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Neurologia Medico-chirurgica Sep 2020Over the last 60 years, many reports have investigated carotid endarterectomy (CEA) and techniques have thus changed and improved. In this paper, we review the recent... (Review)
Review
Over the last 60 years, many reports have investigated carotid endarterectomy (CEA) and techniques have thus changed and improved. In this paper, we review the recent literature regarding operational maneuvers for CEA and discuss future problems for CEA. Longitudinal skin incision is common, but the transverse incision has been reported to offer minimal invasiveness and better cosmetic effects for CEA. Most surgeons currently use microscopy for dissection of the artery and plaque. Although no monitoring technique during CEA has been proven superior, multiple monitors offer better sensitivity for predicting postoperative neurological deficit. To date, data are lacking regarding whether routine shunt or selective shunt is better. Individual surgeons thus need to select the method with which they are more comfortable. Many surgical techniques have been reported to obtain distal control of the internal carotid artery in patients with high cervical carotid bifurcation or high plaque, and minimally invasive techniques should be considered. Multiple studies have shown that patch angioplasty reduces the risks of stroke and restenosis compared with primary closure, but few surgeons in Japan have been performing patch angioplasty. Most surgeons thus experience only a small volume of CEAs in Japan, so training programs and development of in vivo training models are important.
Topics: Carotid Stenosis; Endarterectomy, Carotid; Humans; Monitoring, Intraoperative; Patient Positioning
PubMed: 32801277
DOI: 10.2176/nmc.ra.2020-0111 -
The Cochrane Database of Systematic... Sep 2020Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. This is an update of a Cochrane Review, originally published in 1999, and most recently updated in 2017.
OBJECTIVES
To determine the balance of benefit versus risk of endarterectomy plus best medical management compared with best medical management alone, in people with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke).
SEARCH METHODS
We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) portal to October 2019. We also reviewed the reference lists of all relevant studies and abstract books from research proceedings.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing carotid artery surgery plus best medical treatment with best medical treatment alone. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risk of bias, and extracted the data. We assessed the results and the quality of the evidence of the primary and secondary outcomes by the GRADE method, which classifies the quality of evidence as high, moderate, low, or very low.
MAIN RESULTS
We included three trials involving 6343 participants. The trials differed in the methods of measuring carotid stenosis and in the definition of stroke. Using the primary electronic data files, we pooled and analysed individual patient data on 6092 participants (35,000 patient-years of follow-up), after reassessing the carotid angiograms and outcomes from all three trials, and redefining outcome events where necessary, to achieve comparability. Surgery increased the five-year risk of any stroke or operative death in participants with less than 30% stenosis (risk ratio (RR) 1.25, 95% confidence interval (CI) 0.99 to 1.56; 2 studies, 1746 participants; high-quality evidence). Surgery decreased the five-year risk of any stroke or operative death in participants with 30% to 49% stenosis (RR 0.97, 95% CI 0.79 to 1.19; 2 studies, 1429 participants; high-quality evidence), was of benefit in participants with 50% to 69% stenosis (RR 0.77, 95% CI 0.63 to 0.94; 3 studies, 1549 participants; moderate-quality evidence), and was highly beneficial in participants with 70% to 99% stenosis without near-occlusion (RR 0.53, 95% CI 0.42 to 0.67; 3 studies, 1095 participants; moderate-quality evidence). However, surgery decreased the five-year risk of any stroke or operative death in participants with near-occlusions (RR 0.95, 95% CI 0.59 to 1.53; 2 studies, 271 participants; moderate-quality evidence).
AUTHORS' CONCLUSIONS
Carotid endarterectomy reduced the risk of recurrent stroke for people with significant stenosis. Endarterectomy might be of some benefit for participants with 50% to 69% symptomatic stenosis (moderate-quality evidence) and highly beneficial for those with 70% to 99% stenosis (moderate-quality evidence).
Topics: Adult; Age Factors; Aged; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Ischemic Attack, Transient; Male; Postoperative Complications; Randomized Controlled Trials as Topic; Risk; Sex Factors; Stroke; Time Factors
PubMed: 32918282
DOI: 10.1002/14651858.CD001081.pub4 -
Journal of Vascular Surgery Jan 2022
Topics: Aneurysm; Cardiovascular Agents; Carotid Artery Diseases; Endarterectomy, Carotid; Endovascular Procedures; Humans; Popliteal Artery; Practice Guidelines as Topic; Treatment Outcome
PubMed: 34949335
DOI: 10.1016/j.jvs.2021.07.001 -
British Journal of Anaesthesia Jul 2007Carotid endarterectomy (CEA) is performed to prevent embolic stroke in patients with atheromatous disease at the carotid bifurcation. There is now substantial evidence... (Review)
Review
Carotid endarterectomy (CEA) is performed to prevent embolic stroke in patients with atheromatous disease at the carotid bifurcation. There is now substantial evidence to support early operation in symptomatic patients, ideally within 2 weeks of the last neurological symptoms. Thus, the anaesthetist may be faced with a high risk patient in whom there has been limited time for preoperative preparation. The operation may be performed under local or general anaesthesia. The advantages and disadvantages of both are explored in this review. Carotid shunting may offer a degree of cerebral protection, but carries its own risks and has not been proved to reduce morbidity and mortality. The use of carotid shunts is based on clinical judgement, awake neurological monitoring, and the use of monitors of cerebral perfusion. There is no ideal monitor of cerebral perfusion in the patient receiving general anaesthesia. Both the intraoperative and postoperative periods may be witness to dramatic haemodynamic changes that may compromise the cerebral or myocardial circulations. In particular, postoperative hypotension may compromise both myocardial and cerebral perfusion, and severe hypertension can cause cerebral hyperperfusion. There is as yet limited evidence to guide the management of these problems. In summary, CEA can yield significant benefit, but those with the most to gain from the operation also present the greatest challenge to the anaesthetist.
Topics: Anesthesia; Cerebrovascular Circulation; Endarterectomy, Carotid; Humans; Hypertension; Hypotension; Monitoring, Intraoperative; Postoperative Care; Stroke
PubMed: 17556351
DOI: 10.1093/bja/aem137 -
Annals of Palliative Medicine Nov 2022Extracranial cerebrovascular diseases represent approximately 20% of ischemic stroke cases. Carotid endarterectomy (CEA) was the gold standard procedure for carotid...
BACKGROUND
Extracranial cerebrovascular diseases represent approximately 20% of ischemic stroke cases. Carotid endarterectomy (CEA) was the gold standard procedure for carotid artery stenosis treatment until the introduction of carotid artery stenting (CAS) in the 1980s. While there have been several multicenter randomized trials comparing CEA and CAS, a more efficacious procedure has not been conclusively distinguished. This study reports the results of CAS versus CEA in patients with symptomatic or asymptomatic carotid stenosis and compares them with those from other studies.
METHODS
This study is a single-center retrospective study and included patients who underwent CAS and CEA as elective surgery between January 2012 and December 2020. The final analysis included patient baseline characteristics, postoperative complications, and patient outcomes.
RESULTS
The 235 patients included were assigned to the CAS (n=128) and CEA (n=107) groups. Within 30 days postoperatively, no significant differences were noted in myocardial infarction [n=1, 0.8% (CAS); n=1, 0.9% (CEA); P=0.899], cerebral infarction [n=4, 3.1% (CAS); n=1, 0.9% (CEA); P=0.247], and patient mortality [n=1, 0.8% (CAS); n=0, 0% (CEA); P=0.247].
CONCLUSIONS
In elective surgery, CAS and CEA had the same effect of preventing cerebral infarction with no difference in postoperative complications.
Topics: Humans; Endarterectomy, Carotid; Carotid Stenosis; Retrospective Studies; Stents; Stroke; Treatment Outcome; Cerebral Infarction; Postoperative Complications; Carotid Arteries; Risk Factors; Risk Assessment
PubMed: 36366894
DOI: 10.21037/apm-22-797 -
The Cochrane Database of Systematic... Jun 2017Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. This is an update of the Cochrane Review, originally published in 1999, and most recently updated in 2011.
OBJECTIVES
To determine the balance of benefit versus risk of endarterectomy plus best medical management compared with best medical management alone, in people with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke).
SEARCH METHODS
We searched the Cochrane Stroke Group Trials Register (last searched in July 2016), CENTRAL (2016, Issue 7), MEDLINE (1966 to July 2016), Embase (1990 to July 2016), Web of Science Core Collection, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) portal, and handsearched relevant journals and reference lists.
SELECTION CRITERIA
We included randomised controlled trials. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risk of bias, and extracted the data.
MAIN RESULTS
We included three trials involving 6343 participants. As the trials differed in the methods of measurement of carotid stenosis and in the definition of stroke, we did a pooled analysis of individual patient data on 6092 participants (35,000 patient years of follow-up), after reassessing the carotid angiograms and outcomes from all three trials using the primary electronic data files, and redefined outcome events where necessary, to achieve comparability.On re-analysis, there were no significant differences between the trials in the risks of any of the main outcomes in either of the treatment groups, or in the effects of surgery. Surgery increased the five-year risk of ipsilateral ischaemic stroke in participants with less than 30% stenosis (N = 1746, risk ratio (RR) 1.27, 95% confidence interval (CI) 0.80 to 2.01), had no significant effect in participants with 30% to 49% stenosis (N = 1429, RR 0.93, 95%CI 0.62 to 1.38), was of benefit in participants with 50% to 69% stenosis (N = 1549, RR 0.84, 95%CI 0.60 to 1.18), and was highly beneficial in participants with 70% to 99% stenosis without near-occlusion (N = 1095, RR 0.47, 95%CI 0.25 to 0.88). However, there was no evidence of benefit (N = 271, RR 1.03, 95%CI 0.57 to 1.84) in participants with near-occlusions. Ipsilateral ischaemic stroke describes insufficient blood flow to the cerebral hemisphere, secondary to same side severe stenosis of the internal carotid artery.
AUTHORS' CONCLUSIONS
Endarterectomy was of some benefit for participants with 50% to 69% symptomatic stenosis (moderate-quality evidence), and highly beneficial for those with 70% to 99% stenosis without near-occlusion (moderate-quality evidence). We found no benefit in people with carotid near-occlusion (high-quality evidence).
Topics: Adult; Age Factors; Aged; Carotid Stenosis; Endarterectomy, Carotid; Female; Humans; Male; Randomized Controlled Trials as Topic; Risk; Sex Factors; Stroke; Time Factors
PubMed: 28590505
DOI: 10.1002/14651858.CD001081.pub3 -
Journal of Vascular Surgery Feb 2019
Topics: Endarterectomy, Carotid
PubMed: 30683207
DOI: 10.1016/j.jvs.2018.10.057 -
Stroke and Vascular Neurology Oct 2023In-stent restenosis (ISR) belongs to an infrequent but potentially serious complication after carotid angioplasty and stenting in patients with severe carotid stenosis.... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND AND AIM
In-stent restenosis (ISR) belongs to an infrequent but potentially serious complication after carotid angioplasty and stenting in patients with severe carotid stenosis. Some of these patients might be contraindicated to repeat percutaneous transluminal angioplasty with or without stenting (rePTA/S). The purpose of the study is to compare the safety and effectiveness of carotid endarterectomy with stent removal (CEASR) and rePTA/S in patients with carotid ISR.
METHODS
Consecutive patients with carotid ISR (≥80%) were randomly allocated to the CEASR or rePTA/S group. The incidence of restenosis after intervention, stroke, transient ischaemic attack myocardial infarction and death 30 days and 1 year after intervention and restenosis 1 year after intervention between patients in CEASR and rePTA/S groups were statistically evaluated.
RESULTS
A total of 31 patients were included in the study; 14 patients (9 males; mean age 66.3±6.6 years) were allocated to CEASR and 17 patients (10 males; mean age 68.8±5.6 years) to the rePTA/S group. The implanted stent in carotid restenosis was successfully removed in all patients in the CEASR group. No clinical vascular event was recorded periproceduraly, 30 days and 1 year after intervention in both groups. Only one patient in the CEASR group had asymptomatic occlusion of the intervened carotid artery within 30 days and one patient died in the rePTA/S group within 1 year after intervention. Restenosis after intervention was significantly greater in the rePTA/S group (mean 20.9%) than in the CEASR group (mean 0%, p=0.04), but all stenoses were <50%. Incidence of 1-year restenosis that was ≥70% did not differ between the rePTA/S and CEASR groups (4 vs 1 patient; p=0.233).
CONCLUSION
CEASR seems to be effective and save procedures for patients with carotid ISR and might be considered as a treatment option.
TRIAL REGISTRATION NUMBER
NCT05390983.
Topics: Male; Humans; Middle Aged; Aged; Endarterectomy, Carotid; Constriction, Pathologic; Coronary Restenosis; Risk Factors; Treatment Outcome; Carotid Arteries; Angioplasty; Stents
PubMed: 36972920
DOI: 10.1136/svn-2022-002075 -
Stroke Feb 2022The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid... (Review)
Review
The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients. Stroke and cerebrovascular disease are prevalent in women. There are inherent biological and other differences in men and women, which affect the manifestations and outcome of stroke, with women experiencing worse disability and higher mortality following ischemic stroke than men. Due to the underrepresentation of female patients in most clinical trials, the ability to make firm but alternative recommendations for women specifically on the management of carotid stenosis is challenging. Although some data suggest that women might have worse periprocedural outcomes as compared to men following all carotid revascularization procedures, there is also an abundance of data to support a similar risk for carotid procedures in men and women, especially with carotid endarterectomy and transcarotid artery revascularization. Therefore, the indications for carotid revascularization are the same in women as they are in men. The choice of a carotid revascularization procedure in women is based upon the same factors as in men and requires careful evaluation of a particular patient's risk profile, anatomic criteria, plaque morphology, and medical comorbidities that might favor one technique over the other. When performing carotid revascularization procedures in women, tailored techniques and procedures to address the small diameter of the female artery are warranted.
Topics: Carotid Arteries; Endarterectomy, Carotid; Endovascular Procedures; Female; Humans; Male; Neurosurgical Procedures; Sex Characteristics; Stents; Treatment Outcome; Women
PubMed: 34983240
DOI: 10.1161/STROKEAHA.121.035386 -
British Journal of Anaesthesia Mar 2015Summary Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid... (Review)
Review
Summary Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid cross-clamping; haemodynamic control is predictable; and hospital stay is consistently shorter compared with general anaesthesia (GA). Despite these purported benefits, mortality and stroke rates associated with CEA remain around 5% for both regional anaesthesia and GA. Regional anaesthetic techniques for CEA have improved with improved methods of location of peripheral nerves including nerve stimulators and ultrasound together with a modification in the classification of cervical plexus blocks. There have also been improvements in local anaesthetic, sedative, and arterial pressure-controlling drugs in patients undergoing CEA, together with advances in the management of patients who develop neurological deficit after carotid cross-clamping. In the UK, published national guidelines now require the time between the patient's presenting neurological event and definitive treatment to 1 week or less. This has implications for the ability of vascular centres to provide specialized vascular anaesthetists familiar with regional anaesthetic techniques for CEA. Providing effective regional anaesthesia for CEA is an important component in the armamentarium of techniques for the vascular anaesthetist in 2014.
Topics: Anesthesia, Conduction; Endarterectomy, Carotid; Humans; Length of Stay; Preoperative Care
PubMed: 25173766
DOI: 10.1093/bja/aeu304