Elevated MMP-9 concentration is associated with carotid plaque instability and the presence of macrophages, factors that indicate increased risk for a neurological event. Determination of this gelatinase may enable identification of high-risk subgroups of patients with carotid artery stenosis.
Background and Purpose-Transfemoral carotid stenting, despite becoming very frequent, has some limitations such as difficult groin access in few patients, lack of distal protection during filter placement, or embolization despite protection. Transcervical stenting (TCS) is a novel technique during which a common carotid to jugular vein shunt is placed creating a protective reversal flow in the internal carotid artery after proximal common carotid artery (CCA) clamping. We aim to study, with transcranial Doppler (TCD), cerebral flow changes and microemboli detection during transcervical stenting. Methods-From September 2005 to March 2006, of 65 consecutive patients eligible for carotid revascularization, 23 were considered high risk (sapphire criteria) and underwent TCS. Neurologic examination was performed before and after the procedure by a neurologist and a preprocedure vascular reactivity TCD examination was done in all patients. Results-After CCA clamping, flow inversion was observed in the anterior cerebral artery, supplying blood to the middle cerebral artery (MCA) and internal carotid artery (reversal). TCD did not detect any air/solid emboli during stent deployment and angioplasty confirming the reversal flow protection hypothesis. Mean reversal flow time was 15.4 minutes; in all cases, substantial MCA flow was present during CCA clamping (initial mean velocity 30 cm/s), and a slow gradual increase was observed traducing collateral flow recruitment (mean velocity after 5 minutes 36 cm/s, PϽ0.001). Flow increase was observed in all patients except in those with preprocedural exhausted ipsilateral vascular reactivity (16% versus 2%, Pϭ0.036). The only in-procedure complication was one transient ischemic attack. After CCA unclamping, normal antegrade flow was restored in anterior cerebral artery and mean final MCA velocity increased 16% according to preprocedure flow. Conclusions-TCS with protective internal carotid artery flow reversal can eliminate showers of micoremboli during stent deployment making it a promising carotid revascularization technique in high-risk patients with carotid stenosis.
In our experience, transcervical CAS with flow reversal is a safe technique for treating carotid stenosis in patients aged >70 years. We believe that avoiding the aortic arch and tortuous supra-aortic vessels is responsible for the favorable results in this study.
Aims
To identify the organisational changes faced by front‐line nurses working with COVID‐19 patients during the first wave and describe how they responded to these changes.
Background
The COVID‐19 pandemic has altered the provision of care and the management of health care around the world. Evolving information about SARS‐CoV‐2 meant that health care facilities had to be reorganised continually, causing stress and anxiety for nurses.
Methods
Qualitative study based on Rapid Research Evaluation and Appraisal (RREAL). The research took place in hospital and community health settings of the Spanish national health system with a purposive sampling of 23 front‐line nurses. Semi‐structured interviews were conducted between May and June 2020. The duration was 30–45 min per interview. We used the Dedoose® data analysis software to perform a thematic analysis.
Results
Nurses responded to organisational changes using the following strategies: improvisation, adaptation and learning.
Conclusion
Our rapid approach allowed us to record how nurses responded to changing organisation, information that is easily lost in a disaster such as the COVID‐19.
Implications for nursing management: Knowing about their strategies can help planning for future health disasters, including subsequent waves of the COVID‐19.
In this preliminary experience, transcervical carotid angioplasty and stenting with flow reversal for cerebral protection was as safe at short term as carotid endarterectomy in octogenarian patients, who additionally had considerable comorbidity; thus, it may be possible to extend the indications for carotid revascularization in this population. Studies in larger patient series are required to confirm the trends observed in this study.
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