Rapid Access Carotid Endarterectomy can be Performed in the Hyperacute Period without a Significant Increase in Procedural Risks

Abstract

The VIRTUE Registry of Type B Thoracic Dissections -Study Design and Early ResultsThe VIRTUE Registry Investigators. Eur J Vasc Endovasc Surg 2011;41:8-15. Introduction: Endovascular procedures for repair of Type B aortic dissection have become increasingly common and are often considered to be first line therapy for acute complicated dissections. The long term durability of these repairs is largely undefined.Methods: The Virtue Registry is a prospective, non-randomised, multi centre European Clinical Registry designed to inform on the clinical and morphological outcomes of 100 patients with Type B aortic dissection treated with the Medtronic Valiant thoracic stent graft. Patients with acute, sub-acute and chronic Type B dissections will be prospectively followed for three years. Clinical outcomes and aortic morphology will be defined.Results: Fifty patients had an acute dissection, 24 a sub-acute dissection and 26 a chronic lesion. The 30-day mortality for the acute, sub-acute and chronic lesions was 8%, 0% and 0%. The in hospital composite outcome (mortality, stroke or paraplegia) for the three groups was 16%, 0% and 3.8% respectively. The effect of left subclavian artery (LSCA) revascularisation was defined with the composite endpoint of patients with a covered, nonrevascularised LSCA being 20% as compared to 5.8% in the covered, revascularised group.Conclusion: The early outcomes for the treatment of Type B aortic dissection are reported in the Virtue Registry. Longer term follow-up is planned to report on clinical and morphological outcomes up to 36 months post-procedure. Objectives:To assess the accuracy of colour-Doppler ultrasound (CDUS), contrast-enhanced ultrasonography (CEUS), computed tomography angiography (CTA) and magnetic resonance angiography (MRA) in detecting endoleaks after endovascular abdominal aortic aneurysm repair (EVAR).Design: Prospective, observational study. consecutive patients who underwent EVAR were evaluated with CDUS, CEUS, CTA and MRA as well as angiography, if further treatment was necessary. Sensitivity, specificity, accuracy and negative predictive value of ultrasound examinations were compared with CTA and MRA as the reference standards, or with angiography when available.Results: Twenty-four endoleaks (22%, type II: 22 cases, type III: two cases) were documented. Sensitivity and specificity of CDUS, CEUS, CTA, and MRA were 58% and 93%, 96% and 100%, 83% and 100% and 96% and 100% respectively. CEUS allowed better classification of endoleaks in 10, two and one patients compared with CDUS, CTA and MRA, respectively.Conclusions: The accuracy of CEUS in detecting endoleaks after EVAR is markedly better than CDUS and is similar to CTA and MRA. CEUS seems to be a feasible tool in the long-term surveillance after EVAR, and it may better classify endoleaks missed by other imaging techniques.

Very Urgent Carotid Endarterectomy Confers Increased Procedural Risk

“…We showed that performing CEA as early as 3 to 14 days after the qualifying neurological event was safe compared with later surgery in agreement with recent studies. 19,[25][26][27] Our data thus support recent changes in guidelines advocating the need for early intervention. 16 However, we also found that CEA performed 0 to 2 after the qualifying event was associated with a 4-fold higher procedural risk compared with surgery performed at 3 to 7 days.…”

“…Studies that report risk in urgent (0 -2 days) CEA are very few and include only a small number of patients. [17][18][19] The aim of this study was to determine the procedural risk of CEA for symptomatic carotid stenosis in relation to the time from the qualifying neurological event in a large population-based cohort. We also used a multivariate logistic regression analysis to find predictors of the risk of stroke and death within 30 days of CEA.…”

Letter by Naylor Regarding Article, “Urgent Best Medical Therapy May Obviate the Need for Urgent Surgery in Patients With Symptomatic Carotid Stenosis”

“…A fuller description of the service has been detailed elsewhere. 7 The protocol advises the referring Family Doctor or Emergency Department to administer 300 mg aspirin and 40 mg simvastatin to all patients with a suspected TIA at the time of being seen and these medications were continued until the patient was seen in the Clinic. In the TIA Clinic, patients underwent CT/ MR imaging plus carotid ultrasound imaging and they were then seen by a consultant who specialized in stroke medicine.…”

“…One of the goals was to ensure that patients suffering a TIA/minor stroke underwent CEA as soon as possible after onset of symptoms. 7 To facilitate expedited CEA, patients with an ipsilateral 50e 99% stenosis (NASCET measurement method) were commenced on optimal medical therapy in the TIA Clinic and then transferred directly to the Vascular Unit for expedited CEA. No provision for weekend operating was included in the protocol, but two half-day theatre lists (Tuesdays/Fridays) were kept free for urgent CEAs.…”

Analysis of early Versus Delayed Carotid Surgery after Acute Ischemic Stroke

“…Many randomized trials have shown the bene it of early carotid revascularization for symptomatic carotid stenosis in stable patients [4]. According to recent literature, carotid revascularization (CR) should be performed within the irst two weeks following transient ischemic attack (TIA) or minor stroke, [5][6][7][8] and to some extend in the hyperacute period, within 48 hours [9,10]. In contrast, regarding major strokes or ongoing strokes, major studies recommend that surgery should be delayed four to six weeks after the irst neurological symptoms when clinical and radiological lesions have stabilized [11,12].…”