG). Methods: This retrospective study was conducted between January 2017 and January 2018 and included 166 consecutive patients [130 males (78.31%), 36 females (21.69%); mean age: 64.25±9.78 years] who underwent elective and isolated CABG. Patients who had significant CAS (≥50% stenosis) were compared with patients who had non-significant CAS (<50% stenosis). Logistic regression analysis was applied across the selected parameters to identify risk factors for significant CAS. Results: Of all patients, 36 (21.68%) had CAS ≥50% and 8 (4.81%) had unilateral carotid stenosis ≥70%. Carotid endarterectomy/CABG was performed simultaneously in five (3.01%) patients. None of these patients had cardiac and neurological problems during the postoperative period. The overall incidence of cerebrovascular accident (CVA) after CABG was 1.20% (n=2). Age (P=0.011) and history of CVA (P=0.035) were significantly higher in the CAS ≥50 group than in the CAS <50 group. Significant CAS was identified as a risk factor for postoperative CVA (P=0.013). Conclusion: Age and history of CVA were identified as risk factors for significant CAS. Furthermore, significant CAS was identified as a risk factor for postoperative CVA. For this reason, carotid screening is recommended for patients undergoing CABG even in the absence of associated risk factors.

Relationship of inter-arm systolic blood pressure difference with subclavian artery stenosis and vertebral artery stenosis in patients undergoing carotid endarterectomy

Abstract Introduction: The aim of this study was to examine the association of inter-arm systolic blood pressure difference (IASBPD) with carotid artery stenosis, subclavian artery stenosis and vertebral artery stenosis in patients who underwent carotid endarterectomy. Methods: A total of 141 patients (29 females, 112 males; mean age 71.2±10.4 years; range 47 to 92 years) who underwent carotid endarterectomy between September 2010 and December 2017 were retrospectively evaluated. We classified patients into four groups according to the IASBPD ˂ 10 mmHg, ≥ 10 mm Hg, ≥ 20 mmHg and ≥ 30 mmHg. The stenosis of both subclavian and vertebral arteries was considered as ≥ 50%. Results: Of the 141 patients, 44 (31.2%) had ≥ 10 mmHg, 29 (20.5%) had ≥ 20 mmHg and 4 (2.8%) had ≥ 30 mmHg of IASBPD. 26 patients (18.4%) were diagnosed with significant subclavian artery stenosis and 18 (69.2%) of them had more than 20 mmHg of IASBPD. Of the 29 patients with IASBPD ≥ 20 mmHg, 19 patients (65.5%) had a significant subclavian artery stenosis. We found a significant correlation between preoperative symptoms and subclavian artery stenosis (P=0.018) and overall perioperative stroke was seen more frequently in patients with subclavian artery stenosis (P=0.041). A significant positive correlation was observed between vertebral artery stenosis and subclavian artery stenosis (P=0.01). Conclusion: Patients who were diagnosed with both subclavian artery stenosis and IASBPD (≥ 20 mmHg) had a higher risk of postoperative stroke and death, had higher total cholesterol, LDL-C, blood creatinine level, and were more symptomatic.

Endarterectomía carotídea con medición de presión de muñón, manejo hemodinámico y uso selectivo de shunt / Carotid Endarterectomy with routine carotid stump pressure measurement, intraoperative hemodynamic management and selective use of shunt

Resumen Introducción En la endarterectomía carotídea (EC) durante el clampeo, la perfusión cerebral se mantiene por circulación contralateral a través del Polígono de Willis, que se relaciona con la presión de muñón carotídeo (PM). Si ésta es menor a 50 mmHg existe riesgo de Accidente Cerebrovascular (ACV) por hipoperfusión y está indicado uso de shunt para asegurar suficiente circulación cerebral, pero también se puede elevar transitoriamente la presión arterial sistémica haciendo innecesario el uso de shunt. Objetivo Mostrar los resultados de EC con medición de PM para evaluar la perfusión cerebral del hemisferio clampeado con manejo hemodinámico intraoperatorio minimizando el uso de shunt. Material y Métodos Estudio retrospectivo de 73 pacientes sometidos a EC bajo anestesia general con medición de PM, manejo hemodinámico intraoperatorio y uso selectivo de shunt. Se analizaron variables demográficas, clínicas y morbimortalidad perioperatoria. Resultados 73 pacientes, edad promedio 71,1 años, 69,9% sintomáticos. En 54 pacientes la PM fue superior a 50 mmHg y no se usó shunt, en 19 la PM fue menor a 50 mmHg y con manejo hemodinámico intraoperatorio se elevó en 16 que no requirieron shunt. Sólo en 3 casos la PM no alcanzó los 50 mmHg y se usó un shunt de Pruitt-Inahara. Dos pacientes sintomáticos presentaron déficit neurológico central transitorio postoperatorio y 2 pacientes fallecieron por infarto cardíaco. Conclusión La EC con medición de PM y manejo hemodinámico minimizó el uso de shunt transitorio y fue un procedimiento seguro para tratar los pacientes con estenosis carotídea con indicación quirúrgica.

Introduction During carotid endarterectomy (CEA) clamping cerebral perfusion is maintained by contralateral circulation through the Circle of Willis and it is correlated to the stump pressure (SP). If it is below 50 mmHg there is risk of stroke due to hypoperfusion and a shunt must be used, but systemic blood pressure can be temporarily elevated making the use of shunt unnecessary. Aim Results of CEA with SP measurement to evaluate cerebral perfusion in cross-clamped hemisphere and hemodynamic intraoperative management reducing the use of shunt. Material and Methods Retrospective study of CEAs performed in 73 patients under general anaesthesia with SP measurement, hemodynamic management and selective use of shunt. Demographics, clinical and perioperative morbimortality variables were analized. Results 73 patients, average age 71.1 years, 69.9% symptomatic. In 54 patients SP was above 50 mmHg and shunt was not used, in 19 SP was below 50 mmHg, it was elevated through intraoperative hemodynamic management and shunt was not needed. In only 3 cases SP did not reach 50 mmHg and a Pruitt-Inahara shunt was used. Two patients presented postoperative transient central neurological deficit and 2 died due to myocardial infarction. Conclusion CEA with SP measurement and hemodynamic management reduced the use of carotid shunting and it was a safe procedure to treat patients with severe carotid stenosis who need surgical intervention.

Impact of surgeon experience during carotid endarterectomy operation and effects on perioperative outcomes

Abstract Objective: We evaluated the effect of surgeon experience on complication and mortality rates of carotid endarterectomy operation. Methods: Fifty-nine consecutive patients who underwent carotid endarterectomy between January 2013 and February 2016 were divided into two groups. Patients who had been operated by surgeons performing carotid endarterectomy for more than 10 years were allocated to group 1 (experienced surgeons; n=34). Group 2 (younger surgeons; n=25) consisted of patients operated by surgeons independently performing carotid endarterectomy for less than 2 years. Both groups were compared in respect of operative results and postoperative complications. Results: No intergroup difference was found for laterality of the lesion or concomitant coronary artery disease. In group 1, signs of local nerve damage (n=2; 5.9%) were detected, whereas in group 2 no evidence of local nerve damage was observed. Surgeons in group 1 used local and general anesthesia in 3 (8.8%) and 31 (91.2%) patients, respectively, while surgeons in group 2 preferred to use local and general anesthesia in 1 (4%) and 24 (96%) patients, respectively. Postoperative stroke was observed in group 1 (n=2; 5.9%) and group 2 (n=2; 5.8%). Conclusion: Younger surgeons perform carotid endarterectomy with similar techniques and have similar results compared to experienced surgeons. Younger surgeons rarely prefer using shunt during carotid endarterectomy. The experience and the skills gained by these surgeons during their training, under the supervision of experienced surgeons, will enable them to perform successful carotid endarterectomy operations independently after completion of their training period.

Comparison of early outcomes with three approaches for combined coronary revascularization and carotid endarterectomy

Abstract Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

Hydrocortisone supresses inflammatory activity of metalloproteinase - 8 in carotid plaque / Hidrocortisona suprime a atividade inflamatória da metaloproteinase - 8 presente na placa carotídea

AbstractObjective:Matrix metalloproteinases are inflammatory biomarkers involved in carotid plaque instability. Our objective was to analyze the inflammatory activity of plasma and carotid plaque MMP-8 and MMP-9 after intravenous administration of hydrocortisone.Methods:The study included 22 patients with stenosis ≥ 70% in the carotid artery (11 symptomatic and 11 asymptomatic) who underwent carotid endarterectomy. The patients were divided into two groups: Control Group - hydrocortisone was not administered, and Group 1 - 500 mg intravenous hydrocortisone was administered during anesthetic induction. Plasma levels of MMP-8 and MMP-9 were measured preoperatively (24 hours before carotid endarterectomy) and at 1 hour, 6 hours and 24 hours after carotid endarterectomy. In carotid plaque, tissue levels of MMP-8 and MMP-9 were measured.Results:Group 1 showed increased serum levels of MMP- 8 (994.28 pg/ml and 408.54 pg/ml, respectively; P=0.045) and MMP-9 (106,656.34 and 42,807.69 respectively; P=0.014) at 1 hour after carotid endarterectomy compared to the control group. Symptomatic patients in Group 1 exhibited lower tissue concentration of MMP-8 in comparison to the control group (143.89 pg/ml and 1317.36 respectively; P=0.003). There was a correlation between preoperative MMP-9 levels and tissue concentrations of MMP-8 (P=0.042) and MMP-9 (P=0.019) between symptomatic patients in the control group.Conclusion:Hydrocortisone reduces the concentration of MMP- 8 in carotid plaque, especially in symptomatic patients. There was an association between systemic and tissue inflammation.

ResumoObjetivo:As metaloproteinases são biomarcadores inflamatórios envolvidos na instabilidade da placa carotídea. O objetivo deste estudo foi analisar a atividade inflamatória da MMP-8 e MMP-9 plasmática e presente na placa carotídea, após administração intravenosa de hidrocortisona.Métodos:Participaram do estudo 22 pacientes portadores de estenose ≥ 70% em artéria carótida (11 sintomáticos e 11 assintomáticos), submetidos à endarterectomia de artéria carótida. Os pacientes foram divididos em dois grupos: Grupo Controle - não foi administrado hidrocortisona e Grupo 1 - foi administrado 500 mg intravenoso de hidrocortisona durante a indução anestésica. As dosagens plasmáticas de MMP-8 e MMP-9 foram efetuadas no pré-operatório (24 horas antes da endarterectomia de artéria carótida) e em 1 hora, 6 horas e 24 horas após endarterectomia de artéria carótida. Na placa carotídea foram mensurados os níveis teciduais de MMP-8 e MMP-9.Resultados:O grupo 1 exibiu elevação dos níveis séricos da MMP-8 (994,28 pg/ml e 408,54 pg/ml, respectivamente; P=0.045) e MMP-9 (106.656,34 e 42.807,69, respectivamente; P=0.014) em 1 hora após a endarterectomia de artéria carótida, em relação ao grupo controle. Os pacientes sintomáticos do grupo 1 exibiram menor concentração tecidual de MMP-8, em relação ao grupo controle (143,89 pg/ml e 1317,36, respectivamente; P=0.003). Houve correlação entre os níveis pré-operatórios de MMP-9 e as concentrações teciduais de MMP-8 (P=0.042) e MMP-9 (P=0.019) entre os pacientes sintomáticos do grupo controle.Conclusão:A hidrocortisona reduz a concentração de MMP-8 na placa carotídea, em especial nos pacientes sintomáticos. Houve associação entre a inflamação sistêmica e a tecidual.

Carotid endarterectomy: review of 10 years of practice of general and locoregional anesthesia in a tertiary care hospital in Portugal / Endarterectomia carotídea: revisão de 10 anos de prática de anestesia geral e locorregional num hospital terciário em Portugal / Endarterectomía carotídea: revisión de 10 años de práctica de la anestesia general y locorregional en un hospital terciario en Portugal

Retrospective and prospective randomized studies have compared general and locoregional anesthesia for carotid endarterectomy, but without definitive results.

Estudos retrospectivos e prospectivos randomizados têm comparado a anestesia locorregional e geral para endarterectomia carotídea, mas sem resultados definitivos.

Estudios retrospectivos y prospectivos aleatorizados han comparado la anestesia locorregional y la general para la endarterectomía carotídea pero sin resultados definitivos.

Carotid endarterectomy in awake patients: safety, tolerability and results / Endarterectomia de carótida em pacientes acordados: segurança, tolerabilidade e resultados

Objective: To analyze the results of 125 carotid endarterectomies under loco-regional anesthesia, with selective use of shunt and bovine pericardium patch. Methods: One hundred and seventeen patients with stenosis ≥ 70% in the internal carotid artery on duplex-scan + arteriography or magnetic resonance angiography underwent 125 carotid endarterectomies. Intraoperative pharmacological cerebral protection included intravenous administration of alfentanil and dexametasone. Clopidogrel, aspirin and statins were used in all cases. Seventy-seven patients were males (65.8%). Mean age was 70.8 years, ranging from 48 to 88 years. Surgery was performed to treat symptomatic stenosis in 69 arteries (55.2%) and asymptomatic stenosis in 56 arteries (44.8%). Results: A carotid shunt was used in 3 cases (2.4%) due to signs and symptoms of cerebral ischemia after carotid artery clamping during the operation, and all 3 patients had a good outcome. Bovine pericardium patch was used in 71 arteries ≤ 6 mm in diameter (56.8%). Perioperative mortality was 0.8%: one patient died from a myocardial infarction. Two patients (1.6%) had minor ipsilateral strokes with good recovery, and 2 patients (1.6%) had non-fatal myocardial infarctions with good recovery. The mean follow-up period was 32 months. In the late postoperative period, there was restenosis in only three arteries (2.4%). Conclusion: Carotid artery endarterectomy can be safely performed in the awake patient, with low morbidity and mortality rates. .

Objetivo: Analisar os resultados de 125 endarterectomias carotídeas, realizadas sob anestesia loco-regional com uso seletivo de shunt e remendo de pericárdio bovino. Métodos: Cento e dezessete pacientes com estenose na artéria carótida interna ≥ 70% ao ecoDoppler colorido + arteriografia ou angiorressonância magnética foram submetidos a 125 endarterectomias carotídeas. As medidas de proteção farmacológica intraoperatória incluíam a administração endovenosa de alfentanil e dexametazona. Clopidogrel, aspirina e estatinas eram utilizadas em todos os casos. Setenta e sete pacientes eram do sexo masculino (65,8%). A idade média foi de 70,8 anos, variando de 48 a 88 anos. A operação foi indicada por estenose sintomática em 69 artérias (55,2%), e por estenose assintomática em 56 artérias (44,8%). Resultados: O shunt de carótida foi necessário em 3 casos (2,4%) devido a sintomas de isquemia cerebral após a colocação do clampe carotídeo durante o ato cirúrgico, e os três pacientes tiveram boa evolução. Remendo de pericárdio bovino foi utilizado em 71 artérias ≤ 6 mm de diâmetro (56,8%). A mortalidade perioperatória foi de 0,8%: um paciente faleceu devido a infarto agudo do miocárdio. Dois pacientes (1,6%) tiveram infartos cerebrais isquêmicos ipsilaterais menores com boa recuperação, e 2 pacientes (1,6%) tiveram infartos do miocárdio não-fatais com boa recuperação. O tempo médio de seguimento foi de 32 meses. No pós-operatório tardio, houve reestenose significativa em apenas três artérias (2,4%). Conclusão: A endarterectomia carotídea no paciente acordado é uma técnica segura, sendo realizada com baixas taxas de morbimortalidade. .

Endarterectomía carotídea en pacientes octogenarios / Endarterectomía carotídea em pacientes octogenários / Carotid endarterectomy in eighty year-old patients

Objetivo: No existen diferencias significativas entre pacientes octogenarios y menores de ochentaaños en eventos ACV-Muerte, intervenidos por estenosis carotídea mediante endarterectomía carotídea.Material y Métodos: Desde enero de 2006 hasta junio de 2010 se realizaron 253 endarterectomías carotídeas en 251 pacientes, 24 (9.56%) (IC95% 6.21-13.90) pacientes tenían más de 80 años. Resultados: Del total de las endarterectomías carotídeas realizadas en pacientes menores de 80 años, 4 presentaron ACV y 1 falleció en el perioperatorio (ACV-muerte (n=5/227) (2.2%) (IC 95% 0.71-5.07)). Un paciente presentó un infarto agudo de miocardio perioperatorio en este grupo(0.4%) (IC 95% 0.006-2.43). De los 24 octogenarios, 1 paciente presentó ACV perioperatorio, dando un índice de ACV-muerte de 4.16 % (n=1) (IC 95% 0.05-21.14). Al comparar la poblaciónde ambos grupos no se hallaron evidencias significativas en la aparición de eventos adversos mayores como ACV o muerte que contraindiquen la cirugía en pacientes octogenarios con significación estadística p=0.91.Conclusión: En la muestra estudiada, no existen diferencias significativas entre pacientes octogenarios y menores de ochenta años en eventos ACV-Muerte postoperatoria, intervenidos porestenosis carotidea.

Objetivo: Não existem diferenças significativas entre pacientes octogenários e pacientes menores de oitenta anos em eventos ACV-Morte, operados por estenose carotídea mediante endarterectomia carotídea.Material e Métodos: De janeiro de 2006 a junho de 2010 realizaram-se 253 endarterectomias carotídeas em 251 pacientes, 24 (9.56%) (IC 95% 6.21-13.90) pacientes tinham mais de 80 anos. Resultados: Do total das endarterectomias carotídeas realizadas em pacientes menores de 80 anos, 4 apresentaram ACV e 1 faleceu no perioperatório (ACV-morte (n: 5/227) (2.2%) (IC 95% 0.71-5.07)). Neste grupo, um paciente apresentou um infarto agudo de miocárdio perioperatório (0.4%) (IC 95% 0.006-2.43). Dos 24 octogenários, 1 paciente apresentou ACV perioperatório, dando um índice de ACV-morte de 4.16 % (n=1) (IC 95% 0.05-21.14). Ao comparar a população dos dois grupos, não se encontraram evidências significativas no aparecimento de eventos adversos maiores como ACV ou morte, que contraindiquem a cirurgia em pacientes octogenários com estatística significativa p=0.91. Conclusão: Na amostra estudada, não existem diferenças significativas entre pacientesoctogenários e pacientes menores de oitenta anos em eventos ACV-Morte pós operatória, operados por estenose carotídea.

Objective: There are no significant differences between octogenarians and younger patients than eighty years in stroke-death events, with surgery for carotid stenosis by carotid endarterectomy. Material and Methods: From January 2006 through June 2010 were 253 carotid endarterectomiesin 251 patients, 24 (9.56%) (95% CI 6.21-13.90) were older than 80 years.Results: Of all carotid endarterectomies performed in patients younger than 80 years, 4 patients had a stroke and died in the perioperative patient (stroke-death (n=5/227) (2.2%) (95% CI 0.71-5.07)). One patient had a perioperative myocardial infarction in this group (0.4%) (95% CI 0.006-2.43). Of the 24 octogenarians, 1 patient had perioperative stroke, giving a rate of stroke-death of 4.16% (n=1) (95% CI 0.05-21.14). By comparing the population of both groups were not found significant evidence in the emergence of major adverse events such as stroke or death that maycontraindicate surgery in octogenarians with statistical significance p=0.91.Conclusion: No significant differences between octogenarians and younger patients than eighty years in stroke-death events postoperative surgery for carotid stenosis in the study sample.

Morbi-mortalidad de la endarterectomía carotídea / Morbidity and mortality of carotid endarterectomy

La endarterectomía carotídea (EC) en adición al mejor tratamiento médico mostró reducción del riesgo de eventos cerebrovasculares en pacientes sintomáticos y asintomáticos con estenosis moderada-grave del vaso en ensayos clínicos en centros académicos con cirujanos altamente seleccionados. Las principales guías internacionales recomiendan que el procedimiento se realice en centros con morbi-mortalidad auditada menor al 6% para pacientes sintomáticos y 3% para asintomáticos. Evaluamos la morbi-mortalidad peri-procedimiento en nuestro centro. Esta fue definida como la presencia de accidente cerebrovascular, infarto de miocardio y/o muerte dentro de los 30 días de la cirugía. Se indicó el procedimiento en pacientes sintomáticos con estenosis > 50%. En pacientes asintomáticos o sintomáticos con estenosis ≤ 50% se decidió el tratamiento sobre una base caso por caso. Todos los pacientes fueron examinados por un neurólogo y un cardiólogo antes y después de la EC. Se utilizó en forma rutinaria monitoreo intraoperatorio con Doppler transcraneano en los pacientes con adecuada ventana ultrasónica. Se evaluaron 306 endarterectomías carotídeas. No se registraron muertes. La morbilidad perioperatoria fue de 2.6% tanto para individuos sintomáticos como asintomáticos. Estos índices se compararon favorablemente con informes de otros centros de Latinoamérica y Europa. En conclusión, este informe muestra que la EC puede realizarse en la práctica clínica cotidiana con morbi-mortalidad peri-procedimiento dentro de los niveles recomendados por las guías internacionales.

Clinical trials in academic centers with high selected surgeons have demonstrated the effectiveness of carotid endarterectomy (CE) in addition to best medical treatment in symptomatic and asymptomatic patients with moderate to severe stenosis. International guidelines recommend that the procedure should be done in centers with morbidity and mortality rates of less than 6% for symptomatic and 3% for asymptomatic patients. We evaluated the morbidity and mortality of CE in our institution. This was defined by the presence of stroke, myocardial infarction and/or death within 30 days of surgery. Surgery was indicated in symptomatic patients with stenosis greater than 50%. For asymptomatic or symptomatic patients with stenosis ≤ 50% treatment was decided on a case-by-case basis. All patients were examined by a neurologist with and a cardiologist before and after the procedure. Intraoperative monitoring with transcranial Doppler was routinely used in patients with adequate ultrasonic window. We evaluated 306 procedures. No deaths occurred. Perioperative morbidity was 2.6% for both, symptomatic and asymptomatic subjects. These numbers compared favorably with those reported by other centers in Latin America and Europe. In conclusion, CE can be performed in routine clinical practice with morbidity and mortality results within those recommended by international guidelines.

Endarterectomía carotídea en octogenarios: comparación de desenlaces con pacientes menores de 80 años, experiencia en la Fundación Cardio Infantil / Carotid endarterectomy in octogenarians: comparison of outcomes in younger patients, the Fundación Cardio Infantil experience

Introducción. Dado el incremento de los pacientes con edades superiores a los 80 años que son llevados a cirugía cada año en nuestra institución, consideramos importante conocer el comportamiento en términos de morbilidad y mortalidad tempranas de los pacientes octogenarios sometidos a endarterectomía carotídea. Objetivo. Evaluar los resultados a 30 días de pacientes octogenarios con enfermedad carotídea grave, sintomática y asintomática, sometidos a endarterectomía carotídea, comparados con una cohorte histórica de pacientes de menor edad operados desde 1995 en la Fundación Cardio Infantil. Se registraron como variables dependientes la mortalidad y el accidente cerebrovascular. Resultados. Se registraron 218 endarterectomías carotídeas, 189 (86,6 por ciento) en pacientes menores de 80 años y 30 (13,4 por ciento) en pacientes octogenarios. En pacientes octogenarios no se presentaron accidentes cerebrovasculares (0 por ciento) y la mortalidad fue de 3,3 por ciento.. En el grupo de pacientes menores de 80 años se presentaron accidentes cerebrovasculares (1,7 por ciento) y muerte (1,1 por ciento)...

Background: Given the increase in patients over 80 years old who are taken to surgery each year inour institution we considered important to know the behavior in terms of early morbidity andmortality of those taken to carotid endarterectomy. Objective: To assess outcomes at 30 days in octogenarians with symptomatic and asymptomatic severe carotid disease taken to carotid endarterectomy compared to a historiccohort of younger patients operated since 1995 at Fundación Cardio Infantil. End points were mortality and stroke. Results: A total of 218 carotid endarterectomies, 189 (86,6 percent)...

Morphological and hemodynamic patterns of carotid stenosis treated by endarterectomy with patch closure versus stenting: a duplex ultrasound study

OBJECTIVES: A duplex ultrasound study was performed to investigate morphological and hemodynamic patterns of carotid stenoses treated by endarterectomy with patch closure versus stenting. MATERIALS AND METHOD: Twenty-nine carotid stenoses were treated with stenting and 65 with patch closure. Duplex ultrasound parameters (luminal diameter, mm; peak systolic velocity and end-diastolic velocity, cm/s) were measured 24 hours after the procedures and also at 12 months post-procedure. Residual stenoses (immediately postprocedure) and restenoses (within 12 months of procedure) were defined as narrowings of >50 percent on duplex ultrasound examination. RESULTS: In stented patients, the luminal diameter of the proximal internal carotid artery increased in the interval between the 24-hour and 12-month post-procedure studies, while in the patch closure patients, the diameter decreased. Carotid hemodynamics normalized immediately after both patching and stenting and remained relatively stable thereafter up to 12 months. No statistically elevated flow velocities (in the absence of residual stenosis or restenosis) were observed in the patched or stented carotid arteries. No significant differences in residual stenosis rates were observed between the stenting group (3 cases, 10.34 percent) and the patch closure group (1 case, 1.53 percent, P = 0.08). At 12 months, 2 stenting patients (6.88 percent) and 2 patch closure patients (3.07 percent) had $50 percent restenosis (P = 0.58). One case of late stroke due to restenosis was observed in the stenting group; the patient died 12 months postoperatively, before receiving new intervention. CONCLUSION: Measurements over time in luminal diameter signalized differences in arterial remodeling mechanisms between patched and stented carotids. Both stenting and patch closure were associated with carotid patency and flow restoration. This study does not support a general approach to new velocity criteria indiscriminately applied to stented or patched carotids.

El género femenino como factor predictivo en los resultados de la endarterectomía carotídea / Female gender as a predictive factor in the outcome of carotid endarterectomy

Introducción: Existe evidencia contradictoria acerca del beneficio de la endarterectomía carotídea (EC) en la mujer. Objetivo: Evaluar si el género femenino afecta los resultados inmediatos y alejados de la EC. Material y método: Estudio retrospectivo de 346 EC realizadas entre Enero de 1990 y Julio de 2008 en el Hospital Guillermo Grant Benavente de Concepción. Del total, 137 EC fueron realizadas en mujeres. Como grupo control se consideró a los hombres operados en el mismo período, quienes presentaron características demográficas y otras variables potencialmente adversas en proporción similar a las mujeres. Todas las variables se analizaron en un estudio bivariado y multivariado. Se comparó la morbimortalidad operatoria AVC/muerte), la sobrevida global a 5 y 10 años, el intervalo libre de eventos neurológicos y de reestenosis a 5 años. Se utilizó el método de Kapplan-Meier para la sobrevida actuarial, el Test de Log Rank y Chi Cuadrado para la significación estadística y la regresión logística (Backward Stepwise) para el análisis multivariado. Los resultados alejados se expresan en sobrevida promedio + error estándar. Resultados: El género femenino no mostró ser una variable independiente negativa para los resultados de la EC. La incidencia de AVC/muerte en las mujeres fue 1,5 por ciento.(hombres: 1,4 por ciento) (p= NS). La sobrevida global a 5 y 10 años fue 82,5 por ciento +/- 4,1 y 49,7 por ciento +/- 9,7, respectivamente (hombres: 73,5por ciento + 4,0 y 45 por ciento +/- 7,8) (p= NS). A 5 años, el intervalo libre de eventos neurológicos fue 97 por ciento +/- 1,8 (hombres: 98,3 por ciento +/- 1,0) (p= NS) y el de reestenosis fue 93,9 por ciento +/- 3,6 (hombres: 98,5 por ciento +/- 1,1) (p= NS). Conclusión: El género femenino no afecta los resultados de la EC por lo que no se debe considerar un factor predictivo adverso.

Background: The benefits of carotid endarterectomy (CE) in women have been questioned Aim: to evaluate whether female gender influences the results of CE Methods: 346 procedures of CE performed between January 1990 and July 2008 at Hospital Guillermo Grant Benavente in Concepcion were restrospectively analyzed. 137 CE were performed in women. Demographic characteristics were similar between males and females. A university and multi variate analysis including other adverse factors influencing the results of surgery was performed. Operative morbidity and mortality, global survival, neurologic events free survival and the re stenosis rate at 5 years were analyzed. Actuarial survival was analyzed by the Kapplan-Meir procedure using the Log-rank and Chi square tests; Backward stepwise logistic regression was used in multivariate analysis. Results: Female gender was not found to be an independent risk factor for poorer outcomes of CE. Stroke plus total death in woman was 1,5 percent, versus 1,4 percent in man (P=NS). Survival in woman at 5 and 10 years was 82,5 percent +/- 4,1 and 49,7 percent +/- 9,7, respectively, whereas in man it was 73,5 percent +/- 4,0 and 45 percent +/- 7,8) (p NS). At 5 years follow-up 97 percent +/- 1,8 of woman versus 98,3 percent +/- 1,0 of men were free of neurological events; free of having restenosis were 93,9 percent +/- 3,6 of woman versus 98,5 percent +/- 1,1 of man (p= NS). Conclusion: female gender did not result in poorer results following CE and, therefore, should not be considered an adverse predictive factor for this surgical procedure.

Ring-stripping retrograde common carotid endarterectomy: case report

CONTEXT: Total occlusion of the common carotid is rare and the indications and techniques for surgical treatment are still a matter of controversy. OBJECTIVE: To demonstrate the feasibility of retrograde common carotid endarterectomy. DESIGN: Retrospective case report study. SETTING: Tertiary care private hospital. PARTICIPANTS: Three patients underwent ring-stripping retrograde common carotid endarterectomy. Their ages were 81, 68 and 65 years. All were hypertensive with generalized atherosclerosis, two had diabetes mellitus, and one had undergone coronary artery bypass some years earlier and had non-dialytic chronic renal insufficiency. Symptoms of brain ischemia were present in two patients. All patients had total occlusion of the common carotid, extending from the origin to the bifurcation and localized in the right common carotid in two cases. In two cases the internal carotid artery was also occluded. MAIN MEASUREMENTS: Postoperative early mortality and stroke rate, and the medium and long-term endarterectomy patency. RESULTS: There were no deaths. One patient had a transient ischemic attack. All endarterectomies were patent after eight months, four years and seven years of follow-up. CONCLUSION: There is low mortality, and the procedure can be done through only one cervical incision. Tandem lesions of the carotid arteries can be treated together. It is suitable for long total occlusions of the common carotid, and long-term patency

Early and late results of carotid endarterectomy: retrospective study of 70 operations

CONTEXT: Indications and results of carotid endarterectomy have been defined from clinical multicentric trials like the European Carotid Surgery Trialists, North-American Symptomatic Carotid Endarterectomy Trial and Asymptomatic Carotid Atherosclerosis Study. The patients included in these trials were highly selected, as were the surgeons performing the operations. Clinical practice is different but the same results should be achieved. OBJECTIVE: To study indications, technique, early and late results, and whether carotid endarterectomy has been performed in accordance with standards defined by multicentric trials. DESIGN: Retrospective case report study. SETTING: A tertiary care private hospital. PARTICIPANTS: 57 patients, on whom 70 carotid endarterectomies were performed over a 10-year period. The median age was 66.4 ± 7.8 years; 43 (75.4 percent) were male, 41 (71.9 percent) hypertensive, 36 (63.1 percent) current smokers and 24 (21.0 percent) had diabetes. Bilateral carotid stenosis was present in 31 (54.3 percent) patients, peripheral arterial occlusions in 32 (56.1 percent) and ischemic cardiopathy in 25 (43.1 percent). All patients had had angiography and 41 (71.9 percent) had also had a duplex-scan of neck arteries. Cerebral imaging via computerized tomography scan or magnetic resonance imaging was obtained for 36 patients. Patients were followed up over a period of one to 122 months. MAIN MEASUREMENTS: early and late post-operative death, early and late post-operative stroke, and recurrence of atheroma plaque and symptoms relative to carotid stenosis. RESULTS: There was one post-operative death (1.4 percent) caused by myocardial infarction and two early strokes (2.8 percent): a total complication rate of 4.2 percent. After 3 and 5 years, 95.4 percent and 81.3 percent of patients respectively were stroke-free and 72.8 percent and 67.3 percent were alive. There were four recurrences and two of them related to stroke. Forty-nine (70 percent) stenoses operated on were symptomatic. Brain infarction was detected in 59.2 percent of patients who underwent computerized tomography scan or magnetic resonance imaging. CONCLUSIONS: Carotid endarterectomy was done in accordance with international standards. The most frequent cause of late death was myocardial infarction, and recurrences were related to stroke. Patients should be followed up closely

Endarterectomia de carótida bilateral combinada com revascularizaçäo miocárdica durante o mesmo ato cirúrgico / Bilateral carotid endarterectomy combined with myocardial revascularization during the same surgical act

The best surgical approach for the treatment of patients with severe cerebral artery disease and simultaneous serious coronary artery disease still remains controversial. In this report we present a case of a 72-year-old female patient admitted to the hospital with unstable angina. Triple coronary artery obstructive disease and severe bilateral carotid artery stenosis were diagnosed. A combined, simultaneous surgical procedure was performed. After total circulatory by-pass with a membrane oxygenator, the patient's body temperature was lowered to 32ºC. During the cool-down period, three proximal anastomoses of segments of autologous saphenous veins were performed in the ascending aorta. Immediately afterwards, bilateral carotid endarterectomy was performed, followed by three distal anastomoses to coronary arteries. The patient showed a satisfactory post-operative outcome. It was concluded that the combination of moderate hypothermia, hemodilution with appropriate hemodynamic control, as used in this patient, was an effective method of cerebral protection. The simultaneous approach of carotid endarterectomy and coronary artery by-pass surgery should be seen as a safe option for the treatment of this type of patient.

Endarterectomia da artéria carótida extracraniana / Extracranial carotid endarterectomy

A endarterectomia de carótida com estenose maior de 70 por cento do diâmetro interno está bem estabelecida, tendo evidência clínica que reduz em 17 por cento o risco de acidente vascular cerebral em relaçäo ao tratamento clínico. Porém, a equipe cirúrgica näo poderá ter mais de 5 por cento de complicaçöes globais como acidente vascular cerebral e óbito. Embora já exista indício de benefício da endarterectomia de carótida para doente assintomático com estenose de 60 por cento, como ainda tem controvérsia, é prudente aguardar novos ensaios clínicos para melhor julgamento. Todos os doentes devem ser acompanhados no pós-operatório indefinidamente controlando todos os fatores de risco como hipertensäo arterial, diabetes mellitus, obesidade, tabagismo, sedentarismo, estresse, cardiopatias, coagulopatias, colesterol, triglicerídeos, doenças inflamatórias, alcoolismo, abuso de drogas. É também recomendado o uso continuado de ácido acetilsalicílico na dosagem de 200 a 300 mg por dia.