Cost-Effectiveness of Two Decision Strategies for Shunt Use During Carotid Endarterectomy

Background: Arterial shunting during carotid endarterectomy (CEA) is essential in some patients because of insufficient cerebral perfusion during cross-clamping. However, the optimal diagnostic modality identifying these patients is still debated. None of the currently used modalities has been proved superior to another. The aim of this study was to assess the cost-effectiveness of two modalities, stump pressure measurement (SPM) versus electroencephalography (EEG) combined with transcranial Doppler (TCD) during CEA. Methods: Two retrospective cohorts of consecutive patients undergoing CEA with different intraoperative neuromonitoring strategies (SPM vs. EEG/TCD) were analyzed. Clinical data were collected from patient hospital records. Primary clinical outcome was in-hospital stroke or death. Total admission costs were calculated based on volumes of healthcare resources. Analyses of effects and costs were adjusted for clinical differences between patients by means of a propensity score, and cost-effectiveness was estimated. Results: A total of 503 (239 SPM; 264 EEG/TCD) patients were included, of whom 19 sustained a stroke or died during admission (3.3 vs. 4.2%, respectively, adjusted risk difference 1.3% (95% CI −2.3–4.8%)). Median total costs were €4946 (IQR 4424–6173) in the SPM group versus €7447 (IQR 6890–8675) in the EEG/TCD group. Costs for neurophysiologic assessments were the main determinant for the difference. Conclusions: Given the evidence provided by this small retrospective study, SPM would be the favored strategy for intraoperative neuromonitoring if cost-effectiveness was taken into account when deciding which strategy to adopt

Endarterectomy or carotid artery stenting: the quest continues part two

BACKGROUND: Although randomized trials on carotid artery stenting (CAS) could not establish its equivalence to carotid endarterectomy (CEA) in patients with symptomatic carotid disease, CAS is rapidly evolving. Data on long-term outcome after CAS from randomized trials have now become available and ongoing, prospectively held registries frequently publish their results in increasing numbers of patients. We have therefore reviewed the currently available literature and provide an update of our previous article on this topic. DATA SOURCES: PubMed literature searches were performed to identify relevant studies regarding current status of CEA and stenting for symptomatic carotid stenosis. CONCLUSIONS: The efficacy of CAS in patients with symptomatic carotid artery stenosis remains unclear because of varying results in randomized trials. Although multiple registries do report promising results after CAS, peri-interventional stroke/death rates still exceed those rates currently found after CEA. Therefore, CEA remains the "gold standard" in treating these patients. (C) 2015 Elsevier Inc. All rights reserved

Medical treatment in carotid artery intervention

Medical treatment has a pivotal role in the treatment of patients with occlusive carotid artery disease. Large trials have provided the justification for operative treatment besides medical treatment in patients with recent significant carotid artery stenosis two decades ago. Since then, medical therapy has evolved tremendously. Next to aspirin, antiplatelet regimens acting on a different level in the modulation of platelet aggregation have made their entry. Moreover, statin therapy has been introduced. These changes among others in secondary stroke prevention, along with better understanding in life-style adjustments and perioperative medical management, have led to a decrease in stroke recurrence. Secondary prevention is therefore now the most important pillar of medical therapy. It consists of antiplatelet therapy, statins and blood pressure lowering agents in all patients. Small adjustments are recommended for those patients referred for invasive treatment. Moreover, long-term medical treatment is imperative. In this article, we summarize current evidence in literature regarding medical management in patients with previous stroke or TIA

Protection of stapled colorectal anastomoses with a biodegradable device:the C-Seal feasibility study

BACKGROUND: A colorectal anastomotic leak can be life-threatening. We have assessed the feasibility of a new intraluminal biodegradable bypass device that we designed to avoid anastomotic leakage and the necessity of a temporary stoma.METHODS: Fifteen patients underwent colorectal surgery. Before performing the anastomosis in a standard way, the C-Seal (Polyganics BV, Groningen, The Netherlands) was glued to the anvil of the circular stapler. Consequently, the bypass was fixated in the staple row just proximal of the simultaneously made anastomosis. A water-soluble contrast enema was performed after 1 week.RESULTS: The sheath was well compatible with the standard stapler device and easy to use. All donuts remained intact. No radiologic or clinical leaks were observed after surgery.CONCLUSIONS: This pilot study shows that the C-Seal can be applied successfully in colorectal surgery. Further investigation with large numbers of patients is now necessary to assess the efficacy of the C-Seal as a protective device. (C) 2011 Elsevier Inc. All rights reserved.</p

Relation between B-mode Gray-scale Median and Clinical Features of Carotid Stenosis Vulnerability

Background Vulnerability of the carotid plaque might be useful as a predictor for ischemic stroke risk. The gray-scale median (GSM) of the carotid plaque at B-mode imaging has been described as an objective tool to quantify vulnerability. However, its use is disputed in the published literature. This study sought to validate the GSM as a predictor for carotid plaque vulnerability. Methods We included 89 consecutive patients (64 men; mean ± SD age: 68 ± 1 years) who were evaluated for carotid endarterectomy. The GSM was derived from preoperative B-mode images and related to the presence of clinical symptoms, the presence of ipsilateral infarction on neuroimaging, and to the number of intraoperative ipsilateral microemboli (ME) detected by transcranial Doppler ultrasonography. In addition, we combined the GSM with its standard deviation (GSM-SD), which we hypothesized to be a measure for plaque heterogeneity and thereby vulnerability. Results B-mode imaging revealed a wide variety in GSM among all plaques (median: 36; range: 6–89). The GSM could not be related to cardiovascular risk factors and was not different between symptomatic and asymptomatic patients (37.8 ± 8.9 vs 37.6 ± 17.1; P = 0.97). The GSM of plaques in patients with ipsilateral ischemic lesions on neuroimaging did also not differ from plaques in patients without (36.0 ± 14.6 vs 37.8 ± 16.9; P = 0.64). Finally, no relation between GSM and the presence of intraoperative ME (Spearman correlation; n = 73; ρ = 0.039; P = 0.75) was found. Combining GSM with its GSM-SD also could not identify more vulnerable plaques. Conclusions No relation was found between the GSM and any clinical, radiologic, or intra- and postoperative neurologic phenomena. These data showed no additional value of the use of GSM in evaluating plaque vulnerabilit

Overestimation of contralateral internal carotid artery stenosis before ipsilateral surgical endarterectomy

Objective: The aim of this study was to investigate a possible overestimation of the degree of contralateral carotid artery stenosis by duplex in patients with significant bilateral carotid stenoses who are to undergo carotid endarterectomy (CEA). Methods: A retrospective analysis was performed of all patients undergoing CEA in our center over a period of 11 years. Pre- and postoperative duplex ultrasonography measurements of peak systolic velocity (PSV) and end diastolic velocity (EDV) were compared and used to classify the degree of stenosis. Univariate analysis was performed to indicate possible predictors for contralateral stenosis overestimation. Results: A total of 384 CEA procedures in 357 patients were performed in our hospital. Pre- and postoperative bilateral duplex measurements were available in 135 patients. Forty-four out of 135 patients (33%) were preoperatively identified as having significant stenosis (>60%) of the internal carotid artery on both sides. In these patients, postoperative duplex measurements of the contralateral carotid showed a decrease in mean (SD) PSV from 2.53 (1.11) m s(-1) to 1.97 (0.87) m s(-1) (P <0.01) and a decrease in EDV from 0.87 (0.60) m s(-1) to 0.60 (0.36) m s(-1) (P <0.01). The absolute changes in contralateral PSV and EDV after CEA were larger among patients with a higher degree of stenosis preoperatively. These changes led to reclassification of stenosis to a lesser degree in 24 (55%) patients. In 16 cases (36%), this resulted in a measured stenosis on the contralateral side of less than 60%. Conclusions: One-third of the patients with duplex measurements consistent with bilateral significant carotid stenosis did not have a significant contralateral stenosis by duplex after CEA. Therefore, additional postoperative duplex measurement is advisable before planning contralateral CEA. (C) 2009 Elsevier Ireland Ltd. All rights reserved