Carotid ultrasound findings as a predictor of long-term survival after abdominal aortic aneurysm repair: a 14-year prospective study

AbstractPurposeSeveral factors have been related to long-term survival after open abdominal aortic aneurysm (AAA) repair. The effect of carotid stenosis on outcome has not yet been examined. We performed an open prospective study to evaluate the prognostic significance of carotid stenosis on long-term survival of patients who had undergone elective operative repair of AAA.MethodsTwo hundred eight patients who underwent elective open AAA repair in our department between March 1987 and December 2001 were included in the study. All patients were evaluated preoperatively with color duplex ultrasound (US) scanning of the carotid arteries, and were followed up with clinical examination and carotid duplex US scanning 1 month after the operation and every 6 months thereafter. Median duration of follow-up was 50 months (range, 5-181 months). Cardiovascular morbidity and mortality, as well as all causes of mortality, were recorded and analyzed with regard to traditional risk factors and carotid US findings.ResultsTwenty-seven fatal and 46 nonfatal cardiovascular events were recorded. Both univariate and multivariate analysis showed that carotid stenosis 50% or greater and echolucent plaque were significantly associated with cardiovascular mortality and morbidity. Carotid stenosis was a stronger predictor of cardiovascular death than was ankle/brachial index. Age, hypercholesterolemia, coronary artery disease, and diabetes mellitus were also associated with higher mortality and morbidity from cardiovascular causes.ConclusionPatients electively operated on for AAA repair and with stenosis 50% or greater and echolucent plaque at duplex US scanning are at significantly increased risk for cardiovascular mortality and morbidity. Carotid US can therefore be used to select a subgroup of patients with AAA who might benefit from medical intervention, including antiplatelet and lipid-lowering agents

GALA: an international multicentre randomised trial comparing general anaesthesia versus local anaesthesia for carotid surgery

Background: Patients who have severe narrowing at or near the origin of the internal carotid artery as a result of atherosclerosis have a high risk of ischaemic stroke ipsilateral to the arterial lesion. Previous trials have shown that carotid endarterectomy improves long-term outcomes, particularly when performed soon after a prior transient ischaemic attack or mild ischaemic stroke. However, complications may occur during or soon after surgery, the most serious of which is stroke, which can be fatal. It has been suggested that performing the operation under local anaesthesia, rather than general anaesthesia, may be safer. Therefore, a prospective, randomised trial of local versus general anaesthesia for carotid endarterectomy was proposed to determine whether type of anaesthesia influences peri-operative morbidity and mortality, quality of life and longer term outcome in terms of stroke-free survival. Methods/design: A two-arm, parallel group, multicentre randomised controlled trial with a recruitment target of 5000 patients. For entry into the study, in the opinion of the responsible clinician, the patient requiring an endarterectomy must be suitable for either local or general anaesthesia, and have no clear indication for either type. All patients with symptomatic or asymptomatic internal carotid stenosis for whom open surgery is advised are eligible. There is no upper age limit. Exclusion criteria are: no informed consent; definite preference for local or general anaesthetic by the clinician or patient; patient unlikely to be able to co-operate with awake testing during local anaesthesia; patient requiring simultaneous bilateral carotid endarterectomy; carotid endarterectomy combined with another operation such as coronary bypass surgery; and, the patient has been randomised into the trial previously. Patients are randomised to local or general anaesthesia by the central trial office. The primary outcome is the proportion of patients alive, stroke free ( including retinal infarction) and without myocardial infarction 30 days post-surgery. Secondary outcomes include the proportion of patients alive and stroke free at one year; health related quality of life at 30 days; surgical adverse events, re-operation and re-admission rates; the relative cost of the two methods of anaesthesia; length of stay and intensive and high dependency bed occupancy

Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement

Objectives: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. Materials and methods: A literature review was performed with a focus on data from recent studies. Results: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. Conclusions: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients

Optimal Management of Asymptomatic Carotid Stenosis in 2021:The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement

Objectives: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. Materials and methods: A literature review was performed with a focus on data from recent studies. Results: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80–99% ACS indicate a higher stroke risk than 50–79% stenoses. Conclusions: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients

Vascular surgery training and certification: An international perspective

Objective: Vascular surgery (VS) practice has expanded to incorporate interventional procedures, and this has stimulated changes in training. The purpose of this study was to review current VS training and certification in different countries. Methods. A survey was completed by vascular surgeons involved with national certification in 34 countries. Results are expressed as the mean +/- SD, with comparisons by chi(2) and t tests. Results. VS is currently an independent specialty in 15 surveyed countries, is a subspecialty of general surgery in 10 countries, and is not recognized as a specialty in nine countries. There has been a clear time trend toward independent certification. In countries with independent VS certification, the length of VS training is 3.7 +/- 0.9 years plus 2.3 +/- 0.7 years of associated core general surgery (GS), for a total training length of 5.9 +/- 1.0 years. In countries with VS subspecialty certification, the length of VS training is 2.4 +/- 0.5 years after 5.0 +/- 1.1 years of GS, for a total training length of 7.4 +/- 1.2 years (each P &lt; .01 vs independent certification). The minimum required volume of major open VS operations during training is 151 +/- 78 in countries with independent VS certification vs 113 +/- 53 in countries with subspecialty certification. Endovascular requirements for training are established in 71% of countries with independent certification vs 37% of countries with subspecialty certification (P &lt; .03). Countries with independent VS certification produce 5.4 +/- 2.8 VS trainees per year per million population 65 years of age or older, vs 3.0 +/- 1.8 in countries with subspecialty certification (P &lt; .02). Conclusions. Considerable variation exists in VS training in different countries. There is an international movement toward independent VS certification, with longer VS specific training but shorter overall residency duration. Counties with independent VS certification produce more trainees per year to serve their elderly population

Do carotid surface irregularities correlate with the development of cerebrovascular symptoms? An analysis of the supporting studies, the opposing studies, and the possible pathomechanism

Carotid plaque surface morphology appears to play a controversial role in the occurrence of cerebrovascular symptoms, that is, amaurosis fugax, transient ischemic attacks, and episodes of stroke. A number of researchers favor a strong association between the morphologic abnormalities of the carotid plaque surface and the development of cerebrovascular symptoms. The supporters of this theory have demonstrated that surface contour irregularities not only are important potential sources of flow abnormalities but also contribute significantly to the development of ischemic neurologic symptoms through plaque fragmentation, microthrombi formation, and atheroembolism. However, opposers of this theory also exist. The main arguments for and against this theory, as well as the possible underlying pathomechanism linking the morphology of the carotid plaque surface with the development of cerebrovascular symptoms, are outlined. Detection of carotid surface abnormalities with the aid of angiography or color-flow duplex ultrasonography should play a major role in the early identification of patients at increased risk, this way aiding prompt correction of these usually clinically silent but potentially hazardous lesions