A finger-like projection in the carotid artery: A rare source of embolic stroke requiring carotid endarterectomy
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Abstract:
Atherosclerotic lesions of the extracranial carotid arteries are one of the most common cases of stroke.Rarely, a stroke may result from isolated non-stenotic carotid disease in the absence of systemic manifestations of cardiovascular disease or significant cardiovascular risk factors.We present an unusual case of multiple strokes resulting from a solitary finger-like projection within the posterior wall of the carotid artery in an otherwise healthy patient.This small finger-like projection has a propensity to act as a nidus for thrombus formation and a potential source of cerebral embolism.Keywords:
Stroke
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Interventional radiology
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Carotid artery disease
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Carotid endarterectomy (CEA) is a widespread and safe procedure associated with very little risk. Only at our hospital surgeons perform nearly 1000 of these surgeries annually, with serious complications occurring extremely rarely[1]. Cerebral ischemic events due to external carotid artery (ECA) thrombosis following a successful internal carotid artery (ICA) endarterectomy is one of such complications. We present a case of ECA thrombosis, following ICA endarterectomy that caused ischemic events.
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Occlusion or severe stenosis, with a reduction in the diameter of more than 70% of the extracranial arteries may lead to hpoperfusion of the brain with an increased risk of cerebral infarction. The aim of this study was to investigate whether endarterectomy of stenosed internal carotid arteries leads to alternations in cerebral metabolism in regions in which no infarcts were visible with magnetic resonance imaging (MRI). We studied 10 healthy control subjects and 20 patients with transient or nondisabling cerebral ischemia with MRI and 1H magnetic resonance spectroscopic imaging. All patients underwent carotid endarterectomy. Patients were examined 1 week before and 3-6 months after carotid endarterectomy. The N-acetyl aspartate (NAA)/choline ratio in the symptomatic hemisphere before endarterectomy (2.29 +/- 0.42) was significantly (p < 0.001) lower than for control subjects (3.18 +/- 0.32). In five of the patients lactate was detected preoperatively in regions that were not infarcted. The NAA/choline ratio in the symptomatic hemisphere of these five patients did not increase significantly after endarterectomy (1.99 +/- 0.22 vs. 2.23 +/- 0.48). The NAA/choline ratio in patients without lactate preoperatively increased significantly (p < 0.01) after endarterectomy to a normal level (from 2.39 +/- 0.42 to 2.92 +/- 0.52). These results indicate that the presence of cerebral lactate may predict whether the NAA/choline ratio increases after carotid endarterectomy.
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Carotid endarterectomy has been a widely used method of preventing primary or secondary cerebrovascular ischemic events since the 1950s. Over the past several years, the interest in this surgical procedure has increased due to the publication of several large randomized trials comparing best medical therapy (antithrombotic) with carotid endarterectomy. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) has demonstrated a risk reduction of 65% in patients who underwent carotid endarterectomy for symptomatic carotid stenosis. The Asymptomatic Carotid Atherosclerosis Study (ACAS) also demonstrated a benefit of carotid endarterectomy, however, in a group of asymptomatic patients. There was an approximate reduction of 6% in stroke in patients undergoing carotid endarterectomy in this series. Carotid endarterectomy is the treatment of choice in patients with symptomatic extracranial carotid atherosclerosis. Data is now emerging that this is also an effective therapy in patients with asymptomatic carotid stenosis. The perioperative stroke risk by the surgeon performing the procedure and the patient's co‐morbid medical conditions are important factors to consider before proceeding with surgical treatment of this disorder.
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Octogenarians were not included in the major trials of carotid endarterectomy. Concern has been expressed about the role of carotid endarterectomy in this age group. This concern is based in part on uncertainty about the long-term survival of elderly patients after carotid endarterectomy. The aim of the present study was to assess relative survival in those patients >or=80 years of age undergoing carotid endarterectomy.A population-based record linkage study of all patients who underwent carotid endarterectomy from 1988 to 1998 in Western Australia was undertaken. Long-term relative survival after carotid endarterectomy was assessed against age- and sex-matched controls.During the period 1988 to 1998, 1796 (1306 male, 490 female) cases were identified. There were 151 patients >or=80 years of age. The cumulative survival at 5 years was 64.9% for those >or=80 years of age compared with 80.1% for those <80 years of age. Relative survival at 5 years was 118% (95% CI, 102 to 134) for those >or=80 years of age compared with 94.7% (95% CI, 92 to 97) for those <80 years of age.Long-term relative survival after carotid endarterectomy in patients >or=80 years of age was better than that of an age-matched population. The likelihood of living long enough to gain benefit from a carotid endarterectomy is not jeopardized by being too old.
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BACKGROUND AND PURPOSE: Current indications for carotid endarterectomy are determined by balancing the relative risks of surgery with the benefits of reduced risk of subsequent stroke. Our purpose was to use MR perfusion imaging to assess patients being considered for carotid endarterectomy and to monitor sequential changes in MR perfusion characteristics after surgery. In particular, we wished to determine whether this technique could be used to detect changes that might be related to post‐ carotid endarterectomy hyperemia. METHODS: We used a single-section gradient-recalled echo sequence to investigate 14 patients being examined before possible surgery for carotid artery disease. In the 12 patients in whom carotid endarterectomy was performed, sequential studies were performed 3 to 5 days after surgery and at 3 months. Analysis of bolus-arrival-time (BAT) images was performed. RESULTS: Significant delays in preoperative BAT images of 0.89 seconds (range, 0.05 to 3.22 seconds) were apparent between hemispheres. Excluding the two patients with contralateral internal carotid artery (ICA) occlusion, early arrival, possibly indicating postoperative hyperemia, was seen in five patients immediately after carotid endarterectomy but resolved within 3 to 5 months after surgery. CONCLUSION: MR perfusion imaging shows differences in BAT between hemispheres in patients with ICA stenosis. Changes in perfusion characteristics after carotid endarterectomy are complex, and early BAT on the operative side can occur soon after endarterectomy in over half those patients without an occluded contralateral vessel. The significance of these findings with regard to patient outcome and risk of postoperative hyperemia requires further investigation.
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ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Unlu A, Durukan A. Safe carotid endarterectomy: “one fits all strategy”. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2020;17(3):137-142. doi:10.5114/kitp.2020.99077. APA Unlu, A., & Durukan, A. (2020). Safe carotid endarterectomy: “one fits all strategy”. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 17(3), 137-142. https://doi.org/10.5114/kitp.2020.99077 Chicago Unlu, Ahmet, and Ahmet Baris Durukan. 2020. "Safe carotid endarterectomy: “one fits all strategy”". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery 17 (3): 137-142. doi:10.5114/kitp.2020.99077. Harvard Unlu, A., and Durukan, A. (2020). Safe carotid endarterectomy: “one fits all strategy”. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 17(3), pp.137-142. https://doi.org/10.5114/kitp.2020.99077 MLA Unlu, Ahmet et al. "Safe carotid endarterectomy: “one fits all strategy”." Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, vol. 17, no. 3, 2020, pp. 137-142. doi:10.5114/kitp.2020.99077. Vancouver Unlu A, Durukan A. Safe carotid endarterectomy: “one fits all strategy”. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2020;17(3):137-142. doi:10.5114/kitp.2020.99077.
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Aims: Selective endarterectomy is described as extraction of atheromatous plaque through an arteriotomy made starting from common carotid artery (CCA) and extending to external carotid artery (ECA). The aim of this study was to report the initial experience selective endarterectomy technique at our department.
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Meta-analysis of the results of eversion carotid endarterectomy and endarterectomy with patch plasty
The study was aimed at comparing the results of eversion carotid endarterectomy and carotid endarterectomy with patch plasty in the immediate and remote postoperative periods.The literature was retrieved by means of electronic databases, with the dates of publications ranging from 1970 to 2019. According to the inclusion and exclusion criteria we selected the literature making it possible to carry out a meta-analysis in the immediate and remote postoperative periods. The results were obtained with the help of the Stata 14 software package. Eventually, we retrieved and analysed a total of 2139 articles. Of these, ten were included into the study and contained 3568 patients subjected to 3672 operations (eversion carotid endarterectomy - 1718 and carotid endarterectomy with a patch - 1954). The results of the meta-analysis were as follows: the mean time of carotid artery cross-clamping for eversion carotid endarterectomy was shorter than that for carotid endarterectomy with a patch (4.1±2.9 min); the frequency of using intraoperative temporary bypass in eversion carotid endarterectomy turned out to be significantly less compared with carotid endarterectomy with patch plasty - 13.5% (91/672) and 62.0% (492/793), OR=0.183, 95% CI: 0.136-0.254, p<0.001; the incidence rate of ischaemic stroke in the immediate and remote postoperative periods was significantly lower after eversion carotid endarterectomy than that after carotid endarterectomy with patch plasty - OR=0.452, 95% CI: 0258-0.792, p=0.005 and OR=0.300, 95% CI; 0.155-0.579, p=0.000. The development of restenosis in the immediate and remote postoperative periods was observed less often for eversion carotid endarterectomy compared with carotid endarterectomy with patch plasty - OR=0.604, 95% CI: 0.422-0.864, p=0.006.Eversion carotid endarterectomy was associated with shorter time of carotid artery cross-clamping, lower frequency of intraoperative temporary bypass, lower number of cases of ischaemic stroke in the immediate and remote postoperative periods, as well as those of restenosis in the long-term postoperative period.Цель: сравнить результаты эверсионной каротидной эндартерэктомии и каротидной эндартерэктомии с пластикой заплатой в ближайшем и отдаленном послеоперационных периодах. Материалы и методы: поиск литературы проводился при помощи электронных баз данных с датами публикаций в промежутке с 1970 по 2019 гг. В соответствии с критериями включения и исключения была отобрана литература, которая позволила провести метаанализ в ближайшем и отдаленном послеоперационных периодах. Для получения результатов был использован программный пакет Stata 14. В итоге найдено и проанализировано 2139 статей, 10 из них были включены в исследование и содержали 3568 пациентов, 3672 операции (эверсионная каротидная эндартерэктомия - 1718, каротидная эндартерэктомия с заплатой - 1954). Результат метаанализа: медиана времени пережатия сонных артерий при эверсионной каротидной эндартерэктомии короче, чем при каротидной эндартерэктомии с применением заплаты (4,1±2,9 мин); частота интраоперационного использования временного шунта при эверсионной каротидной эндартерэктомии была значительно ниже, чем при каротидной эндартерэктомии с пластикой заплатой - 13.5% (91/672) и 62.0% (492/793), ОШ=0.183, 95% ДИ: 0.136-0.254, p<0.001; развитие ишемического инсульта в ближайшем и отдаленном послеоперационных периодах было значительно ниже после эверсионной каротидной эндартерэктомии, чем после каротидной эндартерэктомии с пластикой заплатой - ОШ=0.452, 95% ДИ: 0.258-0.792, p=0.005 и ОШ=0.300, 95% ДИ: 0.155-0.579, p=0.000. Развитие рестенозов в ближайшем и отдаленном послеоперационных периодах реже наблюдалось при проведении эверсионной каротидной эндартерэктомии, чем при каротидной эндартерэктомии с пластикой заплатой - ОШ=0.604, 95% ДИ: 0.422-0.864, p=0.006. Заключение: при проведении эверсионной каротидной эндартерэктомии сокращается время пережатия сонных артерий, снижается частота интраоперационного использования временного шунта, уменьшается количество случаев как ишемического инсульта в ближайшем и отдаленном послеоперационных периодах, так и рестенозов в отдаленном послеоперационном периоде.
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