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.

Correlation of restenosis after rabbit carotid endarterectomy and inflammatory cytokines

Objective:To establish rabbit model of restenosis after carotid endartereclomy surgery,and to study tissue inflammatory cytokines(TNF-α,IL-61 involved in restenosis.Methods:A total of 32 rabbits were randomly divided into two groups:model group and control group.The right common carotid artery in rabbits was damaged by carotid endar terectomy in model group.The tissues were harvested at different time points respectively,the pathological changes of the vascular wall after operation were observed at different time points.The changes of expression of tissue vascular wall inflammatory cytokines(TNF-α.IL-6)at different lime points after the surgery was observed by RT-PCR,and the changes of serum inflammatory cytokines(TNT-α,IL-6)were detected by F.I.1SA.Results:The new intima appeared after 7 days of the injury and reached the peak on 28 d which is uneven and significantly thicker than the control group(P<0.01).The tissue inflammatory cytokines(TNF-α,IL-6)were significantlv increased after the rabbit common carotid artery injury,which was significant difference compared with normal control group(P<0.05).Conclusions:The tissue inflammatory factors significantly increase after the rabbit carotid artery injury,which suggests the mutual concurrent effects of inflammatory cytokines can result in the proliferation of vascular restenosis.

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.

症状性颈动脉狭窄患者CEA术后的预后改善及影响因素

目的评估症状性颈动脉狭窄(SCS)患者颈动脉内膜剥脱术(CEA)后长、短期预后情况及影响因素。方法分析首都医科大学三博脑科医院2014年1月—2019年12月经影像学检查确诊的79例SCS患者的临床资料,包括患者的既往病史、临床表现、实验室指标、影像学表现、治疗,以及术前、术后的改良Rankin量表(mRS)分级。分析术后3和24个月的预后改善情况。多因素Logistic回归分析影响因素,建立临床预测模型并对其进行准确性及预测效能评价。结果SCS患者CEA术前、术后3个月、术后24个月的mRS分级分别为(1.78±1.10)、(1.32±1.37)和(0.89±1.25)。与术前相比,术后3和24个月均明显改善(P<0.01)。多因素Logistic回归分析显示,CEA术后3个月,心肌梗死(OR=0.06,95%CI=0.01-0.32)和高脂血症(OR=0.13,95%CI=0.03-0.47)是影响因素。CEA术后24个月,心肌梗死(OR=0.09,95%CI=0.00-0.66)、高脂血症(OR=0.05,95%CI=0.00-0.29)和中性粒细胞/淋巴细胞比值(NLR)(OR=0.11,95%CI=0.02-0.50)是影响因素。通过构建的列线图来进行预测有较高的准确性及预测效能。结论SCS患者CEA术后长、短期神经功能均较术前均有显著改善。心肌梗死、高脂血症是影响CEA术后短期预后的危险因素,心肌梗死、高脂血症、NLR是影响CEA术后长期预后的危险因素。NLR可预测SCS患者CEA术后的长期预后,术前低NLR(<2.62)的患者预后更好。

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.

Carotid artery stenting versus carotid endarterectomy in the treatment of symptomatic and asymptomatic carotid stenosis: a systematic review and meta-analysis

Purpose: To evaluate the short-term and intermediate-to long-term efficacy and safety of carotid artery stenting(CAS) compared with carotid endarterectomy(CEA). Materials and Methods: The published literature was electronically searched for randomized controlled trials(RCTs) between CAS and CEA for the treatment of carotid stenosis performed from January 2000 to January 2017. The short-term and intermediate-to long-term outcomes were evaluated. Results: We identified 10 RCTs including 7,183 participants with symptomatic or asymptomatic carotid stenosis. Our meta-analysis found different results between the patients with and those without symptoms. In patients with symptomatic carotid stenosis, the total stroke incidence in the CAS group was significantly higher than that in the CEA group within the 30-day periprocedural period(p<0.001); however, the myocardial infarction incidence in the CAS group was significantly lower than that in the CEA group(p<0.05). There was no significant difference between the two groups in the mortality within 30 days post-procedure, but the intermediate-to long-term incidence of stroke or death in the CAS group was higher than that of the CEA group(p<0.05). In contrast, for asymptomatic patients, there were no significant differences between the CAS and CEA groups in the short-and intermediate-to long-term outcomes. Conclusion: For patients with symptomatic carotid stenosis, CEA is associated with an increased risk of myocardial infarction, whereas CAS is correlated with an increased risk of procedurally related strokes. However, for patients with asymptomatic carotid stenosis, no significant difference was found in the efficacy or safety between CAS and CEA.

A Prospective Study of Headache after Carotid Endarterectomy: Incidence and Clinical Characteristics

Headache associated with Carotid Endarterectomy (CEA) is a known condition;however, its incidence and etiology are not well defined. In this study, we determined the incidence and evaluated the characteristics of headache following CEA. This prospective study was conducted between January and July 2009, in 32 patients submitted to CEA. 68.7% of patients were male;mean age was 67.3 years-old. Headache incidence was 37.5%, ipsilateral to the CEA in 91% of patients;pressure was the most common pain quality (81.2%) and affected the frontal region alone in 37.5% of headache episodes. All headache episodes were of mild intensity. No correlation (p > 0.05) was found between sexes and no significant value (p > 0.05) was determined between the presence of headache and the mean degree of stenosis in the ipsilateral and contralateral carotid operated. Headache following CEA is a common condition;in most cases it is ipsilateral to the procedure, pressure type, mild and self-limiting.

Continuous Vagus Nerve Monitoring during Carotid Endarterectomy

Backgrounds: Injury to the vagus nerve or one of its branches during carotid endarterectomy can result in vocal fold paralysis but the exact mechanism of injury responsible for vocal fold paralysis after carotid endarterectomy is unclear. Aims: This study was performed to identify potential predictors of vagus nerve injury and obtain feedback by application of intraoperative continuous vagus nerve monitoring. Materials and Methods: Seventy-four patients undergoing carotid endarterectomy were enrolled. A new vagus nerve electrode was designed for less invasive continuous vagus nerve stimulation and monitoring of the vocal fold electromyogram without disturbing the surgical procedure. The device was rectangular (13 mm × 9 mm), with two small round electrodes set on a flexible silicon plate and tube. The electrode was fully implantable during carotid endarterectomy and was positioned at the most distal site of the vagus nerve by suturing to the connective tissue without nerve dissection. All patients underwent laryngoscopy to assess postoperative vocal fold and pharyngeal wall palsy at one week after carotid endarterectomy. Results: Sudden loss of the vocal fold electromyogram was noted in two patients (during plaque removal and during arterial wall suture in one each). In these two patients, incomplete vocal fold and pharyngeal palsy was confirmed by laryngoscopy. The cause of vagus nerve injury may have been traction at the time of distal internal carotid artery manipulation. The vocal fold electromyogram remained normal during the operation in the other 72 patients. However laryngoscopy revealed postoperative vocal fold and pharyngeal palsy in six patients. These findings suggested that delayed vagus nerve injury can occur after carotid endarterectomy. Conclusion: The continuous vagus nerve monitoring may be worthwhile for elucidating the mechanism of vagus nerve injury related to carotid endarterectomy.

CEA联合CABG术式应用于颈动脉狭窄患者对其脑血流动力学、认知功能及预后的影响研究

目的 探讨颈动脉内膜剥脱术(CEA)同期行冠状动脉旁路移植术(CABG)治疗冠心病合并颈动脉狭窄患者的疗效、脑血流动力学、认知功能及预后的影响。方法 选取2020年12月至2022年12月期间在南阳市中心医院就医并确诊为冠心病合并颈动脉狭窄的患者共104例,按照手术干预方式的不同分别建立同期手术组和分期手术组,每组52例。对比两组术中及术后相关指标水平包括手术用时、单支颈动脉阻断用时、桥血管血流量、ICU停留时间、住院时间;对比两组术前及术后1、3、6个月患侧大脑中动脉(MCA)的收缩期峰值流速(PSV)、阻力指数,颈内动脉狭窄管径、PSV、搏动指数及脑血管反应性(CVR);对比两组术前、术后1、3、6个月生活质量评分(ADL)和认知功能评分(MMSE);对比两组患者术后6个月内并发症发生情况。结果 同期手术组手术用时明显高于分期手术组,同期手术组ICU停留时间、住院时间均明显低于分期手术组(均P<0.05);两组术后1、3、6个月的脑血流动力学各指标水平与术前相比均差异有统计学意义(P<0.05),同期手术组术后1、3个月MCA-PSV均明显高于分期手术组(P<0.05);术后1、3、6个月两组ADL评分较术前均明显降低,两组MMSE评分较术前均明显升高(均P<0.05);同期手术组并发症总发生率明显低于分期手术组(P<0.05)。结论 CEA同期行CABG治疗方式应用于冠心病合并颈动脉狭窄患者具有较好的临床效果,安全性较好,亦可促进患者快速康复,但术中用时较长,需针对性注意患者手术适应证。

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.

Comparison of the Modified Eversion Carotid Endarterectomy Technique with the Conventional Carotid Endarterectomy Technique: Early Results

Objectives: In this study, we aimed to compare early results of the modified eversion carotid endarterectomy technique with the conventional carotid endarterectomy technique. The modified eversion carotid endarterectomy technique consisted of a longitudinal arteriotomy that was begun from the common carotid artery proximally to the origin of external carotid artery. We also avoided applying a carotid shunt during surgery in both techniques. Methods: Each patient was evaluated for coronary artery stenosis and valve replacement indications. Diagnosis of significant coronary artery stenosis or valve disease directed us to a combination of CEA and cardiac surgery (CABG/Valvular). We generally had a tendency to perform these two surgical procedures separately. Patients which had surgery for both at the same session were excluded in this study. As a result, our study included 120 patients and 137 carotid interventions. We performed the modified eversion carotid endarterectomy technique in 61 patients (68 carotid interventions) (Group A) and the conventional CEA technique in 59 patients (69 carotid interventions) (Group B). At follow-up, the patients were evaluated by physical examination and color Doppler USG. Results: There was no significant difference between the groups in terms of demographic data. Statistically significant difference was observed in one operative parameter between Group A and Group B;patchplasty requirements during surgery (12 carotid interventions in group B and 4 carotid interventions in group A, p = 0.036). We recorded temporary tongue deviation in five cases, facial asymmetry in eight cases, hoarseness in four cases, neurocognitive impairment in three cases and transient neurologic in two cases with no significant difference between the groups. There was in one case of permanent neurologic deficit (1 in group B). There were two postoperative deaths (1 in group A and 1 in group B). The death in group A occurred because of subarachnoid haemorrhage and the death in group B occurred because of myocardial infarction. After 6 month follow-up, no restenosis occurred in group A. Restenosis occurred in three patients of group B. Conclusion: The modified eversion technique for carotid endarterectomy decrease the incidence of patchplasty applications and postoperative restenosis by avoiding internal carotid artery manipulation and sewing. Besides, it is easy and possible to remove plaques completely from internal carotid artery via the modified arteriotomy line.

Timing of Carotid Endarterectomy: Perioperative Outcome According to Index Event to Operation Room Time

Aim:?Carotid endarterectomy (CEA) is the choice of treatment for prevention of cerebrovascular events in vulnerable patients. In this single-center multi surgeon study, we aimed to evaluate outcomes of neurologically stable patients who underwent CEA after symptoms of cerebrovascular?event according to time between the event and operation.?Methods:?In our clinic during 2008-2012,?we applied 67 CEA to 65 patients. Ten of these 65 patients excluded from trial due to combined CABG operation. 18 patients were asymptomatic prior to operation and excluded. Thirty-nine of these patients were symptomatic and enrolled to study. Data were collected retrospectively. All enrolled patients were divided into two groups, according to the time between event and operation. Group I: Early Group (≤14 days).?Group II: Late Group (>14 days). Results:?In our clinic during 2008-2012, we applied 39 CEA procedures to consecutive 37 patients with symptomatic carotid artery stenosis. None of preoperative variables were associated with postoperative mortality (p > 0.05). We observed postoperative bleeding in one patient who was in Late Group (II). Postoperative bleeding was only associated with hyperlipidemia (p = 0.003). Postoperative stroke was observed in moderate cardiac risk patients in Early Group (I) (p = 0.003). But none of the postoperative complications were associated with study groups. We observed that, closure technique (primary closure) was associated with postoperative stroke (p = 0.030). We have achieved shorter waiting time during study time phrase but it couldn’t reached statistical significance (p = 0.196).?Conclusion:?Although symptomatic patients have a higher risk of perioperative complications compared with asymptomatic patients, early CEA after symptom onset does not influence the results. This raises the question of the optimal timing of Carotid Artery intervention in symptomatic carotid artery stenosis. To answer this question, more data are needed preferably from large randomized trials.

A United States Population-Based Study on Clinical Outcomes Following Primary Carotid Endarterectomy: Who and When?

Introduction: Carotid Endarterectomy (CEA) is widely recognized as effective in significantly reducing the risk of recurrent stroke emanating from extracranial carotid atherosclerosis and approximately 140,000 carotid endarterectomies are performed annually in the United States (US). As such, data are scarce on the prevalence and clinical outcomes of CEA across different age groups. This study aimed to determine and analyze the prevalence, demographic and clinical outcomes of CEA across six decades of life. Methods: Data on 40,276,240 patients were abstracted from discharge data obtained from the Nationwide Inpatient Sample (NIS) database, a part of the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (2004-2008). Demographic and clinical characteristics of patients undergoing CEA as the primary procedure were abstracted including age, gender, elective or non-elective admission, comorbidities, Length of Stay (LOS), secondary procedures, NIS severity of illness and risk of mortality class, complications and mortality. CEA outcomes were compared across six decades of life starting at age 41. Categorical variables were compared using the Chi-square test, and the Student’s t-test was used to compare continuous variables. Results: 118,947 patients who underwent CEA as their primary procedure were identified. Caucasians accounted for 67.1% of the population. The overall mean age was 71.2 ± 9.5 years, with a Male: Female ratio of 1.3:1. Nineteen percent of patients had non-elective admission, with the highest percentage (29.5%) in those >91 years old. Over three percent of patients had a prior stroke. The overall number of CEA performed peaked in the 8th decade of life (38.4%). The most common co-morbidities were hypertension, diabetes mellitus, and chronic pulmonary disease. Mean LOS was 3.3 days. Forty-two percent of all cases were performed in a teaching hospital, with the percentage increasing with advancing age. The overall mortality and stroke rates were 0.4% and 0.9%, respectively, and these rates were highest in the oldest patients (>91 years). The overall myocardial infarction rate was 0.8% which was highest incidence in the 7th and 9th decades (1.1%). On multivariate analysis, age >80 years (Odds Ratio (OR), 2.9;95% Confidence Interval (CI), 1.1 - 8.0), Non-white race (OR, 1.7;CI, 1.1 - 2.7), Charlson co-morbidity index score of 1 - 5 (OR, 1.7;CI, 1.3 - 2.4), carotid artery stenosis with stroke at presentation (OR, 1.7;CI, 1.1 - 2.5), Congestive Heart Failure (CHF) (OR, 3.7;CI, 2.8 - 4.8) and renal failure (OR, 2.2;CI, 1.6 - 3.1) were independent risk factors associated with increased CEA mortality. Conclusions: The percent of patients over 80 years is the fastest-growing segment of the US population, and CEA is an increasingly commonly procedure in elderly patients with a low mortality rate across all age groups. On a population level age >80, non-Caucasian race, the presence of specific co-morbidities (i.e., Stoke at presentation, congestive heart failure, renal failure), and a high Charlson co-morbidity index score are independent predictors of an increased CEA related mortality.

One Case of Suspected Angiostenosis Revealed by MRA Following Carotid Endarterectomy Due to a Rare Cause

We herein report on a case in which magnetic resonance angiography (MRA) following carotid endarterectomy revealed the appearance of angiostenosis due to an artifact of metallic powder, which was thought to have come from an old surgical instrument. The patient was a 77-year-old male. Carotid endarterectomy (CEA) was performed for stenosis in the internal carotid artery of his left neck (82%). Upon observing a decline in renal function following CEA surgery, a postoperative cervical MRA revealed the appearance of high-grade stenosis at the common carotid artery on which surgery was performed. No stenosis was revealed upon carotid ultrasonography and angiography. In the original MRA image, an orbicular low intensity area was observed in concordance with the narrow segment. 3D computed tomography (3D-CT) revealed a metallic finding, suggesting it was an artifact caused by metal powder. Close inspection of the metal surgical instruments used during surgery revealed slight damage to a suture snare which had been used for 30 years. Going forward, it is necessary to pay attention to old surgical instruments, introduce a system by which the number of years and the frequency of use of each surgical instrument can be learned, and replace them with new equipment as necessary.

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.

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.

Advances and progress of endarterectomy in the treatment of carotid stenosis

Carotid stenosis, one of the risk factors that tend to result in cerebral ischemia, infarction as well as ischemic manifestations. CEA (carotid endarterectomy), was initially designed delicately to excise of the thickened, atheromatous tunica intima from the focal stenosis segment, which therefore has been acknowledged as an efficacious way in the management of the prophylaxis of cerebral ischemia. During 1990’s, carotid endarterectomy (CEA) has matured to a widely performed, standard intervention with well defined successive steps. In the recent years, appearance of angioplasty, stenting, and distal protection procedures provides competitive alternatives to classical endarterectomy. However, long-term benefits of carotid angioplasty should be confirmed by larger, randomized, comparative clinical trials. [HJ]

TCD联合SEPMEP监测在重度颈动脉狭窄患者CEA术中的应用

目的探究重度颈动脉狭窄患者颈动脉内膜切除术(CEA)术中采用经颅多普勒超声(TCD)联合体感诱发电位(SEP)、运动诱发电位(MEP)监测的价值。方法选取2021-02—2023-03邢台市第三医院收治的190例重度颈动脉狭窄患者作为研究对象,所有患者均行CEA,术中采用TCD联合SEP、MEP监测,TCD检查手术部位大脑中动脉(MCA)、平均血流速度(Vm)变化,并记录同时段SEP、MEP波幅变化,以TCD作为金标准,探究SEP、MEP对于重度颈动脉狭窄的预测价值。结果术中颈动脉阻断后,32例(16.84%)MCA下降>50%,其19例N20波幅下降>50%,13例N20波幅下降≤50%,以TCD为金标准,SEP波幅下降预测的敏感度、特异度、准确率、阳性及阴性预测值、Kappa为59.38%、91.77%、86.32%、59.38%、91.77%、0.511;32例患者中22例SEP潜伏期延长>10%,10例SEP潜伏期延长≤10%,SEP潜伏期延长预测的敏感度、特异度、准确率、阳性及阴性预测值、Kappa为68.75%、93.67%、98.47%、68.75%、93.67%、0.624;阻断后2 min术侧SEP波幅下降及潜伏期延长幅度均大于手术对侧(P<0.05);32例患者中9例MEP振幅降低50%,MEP振幅下降预测的敏感度、特异度、准确率、阳性及阴性预测值、Kappa为28.13%、58.44%、75.79%、28.13%、85.44%、0.136;阻断后2 min术侧MEP振幅降低幅度大于手术对侧(P<0.05)。结论SEP、MEP可对重度颈动脉狭窄患者进行连续、有效且无创的监测,SEP波幅下降与潜伏期延长与TCD监测具有良好的一致性,临床可将SEP、MEP与TCD联合对重度颈动脉狭窄行CEA的患者进行监测。