H. Bruijnen

The effect of eversion and conventional-patch technique in carotid surgery on postoperative hypertension

OBJECTIVE Postcarotid endarterectomy hypertension (HTN) is associated with neurological and cardiac complications. The purpose of this study was to assess the influence of eversion carotid endarterectomy (E-CEA) and conventional carotid endarterectomy (C-CEA) on postoperative blood pressure in the first 4 days after surgery. METHODS Two hundred seventy-six consecutive CEAs that were performed between February 2008 and September 2009 were reviewed retrospectively with a computerized registry. After exclusion of patients with severe stroke (modified Rankin Scale of 3-5), prior contralateral and ipsilateral carotid surgery and more than 70% stenosis of the contralateral carotid artery, 201 cases remained (E-CEA group: n = 100 vs C-CEA group: n = 101) for analysis. Results in terms of systolic blood pressure, use of intravenous and oral vasodilators, alterations of the existing antihypertensive medications, and perioperative complications (neck hematoma, myocardial infarction, stroke, and death) were compared. RESULTS Groups were similar with regard to age, sex, and cardiovascular risk factors except for a higher incidence of nicotine use (59% vs 43%; P = .02) in the C-CEA group. Patients in the C-CEA group had a significantly higher percentage of symptomatic carotid artery stenosis (54% vs 23%, respectively; P < .0001). Despite a lower preoperative (baseline) mean systolic blood pressure (130 mm Hg vs 135 mm Hg; P = .02) patients in the E-CEA group had a significantly higher mean systolic blood pressure in the postoperative course up to the day 4 after surgery (134 mm Hg vs 126 mm Hg; P < .0001) and required more frequent intravenous (28% vs 9.9%; P = .001) and oral vasodilators (54% vs 27.7%; P = .0002) compared to those in the C-CEA group. Two-thirds (14 of 21 = 66%) of patients in the E-CEA group with preoperative high blood pressure (systolic blood pressure ≥140 mm Hg and diastolic pressure ≥90 mm Hg) required vasodilators and only one-third (11 of 33 = 33%) in the C-CEA group (P = .03). Atropine use due to bradycardia was necessary after 8 cases (8%) in the C-CEA group and only after 1 case (1%) in the E-CEA group (P = .03). Furthermore, the dosage of existing antihypertensive medications was increased and/or additional medications were prescribed twofold more in the E-CEA group (33% vs 17%; P = .009). No statistically significant difference was noted in the perioperative complication rate. CONCLUSION It is concluded that E-CEA is associated with significantly higher postoperative blood pressure that persists for at least 4 days after surgery. Patients with inadequate preoperative high blood pressure control are particularly at risk after E-CEA.

Prospective 2-Years Follow-up Quality of Life Study after Infrageniculate Bypass Surgery for Limb Salvage: Lasting Improvements Only in Non-diabetic Patients

OBJECTIVES To assess health-related quality of life (HRQoL) up to 24 months after successful infrageniculate bypass surgery for limb-threatening ischaemia. METHODS 89 patients with infrageniculate bypass surgery for limb-salvage were studied. HRQoL was assessed using the Short Form (SF)-36v1 questionnaire before, 6, 12, and 24 months after revascularisation. RESULTS 47 patients (53%) with intact limb and functioning graft were assessed after 24 months, 27 patients (30%) died, further 7 required secondary amputation, 3 suffered irremediable graft occlusion, and 4 were lost to follow-up. The 24-months HRQoL-values were significantly improved in 4 domains: physical functioning (p<0.01), bodily pain (p<0.01), mental health (p=0.04), and social functioning (p=0.01). Except for baseline-values, HRQoL remained inferior in diabetics compared to non-diabetics throughout follow-up. Maximum improvement of HRQoL was delayed in diabetics (12 months vs. 6 months) and less pronounced. After 24 months non-diabetic patients maintained improvement in 5 domains and diabetic patients only in bodily pain. CONCLUSIONS Improvement in HRQoL is sustained for more than 12 months after successful infrageniculate bypass surgery. Therefore, an aggressive approach towards revascularisation seems to be justified from the patients perspective. However, this benefit in quality of life is less in diabetic patients, despite similar limb-salvage rates.

Multicenter Experience on Eversion Versus Conventional Carotid Endarterectomy in Symptomatic Carotid Artery Stenosis Observations From the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE-1) Trial

Background and Purpose— Carotid endarterectomy (CEA) is beneficial in patients with symptomatic carotid artery stenosis. However, randomized trials have not provided evidence concerning the optimal CEA technique, conventional or eversion. Methods— The outcome of 563 patients within the surgical randomization arm of the Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE-1) trial was analyzed by surgical technique subgroups: eversion endarterectomy versus conventional endarterectomy with patch angioplasty. The primary end point was ipsilateral stroke or death within 30 days after surgery. Secondary outcome events included perioperative adverse events and the 2-year risk of restenosis, stroke, and death. Results— Both groups were similar in terms of demographic and other baseline clinical variables. Shunt frequency was higher in the conventional CEA group (65% versus 17%; P<0.0001). The risk of ipsilateral stroke or death within 30 days after surgery was significantly greater with eversion CEA (9% versus 3%; P=0.005). There were no statistically significant differences in the rate of perioperative secondary outcome events with the exception of a significantly higher risk of intraoperative ipsilateral stroke rate in the eversion CEA group (4% versus 0.3%; P=0.0035). The 2-year risk of ipsilateral stroke occurring after 30 days was significantly higher in the conventional CEA group (2.9% versus 0%; P=0.017). Conclusions— In patients with symptomatic carotid artery stenosis, conventional CEA appears to be associated with better periprocedural neurological outcome than eversion CEA. Eversion CEA, however, may be more effective for long-term prevention of ipsilateral stroke. These findings should be interpreted with caution noting the limitations of the post hoc, nonrandomized nature of the analysis.

Eversion Carotid Endarterectomy is Associated with Decreased Baroreceptor Sensitivity Compared to the Conventional Technique

OBJECTIVE Impairment of baroreceptor sensitivity (BRS) has been shown to be associated with blood pressure instability after carotid endarterectomy (CEA). The aim of this study was to determine whether there is a difference in postoperative BRS changes following eversion CEA (E-CEA) and conventional CEA (C-CEA). METHODS Sixty-four patients undergoing E-CEA (n = 37) and C-CEA (n = 27) were prospectively studied. Non-invasive measurements of mean arterial pressure (MAP), cardiac output (CO) and total peripheral resistance (TPR) were perioperatively obtained over three 10-min periods. Baroreflex gain was calculated as the sequential cross-correlation between heart rate and beat-to-beat systolic blood pressure. RESULTS Compared with changes observed after C-CEA, E-CEA was associated with an increase in systolic pressure (SP) (P = 0.01), diastolic pressure (DP) (P = 0.008), MAP (P = 0.002) and heart rate (HR) (P = 0.03) on postoperative day 1 (POD-1). BRS decreased after E-CEA from 6.33 to 4.71 ms mmHg(-1) on POD-1 (P = 0.001) and to 5.26 ms mmHg(-1) on POD-3 (P = 0.0004). By contrast, BRS increased after C-CEA from 4.59 to 6.13 ms mmHg(-1) on POD-1 (P = 0.002) and to 6.27 ms mmHg(-1) on POD-3 (P < 0.0001). CONCLUSION E-CEA and C-CEA have different effects on BRS. This is associated with an altered haemodynamic behaviour after E-CEA and C-CEA, respectively. These findings are likely the result of carotid sinus nerve interruption during E-CEA and preservation with C-CEA.

Critical Limb Ischaemia: Initial Treatment and Predictors of Amputation-free Survival

OBJECTIVES To evaluate initial treatment and risk factors for amputation-free survival in patients with critical limb ischaemia (CLI). DESIGN Prospective clinical cohort study at a single vascular surgical centre in Germany. METHODS Data on 104 consecutive patients (115 ischaemic limbs) presenting with their first episode of CLI were collected prospectively over a 3-year period. Initial treatment was classified as conservative therapy, intervention, surgery, or major amputation. Patient co-morbidities were assessed by uni- and multivariate analysis to determine risk factors for limb salvage, survival and amputation-free survival. RESULTS Indications for treatment were rest pain in 27 (23.5%) and tissue loss in 88 (76.5%) limbs. Revascularisation was attempted in 65% of all limbs: 45% by intervention and 55% by surgery. In 9% primary amputation was necessary and 22% received conservative therapy. Median follow-up was 28 months (1-42). The 3-year limb salvage, patient survival, and amputation-free survival rates were 73%, 41%, and 31%, respectively. Diabetes, cardiac disease and renal insufficiency were associated with poor survival. Combined cardiac and renal disease adversely affected amputation-free survival (HR, 3.68; 95% CI, 1.51-8.94; P < 0.001). CONCLUSIONS At least two third of all patients presenting with CLI can be offered some type of direct revascularisation. In patients with major cardiac disease and renal insufficiency, a poor outcome in terms of amputation-free survival is to be anticipated.

Changes in baroreceptor sensitivity after eversion carotid endarterectomy

OBJECTIVE Posteversion carotid endarterectomy hypertension has been suggested to be associated with impaired baroreceptor sensitivity (BRS), which has been identified as a factor of prognostic relevance in patients with cardiovascular disease. The aim of this prospective single-center nonrandomized study was to describe the changes of BRS in the early postoperative period after eversion carotid endarterectomy (E-CEA). METHODS Spontaneous BRS and hemodynamic parameters such as blood pressure (BP), heart rate (HR), cardiac output (CO), and total peripheral resistance (TPR) were evaluated preoperatively as well as postoperatively after 1 and 3 days using a noninvasive sequential cross-correlation method. Additionally, any modification in vasoactive medication due to BP derangement in the postoperative period was noted. Due to non-normal distribution of BRS, HR, and TPR samples, all measured values were expressed as medians with interquartile range (IQR), and a nonparametric test (Friedman) was performed. After adjustment for multiple testing, differences were considered statistically significant when the two-tailed P value was less than .0036. RESULTS Thirty-five patients (mean age, 71 years) with symptomatic or asymptomatic internal carotid artery stenosis were included. The BRS significantly decreased to a lower level 24 hours after surgery (4.71 ms/mm Hg [3.02-6.1]) than preoperatively (5.95 ms/mm Hg [4.68-10.86]; P < .0001), resulting in a within-patient difference of -2.46 ms/mm Hg (95% confidence interval [CI], -8.38 - -1.52). This difference (95% CI, [- 1.58 (-8.24 - -0.80)]) persisted at the 72-hour measurements (5.63 ms/mm Hg [3.23-7.69]; P = .0005). The HR, reflecting the sympathetic activity, increased 24 hours after the operation (69 bpm [61.3-77.7]) compared with preoperative values (63 bpm [57.9-73.2]; P = .005) (within-patient difference [95% CI] 3.7 [1.5-8.5]), and this increase reached significance at 72 hours (69 bpm [65.4-77.5]; P = .001) (within-patient difference [95% CI] 5.5 [2.3-8.8]). Values of systolic pressure, diastolic pressure, mean arterial pressure, CO, and TPR were not significantly different between pre- and postoperative measurements. Overall, 23 (66%) patients developed significant postoperative hypertension requiring aggressive management with additional medications. CONCLUSIONS E-CEA might have a decreasing influence on BRS, leading to increased sympathetic activity. Investigations of the longer-term effects of impaired BRS are warranted. These findings should be interpreted with caution, noting the limitation of an absent control group.

Intraoperative imaging techniques in infrainguinal arterial bypass grafting: Completion angiography versus vascular endoscopy

This prospective study was designed to establish whether vascular endoscopy would provide more information on the graft lumen than standard completion angiography during infrainguinal bypass surgery. Ninety-nine patients with 102 infragenicular bypass grafts who underwent both angiography and angioscopy intraoperatively were evaluated. In 99 of the 102 patients the indication was critical limb ischaemia. Of the 102 bypass grafts, 81 were autogenous vein. Distally, 24 grafts were anastomosed to the below-knee popliteal segment, 64 extended to the crural and 14 to the pedal arteries. On completion of the distal anastomosis, grafts were first evaluated by angiography and then by angioscopy. The images obtained with the two monitoring modalities were compared by the operating surgeon and re-explorations were performed immediately if necessary. Completion angiography and angioscopy produced images of good quality in 96 and 97 cases, respectively. In 12 cases completion angiography showed abnormalities. Of these, five were located below the distal anastomosis and were not accessible to angioscopic examination. Conduit defects were found in seven instances. In one of them angioscopy showed the angiogram to be false-positive. Of the 90 grafts with normal completion angiograms, seven were found to show significant pathology on angioscopy. Compared to angioscopy, the sensitivity and specificity of angiography to detect abnormalities within the graft was 46% and 98%, respectively. Our results suggest that vascular endoscopy is superior to angiography for disclosing conduit defects, but that it does not provide adequate information about the distal arterial anatomy.

Technique and Results of Vascular Endoscopy in Arterial and Venous Reconstructions

In an effort to maximize results, vascular endoscopy was used in our institution to monitor arterial and venous reconstructions. Since 1982, angioscopy was applied as a control method in 182 venous thrombectomies to treat iliofemoral thrombosis and 114 aortoiliac thromboendarterectomies. Of the cases with venous thrombectomy reviewed, 50% were incomplete by endoscopic evidence; of these, in 80% the remaining clots could be partly or completely removed. Additionally, in six patients a venous spur was found. Of 114 attempted aortoiliac thromboendarterectomies, only 91 could be completed. In the remainder, endoscopic evidence of persistent intimal flaps forced us to bypass the affected segments. With further miniaturization of the angioscopes, the method was also applied to check vessel repair on small-caliber arteries. In an initial study with 220 femorodistal bypasses we were unable to find a statistically significant difference of primary patency in grafts that were endoscopically controlled or not. In the learning phase with the in situ technique, we identified competent valve remnants in 40%, but this rate could be reduced to 12.7% with growing experience in valvulotomy. We conclude from our data that angioscopy is very helpful in assessing the morphological integrity of aortoiliac thromboendarterectomies and venous thrombectomies. The actual value in infrainguinal arterial reconstructions still remains to be proven.

Comparison of renin and catecholamine release in patients undergoing eversion or conventional carotid endarterectomy

OBJECTIVE The two techniques for carotid endarterectomy (CEA)--conventional (C-CEA) and eversion (E-CEA)--have different effects on blood pressure. This study compared sympathetic activity after C-CEA and E-CEA, as measured by renin and catecholamine levels. METHODS E-CEA (n = 40) and C-CEA (n = 34) were performed in 74 patients with high-grade carotid stenosis. The choice of technique was made at the discretion of the operating surgeon. All patients received clonidine (150 μg) preoperatively. Regional anesthesia was used. The carotid sinus nerve was transected during E-CEA and preserved during C-CEA. Renin, metanephrine, and normetanephrine levels were measured preoperatively and at 24 and 48 hours postoperatively. RESULTS Compared with baseline, levels of renin, metanephrine, and normetanephrine decreased at 24 and 48 hours after C-CEA (P < .0001). After E-CEA, however, renin and normetanephrine levels were unchanged at 24 hours, and metanephrine levels were increased (P < .0001). At 48 hours, levels of renin (P = .04), metanephrine (P < .0001), and normetanephrine (P = .02) were increased. Compared with C-CEA, E-CEA was associated with significantly increased sympathetic activity at 24 and 48 hours (P < .0001). Although the use of vasodilators for postoperative hypertension did not differ in the postanesthesia care unit (E-CEA 35% vs C-CEA 18%, P = .12), vasodilator use on the ward was more frequent after E-CEA (60% vs 32%, P = .02). CONCLUSIONS E-CEA appears to be associated with greater postoperative sympathetic activity and vasodilator requirements than C-CEA, findings likely related to sacrifice of the carotid sinus nerve during E-CEA but not C-CEA.

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

Objective: Blood pressure (BP) instability after carotid endarterectomy (CEA) is a risk factor for cerebrovascular and cardiovascular complications. The role of the operative technique in the development of post‐CEA hemodynamic instability is unclear. The primary goal of this study was to systematically review the literature to determine whether hypertension in the early postoperative period is dependent on the surgical technique used. Methods: We searched MEDLINE, Cochrane CENTRAL, and Web of Science through June 2016 without restrictions to language or starting date. The interventions of interest were eversion CEA (E‐CEA) compared with conventional CEA (C‐CEA) with or without patch plasty. The primary outcome of interest was the incidence of postoperative need for vasodilator therapy because of hypertension in the early postoperative period, the duration of which was predefined in the individual studies. Secondary outcomes were the intergroup mean difference of the mean within‐group changes of postoperative (24 hours) to baseline systolic BP, the incidence of hypotension requiring vasopressor therapy, and the rate of complications. The odds ratio (OR) of each binary outcome was pooled across studies with its 95% confidence interval (CI). For meta‐analysis of continuous outcomes, the weighted mean differences with the corresponding 95% CIs were pooled. Strength of evidence of the outcomes was judged according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Results: We identified six studies, of which four were nonrandomized prospective and two retrospective with low to moderate risk of bias. In addition, results of a post hoc analyses of a randomized controlled trial were included, resulting in a total number of seven included studies. Duration of the postoperative study period ranged from 1 to 6 days. The meta‐analysis of all studies regarding the primary outcome demonstrated increased rates of post‐CEA hypertension after E‐CEA (pooled OR, 2.75; 95% CI, 1.82–4.16; I2 = 49.9%). The pooled weighted intergroup mean difference between the E‐CEA and C‐CEA effects on postoperative systolic BP was +12.92 mm Hg (95% CI, 8.06–17.78; I2 = 93.6%; P < .0001). Hypotension was significantly higher in the C‐CEA group (pooled OR, 11.37; 95% CI, 1.95–66.46; I2 = 0%). There was no difference in postoperative complications including myocardial infarction, stroke, neck hematoma, or death. Strength of evidence contributing to the primary outcome as well as the hypotension outcome was graded as moderate and that contributing to the other secondary outcomes was graded as very low. Conclusions: 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.