Synchronous carotid endarterectomy and coronary artery bypass graft: Four case reports

BACKGROUND One of the major perioperative complications for coronary artery bypass graft(CABG)is stroke.The risk of perioperative stroke after CABG is approximately 2%.Carotid stenosis(CS)is considered an independent predictor of perioperative stroke risk in CABG patients.The optimal management of such patients has been a source of controversy.One of the possible surgical options is synchronous carotid endarterectomy(CEA)and CABG.Here,we have presented 4 cases of successful synchronous CEA and CABG.Our center’s experience with 4 cases of significant carotid artery stenosis,which were successfully managed with combined CEA and CABG,are detailed.The first case was a female who presented for CABG after a ST-elevation myocardial infarction.She had right internal carotid artery(ICA)occlusion and 90%left ICA stenosis.The second case was a male who was electively admitted for CABG.It was discovered that he had left ICA occlusion and 90%right ICA stenosis.The third case was a male with a history of stroke,two months prior to admission.He presented with non-ST-elevation myocardial infarction.Preoperatively,it was discovered that he had>90%right ICA stenosis.The final case was a male who was electively admitted for CABG.It was discovered that he had bilateral>90%ICA stenosis.We have also reviewed the current evidence and guidelines for managing CS in patients undergoing CABG.CONCLUSION Our case series demonstrated that synchronous CEA and CABG was safe.A multicenter study with additional patients is needed.It is necessary for clinicians to screen for CS in high-risk patients with features.

Internal Jugular Vein Graft after Inadvertent Severing of the Internal Carotid Artery during Carotid Endarterectomy and an Urgent Re-Exploration for Immediate Post-Operative Wound Site Bleeding: A Case Report

Carotid endarterectomy is a well-established treatment for preventing stroke in selected patients. Although there is debate over whether patch angioplasty or primary closure should be used to reconstruct the bifurcation after carotid endarterectomy, there is growing evidence in the literature in favor of patch angioplasty. When compared to primary closure, patch angioplasty during conventional carotid endarterectomy is suggested to lower the incidence of restenosis and recurrent ipsilateral stroke. Various materials have been used as a patch in this procedure, including the saphenous vein, synthetic patches, or less frequently, an internal jugular vein patch where extensive narrowing of the internal carotid artery is evident. In our case, we used an internal jugular vein graft after inadvertent severing the internal carotid artery (ICA) during carotid endarterectomy after the failure of reconstruction with a saphenous vein patch. We also encountered immediate postoperative reactionary hemorrhage following anesthetic reversal, necessitating an urgent re-exploration. The purpose of this case report is neither an attempt to suggest all patients need angioplasty nor to state that an internal jugular vein patch or graft is superior to synthetic material or saphenous veins;rather, it is an attempt to emphasize a potentially effective rescue way to reconstruct inadvertent extensive vascular injury during carotid endarterectomy.

Correlation of Enhancement Degree on Contrast-enhanced Ultrasound with Histopathology of Carotid Plaques and Serum High Sensitive C-Reactive Protein Levels in Patients Undergoing Carotid Endarterectomy

This study was undertaken to investigate the correlation of the enhancement degree on contrast-enhanced ultrasound(CEUS) with the histopathology of carotid plaques and the serum high sensitive C-reactive protein(hs-CRP) levels in patients undergoing carotid endarterectomy(CEA). Carotid CEUS was performed preoperatively in 115 patients who would undergo CEA, and the enhancement degree of the carotid plaques was evaluated by both the visual semiquantitative analysis and the quantitative time-intensity curve analysis. Serum hs-CRP levels were detected using the particle-enhanced immunoturbidimetric assay also before the operation. Additionally, the carotid plaque samples were subjected to histopathological examination postoperatively. The density of neovessels and the number of macrophages in the plaques were assessed by immunohistochemistry. The results showed that among the 115 patients, grade 0 plaque contrast enhancement was noted in 35 patients, grade 1 in 48 patients and grade 2 in 32 patients. The degree of plaque enhancement, the density of neovessels, the number of macrophages, and the hs-CRP levels were highest in the grade 2 patients. Correlation analysis showed that the enhancement degree of the carotid plaques was closely related to the immunohistochemical parameters of the plaques and the serum hs-CRP levels. It was suggested that the carotid plaque enhancement on CEUS can be used to evaluate the vulnerability of carotid plaques.

Association between neutrophil-to-lymphocyte ratio and major postoperative complications after carotid endarterectomy:A retrospective cohort study

BACKGROUND Carotid artery cross-clamping during carotid endarterectomy(CEA)may damage local cerebral perfusion and induce cerebral ischemia–reperfusion injury to activate local inflammatory responses.Neutrophil-to-lymphocyte ratio(NLR)is an indicator that reflects systemic inflammation.However,the correlation between NLR and complications after CEA remains unclear.AIM To investigate the association between NLR and major complications after surgery in patients undergoing CEA.METHODS This retrospective cohort study included patients who received CEA between January 2016 and July 2018 at Beijing Tiantan Hospital.Neutrophil and lymphocyte counts in whole blood within 24 h after CEA were collected.The primary outcome was the composite of major postoperative complications including neurological,pulmonary,cardiovascular and acute kidney injuries.The secondary outcomes included infections,fever,deep venous thrombosis,length of hospitalization and cost of hospitalization.Statistical analyses were performed using EmpowerStats software and R software.RESULTS A total of 224 patients who received CEA were screened for review and 206 were included in the statistical analyses;of whom,40(19.42%)developed major postoperative complications.NLR within 24 h after CEA was significantly correlated with major postoperative complications(P=0.026).After confounding factors were adjusted,the odds ratio was 1.15(95%CI:1.03–1.29,P=0.014).The incidence of major postoperative complications in the high NLR group was 8.47 times that in the low NLR group(P=0.002).CONCLUSION NLR is associated with major postoperative complications in patients undergoing CEA.

Monitoring cerebral ischemia during carotid endarterectomy and stenting

Current therapy for carotid stenosis mainly includes carotid endarterectomy and endovascular stenting,which may incur procedure-related cerebral ischemia.Several methods have been employed for monitoring cerebral ischemia during surgery,such as awake neurocognitive assessment,electroencephalography,evoked potentials,transcranial Doppler,carotid stump pressure,and near infrared spectroscopy.However,there is no consensus on the gold standard or the method that is superior to others at present.Keeping patient awake for real time neurocognitive assessment is effective and essential;however,not every surgeon adopts it.In patients under general anesthesia,cerebral ischemia monitoring has to rely on non-awake technologies.The advantageous and disadvantageous properties of each monitoring method are reviewed.

Carotid endarterectomy for ameliorating the symptoms of transient ischemic attack A six-month postoperative follow-up

BACKGROUND： Carotid endarterectomy has certain risks, but it has obvious effects on preventing the occurrence of stroke. OBJECTIVE： To identify the effects of carotid endarterectomy on ameliorating the clinical symptoms and physical signs of patients with cerebral ischemia. DESIGN： A follow-up study. SETTING： Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology. PARTICIPANTS： Sixteen patients with carotid atherosclerotic stenosis accompanied by ischemic symptoms were selected from the Department of Vascular Surgery, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology from March 2005 to May 2007. There were 11 males and 5 females, aged from 40 to 81 years old with a mean age of 60 years old, and they were all clearly diagnosed by carotid color Doppler ultrasound. Informed consent was obtained from all the patients. The study was approved by the hospital ethical committee. METHODS： （1） All the 16 patients were performed with unilateral stripping of arteriosclerotic plaque and Carotid endarterectomy, and 6 of them with bilateral stenosis was operated on the side with more serious stenosis. （2） The clinical symptoms, physical signs before and after operation, and the operative complications were observed. （3） The patients were followed up for 6 months postoperatively. The smoothness of carotid arteries was detected with color Doppler ultrasound. The degrees of satisfaction to the quality of living were evaluated. MAIN OUTCOME MEASURES： （1） Amelioration of clinical symptoms postoperatively; （2） Smoothness of carotid arteries postoperatively; （3） Degrees of satisfaction to the quality of living; （4） Postoperative complications. RESULTS： All the 16 patients were involved in the final analysis of results. （1） Amelioration of clinical symptoms and physical signs： The postoperative muscle strengths of 3 patients with stroke history were significantly ameliorated; For the 8 patients with TIA symptoms, and the symptoms disappeared completely in 6 cases of them; For the 5 patients with atypical nervous symptoms, the symptoms disappeared completely in 3 cases, and obviously alleviated in 2 cases. （2） All the patients were good in smoothness of carotid arteries. （3） The degree of satisfaction to the quality of living was a little satisfied in 2 patients, very satisfied in 1 patient, and satisfied in the others. （4） Postoperative complications： The complications were injury of hypoglossal nerve in 4 patients （25%） and injury of recurrent laryngeal nerve in 1 patient （6%）, and the complications recovered or turned better after conservative treatments for 1 - 3 months. CONCLUSION： Carotid endarterectomy can ameliorate the symptoms and physical signs of patients with cerebral ischemia, and it has mild postoperative complications.

Diabetes mellitus and adverse outcomes after carotid endarterectomy:A systematic review and meta-analysis

Background:There is still uncertainty regarding whether diabetes mellitus(DM)can adversely affect patients undergoing carotid endarterectomy(CEA)for carotid stenosis.The aim of the study was to assess the adverse impact of DM on patients with carotid stenosis treated by CEA.Methods:Eligible studies published between 1 January 2000 and 30 March 2023 were selected from the PubMed,EMBASE,Web of Science,CENTRAL,and ClinicalTrials databases.The short-term and long-term outcomes of major adverse events(MAEs),death,stroke,the composite outcomes of death/stroke,and myocardial infarction(MI)were collected to calculate the pooled effect sizes(ESs),95%confidence intervals(CIs),and prevalence of adverse outcomes.Subgroup analysis by asymptomatic/symptomatic carotid stenosis and insulin/noninsulin-dependent DM was performed.Results:A total of 19 studies(n=122,003)were included.Regarding the short-term outcomes,DM was associated with increased risks of MAEs(ES=1.52,95%CI:[1.15-2.01],prevalence=5.1%),death/stroke(ES=1.61,95%CI:[1.13-2.28],prevalence=2.3%),stroke(ES=1.55,95%CI:[1.16-1.55],prevalence=3.5%),death(ES=1.70,95%CI:[1.25-2.31],prevalence=1.2%),and MI(ES=1.52,95%CI:[1.15-2.01],prevalence=1.4%).DM was associated with increased risks of long-term MAEs(ES=1.24,95%CI:[1.04-1.49],prevalence=12.2%).In the subgroup analysis,DM was associated with an increased risk of short-term MAEs,death/stroke,stroke,and MI in asymptomatic patients undergoing CEA and with only short-term MAEs in the symptomatic patients.Both insulin-and noninsulin-dependent DM patients had an increased risk of short-term and long-term MAEs,and insulin-dependent DM was also associated with the short-term risk of death/stroke,death,and MI.Conclusions:In patients with carotid stenosis treated by CEA,DM is associated with short-term and long-term MAEs.DM may have a greater impact on adverse outcomes in asymptomatic patients after CEA.Insulin-dependent DM may have a more significant impact on post-CEA adverse outcomes than noninsulin-dependent DM.Whether DM management could reduce the risk of adverse outcomes after CEA requires further investigation.

PERIOPERATIVE STROKE AFTER CAROTID ENDARTERECTOMY ETIOLOGICAL RISK FACTORS AND MANAGEMENT

291 patients were subjected to carotid endarterectomy from January 1985 to June 1992 in two Australian medical institutions. Of the 291 patients, perioperative stroke occurred in 22 (6.3%) after 347 operations (moderate 17 and severe 5). The 22 patients were studied with Doppler scan, angiography, reexploration and CT. Reexploration showed that 12 of 14 patients had thrombosis in the internal carotid artery at operation. The etiological factors for perioperative strokes included thrombosis at the operative sites in 14 patients (64%), cerebral embolism after operation in 4, clamping ischemia in 2, intracerebral hemorrhage in 1 and unknown cause in 1. Six patients (27%) recovered completely in 4 weeks, 10 (45%) had mild residual neurological deficits, 5 (23%) had moderate neurological deficits and 1 died 3 days after operation. Only 6 patients had permanent neurological deficits (6 / 347, 17%).

Commentary on a case report and literature review of acute carotid stent thrombosis

In this commentary on the article entitled“Acute carotid stent thrombosis:A case report and literature review”,the key points of the article are discussed.Acute carotid stent thrombosis(ACST)in the setting of carotid artery stenting(CAS)represents a rare but potentially catastrophic event.There is a wide range of treatment options available,including carotid endarterectomy,which is generally recommended for cases of refractory ACST.While there is no standard treatment regimen,dual antiplatelet therapy is typically recommended both before and after CAS to reduce risk of ACST.

Preliminary results of combined carotid endarterectomy and off-pump coronary artery bypass grafting in patients with coexistent carotid and coronary artery diseases

Background Coexistent carotid and coronary artery diseases are common and patients with them remain at a high risk for perioperative stroke or myocardial infarction after coronary bypass surgery. The aim of this study was to investigate the effect of combined carotid endarterectomy （CEA） and off-pump coronary artery bypass grafting （CABG） in patients with coexistent carotid and coronary artery diseases. Methods Between January 2002 and December 2007, consecutive patients with coexistent carotid and coronary artery diseases underwent one-stage unilateral CEA and off-pump CABG in Heart Institute of Nanjing First Hospital Affiliated to Nanjing Medical University. Perioperative complications were assessed and follow-up was carried out. Results A total of 51 cases of isolated off-pump CABG and unilateral CEA, including 34 right and 17 left, were performed. The mean blocked time of carotid artery in CEA was （25.5_±7.0） minutes. The mean number of distal grafts per patient was 3.30±0.45. The mean ventilation time, intensive care unit stay, and postoperative hospital stay was （11.3±5.4） hours, （2.1±0.9） days, and （12.5±6.1） days respectively. None of the patients had stroke or myocardial infarct. There was one perioperative death due to acute cardiac failure, resulting in an operative mortality of 1.96%. Follow-up was completed for 47 patients （92.16%） with a mean follow-up of （39.5±12.5） months. None of the patients manifested stroke, new angina or newly developed cardiac infarct. No late death occurred. Conclusion Combined CEA and off-pump CABG is a safe and effective procedure in selected patients with coexistent carotid and coronary artery diseases.

Protocol for electrophysiological monitoring of carotid endarterectomies

Near zero stroke rates can be achieved in carotid endarterectomy （CEA） surgery with selective shunting and electrophysiological neuromonitoring.though false negative rates as high as 40% have been reported.We sought to determine if improved training for interpretation of the monitoring signals can advance the efficacy of selective shunting with electrophysiological monitoring across multiple centers,and determine if other factors could contribute to the differences in reports.Processed and raw beta band （12.5-30 Hz） electroencephalogram （EEG） and median and tibial nerve somatosensory evoked potentials （SSEP） were monitored in 668 CEA cases at six surgical centers.A decrease in amplitude of 50% or more in any EEG or SSEP channel was the criteria for shunting or initiating a neuroprotective protocol.A reduction of 50% or greater in the beta band of the EEG or amplitude of the SSEP was observed in 150 cases.No patient showed signs of a cerebral infarct after surgery.Selective shunting based on EEG and SSEP monitoring can reduce CEA intraoperative stroke rate to a near zero level if trained personnel adopted standardized protocols.We also found that the rapid administration of a protective stroke protocol by attending anesthesiologists was an important aspect of this success rate.

CAS and CEA in the Treatment of Severe Internal Carotid Artery Stenosis

Objective:To explore the clinical value of carotid artery stent implantation(CAS)and carotid endarterectomy(CEA)in the treatment of patients with severe internal carotid artery stenosis.Methods:88 patients with severe carotid artery stenosis who underwent CAS and CEA in the First People's Hospital of Changde City(hereafter referred as "our hospital")from January 2018 to December 2020 were selected as the research objects and divided into CAS group(n=43)and CEA group(n=45).To understand the clinical application value and feasibility of the two surgical schemes by comparing the general situation,cerebral blood flow,MMSE scale,MOCA scale score and serum miR-145,IGF1R levels of the two surgical schemes.Conclusions:CAS and CEA in the treatment of patients with severe internal carotid artery stenosis,have good curative effect,can effectively improve the patient's cerebral blood flow,regulate serum miR-145,IGF 1R levels,promote the recovery of cognitive function,but relatively speaking,the incidence of stroke and hypotension after CAS is higher,and the incidence of hypertension after CEA is higher.

Protective Effect of Low-dose Sevoflurane Inhalation and Propofol Anesthesia on the Myocardium after Carotid Endarterectomy： A Randomized Controlled Trial

Background： Myocardial infarction is an important cause of mortality after carotid endarterectomy （CEA）. Sevoflurane provides myocardial protection to patients undergoing coronary surgery, but whether it also reduces the incidence of myocardial injury in CEA patients is unclear. In this study, we evaluated the cardioprotective effect of low-dose sevoflurane with propofol in patients undergoing CEA. Methods： This was a single-center, prospective, randomized study conducted between November 2011 and December 2013. The study population of 122 patients who underwent CEA were randomly assigned to two groups. Group A （n = 62） received propofol for anesthetic maintenance, and Group B （n = 60） additionally received 0.8% end-tidal sevoflurane. The bispectral index was kept at 40-60. Myocardial injury, defined as cardiac troponin 1 （cTnl） levels 〉0.04 ng/ml, was the primary end-point. Levels ofcTnl were measured before anesthesia, and at 4, 24, and 7211 after surgery. Perioperative hemodynamic parameters and adverse cardiovascular events after surgery were also recorded. Results： Myocardial injury was detected in 18 patients in Group A and 7 in Group B. The difference was statistically signifcant （29.0% vs. 11.7%, P= 0.018）. The hemodynamic parameters were comparable between the groups, as were adverse cardiovascular events （P = 0.619）. Conclusions： Low-dose sevoflurane inhalation along with propofol reduces the incidence of myocardial injury in symptomatic patients after CEA.

Impact of metabolic syndrome on short-term outcome of carotid revascularization: a large sample size study in Chinese population

Background:Metabolic syndrome(MetS)is relatively common worldwide and an important risk factor for cardiovascular diseases.It is closely linked to arterial stiffness of the carotid artery.However,the association of MetS with the safety of carotid revascularization has been rarely studied.The aim of this study was to observe the current status of MetS and its components in Chinese carotid revascularized patients,and investigate the impact on major adverse clinical events(MACEs)after carotid endarterectomy(CEA)or carotid artery stenting(CAS).Methods:From January 2013 to December 2017,patients undergoing CEA or CAS in the Neurosurgery Department of Xuanwu Hospital were retrospectively recruited.The changes in prevalence of MetS and each component with time were investigated.The primary outcome was 30-day post-operative MACEs.Univariable and multivariable analyses were performed to identify the impact of MetS on CEA or CAS.Results:A total of 2068 patients who underwent CEA(766 cases)or CAS(1302 cases)were included.The rate of MetS was 17.9%;the prevalence rate of MetS increased with time.The occurrence rate of MACEs in CEA was 3.4%(26 cases)and in CAS,3.1%(40 cases).There was no statistical difference between the two groups(3.4%vs.3.1%,P=0.600).For CEA patients,univariate analysis showed that the MACE(+)group had increased diabetes history(53.8%vs.30.9%,P=0.014)and MetS(34.6%vs.15.8%,P=0.023).For CAS patients,univariate analysis showed that the MACE(+)group had increased coronary artery disease history(40.0%vs.21.6%,P=0.006)and internal carotid artery tortuosity(67.5%%vs.37.6%,P<0.001).Furthermore,the MACE(+)group had higher systolic blood pressure(143.38±22.74 vs.135.42±17.17 mmHg,P=0.004).Multivariable analysis showed that the influencing factors for MACEs in CEA included history of diabetes(odds ratio[OR]=2.345;95%confidence interval[CI]=1.057-5.205;P=0.036)and MetS(OR=2.476;95%CI=1.065-5.757;P=0.035).The influencing factors for MACEs in CAS included systolic blood pressure(OR=1.023;95%CI=1.005-1.040;P=0.010),coronary artery disease(OR=2.382;95%CI=1.237-4.587;P=0.009)and internal carotid artery tortuosity(OR=3.221;95%CI=1.637-6.337;P=0.001).Conclusions:The prevalence rate of MetS increased with time in carotid revascularized patients.MetS is a risk for short-term MACEs after CEA,but not CAS.

Research Progress of Chronic Internal Carotid Artery Occlusion

Chronic internal carotid artery occlusion(CICAO)is a chronic cerebrovascular disease which,from various causes,leads to progressive stenosis of the internal carotid artery lumen and finally to complete occlusion.With an aging society,the detection rate of CICAO is increasing year by year,with the highest incidence of CICAO in elderly men.The main clinical manifestations of CICAO are ischemic stroke and transient ischemic attack.Drug therapy is the first choice for asymptomatic CICAO,and surgical treatment is an optional means of improving prognosis for symptomatic CICAO that cannot be controlled by drugs.The selection of indications needs further study.This article reviews the latest research progress in the epidemiology,etiology,clinical features,imaging analysis,and treatment of CICAO in order to guide clinical diagnosis and treatment.

Prediction of Cerebral Hyperperfusion Syndrome with Velocity Blood Pressure Index

Background：Cerebral hyperperfusion syndrome is an important complication of carotid endarterectomy （CEA）.An 〉 100% increase in middle cerebral artery velocity （MCAV） after CEA is used to predict the cerebral hyperperfusion syndrome （CHS） development,but the accuracy is limited.The increase in blood pressure （BP） after surgery is a risk factor of CHS,but no study uses it to predict CHS.This study was to create a more precise parameter for prediction of CHS by combined the increase of MCAV and BP after CEA.Methods：Systolic MCAV measured by transcranial Doppler and systematic BP were recorded preoperatively;30 min postoperatively.The new parameter velocity BP index （VBI） was calculated from the postoperative increase ratios of MCAV and BE The prediction powers of VBI and the increase ratio of MCAV （velocity ratio [VR]） were compared for predicting CHS occurrence.Results：Totally,6/185 cases suffered CHS.The best-fit cut-off point of 2.0 for VBI was identified,which had 83.3% sensitivity,98.3% specificity,62.5% positive predictive value and 99.4% negative predictive value for CHS development.This result is significantly better than VR （33.3%,97.2%,28.6% and 97.8%）.The area under the curve （AUC） of receiver operating characteristic：AUCvBI =0.981,95% confidence interval [CI] 0.949-0.995;AUCvR =0.935,95% CI 0.890-0.966,P =0.02.Conclusions：The new parameter VBI can more accurately predict patients at risk of CHS after CEA.This observation needs to be validated by larger studies.