Systematic review and meta-analysis of postcarotid endarterectomy hypertension after eversion versus conventional carotid endarterectomy

Demirel, Serdar; Goossen, Käthe; Bruijnen, H.; Probst, Pascal; Böckler, Dittmar

doi:10.1016/j.jvs.2016.10.087

Cited by 41 publications

(28 citation statements)

References 39 publications

(154 reference statements)

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“…In 1924, Hering discovered that these baroreceptors were located in the CS. 5,[11][12][13] The CS is a dilatation in the carotid bifurcation usually at the origin of the proximal ICA. The most common site is the origin of the ICA, in 74.3%, but the CS can also be found in the distal part of the CCA inferior to the bifurcation and it contains baroreceptors that influence BP.…”

Section: Discussionmentioning

confidence: 99%

“…These evidenced post-ECEA high levels of the arterial blood pressure (BP) have been associated with multiple and severe complications and the phenomenon is attributed to the poor functionality of the baroreceptor mechanism. 5 The transection of the baroreceptor sensoring tissue leads to the interruption of the negative feedback reflex. The main mass of the baroreceptor tissue is located in the carotid body's adventitia and media, with the primary location at the medial part of the ICA stem, and these receptors consist the terminal points of the abducting fibers which through the Hering nerve run to the glossopharyngeal nerve.…”

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confidence: 99%

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Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy

2019

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The technique of the eversion carotid endarterectomy (ECEA), as an alternative to the conventional endarterectomy with primary or patch angioplasty, is an established technique for managing internal carotid artery stenoses and recently its application has been upgraded through the European Society for Vascular Surgery guidelines (Recommendation 55: Class 1, Level A). However, the typical eversion method has been associated with postoperative hypertension due to loss of the baroreceptor reflex; the standard oblique transection at the bulb performed in the eversion endarterectomy interrupts either the baroreceptor sensoring tissue, which is mostly located in the adventitia at the medial portion of the proximal internal carotid artery, or even the proper Hering nerve, a branch of the glossopharyngeal nerve. These actions deregulate the natural negative feedback of the carotid baroreceptor. Guided by the anatomical location of the baroreceptor sensor we have elaborated a slight modification of the classical ECEA to maintain as much as possible of the viable carotid baroreceptor sensoring surface. By extending the oblique incision distal to the carotid bifurcation in the medial part of the internal carotid artery stem, an eyebrow-like part of the proximal internal carotid artery is maintained and the axis from the sensoring tissue to the nerve of Hering is protected and following the endarterectomy, postoperative arterial blood pressure levels are lower than in the classical ECEA due to the maintenance of the efficiency of the baroreceptor reflex. During the period from September 2016 to November 2018, carotid endarterectomy was performed in 57 patients. Twenty-eight of them underwent the typical ECEA and 29 patients had the modified eyebrow eversion carotid endarterectomy (me-ECEA). The changes of blood pressure baseline during the postoperative course in ECEA and me-ECEA group were analyzed and compared. Postoperative hypertension was defined as an elevation of systolic blood pressure (SBP) greater than 140 mm Hg. Patients who underwent typical ECEA had significantly higher postoperative blood pressure values compared with those who underwent me-ECEA. Actually, the mean postoperative SBP was 172.67 ± 24.59 mm Hg in the typical ECEA group compared with 160.86 ± 12.83 mm Hg in the me-ECEA group (p = 0.023). The mean diastolic blood pressure in the ECEA group was 65.42 ± 11.39 mm Hg compared with 58.06 ± 9.06 mm Hg in the me-ECEA group (p = 0.009). Our proposed me-ECEA technique seems to be related to lower rates of postoperative hypertension compared with the typical ECEA, probably due to the sparing of the main mass of the baroreceptor apparatus; this improved modification (me-ECEA) of the typical eversion procedure could represent an alternative ECEA technique with its inherent advantages.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy

2019

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“…However, eversion CEA has a signifi cantly lower rate of late stenosis [64,65]. By meta-analysis, Demirel et al [66] found moderate evidence for an increased rate of post-CEA hypertension (OR 2.8) with eversion CEA.…”

Section: Benefi T and Harm From Treatmentmentioning

confidence: 99%

Carotid stenosis – basing treatment on individual patients’ needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy

Langhoff

2018

Vasa

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Summary:Though carotid artery stenosis is a known origin of stroke, risk assessment and treatment modality are not yet satisfactorily established. Guideline updates according to latest evidence are expected shortly. Current clinical weakness concerns in particular the identifi cation of "at-risk" patients. Beside the symptomatic status and the degree of stenosis, further signs of unstable plaque on carotid and cerebral imaging should be considered. Moreover, medical and endovascular therapy are continuously improving. Randomized trials and meta-analyses have shown similar long-term results for protected carotid artery stenting and endarterectomy. However, endovascular revascularization was associated with an increased 30-day rate of minor strokes. Newly developed embolic protection devices could possibly compensate for this disadvantage. Furthermore, high-level optimal medical therapy alone is currently being evaluated comparatively. We assume that a comprehensive evaluation of plaque vulnerability, serious consideration of advanced embolic protection, and more space for optimal medical therapy alone according to latest evidence, will benefi t patients with carotid stenosis.Keywords: Carotid artery stenosis, carotid artery stenting, carotid endarterectomy, optimal medical therapy Risk of strokeIn neurologically symptomatic patients with carotid artery stenosis, in particular in those with a recent stroke or transient ischaemic attack (TIA), severe atherosclerosis is known to be associated with a high risk of recurrent stroke. In a recently published study [2], the recurrence rate of ipsilateral ischaemic stroke in patients with a degree of 50-99 % stenosis increased from 2.7 % within the fi rst day, to 5.3 % within three days, to 11.5 % within 14 days and fi nally to 18.8 % within 90 days after occurrence of neurologic symptoms. Advanced age and cerebral vs. ocular symptoms were associated with a higher recurrence rate. The survey did not reveal associations between the recurrence of neurological events and the degree of stenosis, additional vascular risk factors or medication. However, a large pooled data analysis [3] on symptomatic patients showed an increased benefi t from endarterectomy compared to medical treatment alone,

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“…However, eCEA is limited by an inability to insert a shunt until the plaque has been removed and by a significantly higher incidence of post-CEA hypertension. 1 On the other hand, dCEA is associated with higher rates of perioperative stroke, peri-operative thrombosis and higher rates of late restenosis and late ipsilateral stroke compared with routine pCEA, 2,3 while pCEA is vulnerable to late prosthetic patch infection in about 1% of patients. 4 Several randomised controlled trials (RCTs) and observational studies (OSs) have compared eCEA with cCEA with regard to short-term outcomes (30 day stroke, 30 day death/stroke, 30 day death/stroke/myocardial infarction [MI], cranial nerve injury [CNI], neck haematoma, and 30 day internal carotid artery [ICA] thrombosis) as well as late outcomes (late restenosis, late ipsilateral stroke).…”

Section: Introductionmentioning

confidence: 99%

Editor's Choice – An Updated Systematic Review and Meta-analysis of Outcomes Following Eversion vs. Conventional Carotid Endarterectomy in Randomised Controlled Trials and Observational Studies

Paraskevas

Robertson

Saratzis

et al. 2018

European Journal of Vascular and Endovascular Surgery

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Systematic review and meta-analysis of postcarotid endarterectomy hypertension after eversion versus conventional carotid endarterectomy

Abstract: E-CEA increases the risk for post-CEA hypertension, whereas C-CEA is more often associated with hypotension, Careful BP monitoring at least in the early postoperative period after CEA is mandatory, especially when the eversion technique is used.

Cited by 41 publications

References 39 publications

Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy

Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy

Carotid stenosis – basing treatment on individual patients’ needs. Optimal medical therapy alone or accompanied by stenting or endarterectomy

Editor's Choice – An Updated Systematic Review and Meta-analysis of Outcomes Following Eversion vs. Conventional Carotid Endarterectomy in Randomised Controlled Trials and Observational Studies

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